The AMP for outpatient care

• Promote and strengthen the use of digital technologies to significantly enhance access to and the quality of PHC. Expansion of teleconsultations would help provide better service to patients living in remote areas, the elderly, and those with mobility challenges, and also help maintain essential services during subsequent waves of the COVID-19 pandemic and any future pandemics. In addition to the already existing basic regulations, the government needs a more comprehensive strategy and a realistic action plan to ensure the needed investment, rules, and skills are addressed. • Consider expanding the use of performance-based payments that are complementary to capitation to encourage PHC providers to actively reach out to people in need of services and improve data collection on PHC performance.

This could be one of the first steps to help strengthen the management of major chronic diseases and to stimulate the provision of certain services such as TB and immunization, which may be underprovided. It would also provide data on key areas of PHC performance.

Long term • Review the contracting criteria applied by the NHSU to promote the newly formalized service delivery vision for PHC to increase and align the capacity to address the existing disease burden and strengthen resilience to new challenges such as epidemics. • Introduce standardized clinical protocols mandated for use within the PMG at the primary care level. This will not only help ensure clinical care quality but will also guide providers on the most cost-effective care that they can provide within their capitation budget. • Develop a process for planned, regular revision of the capitation rate to consider any increases in input costs (for example, inflation, salary increases) and changes in the scope of services in the PHC package, supported by robust costing methodologies. • Develop mechanisms for interterritorial (interhromada) cooperation among groups of neighboring hromadas to support sharing resources among small, rural PHC centers.

THE AMP FOR OUTPATIENT CARE

Scope of the AMP

The AMP was introduced in 2017 to increase the availability and affordability of outpatient medicines through contracted pharmacies for patients with highpriority conditions. Originally, it was administered by SNGs and funded with an earmarked grant from the national government. The NHSU assumed the administration of the AMP in 2019, first as a standalone program and then as one of the components within the PMG. Initially, the AMP covered three selected conditions: cardiovascular diseases (CVDs), bronchial asthma (BA), and Type 2 diabetes (DM-2). The list of medicines covered by the AMP has been gradually expanding; it currently includes 27 international nonproprietary names (INNs) and 297 medicines13 but remains focused on the three initial conditions identified as high priority.

The list of eligible medicines in the AMP is defined based on INNs and then specified by brands through a call to willing brand holders whose medicines are included in the national EML. To identify medicines eligible for reimbursement under the AMP, the government approves a list of INNs, none of which are attached to particular brands. Pharmaceutical trademark owners or their representatives can then apply to have their products included as candidates for reimbursement, provided that their medicines are also included in Ukraine’s EML (approved by the Cabinet of Ministers [CabMin]). If their applications are successful, their medicines are then included on the “register of medicines eligible for reimbursement,” which is revised twice a year. Ad hoc revisions are also allowed in cases when the government changes the internationally referenced price limits applied to the national EML. However, the EML is outdated as it includes medicines that do not correspond to modern clinical guidelines as well as monotherapies rather than combination therapies that are preferred by doctors and patients.

Despite some progress toward introducing health technology assessments (HTAs), no regulation defines clear rules and criteria for including and excluding medicines (INNs) on the EML, which would then inform the list of AMP medicines. In December 2020, the government approved guidelines for performing HTAs14 that were expected to be introduced for medicines immediately and include nonpharmaceutical medical technologies from January 1, 2022. The HTA would be performed by a newly created state enterprise, and until the enterprise is established, this function would be temporarily performed by the existing state enterprise, the “State Expert Center,” which operates under the MoH with the general function of state pharmaceutical control. However, detailed rules for performing an HTA for medicines are still to be developed by the MoH.

In 2021, the NHSU extended AMP coverage to include additional medicines for CVDs as well as medicines for outpatient treatment of neurological disease and mental health conditions (from October) and insulin (from July). The NHSU extended the AMP by including 3 more INNs for heart attack and stroke secondary prevention and 10 INNs for treatment of neurological diseases and mental health conditions—psychiatric conditions, anxiety, and depression. However, unlike the medicines for CVDs, BA, and DM-2, which are provided based on prescription by a PHC provider, medicines to treat neurological diseases and mental health conditions will have to be prescribed by neurologists and psychiatrists.

Beginning October 2021, the inclusion of funding for the provision of insulin to patients with diabetes has a slightly different scheme for prescription and reimbursement. Before 2017, insulin treatment for patients with diabetes was funded by SNGs as part of their broad health care responsibility. In 2017, the government launched a pilot project to test a reimbursement payment mechanism for the purchase of insulin, but it was still administered through the SNGs and funded through a health grant from the MoH, with supplementation from local revenue.

The number of pharmacies contracted by the NHSU for the AMP and the number of patients covered by the AMP continues to grow, although the number of prescriptions filled dropped significantly with the spread of the COVID pandemic. Since the transfer of the AMP program to the NHSU in April 2019, the number of patients using the program has grown from 0.3 million to just over 2.5 million in December 2020, as presented in figure 3.4.