need attention? Is it the prevalence of conditions that create an especially high burden of disease in a particular country (for example, malaria in parts of East Africa)? Is it poor performance versus comparable countries on a basic health status index, such as under-five mortality rate? The discussion below of the ethics and politics of priority setting will have more to say about these questions. Some studies of pharmaceutical policy use formal analytical methods to try to measure the potential health status impact of alternative interventions (for example, by calculating their comparative cost-effectiveness in terms of gains in Quality Adjusted Life Years), and a growing number of countries consider these studies as part of their licensing requirements for new medicines (Taylor et al. 2004). As discussed further below, these methods make a series of assumptions about how to value various kinds of outcomes (for example, the value of saving the young versus the old, or the productive versus the disabled) (Musgrove 2000). Thus using such tools does not, in itself, solve the priority-setting problem in an accountable way. Instead, reformers have to be aware of, publicly acknowledge, and accept as valid for their situation, the assumptions that particular methods employ. Citizen Satisfaction In considering pharmaceutical policy, public health professionals tend to focus on objective measurements such as health status. In contrast, both politicians and economists pay great attention to how citizens feel about their situation, that is, to their levels of satisfaction. Economists do so because, within their analytical framework, a good system of pharmaceutical supply is one that responds to market demands—to what people want (rather than to what people may need to improve their health status). Politicians may or may not share economists’ goals, but they do have to be concerned about satisfaction (and respond to dissatisfaction) to recruit support for themselves and their policies. That is so regardless of the political system in which they operate. Even in countries without meaningful elections, most national leaders are at least somewhat concerned about responding to popular demands. As with health status, the distribution of satisfaction (or dissatisfaction) may influence the importance that reformers attach to it. For example, how politically powerful are the dissatisfied, and are they allies or opponents of the governing coalition?
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Pharmaceutical Reform