• Focus on implementation. It is no use having a great plan if the plan cannot be implemented effectively. Again, the time to start worrying about implementation, like the time to start worrying about politics, is in the design phase. That is one reason why worrying about the details is so important. But plan design is not the only set of variables affecting implementation. Political leadership, competent agency management, and sufficient resources are also key. And notice that management and resources are likely to depend in part on leadership. We cannot stress too strongly that agencies carrying out both service delivery and regulatory functions need to be designed, organized, and managed with attention to the six keys to organizational effectiveness. Technological solutions and sophisticated processes are not self-implementing. Any reform ultimately depends on the behavior of frontline workers. And their behavior, and hence successful implementation, depends critically on the quality of the managers who are entrusted with making the reform a reality. • Learn from your mistakes. The complexity of the pharmaceutical system that we sketched at the beginning of this chapter suggests that reforms will rarely turn out exactly as their designers anticipated. Many of the actors in the sector will defend their own interests, acting and reacting in unanticipated ways. That has two implications. First, it is necessary to put in place a serious and honest evaluation mechanism. Too often evaluations are designed to justify government action or to shield it from scrutiny. But true transparency requires just the opposite. Moreover, how can one learn from mistakes if no process is in place for learning what they are? Second, reformers should be prepared to fail, at least partially. That is, they should expect to find that performance on some goals is not up to expectations and that further reforms and adjustments are required. That is the somewhat world-weary implication of the fact that health sector reform is a cycle; and indeed, as we all know, today’s solutions are the source of tomorrow’s problems.
Final Thoughts Finally, why is the work of pharmaceutical reform potentially so challenging, so rewarding, and so important? We argued at the beginning of this book that pharmaceuticals can make a genuinely important contribution to the well-being of citizens. So those who work to improve the functioning of the sector are doing genuinely important work. Second, providing effective access to medicines to those who are most vulnerable is, in terms of our own ethics, an especially urgent and praiseworthy task. The distribution of well198
Pharmaceutical Reform