Browsing by Subject "Subsidy"

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    The Affordable Medicines Facility-malaria in Ghana: Factors Accounting for Antimalarial Availability and Pricing Outcomes
    (2014-06) Amuasi, John
    The use of artemisinin-based combination therapies (ACTs), the most effective treatments for uncomplicated malaria, remains far below need. Reasons for low ACT uptake include: unreliable public sector supply; high prices and limited availability in the private sector, which is the most widely used source of treatment in many malaria endemic regions; and patient self-treatment with less expensive monotherapies. The Affordable Medicines Facility - malaria (AMFm), hosted by The Global Fund to Fight AIDS, Tuberculosis and Malaria, is a financing mechanism designed to increase affordability, availability, market share and use of quality assured artemisinin-based combination therapies (QAACTs). AMFm involves manufacturer price negotiations, factory gate price subsidies, and supporting interventions such as Information, Education and Communications (IE&C) campaigns. Between 2010 and 2012, the AMFm was implemented in 8 pilots including Ghana, where its outcomes were independently evaluated. The AMFm Independent Evaluation (IE) was commissioned to gather evidence needed to inform decisions regarding the future of the AMFm. As part of the IE, national level baseline and endline outlet surveys were conducted involving the collection and analysis of primary data to answer three questions related to the availability, affordability and market share of quality-assured ACTs using a cluster sampling approach. With a budget of up 450 million dollars and some uncertainty about its potential for success, AMFm was fraught with controversy, and provoked intense debate within the global health community on whether or not the program should be continued following the presentation of the IE findings to the Global Fund Board. As some kind of "middle ground" stance, at the end of the 2-year pilot period of AMFm, in November 2012 the Global fund Board decided to integrate the AMFm into core Global Fund grant management and financial processes, following a transition period in 2013. In countries like Ghana, where the phase I pilot was shown to be highly successful, stakeholders were disappointed and angry with this decision, believing that the decision would reverse the gains made in availability and affordability of ACTs. The Global fund Board's decision further meant eligible countries would decide whether or not to allocate funding from their core Global Fund grants to subsidies for ACTs, and Ghana has already indicated that it will be moving in this direction. Being a complex intervention, there are many aspects of the AMFm that can be researched. The purpose of this work is to contribute to the emerging body of knowledge on the outcomes of the AMFm in Ghana by exploring "why" and "how" the outcomes documented in the IE report came to be observed. The following specific aims are being pursued: 1. In both the public and private sectors, to assess the differences in characteristics between outlets stocking QAACTs and those not having QAACTs in stock by exploring the relationship between having received training on co-paid QAACTs and stocking of QAACTs. 2. To further examine pricing of QAACT by determining how retailer's knowledge of the recommended retail price for QAACTs and other factors account for outlet's adherence to their recommended retail price in the private-for-profit sector. 3. To identify differences between urban and rural outlets in the impact of training on knowledge of the recommended retail price for co-paid QAACTs in private-for-profit outlets. Findings from this project will shed light on the factors influencing the outcomes of the AMFm in Ghana and inform the implementation of subsequent interventions involving price subsidies on antimalarials and possibly other essential medicines in Ghana.
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    Out-Of-Pocket Costs, Subsidies, And The Delivery Of Breast Cancer Care Among Elderly Women
    (2020-11) Qin, Xuanzi
    Out-of-pocket (OOP) costs can affect patients’ access to care and clinical outcomes. This dissertation takes advantage of the natural experiment provided by the combination of the introduction of generic aromatase inhibitors (AIs) and Medicare Part D low-income subsidy (LIS) policy to understand the role of OOP costs and subsidies in the delivery of breast cancer care. Guidelines suggest postmenopausal women diagnosed with hormone receptor-positive (HR+) breast cancer initiate adjuvant hormonal therapy with either AIs or tamoxifen. Switching to another therapy drug is an important strategy to manage treatment related side effects. Those diagnosed at early stages should also receive surgery and/or radiation before or after the initiation of hormonal therapy. The three AIs, anastrozole, exemestane and letrozole, went off patent sequentially in 2010 and 2011. Generic entry lowered OOP costs for AIs. Medicare Part D beneficiaries receiving LIS (subsidized) have substantial lower OOP costs for prescription drugs than those without LIS (unsubsidized), and thus are unlikely to be affected by changes in OOP costs due to generic entry. Medicare and Medicaid dually eligible beneficiaries (duals) receive LIS and Medicaid support for other medical services. This dissertation uses the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify the main study cohort that consists of women first diagnosed with HR+ breast cancer at age 65 years and older between 2007 and 2013 (N=93,650). I find the introduction of generic AIs was associated with improved pharmaceutical access indicated by increased probability of initiating any hormonal therapy drugs, increased timeliness of initiation and increased probability of receiving AIs over tamoxifen. Despite the minimal reduction in OOP costs for AIs after generic entry among the subsidized group, the subsidized experienced similar changes in outcomes like the unsubsidized group who had large reductions in OOP costs after generic entry. Thus, reduced OOP costs due to generic entry can only partially explain the improved access after generic entry. I also find that generic entry increased therapy adherence and reduced early discontinuation both directly through reduced OOP costs and through intermediary changes in switching behaviors resulted from reduced OOP costs. Generic entry affected therapy adherence and continuation without drug switches directly through reduced OOP costs, and thus increased adherence and continuation without drug switches after generic entry were only observed in the unsubsidized group. Generic entry might affect adherence and continuation with drug switches through both reduced OOP costs and improved management of side effects, and thus increased adherence and continuation with drug switches were observed in both the subsidized and unsubsidized groups. Finally, I find that although duals have their medical service use and prescription drug use subsidized, duals were less likely to be diagnosed at early stages, receive guideline-compliant treatment and initiate hormonal therapy than non-duals. Among duals, those with Medicaid coverage gaps or coverage changes were less likely to be diagnosed at early stages and more likely to discontinue their hormonal therapy than duals without any coverage changes. These results demonstrate that interventions simply reducing OOP costs may be not enough for improving access to care. The inconsistent relationships between costs and health care use and outcomes among the subsidized group highlight the importance to understand non-financial barriers to access, such as health insurance literacy, physician and pharmacist behaviors.