Abstract

Universal health coverage is increasingly being embraced by low- and high-income countries alike, and pharmaceuticals are an integral part of it. With Nepal adopting national health insurance policy and willing to implement the same, guidance regarding pharmaceutical pricing, coverage and reimbursement becomes the order of the day. This study reviews pricing and reimbursement policies and techniques in low- and lower-middle-income countries which are implementing or intend to implement universal health coverage schemes, and provides recommendations on policies and techniques applicable and most pertinent to Nepal. For this, relevant literature on 11 countries was searched. The countries studied here are at different stages of universal health coverage, and they are aligning their pharmaceutical pricing and reimbursement policies and techniques with their universal health coverage policy. Considerable variation exists among these countries in regard to pricing, ranging from ceiling pricing (based on cost-plus, external referencing or market-based technique) to free pricing. All these countries have framed their essential medicines list; few or all of the medicines in the list are provided free of charge to targeted groups. Different universal health coverage schemes are at work in these countries, financing strategy for which span tax-based, premium-based and payroll deductions. Reimbursement decisions are intricately linked with pricing, with majority of the countries putting into effect a fixed reimbursable amount strategy for reimbursed products. In regard to Nepal, as it is beginning its universal health coverage journey, the ideal approach would be a ceiling price for essential medicines (applicable to both in-insurance and out-insurance) and reference or index pricing for reimbursed products.