Policies to improve access to pharmaceutical products in shortage: the experience of Iran food and drug administration

Out-of-pocket pharmaceutical expenditure and its determinants among Iranian households with elderly members: a double-hurdle model

OBJECTIVES

The population of older adults continues to grow in Iran, with pharmaceutical costs as a leading driver of household health-related costs. The present study was conducted to estimate the out-of-pocket pharmaceutical expenditure and its socioeconomic predictors among households with the elderly in Iran.

METHOD

This study is a secondary analysis using 2019 national household expenditure and income survey data in Iran. The sample size was 9381 households with at least one member older than 65. The double-hurdle model in STATA 16 was used to examine the association between independent variables and households' out-of-pocket pharmaceutical expenditures.

RESULTS

The mean out-of-pocket pharmaceutical expenditures for each household with elderly member was $8065 per year. There was a positive association between the (female) gender of the household head, urban residence, employment status, insurance expenditure and a higher level of education of the head of the household with the out-of-pocket pharmaceutical expenditures (P < 0.05). The income of elderly households did not affect these expenditures (P > 0.05).

CONCLUSIONS

This study showed that the socioeconomic characteristics of elderly families not only influenced their decision to enter the medicine market, but also the rate of medicine purchase. It is helpful to manage and control the pharmaceutical costs among the elderly.

A Cost-effectiveness Analysis of Adding Cetuximab to the First-line Treatment of Metastatic Colorectal Carcinoma in Iran; Considering Genetic Screening for Precision Medicine

PURPOSE

This study aimed to evaluate the cost-effectiveness of cetuximab in different genetic populations of metastatic colorectal carcinoma patients, including KRAS and RAS wild types and mutants, when added to FOLFIRI treatment regimens for evidence-based disease management in Iran.

METHOD

A Markov decision model was designed in TreeAge software with the three states of stable, progress, and death. Clinical outcomes were extracted from published clinical studies, and costs were extracted from the Iranian local data. The primary outcome was an incremental cost-effectiveness ratio (ICER) in the simulated population.

RESULTS

The cost-utility model from the perspective of the health system indicated that the average direct medical costs of a patient that has not been genetically screened are $56,985.27 and $20,767.74 in FOLFIRI + cetuximab and FOLFIRI regimens, respectively. However, costs per patient in the KRAS wild-type population were $21,845.52 in FOLFIRI and $78,321.22 in FOLFIRI + cetuximab. In RAS wild-type patients, FOLFIRI and FOLFIRI + cetuximab costs per patient were $23,111.62 and $84,976.39, respectively. Incremental QALYs for the above scenarios were 0.069, 0.193, and 0.285, respectively. Therefore, the ICER of add-on cetuximab in Iran compared to the treatment alternatives in the scenarios with and without KRAS screening was $520,771.55/QALY, $292,768.16/QALY, and $217,460.51/QALY.

CONCLUSION

Although genetic screening in precision medicine reduces costs per outcome, according to the willingness-to-pay threshold of $4349.50 in the Iranian health system, add-on cetuximab to the FOLFIRI regimen is not a cost-effective strategy even with genetic screening and a 20% price reduction.

Cost-Effectiveness of Ibrutinib as First-line Treatment for Older Patients With Chronic Lymphocytic Leukemia in Iran

OBJECTIVES

We aimed to evaluate the cost-effectiveness of ibrutinib versus chemoimmunotherapy for frontline treatment of elderly patients with chronic lymphocytic leukemia in Iran.

METHODS

We developed a partitioned survival model with 3 health states (progression-free survival, post-progression survival, and death) and a lifetime horizon. State memberships were determined by parametric survival analysis of the ALLIANCE (A041202) randomized controlled trial's results, comparing first-line ibrutinib with bendamustine plus rituximab. Direct medical costs were calculated from an Iranian health system perspective. Utility values were extracted from the literature to calculate the incremental costs and quality-adjusted life-years (QALYs) associated with each strategy. To address parameter uncertainties, deterministic and probabilistic sensitivity analyses were also performed.

RESULTS

In the base-case analysis, ibrutinib and bendamustine plus rituximab were associated with $3739.72 and $3991.20 costs per patient as the first-line treatment strategy, respectively. They resulted in an average of 2.86 and 2.66 QALYs per patient. Thus, first-line ibrutinib was associated with 0.20 incremental QALY and $251.48 cost-saving per patient and was therefore the "dominant" strategy. In deterministic sensitivity analysis, drug prices were the key drivers of model outputs. However, none of the resulting incremental cost-effectiveness ratios exceeded the currently accepted threshold by the Iranian Food and Drug Administration ($1550 per QALY). In probabilistic sensitivity analysis, 63.3% of iterations were cost-saving and 77.4% were cost-effective.

CONCLUSIONS

Our findings suggest that ibrutinib as a first-line treatment appears to be the dominant strategy, compared with the standard of care, for unselected older adults with chronic lymphocytic leukemia in Iran.

How does external reference pricing work in developing countries: evidence from Iran

Introduction: Governments apply different pricing policies to ensure public accessibility, availability, and affordability of medicines. In this way, external reference pricing (ERP) because of its easy implementation is used widely across countries. However, ERP is completely path dependent, and it would both bring pros and cons, related to its implementing strategy which makes understanding of its impact in different countries challenging. In this study, we examine the performance of the ERP approach in Iran as a pricing tool. Method: We conducted a cross-sectional descriptive study. Although Iran officially uses a reference country basket for ERP, in this study, we use different reference countries based on socioeconomic comparability, access to their price data, medicine pricing approaches, and pharmaceutical expenditure to examine the effect of reference countries as well as the method performance. Then, an empirical study was applied to a list of selected samples of medicines in the Iranian market to compare their price with our new reference countries. Then, we discuss the performance of ERP process based on the real prices in the Iranian pharmaceutical market. Result: The prices of 57 medicines, which contain about 69.2% of the imported Iran pharma market in value, were compared with their prices in selected reference countries. It was found that 49.1% of prices were more expensive in at least one of the reference countries, and in 21% of products, the average price in Iran was higher than the average price in reference countries. Conclusion: Achieving efficient and fair pricing of pharmaceuticals between and within countries is still a complex conceptual and policy problem that ERP in short term can handle. ERP cannot be considered a perfect tool for pricing alone, although its effectiveness is acceptable. It is expected that using other pricing methods alongside the ERP will improve patients' access to medicines. In Iran, we use value base pricing as the main pricing method for every new molecule. Then, we use other methods such as ERP as a complementary method.

Health system to response to economic sanctions: global evidence and lesson learned from Iran

BACKGROUND

Sanctions have direct and indirect impacts on people's lives. Therefore, the health systems of countries targeted by sanctions must respond effectively. This study proposes a set of mitigating measures and response strategies to improve the health systems of countries under sanctions.

METHODS

This three-stage study was conducted in Iran within the 2020-2021 period, in which a rapid review of evidence was carried out to identify the measures implemented or proposed to make the health system resilient in confronting sanctions. A qualitative approach was then adopted to determine how the health system could be improved to response to sanctions from the perspectives of 10 key experts. Semi-structured interviews and document analysis were conducted for data collection. Finally, a two-round Delphi technique was employed to help eleven experts reach a consensus on a set of mitigating measures, which were then prioritized.

RESULTS

In this research, 62 proposed or implemented mitigating measures were extracted from 13 eligible studies to improve the health system performance in confronting sanctions. Moreover, 18 measures were identified in interviews for a better health system response to sanctions. They were then classified as five categories: sustained financing, good governance, integrated and updated health information systems, qualified workforce, and efficient and equitable service delivery. In the first Delphi round, 28 mitigating measures were discovered. Nine measures were identified as more effective and feasible in both short and long runs. They were introduced as below: conducting proactive inventory control, developing the nationally essential list of medicines, providing additional clarification that oil revenues can be freely used for medicines procurement, defining tailored health service packages for vulnerable populations, establishing and enhancing an efficient surveillance system, reducing prices of imported medicines, developing dual policies of equity and priority for vulnerable groups, institutionalizing fair and effective resource allocations, and providing clinical guidelines.

CONCLUSIONS

According to the findings, the most critical areas for the resilience of a health system in confronting sanctions include strengthening particular components of governance, improving efficiency, and caring for vulnerable populations. The experts collectively emphasized investment in domestic capacities, public participation, and health diplomacy. Despite the proposed measures, it is unclear how effective these are and, especially whether they can significantly affect the harsh impacts of sanctions on health. Moreover, intensive and long-term sanctions have significant irreversible outcomes that cannot be reversed easily or quickly.

The Violence of Non-Violence: A Systematic Mixed-Studies Review on the Health Effects of Sanctions

The use of sanctions as a policy tool to affect change in the political behavior of target states has increased over the past 30 years, along with a concern about their impact on civilian health. Some researchers have proposed that targeting sanctions can avoid their moral costs, yet others have challenged this claim. This systematic mixed-studies review explored the debate about targeted sanctions by appraising their health effects as reported in the medical and public health literature, with a global focus and through the COVID-19 era.We searched three electronic databases without temporal or geographical restrictions and identified 50 studies spanning three decades (1992-2021) meeting our inclusion criteria. Using a piloted form, we extracted quotations addressing our research questions and identified themes that we grouped according to the effects of sanctions on health or its determinants, generating frequency distributions to assess the strength of support for each theme. While no study posited a causal relationship between sanctions and health, or engaged the morality of sanctions, most implied that when sanctions were present, health was inevitably impacted, even for sanctions ostensibly targeted to minimize civilian harm. Our findings suggest that given the integrated nature of the global economy, it is all but impossible to design sanctions that will achieve their stated goals without inflicting significant harm on civilians. We conclude that the use of sanctions as a policy tool threatens global health and human rights, especially in times of crises.

Policies and measures implemented to reduce the impact of international sanctions on Iran's pharmaceutical sector

Background and purpose

Continuous evaluation of the policies and interventions could explore their efficacies in improving the accessibility and availability of medicines in the local market. This study explained the health system policies of the Islamic Republic of Iran concerning the impact of the economic sanctions on the local pharmaceutical market and addressed the issue of whether these policies were able to improve patients' access to medicines.

Experimental approach

In this study, qualitative and quantitative research methods were used. In the qualitative part, semi-structured interviews with pharmaceutical system experts were used. In the next step, the structural analysis method was used. In the quantitative part, numerical sales data of the selected medicines were extracted and analyzed.

Findings/Results

Reported statistics regarding the presence of the medicines in the market indicates the obvious fluctuations in the numerical sales of medicines in the studied years. This may indicate that the policies implemented are not able to fully compensate for the negative effects of sanctions and improve access to medicine. In addition, according to some experts, policy, and management weaknesses are mainly rooted in unresolved domestic hurdles which have exacerbated the effects of international sanctions on the country's pharmaceutical market.

Conclusions and implications

Effective policy-making in response to economic sanctions can reduce the negative effect of international sanctions and result in drug shortages. Results of this study showed despite efforts made by the Iran health sector to subside the impact of sanctions on the pharmaceutical sector, there is an obvious disruption of the medicine supply chain in the market.

Transparency in public pharmaceutical sector: the key informants' perceptions from a developing country

Background

Policymaking in the pharmaceutical sector plays a pivotal role in achieving the health systems’ goals. Transparency in the pharmaceutical policy could increase confidence in decision-making processes. This study aims to assess transparency in the public pharmaceutical sector of Iran.

Methods

This qualitative study with a content analysis approach was conducted in 2017 using the World Health Organization tool to explore pharmaceutical transparency. The perceptions of the various stakeholders of the health system through semi-structured interviews with a maximum variation of stakeholders were obtained in eight functions, including registration, licensing, inspection, promotion, clinical trials, selection, procurement, and distribution of medicines.

Results

There are some problems in two main categories: (1) General problems, including lack of transparency, conflict of interest, centralization, and monopoly. (2) Ethical problems include illegal payments, gifts, bribes, conflicts of interest, hidden power, hoarding, relationship-oriented behavior, medicine trafficking, and counterfeit medicine. Suggested solutions include evidence-based decision-making, the use of transparent and accountable processes, standardization, needs assessment, declaring a conflict of interest, skilled human resources, and tracking prescription.

Conclusion

Despite the development of effective pharmaceutical policy in the health care system and government interventions for the control of the market, in some functions, reviewing the pharmaceutical policy is essential. Additionally, declaring a conflict of interest statement must be at the core of policy development to provide greater transparency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07319-x.

What impact does medicines shortages have on patients? A qualitative study exploring patients' experience and views of healthcare professionals

Background

The shortage of medicines represents a complex global phenomenon that triggers patient care and safety issues. The study was undertaken to explore the impact of medicines shortages on patients in Pakistan. The study also identified barriers which hinder the solutions of medicines shortages issue.

Methods

A qualitative study design was adopted and the data was collected in stages between July and September 2019using an in-depth interview approach. The purposive and convenient sampling strategy was used to recruit the study participants. Sample size was limited by using the saturation point criteria. All interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Results

A total of 35 stakeholders including 13 physicians, 12 pharmacists and 10 patients participated in the study. The findings of the study were classified into five key themes and seven subthemes. The five themes included, ‘impact of medicine shortages on patients’, ‘patients’ practices in response to medicine shortages’, ‘influence of medicines shortages on medical practice or pharmaceutical business’, ‘barriers to solutions for medicines shortages’, and ‘suggestions to assuage the impact of medicine shortages.’This study showed that the medicine shortages had significant clinical and financial impact on patients. Patients’ opted for a number of risk-prone practices to avoid treatment disruption during shortages. An array of pharmaceutical market, medicines quality and patient related factors refrain physicians to switch from brand name medicine to generics and lead to ineffective management of medicines shortages. Promotion of generic prescription, implementation of punitive policies and proper patient consultation was advised to assuage the impact of medicine shortages on patients.

Conclusion

The adverse clinical, economic and humanistic impact affirmed in this study demand the introduction of risk-management strategies for medicines shortages in hospital and community settings in accordance with the international standards. Promotion of effective patient counselling by the healthcare professionals to deter risk-prone practices associated with medicines shortages is mandatory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06812-7.

Physical rehabilitation in Iran after international sanctions: explored findings from a qualitative study

Background

Although the main aims of sanctions are the political and economic pressures on governments, literature has demonstrated the harsh effects of sanctions on the general public, especially on the patients, poor and disabled people. Since the international sanctions regime negatively affected almost all dimensions of Iran’s health sector, this qualitative study was conducted to investigate the situation of the physical rehabilitation sector after these sanctions.

Methods

This qualitative study was conducted from January 2019 to June 2019 in Iran using Skype, telephone, and face-to-face in-depth semi-structured interviews. Purposive and snowball sampling approaches were used to identify the participants. Also, framework analysis approach was applied to analyze the collected data.

Results

In total, 38 individuals including health policy-maker, faculty member, rehabilitation expert, Physiotherapist, Occupational therapist, and Orthotist/Prosthetist, were involved in the study. Based on our findings, a number of challenges facing the Iranian physical rehabilitation sector during the international sanctions period included: 1) socioeconomic challenges (inadequate funding, rising inflation rate, high unemployment rate, catastrophic expenditures, and inappropriate employment status of practitioners); 2) education challenges (decreased international collaboration and shortage of training devices and materials); 3) international challenges (rising issues in accessing services for patients from neighborhood countries); and 4) service delivery challenges (shortage of raw materials for producing the orthoses and prostheses, hardening of the importing the needed equipment, inappropriate infrastructures, and impossibility to use external assistance).

Conclusion

After international sanctions, the Iranian physical rehabilitation sector has faced considerable multifaceted challenges. Therefore, the international community must be aware of the situation and be concerned about the irreparable consequences.

An application of analytic network process model in supporting decision making to address pharmaceutical shortage

Background

The present study aimed to develop an Analytic Network Process (ANP) model to assist policymakers in identifying and prioritizing allocation indicators, which are being used or should be used to distribute drugs in short supply among different provinces.

Methods

The model encompasses the interactions between various indicators and efficiency, equity, and effectiveness paradigms. Accordingly, a set of clusters and elements, which were associated with the allocation of drugs in short supply in Iran’s pharmaceutical system, were detected to develop the model and were then compared in pairs in terms of a specified factor to show the priorities.

Results

Equity had the highest priority (0.459) following by Efficiency (0.37), and Effectiveness (0.171). The 4 most important allocation indicator were “number of prescriptions” (0.26) and “total bed occupancy rate” (0.19) related to equity, “total population” (0.21) in efficiency and “the burden of rare and incurable disease” (0.07) in effectiveness paradigm.

Conclusions

The capability to overcome inefficient resource allocation patterns caused by both oversupply and undersupply derived from historic resource allocation may be highly limited in the absence of the need indicators. The quality of the decision is related to a careful balancing act of the three paradigms which represents roughly the triple aim of public healthcare systems: clinical improvement (effectiveness), population health improvement (equity and access), and reducing cost (economic aspects -efficiency).