the appropriate set of goods and gets them to the appropriate end users, to reach the goals being sought. In the pharmaceutical sector, “technical efficiency” means, for example, buying drugs at the lowest possible prices for the public sector and keeping the operating costs of public supply chains as low as is consistent with meeting delivery objectives. “Allocative efficiency” refers to what is provided and to whom. In the pharmaceutical context it means, for example, getting the right products onto the nation’s essential medicines list and getting them dispensed to the right patients. It also means encouraging appropriate purchases in the private sector. Clearly judging allocative efficiency depends on how the system’s goals are defined. Knowing who are the desired consumers of which drugs depends on a nation’s goals and priorities. Quality. Again, the concept of quality contains a simple core idea, despite widely varying uses in the literature. “High quality” means that a good or service performs in the way that someone desires. So quality, too, is purpose dependent and observer dependent. Different users and producers of a good or service might well have different goals. In part the reason is that quality is multidimensional. Thus one formulation of a drug may be faster acting, whereas another has a longer shelf life. Which is higher quality? The answer depends on a particular observer’s priorities. Following the Flagship Framework, we divide the multiple pharmaceutical sector quality dimensions into two broad groups; we have relabeled them slightly to fit the pharmaceutical context: • Clinical Quality. In the pharmaceutical context, clinical quality involves the pharmacological activity of the medicines people use and the clinical appropriateness of the treatment regimes they pursue. Thus this category includes the exact levels of active ingredients in medicines and their purity. Substandard and counterfeit medicines are obviously aspects of poor clinical quality. Patients’ use of the wrong medicines is also an aspect of clinical quality. Hence misprescribing and antibiotic overuse are aspects of poor clinical quality. But so, too, is the use of needlessly expensive compounds when simpler alternatives will do. When patients purchase an expensive and powerful, branded pain reliever such as Percocet, when all they really need is ordinary ibuprofen, that is a manifestation of poor clinical quality. The appropriateness of the advice patients receive from dispensers (relative to rational drug use standards) is also an aspect of clinical quality. • Nonclinical Quality. “Nonclinical quality” refers to quality dimensions that do not directly affect clinical outcomes (but that may do so indirectly
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Pharmaceutical Reform