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Feature Essay

How moves towards universal health coverage could encourage poor quality drugs: an essay by Elizabeth Pisani

BMJ 2019; 366 doi: (Published 04 September 2019) Cite this as: BMJ 2019;366:l5327

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  1. Elizabeth Pisani, associate professor, epidemiology
  1. Erasmus School of Health Policy and Management, Rotterdam, The Netherlands, and King’s College London, UK
  1. pisani{at}

Universal health coverage depends on affordable medicines. But pushing down prices without also investing in quality assurance will increase the sale of substandard and falsified drugs, warns Elizabeth Pisani

Many governments in middle income countries are working hard to deliver on political promises that all their citizens will have access to quality health services, without being impoverished. They are finding that universal health coverage (UHC) doesn’t come cheap.

Indonesia’s national health insurance scheme, for example, has given out 223.4 million health cards since its inception in 2014. Nationwide, 73% of households said at least one household member had some health insurance in 2018, up from 52% in 2013.12 Yet the scheme has been in permanent deficit; by 2018 it had a shortfall of 23 trillion rupiah (£1.3bn; €1.5bn; $1.6bn.3

Such deficits lead to belt tightening. Globally, about a quarter of all health spending is on drugs. In poorer countries the proportion is higher, and patients typically foot more of the bill.4 As governments move towards UHC, they increasingly pay for drugs that used to be paid for by patients—and look for ways to push prices down.

Cheaper drugs should mean more people effectively treated for the same budget, taking countries towards UHC. There’s plenty of room for belt tightening. Generic and branded drug makers often charge whatever they can.5 Inefficient procurement and plain old corruption push prices up; some poorer countries pay 30 times more than the international reference price for basic generic drugs.6

But countries with under-resourced health budgets seeking to push down prices should be careful what they wish for. Recent research in China, Indonesia, Romania, and Turkey found evidence that drug manufacturers and distributors react quickly to keep profits as high as possible,7 potentially leaving patients exposed to substandard drugs, …

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