Table 2:
Perceived factors influencing the acceptability and feasibility of an essential medicines list in Canada through the lens of Kingdon’s Multiple Streams Framework
| Stream | Factors identified | Example quotes |
|---|---|---|
| Perceptions of the problem (problem stream) | Inequitable access to medicines across Canada | “I think number one, that those challenges [to providing prescription drugs] probably look differently depending on which province you’re in, right. That’s one of the challenges of who we cover, how we cover, and in some cases what we cover look different.” — PT5 |
| Health system sustainability concerns (including high medicine costs) | “Canada pays among the highest prices for medicines in the world. ... And Canada’s gotta equip itself with the institutional capacity to push back and to make sure our prices remain reasonable. And in some sense the most clinically and economically rational way of doing that is through the careful evidence-based negotiation of what gets covered and at what price is it covered.” — CSO1 | |
| “... there’s a huge amount of inefficiency for the sake of jurisdictional autonomy.” — FED4 | ||
| Policy content and process factors (policy stream) | Content | |
| No shared understanding of an essential medicines list and how to define essential medicines | “I don’t think the public understands. And I use public not only the person on the street, but other sort of stakeholders in the health care system. I don’t think they have an agreement of what that list means, and even I don’t know if I know what that means.” — PT5 | |
| “To me that is a policy approach that is used more for developing countries and is potential confusing term in developed countries like Canada.” — PT4 | ||
Examples of the 2 most common ways that essential medicines were defined:
| ||
| Concerns around therapies that would be excluded from the essential medicines list | “Often anything taken away is a bad thing. Even if it was causing harm, but if one person benefited, they will see it as a bad thing. If the new list is much smaller and less, it will be seen as less benefit for the person.” — FED2 | |
| “So what happens to those other ones, right? All the people using those. So the tension that that would create to maintain an essential drug list ... everyone will want to be deemed essential, right?” — PT4 | ||
| Process | ||
| Need for an independent and accountable decision-making body | “If it’s going to be national, some sort of pan-Canadian body or bodies that report into one central mechanism. And it would need representatives from clinical community, patients, caregivers, family members, public, methodologists — the people who will do evidence synthesis, systematic reviews, pharmacists ... and we would need people who were representing jurisdictions, so the drug plan managers. But again, not political people. And likely also specific representation from the First Nations community. ... And they should have very clear terms of reference, publicly announced meetings, you know whether their deliberations should become public. ... you would need to make sure that everybody engaged would disclose conflicts of interest and those are managed appropriately, which could mean excluding anybody with conflicts. I would say ... that there would not be reps from industry on this [decision-making body].” — FED5 | |
| Clear and agreeable selection factors for the development and management of a list: clinical evidence and cost-effectiveness | “... if it’s truly marginally beneficial, why the heck is someone even considering to pay for it today, whether it’s public or private?” — IND1 “It’s not all or nothing, but the degree to which you fund a drug, and how much of that drug you fund, depends on how much evidence you have for benefit for that population.” — FED4 |
|
| “... it’s an exercise about trying to make good judgments about what investment in which drugs at any particular point in time will provide the best outcome for the patient. And at what cost should that occur? At what cost should that investment come.” — CSO8 | ||
| Framing and communication of an essential medicines list | “This is not about restricting access to medicines for people, it’s about improving access to medicines. There are a lot of people who do not have access to the meds that would be on an essential medicines list at all. So thinking about how you frame it I think also matters.” — CSO7 | |
| “... you have to put it into a language where we will guarantee Canadians that the prescription drugs that will be put on the list will be scientifically proven, evidence based ... and efficient, and better prescribing habits. ... It doesn’t matter if it’s 2 drugs or 10 000, but what’s on that list is what you will need based on what the experts are saying and that’s that guarantee we need to give.” — CSO6 | ||
| Political factors (politics stream) | Federal financing and the pharmacare model | “[Federal financing for] perhaps a half of the costs of that formulary, which is sort of the medicare bargain: the feds pay half, the provinces pay half, at the outset of Canadian medicare.” — CSO1 |
| “[Who should decide] depends on who is paying the bills. And that’s the real challenge right now, is that you have all these different payers, right. If one group actually wants to take that on, then they would be accountable for that process. ... but we would have [to] rely on a national approach that actually looks at formulary management besides just the drugs that are being submitted [to CADTH]. ... And if it is decentralized, then the jurisdictions should have the right to manage their own formulary.” — PT4 | ||
| Management of diverse stakeholder interests and safeguards against conflicts of interest by an independent body | “You also absolutely need to insulate the people involved in making the final decisions about what’s on and what’s off from political pressures. And I believe firmly that’s a benefit to our political leaders, because they are vulnerable as representatives of particular constituents ... to threats by industry stakeholders that they will withhold funding, they will withhold industrial projects, they will withhold research activities, they will lay off people working in their workforces, if a decision doesn’t go their way. ... It’s a form of political extortion, right.” — CSO1 | |
| “I think it’s critical to have citizen involvement. I don’t think that these things should be done just by so-called experts. How you select the citizens who get involved in that, that they don’t have a particular bone to pick or a particular disease that they care about, is always very tricky. But it’s not an excuse not to have citizen involvement.” — CSO7 |
Note: CADTH = Canadian Agency for Drugs and Technologies in Health, CSO = civil society, FED = federal government or pan-Canadian institutions, IND = private sector, PT = provincial or territorial government.