fter years of hints and delays, some visible progress is underway toward a National Pharmacare system in Canada that would provide affordable, insured access to medicines for all Canadians regardless of where the care is received in Canada. But concerns and uncertainties remain.

Background

When the Liberal government took power in late 2015, the Federal Health Minister’s Mandate Letter spoke to a number of initiatives related to pharmaceutical policy. Movement on these issues has been slow, with most initiatives not starting in earnest until 2017 and an expected delivery in the second half of the government’s mandate.

For instance, the federal government joined the pan-Canadian Pharmaceutical Alliance (pCPA) in 2016 to enable federal drug plans to participate in drug pricing negotiations. More recently, there have been proposed changes to the mandate and activities of the Patented Medicine Prices Review Board (PMPRB), as outlined in previous DIA Global Forum updates.

National Pharmacare has been part of the national dialogue since the mid-90ies, so real progress on this issue is long overdue. Early hints of a National Pharmacare program in the 2015 Mandate Letter were quickly pulled off the table, with the Minister stating in August 2016 that a National Pharmacare program is likely years away because of more pressing priorities.

But that was then. This is now. There have been two major announcements related to National Pharmacare, signaling renewed interest on the part of the federal government to make this issue as a major discussion point in the run up to the next election in October 2019.

Advisory Council on the Implementation of National Pharmacare

During presentation of the federal budget on February 27, 2018, the federal Finance Minister announced a new Advisory Council on the Implementation of National Pharmacare to be chaired by Ontario’s former Health Minister, Dr. Eric Hoskins.

The Advisory Council will report to the Ministers of Health and Finance and will work closely with experts to complete an economic and social assessment of domestic and international pharmacare models. The goal is to report back to the government in 2019 with recommended options for how to move forward with National Pharmacare in the Canadian context.

There are few details available regarding the Council, its terms of reference, qualification of board members, project plan, etc. The chair is expected to work with board members (who are not yet announced) to “begin a national dialogue that will include working closely with experts from all relevant fields as well as with national, provincial, territorial, and Indigenous leaders.”

Standing Committee on Health

On April 18, 2018, the House of Commons Standing Committee on Health released a report and recommendations on the development of a National Pharmacare program in Canada. The report reflects two years of assessment of the available evidence, through meetings and hearing testimonies from 99 witnesses.

The report is entitled Pharmacare Now: Prescription Medicine Coverage for All Canadians, and its primary conclusion is that Canada should move towards a universal single payer public prescription drug coverage program rather than reform the existing system of public and private prescription drug coverage. A study by the Office of the Parliamentary Budget Officer examined this approach and found that it has the potential to reduce total annual prescription pharmaceutical expenditures by $4.2 billion. It is proposed that such an approach would also ensure that all Canadians have equitable and affordable access to life saving prescription drugs.

To this end, the report outlines 18 recommendations to enable a move towards a National Pharmacare system. Among the suggestions made to the Government of Canada are the following:

• Expand the Canada Health Act to include prescription drugs dispensed outside of hospitals as an insured service under the Act (in other words, include drugs on national formulary as an “insured health service”).
• Provide additional funds to provinces/territories via the Canadian Health Transfer based on the assumption that the program should be cost-shared between federal, provincial, and territorial governments.
• Develop a common national formulary to be maintained by the Canadian Agency for Drugs and Technologies in Health (CADTH).
• Develop a transparent framework for pCPA and designate it as the common bulk-buying agent for prescription drugs.
• Align PMPRB’s mandate with CADTH’s policies and priorities.
• Investigate pharmaceutical market practices to promote price reductions through greater competition.

The report is very ambitious in its goals for the future of pharmacare in Canada, but it also misses some important nuances in the philosophy underpinning the overall system. Furthermore, it does not sufficiently address the significant complexities of the current public and private drug plan environment. For instance, it prioritizes the need for a common national formulary but at the same time does not address how that would be operationalized given the existing division of powers between the federal and provincial/territorial governments.

Implications

• It is clear that the Liberal government has identified National Pharmacare as an election issue for 2019 and seeks to leverage the outputs of the Advisory Council as part of its platform.
• The extent to which the Advisory Council will engage stakeholders in the development of potential models (versus push through a proposal in order to have a “deliverable” ready for 2019) is not clear.
• It is also not clear whether and/or how the House of Commons report and its recommendations will be integrated into the work of the Advisory Council.
• The interplay between National Pharmacare discussions, PMPRB changes, and the ongoing evolution of the pCPA and CADTH make it difficult to predict where the Canadian pharmaceutical policy system will stand five years from now.
• The key concern in all of this activity is the absence of dialogue about the role of innovation in the overall health system. This speaks to a very real threat to patient access to innovative therapies and an impact on the pharmaceutical companies, who bring them to market.