European collaborations on medicine and vaccine procurement

A Framework for Studying EU Health Policy through a Political Determinants of Health Lens: The Case of the European Health Union

CONTEXT

The COVID-19 pandemic has highlighted how the European Union (EU) impacts national health systems and people's health. In November 2020, the European Commission launched the European Health Union (EHU) to better coordinate and maximize EU member states' abilities to deal with cross-border health threats. This article scrutinizes the early institutionalization of the EHU and its implications for EU health policy as a political determinant of health (PDoH).

METHODS

The article explores how EU health policy may be appreciated from a PDoH perspective. It draws from EU documents and existing research to analyze the early-stage institutionalization of the EHU. The study complements this policy output-focused perspective with an outcome-based exploratory assessment of EU health policy as a PDoH focusing on three examples: joint vaccine procurement, health reforms and investments under the Recovery and Resilience Facility, and the development of a European Health Data Space.

FINDINGS

The article shows that the policy change triggered by the EHU and the potential impact on citizens' health are not necessarily congruent. Modest change can have a potentially strong impact on health outcomes and vice versa.

CONCLUSIONS

The article argues that the PDoH perspective provides a useful approach that is complementary to policy output-based perspectives, allowing for a more comprehensive assessment of the EU's role in health.

A Scoping Review of Factors Affecting COVID-19 Vaccination Uptake and Deployment in Global Healthcare Systems

Introduction: COVID-19 vaccines were rapidly developed and deployed on a large scale during a global crisis. A range of deployment strategies were used globally to maximize vaccine uptake. In this scoping review, we identify and analyze the main healthcare system and policy factors that guided and influenced COVID-19 vaccination deployment and uptake globally. Materials and Methods: JBI guidelines, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), and the population, concept, and context (PCC) framework were applied. Studies on individual COVID-19 vaccination factors, such as vaccine hesitancy, were excluded. The search was last conducted in May 2024 yielding 26,686 articles from PubMed, Embase, CINAHL, Scopus, and COVID-19 websites. A total of 47 articles and 3 guidance documents were included. The results of the thematic analysis were mapped to the Consolidated Framework for Implementation Research (CFIR). Results: The results found the following healthcare system and policy factors as integral to COVID-19 vaccination: types of vaccine products, healthcare workforce capacity, procurement strategies, distribution and cold-chain capacity, partnership, coordination, and leadership, information, communication, and registration strategies, delivery models, organizations, the existing health systems and policies on prioritization of at-risk groups and deployment plans. Discussion: Globally, COVID-19 vaccination programs responded to the pandemic by leveraging and reforming the existing healthcare systems, relying on strong leadership and global cooperation (such as the COVID-19 Vaccines Global Access Initiative). Deployment was enabled by effective communication and adoption of innovative technologies using data-driven policies to create high vaccine demand while overcoming limited vaccine supply and rapidly adapting to uncertainties.

Opportunities and Challenges in Cross-Country Collaboration: Insights from the Beneluxa Initiative

National pricing and reimbursement agencies face growing challenges with complex health technologies, prompting European policy advancements. Beneluxa is a cross-country collaboration involving Belgium, the Netherlands, Luxemburg, Austria, and Ireland that aims to address sustainable access to medicines. In view of the soon-to-be-implemented EU HTA Regulation, insights and experiences from stakeholders with Beneluxa cross-country collaboration could provide possible transferable learnings. Therefore, this research aims to (i) identify the opportunities and challenges faced by Beneluxa, (ii) gather insights from stakeholders, namely (possible) applicants and policymakers, within and beyond Beneluxa on the initiative and broader cross-country collaboration principles, and (iii) transfer these insights into learnings and recommendations in anticipation of the full implementation of the new HTA Regulation. Fifteen semi-structured interviews were conducted with industry and European HTA/policy stakeholders. The principal challenges discussed by stakeholders encompass hesitancy from the industry toward Beneluxa assessments, which were attributed to procedural and timeline uncertainties, legislative framework ambiguity, and challenges in terms of industry's internal organization. Another challenge highlighted is the resource-intensive nature of the procedure due to diverse approaches among member states. In addition, industry stakeholders mentioned limited communication and procedural complexity. Despite challenges, both stakeholder groups recognized important opportunities for cross-country collaboration. Transferable insights for future cross-country collaboration include transparent communication, clear legislative embedding, internal industry restructuring to facilitate joint HTAs, and member state support for conducting collaborative assessments. The study underscores diverging views among stakeholders on cross-country collaboration's potential to support HTA and the market access of complex health technologies. While acknowledging benefits, there still are challenges, including industry hesitancy, emphasizing the need for transparent communication and clear guidance in the evolving EU HTA landscape.

Innovations in pharmaceutical policies and learnings for sustainable access to affordable medicines

Sustainable access to affordable medicines remains a public health issue globally, including for high-income countries. To foster the debate on avenues for the future, the fifth PPRI Conference held in Vienna on 25 and 26 April 2024 will offer a forum for the debate on innovating pharmaceutical policymaking to develop and implement futureproof policy options, which are able to address current and future challenges. The Conference invites a broad audience of stakeholders, including researchers, policymakers, payers, patients, industry and health professionals. The conference topics are organised in three strands: Strand 1 on 'Local challenges, global learnings' aims to contribute to lively discussions on the implementation of pharmaceutical policies across the globe. Best-practice examples will be presented, supplemented by case studies of less effective policies which can offer rich learnings. Strand 2 on 'Strengthening the evidence base' is the place for presentations and discussions on topics such as health technology assessments, managed entry agreements and real-world data. Strand 3 'Futureproofing pharmaceutical policies' is particularly dedicated to explore innovation in policymaking to achieve sustainable access to affordable medicines.

Hybrid model: a promising type of public procurement in the healthcare sector of the European Union

The management of health supplies in public hospitals has been a major concern of national and European institutions over time, often being a field of reforms and regulatory interventions. Health procurement systems constitute complex decision-making and supply chain management mechanisms of public hospitals, involving suppliers, health providers, administrators and political bodies. Due to this complexity, the first important decision to be taken when designing a procurement system, concerns the degree of centralization, namely to what extent the decision-making power on the healthcare procurement (what, how and when) will be transferred either to a central public authority established for this purpose, or to the competent local authorities. In this perspective, we attempt to analyse the types of public procurement in the healthcare sector of the European Union, in terms of degree of centralization. Employing a narrative approach that summarizes recent interdisciplinary literature, this perspective finds that the healthcare procurement systems of the EU Member States, based on the degree of centralization, are categorized into three types of organizational structures: Centralized, Decentralized and Hybrid procurement. Each structure offers advantages and disadvantages for health systems. According to this perspective, a combination of centralized and decentralized purchases of medical supplies represents a promising hybrid model of healthcare procurement organization by bringing the benefits of two methods together.

Does structural form matter? A comparative analysis of pooled procurement mechanisms for health commodities

INTRODUCTION

Pooled procurement can be seen as a collaboration initiative of buyers. Such mechanisms have received increased attention during the Covid-19 pandemic to improve access to affordable and quality-assured health commodities. The structural form of pooled procurement mechanisms ranges from a third-party organization that procures on behalf of its buyers to a buyer's owned mechanism in which buyers operate more collaboratively. However, little is known about how these types of pooled procurement mechanisms differ in terms of characteristics, implementation and developmental process. To fill this gap, we compared four pooled procurement mechanisms. Two buyer's owned mechanisms: the Organisation of the Eastern Caribbean States (OECS) and the Pacific Island Countries (PIC). And two third-party mechanisms: the Global Drug Facility (GDF) and the Asthma Drug Facility (ADF).

METHODS

For this qualitative study, we used a multiple case-study design. The cases were purposefully selected, based on a most-similar case study design. We used the Pooled Procurement Guidance to collect data on individual cases and compared our findings between the case studies. For our analysis, we drew upon peer-reviewed academic articles, grey literature documents and 9 semi-structured interviews with procurement experts.

RESULTS

Buyers within a buyer's owned mechanisms differ in procurement systems, financing structures, product needs and regulatory and legal frameworks. Therefore, buyers within such mechanisms require relative alignment on motivations, goals and operations of the mechanism. Our study showed that buyers' relative homogeneity of characteristics and their perceived urgency of the problems was particularly relevant for achieving that alignment. Third-party organization mechanisms require less alignment and consensus-building between buyers. To participate, buyers need to align with the operations of the third-party organization, instead of other buyers. Elements that were essential for the successful implementation and operation of such mechanisms included the procurement secretariat's ability to create local and global awareness around the problem, to induce political will to act upon the problem, to mobilize sufficient funding and to attract qualified staff.

CONCLUSION

To successfully sustain pooled procurement mechanisms over time, key actors should drive the mechanism through continuous and reflexive work on stakeholder engagement, mobilization of funding and alignment of interests and needs.

A National Cancer Grid pooled procurement initiative, India

In health systems with little public funding and decentralized procurement processes, the pricing and quality of anti-cancer medicines directly affects access to effective anti-cancer therapy. Factors such as differential pricing, volume-dependent negotiation and reliance on low-priced generics without any evaluation of their quality can lead to supply and demand lags, high out-of-pocket expenditures for patients and poor treatment outcomes. While pooled procurement of medicines can help address some of these challenges, monitoring of the procurement process requires considerable administrative investment. Group negotiation to fix prices, issuing of uniform contracts with standardized terms and conditions, and procurement by individual hospitals also reduce costs and improve quality without significant investment. The National Cancer Grid, a network of more than 250 cancer centres in India, piloted pooled procurement to improve negotiability of high-value oncology and supportive care medicines. A total of 40 drugs were included in this pilot. The pooled demand for the drugs from 23 centres was equivalent to 15.6 billion Indian rupees (197 million United States dollars (US$)) based on maximum retail prices. The process included technical and financial evaluation followed by contracts between individual centres and the selected vendors. Savings of 13.2 billion Indian Rupees (US$ 166.7million) were made compared to the maximum retail prices. The savings ranged from 23% to 99% (median: 82%) and were more with generics than innovator and newly patented medicines. This study reveals the advantages of group negotiation in pooled procurement for high-value medicines, an approach that can be applied to other health systems.

Implementing a Managed Entry Agreement Framework in Cyprus

INTRODUCTION

The aim of this study is to explore the current practice in Cyprus regarding the introduction and reimbursement of innovative pharmaceuticals through Managed Entry Agreements (MEA), assess its operational context, and suggest approaches toward spanning the knowledge gap consequential to these efforts, especially the barriers of a small country context.

AREAS COVERED

The recent introduction of a National Health System (NHS), brought about fundamental reforms in Cyprus' Healthcare sector. Among such reforms, of particular interest, has been the introduction of a Managed Entry Agreements (MEA) mechanism. The first preliminary results indicate that despite being a small and unattractive market, Cyprus can apply a substantial MEA program. Concomitantly, it annotates the need to design an operational framework which should include, the definition of important technical parameters, clear demarcation of the scope, cooperation principles ensuring the effective operation of scientific committees, and clear delineation of what 'value' is. Moreover, in the context of the unified healthcare market, budget transfers should be considered, which could alleviate the inordinate budget impact of new products, which nevertheless will cut down on hospital expenditures. Narrative synthesis and health policy analysis-related resources were used.

EXPERT OPINION

The implementation of MEA in Cyprus provides an ideal testing ground for innovative reimbursement approaches. This will streamline the country's efforts toward reimbursement of innovation, while concomitantly add to the collective MEA experience.

Voluntariness or legal obligation? An ethical analysis of two instruments for fairer global access to COVID-19 vaccines

Introduction

There is currently no binding, internationally accepted and successful approach to ensure global equitable access to healthcare during a pandemic. The aim of this ethical analysis is to bring into the discussion a legally regulated vaccine allocation as a possible strategy for equitable global access to vaccines. We focus our analysis on COVAX (COVID-19 Vaccines Global Access) and an existing EU regulation that, after adjustment, could promote global vaccine allocation.

Methods

The main documents discussing the two strategies are examined with a qualitative content analysis. The ethical values reasonableness, openness and transparency, inclusiveness, responsiveness and accountability serve as categories for our ethical analysis.

Results

We observed that the decision-making processes in a legal solution to expand access to vaccines would be more transparent than in COVAX initiative, would be more inclusive, especially of nation states, and the values responsiveness and accountability could be easily incorporated in the development of a new regulation.

Discussion

A legal strategy that offers incentives to the pharmaceutical industry in return for global distribution of vaccines according to the Fair Priority Model is an innovative way to achieve global and equitable access to vaccines. However, in the long term, achieving the Sustainable Development Goals will require from all nations to work in solidarity to find durable solutions for global vaccine research and development. Interim solutions, such as our proposed legal strategy for equitable access to vaccines, and efforts to find long-term solutions must be advanced in parallel.

How to balance valuable innovation with affordable access to medicines in Belgium?

Background: Countries are struggling to provide affordable access to medicines while supporting the market entry of innovative, expensive products. This Perspective aims to discuss challenges and avenues for balancing health care system objectives of access, affordability and innovation related to medicines in Belgium (and in other countries). Methods: This Perspective focuses on the R&D, regulatory approval and market access phases, with particular attention to oncology medicines, precision medicines, orphan medicines, advanced therapies, repurposed medicines, generics and biosimilars. The authors conducted a narrative review of the peer-reviewed literature, of the grey literature (such as policy documents and reports of consultancy agencies), and of their own research. Results: Health care stakeholders need to consider various initiatives for balancing innovation with access to medicines, which relate to clinical and non-clinical outcomes (e.g. supporting the conduct of pragmatic clinical trials, treatment optimisation and patient preference studies, optimising the use of real-world evidence in market access decision making), value assessment (e.g. increasing the transparency of the reimbursement system and criteria, tailoring the design of managed entry agreements to specific types of uncertainty), affordability (e.g. harnessing the role of generics and biosimilars in encouraging price competition, maximising opportunities for personalising and repurposing medicines) and access mechanisms (e.g. promoting collaboration and early dialogue between stakeholders including patients). Conclusion: Although there is no silver bullet that can balance valuable innovation with affordable access to medicines, (Belgian) policy and decision makers should continue to explore initiatives that exploit the potential of both the on-patent and off-patent pharmaceutical markets.

Centralised Pharmaceutical Procurement: Learnings from Six European Countries

Several European countries have introduced centralised procurement for all or some medicines. This article comparatively describes key features of national centralised pharmaceutical procurement (CPP) systems of six European countries (Cyprus, Denmark, Estonia, Italy, Norway and Portugal). Additionally, it aims to identify benefits, challenges and prerequisites for successful CPP, with a view to offering learnings for other countries. Information was collected based on literature and interviews with national procurement experts. While all countries studied established a designated procurement entity, other institutional and organisational features of the CPP systems vary across the countries. All CPP systems apply a mix of procurement procedures depending on the type of medicine (mainly tendering and negotiations). Reported benefits of CPP include lower purchase prices, stronger bargaining power of the public purchasers, enhanced transparency and governance, improved equity, and eventually improved access to medicines. Challenges that are to be met particularly in the starting phase are opposition of some users and the management of stakeholders with different expectations. Issues such as limited competition and non-availability of medicines may continue in the CPP setting. Compliance with good procurement principles is indispensable for any procurement, including CPP. Further prerequisites for successful CPP include a consistent, comprehensive and regularly updated procurement strategy, sufficient funding and appropriate staffing of the procurement entity, efficient processes including contract management and logistics, data collection and monitoring as well as interaction with users and suppliers.

Purchasing medicines for the public sector: Evaluation of the performance of centralised procurement in Portugal

OBJECTIVE

The study aimed to evaluate centralised procurement of medicines (CPM) in Portugal.

METHODS

Data were collected through different methods, including a review of the literature and (procurement) documents and an analysis of selected bids. Thirty-seven face-to-face interviews with representatives of public authorities, users (hospitals and regional health administrations), patient associations and pharmaceutical industry were held in Portugal in Q1/2020.

RESULTS

CPM has contributed to improved transparency in processes and governance, to increased equity in access to medicines across the country and to lower workload for some users. The findings of the impact on medicine prices and availability are mixed. The benefits of CPM are undermined by some gaps: Lengthy, bureaucratic processes have resulted in delayed availability of medicines at the beginning of a year and in coping strategies of hospitals such as parallel individual procurements. The list of active ingredients under CPM has not been updated since 2016. The procurement agency does not routinely perform market consultations. Key performance indicators for CPM are lacking.

CONCLUSIONS

Portuguese policy-makers are urged to develop an updated procurement strategy to provide guidance and clarity on the objectives of CPM, the role of the procurement agency and further authorities and key performance indicators.