Journal of Health Politics, Policy and Law Advance Publication, published on March 6, 2014

Report from Europe

Pharmaceutical Policy Reform in the Russian Federation Caroline Rudisill London School of Economics and Political Science Sotiris Vandoros King’s College London Joseph George Antoun University of Chicago

Abstract Of Russia’s 142 million citizens, fewer than 20 million are enrolled in outpatient drug coverage plans. The current government aims to establish universal health insurance including outpatient medicines. Based on the current political and regulatory environment, this report explores pharmaceutical pricing options for Russia that balance greater access to medicines with achieving government plans of boosting local pharmaceutical production. To match innovative medicine prices with their health benefits, in the long run, we suggest that Russia consider adopting value-based pricing, and in the short term, that it introduce direct price negotiations and prices drugs according to reference countries that use health technology assessment. Although generic market shares are high, generic medicine prices are higher than they should be. We propose tenders at the manufacturer level for the pricing of high-selling generics, and free pricing for products with sufficient market competition. These policy recommendations are a jumping-off point for further discussion about how pharmaceutical policy could aid this major economy to achieve its population health and health service goals.

Over the past fifteen years, Russia has made some marked improvements in expanding prescription medicine access. Nonetheless, many challenges remain (Perlman and Balabanova 2011). The first is that public expenditure on health as a percentage of total health expenditure has increased dramatically in Russia from 30 percent in 2003 to 83.4 percent in 2007 (Pharmexpert 2010), yet outpatient medicines coverage remains limited We are grateful to the editor of the journal, the editor of this section of the journal, and two anonymous reviewers for their comments on this article. We acknowledge financial support from Eli Lilly for the research that has led to this publication, but all ideas are the authors’ own. All outstanding errors are also our own. Journal of Health Politics, Policy and Law, Vol. 39, No. 3, June 2014 DOI 10.1215/03616878-2682659  2014 by Duke University Press

Copyright 2014 by Duke University Press

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(15 percent of the population covered). Second, questions remain as to whether these public expenditures are being spent effectively. Is Russia receiving good value for its money? Third, there is concern that Russia’s pharmaceutical industry should be reformed to increase efficiency and quality. To address some of these issues, the current government plans to establish universal health insurance, including outpatient pharmaceutical coverage. As a corollary to this broad goal, it also intends to focus on building a local pharmaceutical industry to meet world-class quality standards. This article focuses on how Russia should approach the key question of pricing pharmaceuticals to improve efficiency and quality. While pharmaceutical policy steps well beyond pricing into topics such as reimbursement criterion, supply chain characteristics, financing mechanisms, and prescribing policies, we limit our analysis and policy recommendations in this article to pricing in- and off-patent medicines. Our recommendations come from examining international evidence such as policy reports and peer-reviewed articles as well as the policy and political environment in Russia through international and local media coverage, local meetings, and from our experience with pharmaceutical economics and policy in other markets. We attempted to incorporate Russia’s unique health care system and its political context when considering solutions. The idea is to design policy for maximum effect within the country’s environmental context. As such, we start by describing the current pharmaceutical policy environment in Russia, including health services related to pharmaceutical coverage and the political setting. Given this policy environment and using international evidence, we then discuss policy options for in- and off-patent markets. These policy recommendations should be viewed as a starting point for further engagement. Others will surely (and should) recommend alternative policy ideas. Given the amount of financial investment and the lives at stake, multiple ideas should be on the table for serious debate and discussion. Background on the Politics of a Russian National Drug Policy

Although the 1994 Russian constitution mandates free and universal health care, many Russians find this promise to be rather hollow given the high out-of-pocket expenditure burdens assumed by many Russians. All Russians are assured a certain level of health care coverage through the Guaranteed Package program, which is extensive given the relatively low

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amount spent on health care (only 5.3 percent of GDP) (Espicom 2010). In addition, the Obligatory Medical Insurance Model promises free and pseudo-universal access to medications prescribed in the inpatient setting. In reality, however, about 80 percent of patients pay some portion of inpatient drug costs (Tompson 2007). Moreover, a lack of coverage for outpatient medicines leaves a gaping hole in Russian pharmaceutical coverage (Tragakes and Lessoff 2003). Given the burden of prescription drug costs, in 2005 President Vladimir Putin launched a pharmaceutical reimbursement program providing outpatient coverage for Russian citizens considered vulnerable (and therefore deserving of state help) in some way. What was then called the Drug Reimbursement Program and is now known as the Essential Drugs Program (ONLS) covers mostly seniors, the disabled, children, pregnant women, the poor, and veterans. Put in US terms, the ONLS program is like a Medicare Part D benefit package for Medicare, Medicaid, and Veterans Affairs patients but without the drug plan options. Unfortunately, take-up in the ONLS program is quite low. Among the 15 million people eligible for subsidized drug coverage, only 4.6 million (31 percent) of the Russian population were enrolled in 2011 (Cegedim 2012; Pharmexpert 2012). The ‘‘opt-out’’ clause in the ONLS program allows individuals to take cash payment in place of plan participation. As a result, the healthiest tend to leave the plan in favor of cash support, creating an adverse selection problem where only the very poor and sickest remain in the ONLS (Antoun, Philips, and Johnson 2011). Moreover, individuals receiving social benefits (other ‘‘welfare payments’’) on the ONLS are exempt from co-payment requirements, raising concerns about moral hazard. Thus, despite low take-up, adverse risk selection and high utilization rates among ONLS participants have resulted in very high expenditure. Although there are huge regional differences in take-up—16 percent of those eligible opted out in the Moscow region, whereas up to 58 percent opted out in the Voronezh region (Zasimova 2010)—this small group of ONLS participants overall consumes about US$1.4 billion in prescription drugs annually (Pharmexpert 2012). In addition to ONLS, another pharmaceutical insurance plan, called the ‘‘Seven Nosologies,’’ was also enacted to cover medicines for named rare and chronic diseases. Obviously, this program by design is quite expensive because it provides coverage for very sick individuals. In 2011 this program cost US$1.3 billion to cover only seventy-seven thousand citizens (Pharmexpert 2012). At the regional level, similar outpatient drug coverage programs were also enacted to cover medications for specific diseases (e.g.,

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Figure 1 Reimbursement System in Russia Source: Cegedim Strategic Data, Pharmexpert database data as of January 2, 2012

insulin for diabetic patients). There is also a three-year-old ‘‘Modernization’’ program with a budget of US$1.2 billion, which is largely aimed at improving access to prescription drugs in the hospital and clinic care delivery systems by adding a funding stream (Cegedim 2012; Pharmexpert 2012). Finally, while there are some private insurance plans in Russia, they cover only 4 percent of the population (Kolosnitsyna, Rakuta, and Stepanov 2007) and do not provide coverage for outpatient drugs. In sum, between the ONLS, the high-risk coverage plans, and the meager funding amounts under the Modernization plan and private coverage, the bulk of the population has no insurance coverage for outpatient prescription drugs and pays for such expenses out-of-pocket (see fig. 1). Despite these deficits in coverage, Russia has not yet developed (or published) a well-defined national drug policy. The closest it has is the Russian Pharma2020 Plan set forward by the Ministry of Industry and Trade in 2009, aimed at improving the local production of both generic and innovative (branded) medicines. This is crucially important, because as much as Russia is concerned about reaching universal drug coverage, it is also interested in making major state investments to develop its pharmaceutical industry. In fact, policy progress thus far suggests that development of the domestic industry be the first agenda item, with greater coverage the second. Plans for the industry are illustrated in the three milestones specified in the Pharma2020 Plan: (1) localization of production and

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development of drugs between 2009 and 2012; (2) achieving 50 percent import substitution of generic drugs between 2013 and 2017; and (3) reaching 50 percent import substitution of innovative drugs by 2020. If Pharma2020 is fully implemented as specified, it would increase domestic production of brand-name drugs and generics substantially—from 20 percent in 2007 to 50 percent of market share in 2020 (Malysheva 2011). Indeed, the government is investing significantly to build up the sector through research, training, infrastructure development, good manufacturing practice (GMP), and internationally recognized quality assurance mechanisms for medicine production and control (Moscow Times 2010). Thus the key to thinking about pricing policy in Russia—rightly or wrongly— is that the government does not simply want to pay a good price but wants to encourage economic development in this sector. As a result, when considering recommendations for pricing reform policies we took industrial policy implications into account. If we start with that premise, it moves us further from traditional economic canons of wanting government to select the best price among ‘‘private bidders’’ through a competitive bidding process. Instead, domestic producers would likely be privileged, even if their pricing was higher. However, the government might demand lower prices from domestic producers as a condition of its initial investment. These were the types of balancing considerations that we took into account to assess medicine pricing policies. In particular, we considered the need to secure efficient pricing (i.e., getting the best price for the value), boosting domestic production, and expanding to universal drug coverage. Given Russia’s political preference for universal coverage through a government insurance plan and plans to build up the local industry, these recommendations address both goals. We start by examining pricing and procurement of patented medicines and then discuss both issues for generic medicines. Afterwards, we offer an update of the current policy situation in Russia and conclude with proposals for the way forward. A Roadmap for Russia National Drug Policy Pricing Reform Pricing and Procurement of Patented Medicines

Pricing of patented medicines. Retail prices for patented drugs covered by public programs are informally set using the lowest price for that drug in twenty-one reference countries (external price referencing). Prices for

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patented drugs not covered by public programs are set by manufacturers without price regulation. Since population-wide outpatient medicine coverage is the government’s reform goal, we discuss policies for the public pricing and purchasing model as a starting place for coverage expansion. Choosing a drug’s price based on other countries’ prices contains costs through low prices, but has five drawbacks. The first two are that prices are unrelated to product value and that it undermines efforts to encourage domestic research and development of new drugs (R&D). External price referencing may work for policy makers in small countries prioritizing short-run price reductions. Russia is not, however, in that situation, as it wishes to encourage domestic R&D as well as manufacturing, and previous research has demonstrated a link between R&D investment and price regulation (Koenig and MacGarvie 2011). Internationally, most countries with viable domestic industries do not undertake external reference pricing but instead use a host of other regulations. There are three more minor concerns associated with international reference pricing. First, cross-country spillover effects are a concern, as many countries reference each other for the same products. For example, price cuts in Greece because of the larger financial situation affect other countries’ prices solely through price comparisons. While there are twenty-one reference countries in Russia’s basket, other countries also use international reference pricing such that changes in one country can have magnified impacts. Second, this pricing policy also does not allow flexibility in cases of national health priorities where price reductions are urgently needed or where variation in geographic location lends itself to differential supply chain costs across the country. And finally, it does not reflect differences in socioeconomic circumstances and health care systems of the countries within the basket. Middle-income and high-income countries have differential abilities to pay for medicines, and health care systems may offer entire population coverage or medicines coverage only for subpopulations, which may be reflected in medicines pricing. To deal with this problem, countries can abolish external reference pricing to limit the unpredictability of referencing to countries with different priorities or exceptional circumstances. Or countries can use external reference pricing but limit the choice of reference countries to those performing health technology assessment (HTA) or value-based pricing (VBP). This would allow Russia to benefit from the economic evaluation performed in other countries while building domestic HTA capacity to undertake Russiaspecific evaluation in the future.

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VBP explicitly uses HTA to determine prices rather than simply to make coverage decisions. This is, in theory, a rational way to price pharmaceuticals, as products will be priced according to their health outcome value, rather than arbitrarily copying other countries’ prices. To undertake this kind of pricing evaluation, considerable domestic capacity would be required to establish and run an HTA body, which means VBP cannot be implemented in Russia’s near future. Instead, VBP poses a much longerterm policy option as the evidence base builds in Canada, Germany, and Australia and as Russia develops domestic capabilities. While Russia could adopt methods used elsewhere, this still requires local knowledge for implementation. Of course, VBP has the same methodological downsides of using HTA for reimbursement decisions such as how to appropriately assess value and what to do about medicines with limited available data, but with time there is at least some agreement about how to handle many of these methodological challenges. However, once Russia develops the mechanisms that can support VBP, this would be an appropriate policy to replace external price referencing. Another policy option considered in some countries for the pricing of patented medicines is therapeutic reference pricing (also known as internal reference pricing at the therapeutic level). Reference pricing groups medicines according to molecule type and allows for reimbursement at either the lowest price in the group or at the average of the lowest prices in the group. Although this is typically done at the molecule level or for medicines of the same chemical substance, internal reference pricing for off-patent products has been expanded to include patented originator drugs in the Netherlands and Germany. This is a strong policy intervention that targets the so-called me-too products that do not always offer substantial added therapeutic value in comparison with other products in the same class. While HTA rewards any additional therapeutic value, therapeutic reference pricing assumes that different molecules have the same therapeutic effects, as the reimbursement price is the same across the entire therapeutic class. Empirical evidence has shown that postpatent expiry, there is a shift in consumption from the molecule that lost its patent toward other, onpatent, molecules of the same therapeutic class (Vandoros 2013). Such a switch can lead to higher costs, as on-patent molecules do not have generic alternatives, and health insurance would be burdened with the higher price of an on-patent product. Therapeutic reference pricing can discourage such a switch by setting a reimbursement price at the level of generic alternatives. Because one of the major challenges facing medicine innovation is misaligned incentives (Light and Lexchin 2012), such a policy would

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encourage the industry to focus on breakthrough products providing added value and would actively discourage incremental innovation. Even with such a scenario, physicians should have the flexibility to prescribe, and health insurance should be accommodating for patients who cannot tolerate specific molecules. Using procurement as a pricing tool for patented branded medicines. In Russia by law, ONLS-covered medicines (branded and generics) are procured through competitive tenders involving wholesalers. The bid process is based solely on price, where wholesalers place their bids to supply a basket of products. Participants are not required to prove their supply ability, and there is little quality assurance built into the process. As a result, despite a competitive bid process, there is no guaranteed connection between quality and price and therefore no promise of higher quality for a lower price. Tendering (or bidding) in Russia serves different purposes than tendering in European Union (EU) outpatient markets. In Russia, wholesalers apply to win tenders to supply the market. In some EU countries (Germany and the Netherlands), manufacturers, not wholesalers, apply to win tenders. Tendering with manufacturers has a few advantages over tendering with wholesalers. First, faced with the possibility of not supplying the market for a molecule, manufacturers may offer the lowest possible price in an effort to win the tender. Second, wholesalers have less bargaining power with manufacturers when they are obliged to supply a market for which they have won a tender. Overall, price cuts are expected to be greater when manufacturers, rather than wholesalers, participate in the tendering process, as they are more directly incentivized to reduce prices. Bulk purchasing based on annual expected demand across disease areas as evidenced by the Pan American Health Organization’s (PAHO) vaccine fund is one possible model for ways to allow open competition for market supply while meeting quality objectives (PAHO 2012). Pricing and procurement in off-patent medicines

While generic medicine pricing and procurement could have some of the same policy solutions as for branded medicines, Russia’s local policy goals must be taken into consideration for reform to be enacted. Pricing in off-patent markets. Generic market penetration is much higher in Russia than in the EU or other Organisation for Economic Co-operation and Development (OECD) countries (fig. 2) despite the absence of

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Figure 2 Generic Drugs Market Share, 2006 Source: Switzerland, Italy, Spain, France, Sweden, Netherlands, Germany, UK, Turkey, Denmark: European Generic Medicines Association. Canada: Canadian Generic Pharmaceutical Association. Russian Federation: Remedium Data. United States: Generic Pharmaceutical Association. Data for the United States are from 2009.

mandatory generic substitution. High generic uptake is more due to historic reasons than the policy environment (Espicom 2010). On the whole, physicians and patients still tend to prefer branded originators because of quality and reliability concerns with some generics (Tompson 2007). Generic prices appear high in Russia despite a large share of the pharmaceutical market being held by generics. The gap between the percentage of total pharmaceutical expenditure spent on generics versus the percentage of the total volume of prescriptions on generics would be large if prices are low (see, e.g., the United States in fig. 2). In the case of Russia, there is a relatively small gap between the volume and value of the generics market, which signals a pricing problem. Paying a high premium to generic manufacturers, who are not involved in developing new molecules themselves (R&D), is inefficient. Once again, balancing Russia’s extension of medicine coverage goals alongside its efforts to grow the domestic industry, a number of policy options could apply. There are a number of pricing options for off-patent medicines: free pricing, internal reference pricing, and price cuts. Free pricing provides a good policy option if the real aim is to achieve low prices so that medicine expenditure is associated with value. The United States and the United Kingdom, where generics are freely priced, have lower generic prices than countries with pricing regulation (Kanavos, Costa-Font, and Seeley 2008). To adopt free pricing, however, there must

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be enough providers for each product and presentation to have true competition. Before taking such a step, antitrust authorities should be confident that they would be able to prevent any collusion. Russia, with its very active Federal Anti-Monopoly Service (FAS) might control or prevent such market failure. Internal reference pricing at the molecule level is one of the most common types of generic price regulation (e.g., across Europe, Canada, and Australia). Grouping medicines according to molecule type and reimbursing at a defined reference price initially leads to substantial price cuts (Stargardt 2011). To have their product reimbursed, manufacturers decrease their price to the reference price level. However, this also works as a price floor, as manufacturers have no incentive to further reduce prices below the reimbursed reference price (Kanavos et al. 2008). As discussed earlier, reference pricing at the therapeutic (rather than molecular) level can be a response to ‘‘me-too’’ drugs that do not offer any additional therapeutic value. It has been suggested that most products developed over the past fifty years offer few therapeutic benefits (Light and Lexchin 2012). What matters is to compare drugs that have similar clinical effects, rather than limit comparisons to a single molecule. Therefore, such a policy is a good response to the introduction of new molecules that have similar effects compared with existing products, and may actually provide incentives for manufacturers to invest in R&D on innovative products rather than me-too drugs. Generic price caps or, in practice, setting generic prices as a certain percentage of originator prices is similar to reference pricing and can achieve immediate price cuts postpatent expiry. However, this price ceiling also works as a price floor, deterring further price reductions (Kanavos, Costa-Font, and Seeley 2008). Neither internal reference pricing at the molecule level nor price caps would bring the needed generic price cuts in Russia. However, Russia could make a decision based on industrial policy to adopt these less aggressive polices. They would not decrease generic prices as much as free competition or tendering would, hence encouraging the local generic industry. This would be an industrial policy decision for increasing employment and economic growth rates at the expense of efficiently using health care funds. Using procurement as a pricing tool in off-patent markets. The procurement process for generics purchased by the ONLS suffers from the same issues as the ONLS tendering processes for branded medicines. Tenders take place at the wholesaler level, encouraging competition

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among wholesalers but not directly between manufacturers. In generics markets, tendering at the manufacturer level has been associated with substantial reductions in generics pricing in the EU. Evidence from the Netherlands shows that prices decreased by up to 93 percent for highvolume products after the introduction of tendering (Kanavos, Seeley, and Vandoros 2009). Although tendering at the manufacturer level in Russia would generate savings via price cuts, it may also contradict industrial goals to support Russian generic manufacturing and R&D if used for a large part of the market. Also, a single manufacturer winning a tender and supplying the whole market may drive out competition in the long run, as some manufacturers who fail to win tenders may not be able to keep up with the fierce price competition. So although generic prices may temporarily decrease because of the tender process, in the long run this effect may be crowded out because of smaller manufacturer numbers. A good policy option could be to introduce tenders (at the manufacturer level) only for certain high-selling products. Savings would occur, but generic manufacturers will still be able to supply other products, so we would not expect a substantial decrease in the number of generic providers in the long run. Pharmaceutical Policy Reform in Russia Today

Russia now plans to have full outpatient medicines coverage by 2025 (Strategy 2025). On May 7, 2012, President Putin signed an executive order to improve state policy in health care. The underlying aim of this order was to maintain and strengthen the health of the Russian people and increase their life expectancy. As a consequence, on October 26, 2012, the Russian Ministry of Health initiated an open consultation via its website on Strategy 2025 for drug provision (2012). The Strategy’s main goals are to ensure patient satisfaction with rational, cost-effective, and high-quality pharmaceutical provision. The Strategy aims first to control prices of medicines and then to expand coverage to the entire population. Three particular tasks (out of the ten) from this strategy are relevant to the present article: to provide an efficient price regulation system allowing increased drug availability and medicinal treatment for outpatients (task 2); to ensure rational prescribing and use of medicines based on principles of evidence-based medicine and HTA (task 3); and to explore introducing pricing and risk-sharing negotiations with innovative drug manufacturers (task 7). This strategy clearly states the objective of developing a rational drug coverage model for outpatient care, including partial

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reimbursement of medicine cost, and hence responds to a major reimbursement gap identified in this report’s first section. The Strategy is a critical step toward improving medicine provision, but it needs to be balanced with other ministries’ plans for the sector, namely, Pharma2020 from the Ministry of Industry and Trade. Furthermore, in December 2012, the Ministry of Health revisited Strategy 2025 and issued a new version focused mostly on price controls under a scenario called ‘‘Optimization of current system’’ and kept the door open to a ‘‘Modernization’’ scenario where extra funds could be used to cover the working population. Conclusion

Efforts to amend Russia’s medicine pricing and procurement arrangements as part of larger health system goals require multiple stages. The first set of policy reforms could focus less on outright cost containment and more on improving the way current funding is used. Appropriate pricing mechanisms as suggested here would release funds that can be used to cover a larger part of the population. For branded medicines, Russia could employ external price referencing using countries that undertake HTA. This pricing policy would establish a maximum public price. Second, it could use price negotiations with manufacturers in the short-term for contracted volumes of specified quality. This approach offers a step forward from the present system of external reference pricing based solely on prices set by other countries and tendering at the wholesaler level where value and quality are not part of the decision-making process. For generics, Russia should propose tenders at the manufacturer level for the pricing of high-selling generics and free pricing for molecules with sufficient market competition. These approaches balance the reality of industrial and resource allocation considerations. Individuals should also no longer be allowed to opt out of the ONLS (or any other possible future medicine coverage program) for cash, as it creates an adverse selection problem in the coverage pool. In addition, relatively low patient user charges would help with financing and avoiding moral hazard, subject to exemptions for vulnerable groups. The local generic market can then still develop within the first two milestones of Pharma2020, which focus on local medicine manufacturing growth, especially for generic medicines. Mid- and long-term reforms could focus on generic market cost containment, while savings would be invested in developing local HTA capacity and rewarding the production and procurement of innovative medicines. By then, local generic manufacturers

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of quality products at competitive prices will have survived, and the local R&D sector will flourish under the third milestone of Pharma2020 where Russia plans to produce more innovative drugs domestically. Finally, and most importantly, Russia would have improved access to high-value medicines aided by improved pricing and procurement mechanisms, thus moving toward increasing social welfare.

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Caroline Rudisill is assistant professor in health economics at the London School of Economics and Political Science. She teaches courses on economic evaluation in health care and health economics. Her research interests include evaluating the effectiveness of interventions in health care, including the use of economic evaluation to play a role in coverage decisions, decision making regarding health-related risks, and the economics of health and pharmaceutical care. Her most recent work has been on the use of financial incentives in health care and the economics of a primary care–led strategy to promote physical activity. Her work appears in a variety of health services, risk research, medical, and health economics journals. Sotiris Vandoros is a lecturer in health economics in the Department of Management at King’s College London. Prior to this he was a lecturer in economics at Brunel University and a research fellow at the London School of Economics. Among other courses, he has taught health economics, pharmaceutical economics and policy, business economics, and quantitative methods for BSc and MSc programs. Sotiris’s research interests include health economics, pharmaceutical economics and policy, and experimental economics. He has conducted research for governments and international organizations, including the NHS and the World Health Organization. His most recent publications focus on cross-country pharmaceutical price comparisons, therapeutic competition, parallel trade, and the link between recessions and health. Sotiris holds a PhD in health economics from the London School of Economics. Joseph Antoun is codirector of the Center for Health Policy at the University of Chicago, a professor of health and pharmaceutical policy at the Buck Institute for Research on Aging, and a fellow in the Department of Social Policy at the London School of Economics and Political Science. He is also the CEO of Health Systems Reform, a boutique consultancy aimed at improving public health through reforming health systems, strengthening health care management, and improving health care delivery. He has an MPP from Harvard University and has studied health system financing and management at Johns Hopkins University. He obtained his MD and MS in medical and biological sciences from Saint Joseph University. His recent publications focused on health systems and systems reform, on leadership and new public management in health care, and on increasing access to medicines.

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Tragakes, Ellie, and Suszy Lessoff. 2003. Health Care Systems in Transition: Russian Federation. Copenhagen: European Observatory on Health Systems and Policies. Vandoros S. 2013. ‘‘Therapeutic Substitution Post-Patent Expiry: The Cases of ACE Inhibitors and Proton Pump Inhibitors.’’ Health Economics. doi:10.1002/hec.2935. Zasimova, Liudmila. 2010. ‘‘Public Policy and Access to New Drugs: Evidence from Russian Pharmaceutical Market.’’ Electronic Publications of Pan-European Institute 2/2010. Turku School of Economics. www.utu.fi/fi/yksikot/tse/yksikot/PEI /raportit-ja-tietopaketit/Documents/Zasimova%20final%20netti.pdf.

Pharmaceutical policy reform in the Russian Federation.

Of Russia's 142 million citizens, fewer than 20 million are enrolled in outpatient drug coverage plans. The current government aims to establish unive...
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