tend to focus on four major problems: (1) high out-of-pocket spending caused by high prices and the purchase of inappropriately expensive products in the private sector; (2) poor private sector quality; (3) poor public sector availability; and (4) underuse, overuse, and misuse. As figure 4.1 suggests, all of these problems affect health status, given the potential health benefits of appropriate drug use. Two of the four—high spending due to high private sector prices and poor public sector availability—also affect both satisfaction and financial protection and do so with strong interaction effects. When drugs are not available in the public sector, citizens turn to the private sector, leading to both dissatisfaction and a lack of financial protection. Poor quality of medicines affects both health and satisfaction, although it only decreases satisfaction to the extent that consumers are aware of those failings. Finally, overuse and underuse are mainly problems from a health status perspective. Indeed, such problems may even reflect (or, in a sense, cause) an increase in satisfaction because of actual consumer preferences. It is also important to address the distribution of these outcomes. In particular, the lack of financial protection caused by high private sector prices disproportionately affects low-income families. Similarly, the lack of availability of medicines in the public sector is likely to be of most concern for those families, since higher-income citizens can afford to purchase private sector medicines. Availability problems are likely to have a geographic as well as an economic dimension. For example, such probFigure 4.1 The Relationship of Pharmaceutical Sector Problems to Ultimate Performance Goals High private sector prices
Health status Poor private sector quality
Citizen satisfaction
Poor public sector availability Financial protection Overuse and underuse Source: Authors’ representation.
Ethics and Priority Setting in Pharmaceutical Reform
57