An application of a proposed framework for formulary listing in low-income countries: the case of Côte d'Ivoire

The General Mutual Benefit Fund for Civil Servants and State Employees of Côte d'Ivoire (MUGEFCI; Mutuelle Générale des Fonctionnaires et Agents de l'État de Côte d'Ivoire) is a health mutual fund providing coverage (medical consultations, laboratory tests and treatment) for its enrolees (government officials and agents). This organization aims to improve its current drug reimbursement process because of budgetary constraints. One method of achieving this is to implement a formulary-listing framework specifically developed for low-income countries.

The aim of this study was to evaluate the feasibility of developing a new formulary for the MUGEFCI in Côte d'Ivoire, by implementing a formulary-listing framework specifically designed for under-researched settings.

The application of this formulary-listing framework (based on multi-criteria decision analysis [MCDA]) consisted of four steps. First, relevant formulary-listing criteria and their levels of variation were identified and weighted according to their importance in the decision making around drug reimbursement. Second, a set of priority treatments to be assessed was determined. Once the treatments eligible for reimbursement were determined, scores were assigned to these treatments according to their performance on the formulary-listing criteria levels. Finally, a composite league table (weighted matrix) was constructed to rank the set of treatments by priority order of reimbursement. A budget-impact analysis (BIA) was also conducted to appraise the economic implications of the new composite drugs league table. The extent to which the new priority list of reimbursable drugs was affordable for the MUGEFCI was then measured.

Policy makers in Côte d'Ivoire considered severity of disease and cost effectiveness of treatment to be the most significant criteria for priority reimbursement of drugs. This translated into a general preference for antimalarials, treatments for asthma and antibacterials for urinary tract infection. Moreover, the results of the BIA suggest that the new priority list of reimbursable drugs would be affordable if the real economic impact of drugs per member is less than $US66. Over this threshold, the MUGEFCI would have to select reimbursable drugs according to their rank in the priority list and their respective budget impact per patient (cost per patient). This selection would start from the first treatment, going down the list until the $US66 per patient is exhausted.

It was possible to use MCDA to simultaneously consider different decision criteria for drug reimbursement in Côte d'Ivoire; therefore, it is feasible to use MCDA to establish a formulary for low-income countries. The application of this method is a step towards transparency in policy making.