Table 2.

Summary of issues

General medicines policy	Ethnicity	PHARMAC	TPPA	HCM
▸ By whom and how are decisions made? ▸ Poor medicines policy awareness ▸ Poor health literacy; impacting timing of presentation and medicines adherence ▸ Access to prescribers; physical, timing and affordability ▸ Socioeconomic factors (encompassing rural residents) ▸ Sole supply; out of stock vulnerability and cost, options for intolerance ▸ Discord in recommendations between PTAC and subcommittees ▸ Access challenges on the ability to pay for litigation; non-medical person then decides access ▸ Lack of health impact monitoring ▸ Need for integrated electronic patient records, prescribing information and PHARMAC schedule ▸ Efficiency is static; needs to move towards increases in therapeutic benefit ▸ Registration, evidence and manufacturing requirements constraining for low demand medicines ▸ Increasing demand and cost of medicines impacting affordability ▸ Need for clinical expertise and New Zealand specific research ▸ Need for better medicines management	▸ Socioeconomic factors ▸ Need to use ‘Health Equity Assessment Tool’ to assess policy and inequities/inequalities ▸ Higher burden of disease for Māori and Pacifica; needing risk factor lens ▸ Lacking proper engagement at times ▸ Cultural competency ▸ Use of complementary medicine ▸ Need to capture ethnicity statistics in new initiatives	▸ Very powerful position of provision; will they cope with role expansion? ▸ Young inexperienced staff and high attrition rate ▸ What health outcomes are being measured? ▸ Is the lost health opportunity being measured? ▸ Budget too small; need higher percentage of health budget; ‘Vote Health’ ▸ Cost driving value and causing delays ▸ Need to move to dynamic efficiency ▸ Need analytical framework to compare all health technologies ▸ Submission process inefficient ▸ Economic evaluation influencing therapeutic value evaluation; need to be separated ▸ Questionable how well health professionals understand pharmacoeconomic modelling ▸ In-house economic variables are not necessarily consistent with standard practice or PHARMAC's requirements of suppliers ▸ Hard for suppliers to understand outcome or evaluation process when variables changed ▸ Website very informative but hard to navigate ▸ Concern with expansion into hospitals and limiting choice in acute care and moribund disease setting ▸ Sustainability of current access with increasing demand ▸ Affordability of a panacea	▸ Many unfamiliar and sceptical of the benefits and who gets them vs the trade offs ▸ New Zealand, a small country that needs trade partners ▸ Where will the financial cost be felt and how will it be dealt with? ▸ Will there be an increase in the cost of provision? ▸ A lot of money is being spent on health already and the benefits are low ▸ Australia lost a lot with their agreement with the USA; we should learn from it ▸ America's influence is reducing and other forms of protection may evolve ▸ Patent extensions will delay generic entry and raise costs ▸ Will the pharmaceutical industry have a greater influence on supply? ▸ Access to new medicines may improve ▸ Sovereignty of choice; will there be increased public appeals and litigation? ▸ What does transparency mean and does it ‘cut both ways’? ▸ PHARMAC's monopsony is an anathema to the USA ▸ NZ pharmaceutical representative educating ‘sister’ organisation in NZ system ▸ Once a medicine is registered for use, it can be prescribed; PHARMAC may choose to not fund it	▸ Special Authority access unnecessary once appropriate prescribing established ▸ Need to differentiate high cost vs highly specialised need and cost ▸ NPPA access scheme brings equitable access for oncology but too early to assess ▸ NPPA capturing patient sub-type classification ▸ NPPA process inefficient and consuming valuable specialist time ▸ Limits access due to cost; but about collective good and who pays ▸ Access cheaper in other countries? ▸ Pharmaceutical companies have good profit margins ▸ Oncology stigma that everyone dies but differences in survival seen at the margins ▸ Evidence does not meet PHARMAC's evaluation criteria ▸ Constraints of ‘rule of rescue’ vs utilitarian provision

HCM, High Cost Medicines; NPPA, Named Patient Pharmaceutical Assessment; NZ, New Zealand; PHARMAC, Pharmaceutical Management Agency; PTAC, Pharmacology and Therapeutics Advisory Committee; TPPA, Trans Pacific Partnership Agreement.