In June 2017, PharmaBoardroom hosted an exclusive round table discussion with key players in Algerian healthcare on the role of health economics and patient data in health policy decision making. The participants were Dr Djaouad Brahim Bourkaib, Director General of Social Security in the Ministry of Labor, Jean-Paul Digy, Vice President for Africa Maghreb Region at Novo Nordisk, Senator Louisa Chachoua, President of the Health Commission in the Council of the Nation, Professor Mondher Toumi of Aix Marseille University, and Tom Achoki, Clinical Assistant Professor at the University of Washington.
Chair: When reviewing Algeria’s evolving epidemiological profile, comparative studies like that of Professor Achoki appear to demonstrate a significantly higher prevalence of non-communicable, so-called “lifestyle diseases” such as diabetes in Algeria than in nearby Sub-Saharan states. Are we sure that this actually reflects the reality on the ground? Or could this really just be a case of bias caused by unreliable source data?
“The evolution of the prevalence of diabetes in Algeria compared to the scenarios encountered in Sub Saharan Africa has firstly to do with the transformation of the in-country economic and health profile”
Prof. Modher Toumi
Professor Achoki: The burden of disease approach strives to depict comparability across countries, age groups and sexes. For places where we do not possess good enough data, like in some Sub-Saharan countries, we applied a confidence interval to our estimate, which, at times, can indeed be rather wide. Yet the data is comparable, as we chose to ensure age standardization, so as to offset the effects of demographic difference. This enables us to ascertain with a certain amount of reliability that the diabetes epidemic is afflicting Algeria rather more heavily than some of its neighbors.
Professor Toumi: I would conjecture that the evolution of the prevalence of diabetes in Algeria compared to the scenarios encountered in Sub Saharan Africa has firstly to do with the transformation of the in-country economic and health profile: for example, the risk is not going to be the same in circumstances of famine or malnutrition. A second decisive factor has to do with differences in cultural food preferences and habits. For instance, millet does not present the same diabetes risk as a foodstuff like baklava, so disparities in eating behavior patters will also go some way towards explaining some of these geographical variations. This is further reflected by the data itself. Lifestyle factors obviously closely influence patterns of weight gain, which is, of course, closely associated with the onset of type 2 diabetes, so we should not necessarily be surprised to encounter divergences in the burden of no transmissible disease from one nation to another. Since type 2 diabetes is actually an acquired pathology, we’re not just talking about genetic predisposition. A key differentiator may indeed be whether or not a country possesses a robust and comprehensive education strategy that raises awareness about and actively promotes healthy living.
Factoring health economics into drug reimbursement decision-making will supposedly impact the way in which local drug prices are set, since overall societal benefit will, for the first time, be taken into account during the evaluation process as opposed to just the clinical outcomes. How much of a game-changer is this really though?
Dr Djaouad Brahim Bourkaib: Our existing drug evaluation system has allowed us to function adequately in the past, but has now reached its limit and is no longer “fit-for-purpose” in an evolved Algerian public health landscape. Medical science has witnessed great advancement with the development of new categories of often costly, but effective biologics and our nation has simultaneously undergone significant demographic and epidemiological transformation. This confluence of factors compels us to rethink our reimbursement criteria. One pathway forward could be the adoption of “conditional reimbursement” and “restrictive indications.” Recently, for example, having evaluated the requisite data, the Ministry of Health gave the go-ahead for the national Social Security apparatus to reimburse a new diabetes therapy, but only under a specific given set of circumstances. Essentially we ring-fenced the state’s expenditure on this particular medicine so that reimbursement would only be authorized for the actual population of diabetics who could derive maximum benefit from this innovation – in this particular instance that would be those patients for whom oral anti-diabetics have previously proved to be a failure.
Right now, we are busy working alongside all stakeholders to jointly define the modalities of application of the new reimbursement mechanism that we wish to introduce across the country. We are striving to forge consensus in building a new order of public healthcare provision and seek to join forces in fashioning a sustainable model of national care that does not jeopardize the health needs of our citizens. It is essential to emphasize that maintianing the status quo is simply not an option anymore because that would risk either destabilising the financial integrity of our national welfare system or abandoning patients with imporant needs. Continuing down the same path as before would risk provoking a situation in which the Algerian Social Security system, given the sheer cost of certain innovative drugs, would have to forego their inclusion on the list of reimbursable drugs because the additional cost would simply exceed our payment capacity.
Jean-Paul Digy: From an industry perspective we are fully cognizant that the way we do things is going to have to change and that the “business as usual” trajectory will no longer suffice anymore. Nowadays the scope for deploying targeted treatments is much broader than it was in the past and as a company we are wholly suppotive of the Algerian authorities’ agenda to restructure and rationalise the way that they go about paying for new therapies. Under Novo Nordisk’s partnership agreement with the authorities, the risk sharing model will include precise modalities to determine how the patients who no longer benefit from traditional molecules should be treated. The goal is thus to maximize the number of patients who best respond to a drug. There will be other patients who will perform better under a different therapy, more likely to prolongue life expectancy and trigger fewer complications. We want the best medicine to be provided to each patient. In this day and age of targeted, precision therapy, it makes little sense to be supplying identical medicine to everyone in a “one-size-fits-all” manner. At Novo Nordisk, we do not treat “diabetes” per se, but people with diabetes, hence the desire is very much to adapt therapies to the personal needs of each and every individual.
Professor Achoki: Right across the African continent, we have been witnessing a whole array of fresh challenges cropping up when trying to improve population health. On the one hand, there have been a number of successes such as the profound decrease in infectious disease and very visible advancements in child health. On the other hand, incidence of non-communicable disease such as cardiovascular maladies and diabetes is definitely on the rise, in some cases exponentially. The extent of this “gathering storm” becomes apparent when you survey the growing numbers of obese young adults registering low levels of physical activity, because they will, almost certainly, comprise the patient population of tomorrow. Health economics can be leveraged as a most invaluable tool for the state to appropriately respond to and adapt to this shifting paradigm. Genuine health technology assessments that factor in both the overall socio-economic and clinical outcomes will be of considerable assistance to the Algerian public health system in the allocation of scarce resources more efficiently and will ultimately empower the state to be able to sustain the sort of progress that has already been attained over the past 25 years.
Subsequent to the proper adoption of health economics, how, then, can we expect the new Algerian Reimbursement system to look?
Dr Bourkaib: The fresh approach to innovative medicine that the Algerian state is now embracing revolves around two highly important aspects: namely how best to manage the cost of new drugs, and optimum strategies for handling uncertainty. We are very keen to ensure that the services that we are paying for are actually effectively rendered, rather than relying solely upon expected and percieved outcomes, as in the past. Moreover, we are committed to stabilising and safeguarding the repayment capacity of the national social security apparatus, which means spending within our means.
Our traditional reimbursement eligibility evaluation process has sadly, at times, led us down a cul-de-sac because it concluded that the budgetary impact demanded by patients exceeded the social security system’s actual financing capacity, so resulted in the exclusion of some highly effective medicines from the final reimbursement list. In the future, we intend to avoid the kind of scenario in which Algerian citizens are deprived of the therapies that they need. Instead we are committing to seeking out a more inclusive, universalistic pathway by joining forces and fostering the sort of enabling conditions in which private industry can contribute to, and actively participate in, the sharing of financial risk. By being much smarter in terms of our resource allocation, we are confident that we can engender accessibility to all important therapeutic innovations. In short, we intend to be able to generate a bigger bang for every dinar expended.
Jean-Paul Digy: I would like to take this opportunity to stress our enthusiasm for being partners to the government in their endevours on this front. We are very much in favor of transparency and collaboration in order to launch innovative molecules on the market, for they are currently highly expensive, given their development cost. Working with the appropriate authorities – whether the Ministry of Health, the Ministry of Labor or the Social Security – will allow us to define which target populations will best benefit from these therapeutic innovations. This is particularly interesting in the case of the Algerian social security apparatus, because those institutions possess access to a large amount of data on diabetes, on the persons affected by this condition, on the level of complications and also on the cost of the usual treatments. Were private sector entities like us able to incorporate these findings into our drug development and local market development strategies, then we would be able to deliver a much more “patient-centric” offering. Deploying a joined up approach can only constitute a step in the right direction, bringing beneficial results to all concerned.
Professor Achoki: I am encouraged and impressed when I witness the progressive and enlightened stance taken by the incumbent Health Ministry and Social Security bodies. The director general of social security is correct to draw attention to the imporance of co-opting in the private sector and other competencies. Alongside possessing the requesite technical competencies to carry out reliable health economic assessments, it will be vitally important to mobilise support from right across the spectrum of stakeholders with a view to assembling the sort of integrated healthcare delivery vehicle that can enhance different population groups’ access to novel medicines without the country being plunged into a scenario in which it is living beyond its means. The round table discussion that we are participating in today is testament to the sheer solidarity and willingess of all actors to collaborate in identifying common solutions to the pressing issues of our time.
Dr Bourkaib: With the introduction of a dimension that balances financial risk, we can optimise our decision-making and produce carefully calculated choices that are fair and equitable for all parties concerned. Once we have effected the necessary changes our social security system will be considerably more results-oriented and effective in ensuring maximal value for all resources expended. When confronted with the arrival of new innovations on the market, we will be able to assess the overall value of those products much more profoundly and scientifically. Moreover, by harnessing the new assessment methodologies, we will be able to track the performance of reimbursed products and adjust our evaluation of them in accordance with the reality. As such we will be able to minimize uncertainty and secure better value for taxpayers’ money.
Right now, I think you will all agree that we have a fairly broad list of reimbursed medicines, which covers the population’s most pressing needs, but which requires control valves to confer access to latest generation therapies and cutting-edge medical innovations. Deeper embracement of pharmacoeconomics will enable us to fine tune the operation of these valves, and put in motion a well oiled machine that actually delivers on its objectives. Right now, we have a tremendous opportunity to refine the criteria for integrating new medical innovations and to adopt a transparent pharmaceuticals selection process in which we afford considerably greater visibility to our partners, whether local or international labs and drug developers, about how we are handling and adjudicating new product entrants to the market.
Much has been said about co-opting the private sector and all pulling together to build a new inclusive system. Nonetheless it is surprising to note the absence of the other authorities, apart from the Social Security and the Ministry of Health, around this round table. Why is that?
Dr Bourkaib: Highly constructive work is currently ongoing within the Department of Health and new drug agency. We have to bear in mind that the regulatory bodies are, right now, in the midst of a radical restructuring and reshuffling, and their task is growing more complex every day. The drug agency will become a great asset and opportunity for the country, but further work is still needed to expand the resources allocated to it. In turn, the new structures will enable us to refine our national pharmaceutical strategy. We firmly believe that the establishment of the new drug agency is a decisive milestone in the construction of a bright health future for our nation.
During your presentation, Mr. Bourkaib, you referred to the concepts of “expensive” and “highly expensive drugs”. How will integrating a consideration of pharmacoeconomics into the national drug selection criteria serve to modify these definitions?
Dr Bourkaib: The concept of expensive medicines, by legal definition, depends on medical risk (covered or not), in comparison with what already exists, and budgetary impact on all potentially affected populations. We may, for example, be talking about an innovation for a high-prevalence disease which consequently will weigh heavily on state coffers if granted reimbursement. At a certain population / price threshold, the drug is considered expensive. It is also a question of the added value generated by the new product: some innovations demonstrate a clear improvement on the current status quo, while other products, though technically and scientifically advanced, might be doubling up in responding to a need that is already amply catered to. Finally, the face-value price alone can make it an expensive drug, according to Social Security criteria. This definition is, of course, relative to the financial firepower of the social security budget at any specific point in time.
Despite a welter of highly acclaimed and successful health policies, budgets, including that of social security, have been gradually diminished by the Algerian government as the national economy, overly reliant on global oil prices, has soured. Is there a risk that health spending might sink too low to be able to adequately meet the needs of the population, irrespective of the impact of the new pharmacoeconomic methodologies being introduced?
John Paul Digy: This is always a bit of a scare to private business leaders like myself because if you cut volumes and prices, it clearly becomes more difficult to fund new innovations. It should be noted that a large part of the escalating drug bill relates to the administrative authorities’ demands: they require, at the international level, to follow an increasingly exorbitant registration process, in terms of number of patients and length of follow-up. For an insulin, for example, compared to the 80s when a 200 to 300-patient study was sufficient, 10 to 20 000 are now required to get the product on the market, in addition to three to five years of follow-up, pre- or post-marketing authorization, to verify the cardiovascular safety of a new molecule. Obviously, these constraints have consequences on overall costs, which are ultimately reflected in the final price of the drugs. It’s ultimately a question about achieving the optimum balance between competing objectives, but this is an issue that demands much closer attention
Public authorities, and journalists alike, sometimes tend to clamber upon their soapboxes hastily – as was the case recently in the United States – but if the face value price of medicines is increasing, it is, in the majority of cases, because the price of development has exploded. And in some cases, the health authorities themselves are the ones to impose this increase on their beneficiaries. The Algerian social security will have to make a critical choice, between greater short-term cost and lower complication-related costs in the long term. The difficulty will be to find some balance between the short and long term benefits of the new molecules.
The best way to surmount these kinds of obstacles is actually to all get around same table and discuss each others’ concerns and to identify win-win solutions. I am thankful to say that here in Algeria we have a very willing interlocutor and there is immense willpower on all sides to identify common pathways forward.
Dr Bourkaib: Then there are are also national specificities that have to be factored into the equation of financing social security. With regard to diabetes, for example, experts who work in Algeria with indigenous patients, all tend to agree about the significance of patient education. Thus the percieved failure of a conventional therapy does not necessarily mean that the drug itself has failed. It may instead be that drug adherance behavior is low and many patients are not taking their medicines in the proper prescribed way or that they are not managing to curb unheathy lifestyles and this is distorting end health outcomes. We are thus intent on adopting an smart and transparent drug selection criteria takes these sorts of elements into account.
It is worth bearing in mind also that the Ministry of Health is stridently committed to going after the low hanging fruit and introducing measures that can really take substantial costs out of the system such as promoting preventative healthcare, raising awareness and investing in diagnostics that can catch diseases at their inception before heavy, costly treatment is required.
The deployment of “class reference rates” remains an important mechanism in the social security apparatus’ toolbox for enforcing cost containment. How would you describe the new criteria for class assignment?
Dr Bourkaib: Our overarching objective is very noble and is all about making therapeutic access real for as many of our citizens as possible. It’s all about making sure that as many patients as possible get access to drugs that work, at the best possible price/value ratios. Our general premise is therefore that the generic-ized version of an originator product should be reimbursed in line with the extent of the medical needs of the population and that this should take place under conditions of quality and minimization of costs for the payer. Privileging generics and deploying class reference rates, therefore constitute important levers in the hands of the Social Security for ensuring proper cost control.
From 2008 onwards, we rolled out a new system that has subsequently proved to work very effectively: essentially, based on available data, classes of molecules with equivalent health performance were created. For statins, for example, certain molecules were found to be as much as four times more expensive than others, but our meta-analysis was sophisticated and appropriately took into account the performance in terms of care (such as the individual benefits of each product in terms of reduction of cholesterol for example). Armed with these calculations, social security began to reimburse products accordingly, applying the same base rate to molecules of similar effectiveness. This process has been a resounding success, and the laboratories themselves have followed suit by aligning their prices with the social security class rates.
Will biosimilar products be treated in the same way as generics?
Dr Bourkaib: In the case of biosimilars, Social Security enters the process at a downstream juncture when it processes files according to the regulatory documents provided by the health authorities. In Algeria the marketing authorization is a registration decision which contains the international common denomination code of the new molecule. If the molecule has the same denomination code as an originator, then Social Security cannot offer a different reimbursement than the one granted to the originator. This is the case for Erythropoietin, which is covered by existing conventions with private hemodialysis centers in Algeria, and which we reimburse at the same base rate as the corresponding generics. Ultimately, though Social Security is tasked with rationalization of expenditure, it cannot challenge the decision of the health authorities. The same goes for biosimilarity which is also tightly controlled upstream.
We are, of course, closely monitoring any developments brought about by the Ministry of Health and the associated authorities when this issue is addressed, because biosimilar products allow for greater accessibility. The same thing happens all over the world: biosimilar status makes it possible to lower prices and improve availability. So this is a question that should largely be addressed to the authorities in charge of marketing authorizations and regulations. For our part, though, we are profoundly in favor of allowing biosimilar products to appear on the list under conditions of safety, efficiency and quality.
The centrepiece of health economics is drug pricing. When we consider the remuneration of pharmacists, is it preferential to leave this solely to maket forces and takings from profit margins or would it be better to peg their income to the actions being carried out?
Professor Toumi: If we deconstruct the role of the pharmacist, we discover he or she carries out two core functions. First, the pharmacist delivers a medicinal product, either expensive or cheap. It is legitimate to be remunerated for the delivery of that product, irrespective of its price, on a standardized rate. Secondly, the pharmacist immobilizes money given the investment that occurs between buying and reselling the pharmaceuticals. The turnover on each product also has an impact, so it seems legitimate that the remuneration takes it into account and combines the price of the product and the act of delivering it to the patient.
There is a third, sometimes forgotten, function which relates to the instuctive and educative mission of pharmacies. In my opinion, the expert guidance and counsel that the pharmacist delivers should also be remunerated. If we are really serious about raising awarness about acquired pathologies and countering chronic lifestyle disease, then the pharmacist surely has to be regarded as one of the cornerstones of this new education strategy. If this work is not assigned a monetary value, it risks remaining superficial. The greater the transparency, the better. Individual tasks and missions have to be individualized so that we know which specific stakeholders are accountable for each activity and remuneration must integrate and reflect each of these tasks in a clear manner. In return, it then becomes a contractual obligation to fulfill these assignments. What I’m calling for is an explicit system where the roles are defined, that is then backed up financially so it is no longer left to the discretion of the pharmacist about whether he chooses to impart knowledge and advice or not. Instead the contract ensures accountability, pays for and rewards a clearly defined service and verifies the actual attainment of the task.
One obvious obstacle to mainstreaming pharmacoeconomics across the Algerian administration’s decision-making chain and drug evaluation process is the sheer lack of local academic knowledge about the discipline. Just how long is it going to take for Algeria to get up to speed on this issue? What will be the steps for acquiring the requisite knowledge? And is it really relevant to talk about bringing in health economics today, when that basic knowledge is still lacking?
Professor Toumi: Numerous examples demonstrate that it is the obligation to submit economic data and to generate, for the decision-making bodies, an impact assessment on medico-economic data that has fostered the growth of the health economy, in all countries where it has been implemented to date. Anything that aims to create itself “just for its sake of it” risks being ineffectual. Effectiveness starts to kick in once, in order to facilitate that the right decision is made, it is rendered compulsory for all parties to systematically provide the information. The entire chain of events starts of with the compilation of good, reliable data.
“Once the authorities have secured a steady flow of quality raw data and once it becomes the norm and standard modus operandi for stakeholders to gather, record and transmit critical information, then the capabilities for extrapolating and processing that data will naturally follow on very quickly”
Once the authorities have secured a steady flow of quality raw data and once it becomes the norm and standard modus operandi for stakeholders to gather, record and transmit critical information, then the capabilities for extrapolating and processing that data will naturally follow on very quickly. As soon as the demand is there for those types of skill sets, you will find people training up to acquire them. In Algeria, this dynamic is already underway. Our national social security apparatus is already stipulating the collation and handover of certain types of economic data even in instances where it cannot yet be exploited for more astute decision making. This will serve us well for the future. Our national data repository is slowly being built up day-by-day that information will, in time, be harnessed to oil the wheels of a brand new, fit-for-purpose drug evaluation and health technology assessment infrastructure.
In France, it became mandatory in 2013 for innovative products to submit new data dossiers to the authorities, and it was from this date that the number of courses increased dramatically, as did the number of experts, the number of service providers and the number of health economist recruitments. Academics also began to work more intensively in this field, opened training courses, and government actors also began to recruit and train. It all went extremely fast: within two years, the economic fabric multiplied by five or six and an entire new cluster industry had materialised.
From exisiting examples abroad, the tendency is towards a virtuous circle. When the Parliament, the Ministries of Research or Health, or even the health insurance outfits, start to repeatedly demand research on a given economic theme the various academics participating in the tenders tend to raise their game. They home their skills and knowledge bases as they compete amongst themselves for the contracts. Therefore, it will probably suffice just to start the ball rolling. The rest will take care of itself. A strong, consistent and resolute demand for data will foster the enabling conditions in which that data can be properly processed.
Dr Bourkaib: There is no doubt that pharmacoeconomics is a new discipline for the Algerian state. As late as 2014, our economic evaluation of pharmaceuticals rarely went beyond simple exercises such as comparative reviews of the cost structure between original products and their generic versions. It has been a steep learning curve, but we now plan to harness the expertise of health economists, as a complement to that of our clinicians, so as to gain a more holistic perspective of the different dynamics at play and so as to embolden and rationalise the decisions of the drug reimbursement committee.
An action plan has already been drawn up to this effect and we will be proceeding with the provisions of the Financing Act 2017 which should, in turn, trigger the demand for new capability building. The new measures will provide a powerful incentive to international experts. There will be much to do in Algeria to train national experts, exchange expertise and international experience, and get involved in the new system. I believe that we will fast become an attractive platform for health economics experts, everywhere in the world.
We can, naturally, expect the application process for novel therapies to become more complex and rigorous, as is the case at the international level, but the end outcome will be worth it. By exposing reimbursement decision making to objective economic and scientific logic, we aspire to elminiate the subjectivity of the process and depoliticize it, instead forging consensus between disparate stakeholders. In this way, through concerted action, we can altogether focus on meeting Algeria’s double challenge: integrating therapeutic innovation, while sustaining the reimbursement system over the long run.
John-Paul Digy: In my opinion Algeria is already beginning to cultivate a good appreciation of pharmacoeconomics. A few years ago, the authorities used equivalence of quantity as the main comparative means – one milligram of molecule A equals one milligram of molecule B – whereas today they assess surplus value, advantages and disadvantages of each molecule, benefits for specific patient targets. Since 2008, the country’s regulators and policymakers have demonstrated a strong willingness to reimburse all effective therapies. Results of this effort are increasingly tangible, as more and more molecules become available to improve healthcare.
For a therapeutic area such as diabetes, this is a very timely moment to be rethinking the pharmaceuticals assessment process, because of the huge advancements being made in new drug discovery and delivery mechanisms. Remember that in 50 years, since the discovery of sulfonamides, insulin became humanized, then modern insulin arrived – the galenic form evolved and brought very clear benefits – but there had been no true revolution in that field. With the discovery of the GLP1-incretin class, more and more innovative molecules are now being invented, which will bring real added value. It is more important than ever to therefore have an evaluation process that can properly handle these new therapies.
In my opinion, new molecules will have to prove not only that they improve blood sugar, but also that they cause fewer complications. Therefore incretins represent a real revolution when compared to statins. GLP1 analogs and EPGs have demonstrated a cardiovascular benefit to an extent that insulin never achieved. The fact that Algeria is now attempting to put in place an infrastructure that is able to assess these sorts of complexities is very welcome news indeed.
How optimistic are you that Algeria can be a showcase example and paragon within Africa of how to correctly integrate pharmacoeconomics within a public health infrastructure?
Senator Louisa Chachoua: I am glad to see that the sentiments being expressed in this round table forum very much echo the work of the Senate and the sorts of initatives that we have been an enthusiastic proponent of. Much has been achieved to date, but we have still a lot of work to do if we are going to truly combat the sorts of lifestyle diseases afflicting Algeria, some of which have now reached epidemic proportions. The time has come to carefully reflect upon the facts of the matter. The epidemiological transition of Algeria since the 1960s has been carried out under favorable and acceptable conditions. Life expectancy has risen from 50 years to 77 years, communicable diseases have fallen considerably, and the country is now facing the characteristic diseases of developed countries, such as diabetes or hypertension. This is not unexpected, but it does necessitate the urgent adoption of a fresh approach to public healthcare. The old model needs to be rewired so as to respond to the needs of today and tomorrow.
Pharmacoeconomics offer us an entirely new way of evaluating costs, and the health system must identify practical solutions to adapt its response to the widespread onset of non-communicable disease. In the Senate, we have discussed a tranche of new measures with Dr. Bourkaib including price ceilings and the drawing up of performance contracts. It is clear that we are going to have to stretch our exisiting resource pool further than we have proved able to do in the past. We need to inject greater rationality into our decision making and make sure that out spending is conducted wisely on the right items that are guaranteed to generate a commensorate value in terms of end outcomes. I am confident that the forthcoming Finance Act 2017, once adopted, will enable the practical implementation of these measures, and the promotion of a sound public healthcare policy that is appropriate for the Algeria of today.
Jean-Paul Digy: I believe that within the African continent, the Algerian authorities can be viewed as pioneers and trailblazers in developing the pharmacoeconomic approach. Indeed they share this leadership with the Tunisian authorities. Most other African states, with the exception of South Africa, have not yet developed these methodologies and techniques in pharmacoeconomics and technology assessment. In South Africa, the necessary competence is developed, but not especially useful as such for the industry yet because they are conceived in the context of the progression of universal health protection, to absolutely ensure core treatments access to the population.
The Algerian authorities, for their part, hold a different vision: they aim to expand full reimbursement every time it is possible, including for therapeutic innovations, of course within the budgetary constraints of the country. The system is already well advanced in its implementation. And with the new items included within the Finance Act 2017, and I am optimistic that we will very soon see Ageria’s new health future taking shape.