Impureza conceptual: Blumenberg y su metaforología

The overall health reform and primary care transformation also affected medicine supply. Before the reform period, most transition countries had expanded limit-free pharmaceutical policies, without any limitations on prescribing or dispensing, which were available free of charge to all patients. The pharmaceutical list was one of a utopian health system, where everything, including vitamins and supplements, was prescribed and dispensed free of charge at the point of delivery, within the possibilities of the rather confined reality of command economies (Joncheere and Paal 2002).

and distribution companies. Countries liberalised markets for provision of services, including medicines (Nordyke and Peabody 2002), as a complementary reform to privatisation (Goodhue et al 1998). The liberalisation was quickly embraced by both the public and private sectors; for the former it was seen as a possibility to encourage competition and lower prices while expanding medicines availability for the benefit of the citizens. The latter saw it as an opportunity for expanding markets and generating welfare (Granville and Leonard 2003). In its own right, this enabled competition in the supply side, bringing indeed wider availability of medicines, which consequently affected the demand side in which the consumers, i.e. patients became empowered to recognize the variations in the scope and quality of services and medicines provided (Hebrang et al 2003). The changes had drawbacks too; a study on access to medicines in Russia by Perlman and Balabanova (2011) showed that between the early 1990s and 2000s the availability of prescription medicines in pharmacies improved, but at the same time the percentage of patients unable to obtain prescriptions rose sharply. Similar situations were reported in Armenia, Moldova, Ukraine and Kyrgyzstan (Falkingam et al 2010; Jakab and Kutzin 2009; Balabanova et al 2012) where still in 2010 over half of the respondents reported lack of access to medicines (Footman et al 2014).

Returning to the issue of interest, models in which the transition economies have regulated the pharmaceutical market did not differ much from the models explained earlier in this thesis; countries introduced both supply side and demand side measures adapted to the given health system. Without reiterating the details of the pharmaceutical market regulation explained earlier in this chapter, I will briefly explain the demand side measures introduced, as these are of particular interest to the research questions.

Regulation of the pharmaceutical market did not necessarily come with the expertise of the public sector to deal with the new public-private interaction. In the first years, the public sector, still under the old paradigm of health being ‘the most valuable public good’ that needs to be undisputedly funded, was producing policies that were not too successful in pharmaceutical cost containment. Just as an illustration, in the late 1990s, the transition economies still spent between 16-26% of health expenditures on medicines, whereas in the EU countries this share was between 7-11% (Joncheere and Paal 2002). A further difficulty was posed by the necessity for mind shift in terms of explaining to voters that the new ‘better’ society would actually provide ‘less’ of what was available before. Thus, with predominantly political motivation, as well as to maintain social stability (Markota et al 1999), governments considered introducing incremental changes in cost containment policies.

At first, in transition countries adopting the capitation model (e.g. Croatia, Macedonia) there was a limitation on the number of prescriptions (and referrals) that primary healthcare physicians could prescribe for their pool of registered patients. This policy intervention intended to ‘train’ physicians to plan and rationalize their decisions for prescribing (Hebrang et al 2003). At the same time, a health insurance-covered list of medicines was introduced, as another measure to confine the previously soaring use of medicines and high pharmaceutical spending (Joncheere and Paal 2002). In parallel with these policy interventions, many transition countries have introduced evidence-based clinical guidelines for the recommended pathways of treatment, most of them taking and adapting the procedures from developed countries, mainly the UK (Kanavos 1999). At this point, the policies still did not have a sufficient effect, keeping costs high and

considered, and countries introduced fixed prescribing budgets in primary care (e.g. Croatia, Macedonia) or substitution of brand-name with generic medicines (e.g. Czech Republic, Romania, Slovakia). In addition, patients’ co-payments for prescription medicines with varying rates between 10 and 50% were introduced as a measure for preventing overprescribing and overdispensing (e.g. Croatia, Czech Republic, Macedonia). The applied combination of changes depended on many factors (Hlavacka et al 2004; Rokosova et al 2005; Golinowska 2007; Gjorgjev et al 2006), mainly driven by overall higher levels of prescribing compared to western countries. At this point, countries also introduced reference pricing and related policies, but as those are supply side mechanisms, for clarity of the text these are not elaborated further in this thesis. Yet, in some countries (e.g. Slovakia) even after pharmaceutical reform, the share of medicines remained as high as 28% (in 2008) of the total health expenditures (Golinowska 2007). In Macedonia, too, as already elaborated in the previous chapter, the number of prescriptions and pharmaceutical expenditure show a steady increase over the years, despite the introduced policy changes.

With the above in mind, it can be argued that other factors – stemming from and related to the lifeworld and its interactions with the system – are influencing prescribing and dispensing levels. This is confirmed in the literature from the aspects already discussed above. However, although some findings might be universal to the physician- patient relationship, their communication and outcomes of their communicative action, still their specific effects within the context of transition countries requires further attention.