Two new reports on Generic Drugs in Canada reaffirm Health Council’s findings

John G. Abbott, CEO, Health Council of Canada

Earlier this week, I read with great interest the latest reports on generics drugs released by the Patented Medicine Prices Review Board (PMPRB).

One report, Generic Drugs in Canada: Price Trends and International Price Comparisons, 2007 compares the price trends of generic drugs in Canada to 11 other countries. The report found that ”…generic drugs cost less in foreign markets than in Canada. These price differences are substantial. The implications of the international price comparisons are clear… foreign prices are, on average, only about two-thirds of corresponding Canadian prices… for the majority of drugs and nearly all therapeutic classes”.

This independent assessment reaffirms findings in The Health Council’s recent report on generic drugs Generic Drug Pricing and Access in Canada: What are the Implications? Our report found that that international prices for generic drugs in 10 other developed countries to be 15-77% lower than average Canadian prices. Obviously little has changed (at least up to now).

The second PMPRB report Generic Drugs in Canada: Market Structure – Trends and Impacts suggests that generic drug products are highly concentrated in terms of sales. In 2007 the top four leading suppliers accounted for 96.7% of sales of generic drugs. The report noted that this concentration is not the fundamental source of difference between the Canadian and foreign prices. It goes on to refer to a recent study of the Canadian Competition Bureau that concluded “…competition among Canadian companies occurs principally through rebates provided to retailers. In a market framework of this sort one would expect more vigorous competition among companies to produce larger off-invoice rebates rather than lower prices”.

These reports reveal valid insight into generic drug pricing in Canada; however, their findings are based on 2007 and earlier data. Thus, they do not reflect the potential impact of recent policy changes to generic drug re-imbursement policies in Canada where provinces like Quebec, Ontario, Alberta, and British Columbia have taken major steps to reduce the cost of generic drugs.

For our health policy leaders, industry professionals, and the Canadian public to continue to make informed choices about generic drugs reports of this nature must be researched and published regularly.

Finally, I am encouraged by the progress to date. With leadership, positive changes are possible to control health system costs while improving access and maintaining quality. I look forward to reading future discussion papers that report on how the newly implemented policies and planned joint purchasing initiatives are reflected in downward pressure on generic drug prices in Canada and improved access to these drugs for Canadians.

Key Words: Pharmaceuticals Management, Generic Drugs

Social Determinants of Health - National Collaborating Centre for Healthy Public Policy Responds

Michael Keeling, English Writer and Editor, National Collaborating Centre for Healthy Public Policy and François Benoit, Lead, National Collaborating Centre for Healthy Public Policy

“Why do we have to structure our society in such a way as to create ill health?”

In the May/June edition of the Canadian Journal of Public Health (25 years ago) Dr. Trevor Hancock’s Beyond Health Care: From Public Health Policy to Healthy Public Policy contrasted public health policy, which “accepts the givens of our present socio-cultural system and within those givens plans an illness care system” to healthy public policy, which questions those givens by asking: “Why do we have to structure our society in such a way as to create ill health?” (1)

Responses to this and similar questions have produced a convincing body of literature calling for collective action to influence the economic, social, cultural and environmental landscapes that determine health. This includes acting on the policies informing them.

The Health Council of Canada’s Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada draws on this literature to show that policies which nominally have nothing to do with health can have profound, inequitable effects on the health of populations and different sub-groups. Stepping It Up engagingly summarizes and contributes to the story of making the case for acting structurally.

Despite the convincing arguments for the why of acting on the social determinants of health, we continue to confront the how. Among other things, this paper contributes to the how by asking us to observe:

• That “health is everybody’s business” (pp. 7, 20, 33). This expands the circle of responsibility to learn about and act upon health outcomes.
• That we must leave our silos in order to act. Intersectoral action is the way to address “complex, long-term and intertwined” issues (pp. 20, 23).
• That structural prevention influences behaviours. Healthy living strategies have limitations, and to advance further we need to act on determinants. (pp. 17, 32).

This critical perspective contributes to shifting thinking from the simple dossier (linear, unisectoral, clear cause-effect) towards the complex dossier (nonlinear, multisectoral, less-predictable). These latter features are the domain of the study of wicked problems, wherein interventions demand a “seismic shift” in our understanding.

In our role as a centre for expertise in healthy public policy, we are seeing promising trends.  First, there are tools emerging for tackling these issues. Health impact assessment uses a social determinants of health framework with an equity focus embedded in the process. Other promising tools include policy analysis methods which incorporate equity and applicability, and integrated approaches to guide issue mapping on wicked problems.

Another trend is that we are seeing more and more public health practitioners, community organizations, not-for-profits and members of communities working collaboratively across sectors to make a difference, whether in Sudbury, Saskatoon, Vancouver, Montréal, Toronto or Natuashish.

This paper will be a stimulating tonic to foster all of these efforts, adding to the pan-Canadian movement to prevent or relieve the “hardening of the categories.”

Note 1. Trevor Hancock (1985) “Beyond Health Care: From Public Health Policy to Healthy Public Policy” Canadian Journal of Public Health (76, Supplement 1, 1985)

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Michael Keeling is the English Writer and Editor and François Benoit is the Lead at the National Collaborating Centre for Healthy Public Policy. The NCCHPP seeks to increase the expertise of public health actors across Canada in healthy public policy through the development, sharing and use of knowledge. The NCCHPP is one of six centres financed by the Public Health Agency of Canada. The six centres form a network across Canada, each hosted by a different institution and each focusing on a specific topic linked to public health.  More details are available from their website at www.ncchpp.ca.

Social Determinants of Health - Debra Lynkowski Responds

Ms. Debra Lynkowski, CEO, Canadian Public Health Association

The Canadian Public Health Association (CPHA) congratulates the Health Council of Canada on the launch of this important report that highlights the need for an intersectoral and multifaceted national effort to address the determinants of health as a means of achieving Health for All in Canada.

At the opening plenary session of CPHA’s 2008 Conference, Sir Michael Marmot reminded us that all government ministers are health ministers. We have been speaking about “determinants of health” for over three decades. CPHA, along with many other professional associations, non-governmental organizations and health groups, has advocated for investment in the “up-stream” population health issues. There is now mounting strong evidence, including the recent Manitoba study referred to in the Health Council’s report, as well as data from other countries, demonstrating the “business case” for investment in a determinants of health approach that addresses health equity.

As the Senate Subcommittee on Social Affairs, Science and Technology noted in its landmark 2009 report, Canada is far from where it should be in terms of the health status of our population. This is especially true for our country’s Indigenous peoples, for many population sub-groups in rural and remote areas, as well as those who fall into the lower socio-economic strata in our urban centres. Leadership by the federal government is essential to propel a national agenda for a pan-Canadian population health strategy. This report’s first two recommendations articulate what would be the foundational blocks of this national effort: that the Prime Minister take the lead in announcing, developing and implementing a population health policy at the federal level through the establishment and chairing of a Cabinet Committee on Population Health, and that the Prime Minister convene a meeting with First Ministers to establish an intergovernmental mechanism for collaboration on a pan-Canadian population health strategy.

This year marked a historic moment in the United States, when its Congress enacted the Affordable Care Act. Included in this landmark legislation are explicit, comprehensive prevention provisions with funding allocations that promote health and wellness. The Act addresses the fragmentation of policy and action and the lack of coordination across local, municipal, state and federal agencies through two initiatives. The first of these is the establishment of the National Prevention, Health Promotion and Public Health Council. Chaired by the U.S. Surgeon General, it is tasked with coordinating and implementing the national prevention agenda. The second initiative is the Prevention and Public Health Fund, designed to invest in prevention and public health programs to improve health outcomes and reduce health care costs. While we often criticize the US for failing to facilitate access to basic health care services for millions of its citizens, we might want to examine the provisions of the new health reform legislation and consider some of its progressive aspects, particularly those pertaining to public health.

Over the past few decades CPHA has called consistently for a population/public health approach here in Canada. Our Association fully endorses all of the recommendations of the Senate Subcommittee report. It wrote a letter to the Prime Minister urging him to take a lead role in putting into place a process that would result in the formulation of a pan-Canadian population health strategy.

Given the importance of income, employment and job security, housing, education, food security, and early childhood development, CPHA urged the Government of Canada, through the 2009 Budget, to create a special fund dedicated to supporting initiatives that take action on the social determinants of health. CPHA suggested an initial investment of $60,000,000, equivalent to approximately 10% of PHAC’s annual budget. This fund, to be administered through the Agency, would be dispersed in support of national, provincial/territorial and local level initiatives.

CPHA has called upon the federal government on several occasions to consider putting into place a new funding mechanism for public health, given that it is not included in the Canada Health Act, nor are public health services explicitly covered through the Canada Health Transfer (CHT). Given the lack of funds earmarked for public health through the CHT, CPHA recommended in its 2010 Budget brief to the Department of Finance the creation of a National Public Health Infrastructure Fund, valued at $1.0 billion over three years. The intent of this Fund would be to assist public health units across the country to implement the programs required to meet their client populations’ present needs. This Fund would also support national, provincial/territorial, and local-level disease prevention and health promotion initiatives, including those related to the social determinants of health.  As noted by Informetrica Limited, a $1 billion investment in health-related services could boost GDP by a factor of 1.8 and create almost 18,000 jobs.

Canada cannot mask the fact that a very serious situation exists in our country in terms of disparities in health across population groups. Public health is a public good. The federal government has an obligation and responsibility for national leadership that results in a high level of health equity for all Canadians. Investing in public health is critical, whether through core support to the Public Health Agency of Canada, through transfer payments to the provinces and territories which include funding earmarked in support of public health functions and/or programs, or through mechanisms that increase the amount of money available to Canadians to provide for their basic needs and which protects and enhances their health and well-being. The goal of Health for All is achievable. As the WHO Commission highlighted, “[a]chieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it.“ Collectively, we can make a difference, and the time to do this is now.

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Ms. Debra Lynkowski is the CEO of the Canadian Public Health Association.