Impact of austerity on European pharmaceutical … of austerity on European pharmaceutical policy...

Impact of austerity on European pharmaceutical policy and pricingStaying competitive in a challenging environment

Foreword 1

Executive summary 2

Part 1. The environment today 3

Part 2. Mechanisms for reducing pharmaceutical spending 7

Part 3. The future pharmaceutical landscape 12

Part 4. Imperatives for the pharmaceutical industry 14

Notes 18

Contacts 21

Contents

The Deloitte Centre for Health Solutions

The Deloitte Centre for Health Solutions, part of Deloitte UK, generates insights and thought leadership based on the key trends, challenges and opportunities within the healthcare and lifesciences industry. Working closely with other centres in the Deloitte network, including the US centre in Washington, our team of researchers develop ideas, innovations and insights that encourage collaboration across the health value chain, connecting the public and private sectors, health providers and purchasers, and consumers and suppliers.

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Foreword

Welcome to the Deloitte UK Centre for Health Solutions report on the Impact of austerity on European pharmaceutical policy and pricing: Staying competitive in a challenging environment. This report was generated using a combination of secondary desk research, analysis of historical precedents and insight derived from project work and client conversations. It presents the Centre’s views on:

• current challenges faced by the pharmaceutical industry due to on-going austerity in Europe

• mechanisms being employed by governments to reduce overall spending on pharmaceuticals

• the likely future pharmaceutical landscape and the implications for pharmaceutical sales and profitability within Europe

• options available to the industry that will allow them to remain competitive in this challenging environment.

We hope that you find the research and insight informative and thought-provoking and welcome your feedback and comments.

Karen Taylor Director, Centre for Health Solutions

Impact of austerity on European pharmaceutical policy and pricing Staying competitive in a challenging environment 1



Executive summary

Across Europe, a high percentage of healthcare spending is publicly funded. The current financial climate has placed significant pressure on public spending and while the majority of governments acknowledge healthcare provision to be strategically important, their willingness and ability to pay is subject to increasing pressures. As a high percentage of healthcare costs are fixed and difficult to tackle in the short term, governments are adopting a number of aggressive pricing strategies to exert downward pressure on drugs. These include the price they are willing to pay for new drugs as well as the introduction of policies to promote the use of cheaper, generic equivalents. Indeed, evidence indicates that European Union countries are now paying less for their medicines. This, along with the high levels of debt owed by struggling governments to pharmaceutical manufacturers, is having a significant, negative impact on the operations of pharmaceutical companies active in Europe.

Countries within the European Union are experiencing different levels of pressure to rein in their pharmaceutical spending. Ten eurozone countries exhibit higher than average pharmaceutical expenditure and these are the countries currently implementing the most aggressive cost-containment policies.

Revenues from branded drugs which have been launched are of paramount importance for funding future pharmaceutical innovation. As governments seek to drive increased value from their healthcare spending, the path to commercialisation is becoming more challenging. New product launches are likely to deliver less revenue which could lead to a decline in the funding pool available for research and development. The future pharmaceutical landscape will continue to prove challenging for the industry, as financial crises exert long-term effects on a country’s pharmaceutical industry. Spending levels on drugs normally recover quickly (in absolute terms) post-recession, but with higher generic penetration.

The changing environment is hastening the development of a two-tier market, in which reimbursement prices of innovative and ‘me-too’ medicines are more widely differentiated. This has implications for pharmaceutical sales and profitability in Europe. Branded manufacturers need to be more proactive in this period of austerity, so that they can compete effectively. There are a number of strategies that manufacturers could adopt including across market and in-market actions.

Unfortunately for the pharmaceutical industry, spending on pharmaceuticals will remain a relatively easy target for rationalising healthcare costs. With governments likely to continue to apply downward pressure on pharmaceutical spending, the industry will need to adopt proactive strategies both within and across markets.

The future pharmaceutical landscape will continue to prove challenging for the industry, as financial crises exert long-term effects on a country’s pharmaceutical industry.

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Part 1. The environment today

The recent global financial crisis has impacted on governments and industries across the world. This report focuses on the crisis in Europe, and its impact on pharmaceutical companies who are active in Europe, particularly Western Europe which has borne the brunt of the crisis.

The financial crisis in Europe has ended the tendency for pharmaceutical spending growth to be above GDP growthPrior to the onset of the financial crisis in 2008, pharmaceutical companies shared in the growth of healthcare expenditure experienced across Europe. Analysis conducted by the Organisation for Economic Co-operation and Development (OECD) shows that across the OECD European Union (EU) member states, healthcare spending as a proportion of gross domestic product (GDP) increased significantly from 7.3 per cent in 2000, to 9.2 per cent in 2009. However, by 2010 healthcare spending had marginally declined to 9.0 per cent of GDP.1 Over the same period, growth in expenditure on pharmaceutical products, comprising prescription-only medicines (PoMs) and over the counter (OTC) products, had consistently been higher than GDP growth until the emergence of the financial crisis (see Figure 1).

… growth in expenditure on pharmaceutical products, had consistently been higher than GDP growth until the emergence of the financial crisis.

Figure 1. Western European pharmaceutical spending growth vs. real GDP growth, 2000-10

-5

0

5

10

15

20

GDP growthPharma spend growth

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: EIU, data accessed 15 May 2013

Western Europe defined as: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom

Gro

wth

(%)

The financial crisis has created an age of austerity across Europe with widespread cuts to public spendingThe current economic climate in the EU has placed significant pressure on government public spending with many governments implementing cost cutting initiatives. OECD data indicates that on average, in 2010, 73 per cent of healthcare was publicly funded. While the majority of governments have deemed healthcare provision as strategically important, their willingness and ability to pay for health services is under threat. Despite this, governments in the major European markets have maintained their absolute spending on healthcare since the onset of the financial crisis in the middle of 2008, due mainly to a high percentage of spending on fixed costs and increasing demand from their ageing populations.2




Unfortunately for the pharmaceutical industry, spending on pharmaceuticals remains a relatively easy target for rationalising healthcare costs. Indeed, data from the Economist Intelligence Unit (EIU) indicates that while healthcare expenditure in absolute terms has been maintained during the crisis, this is not the case for spending on pharmaceuticals (PoMs and OTC) which has declined across major European markets since 2009. In the ten years to 2009 spending on pharmaceuticals across the EU increased, on average, by 3.2 per cent annually, however in 2010 spending stalled.3

Reduced pharmaceutical spending across the region is having a significant, negative impact on the operations of pharmaceutical companies active in Europe. Evidence indicates that EU countries are paying less for pharmaceuticals. According to the European Federation of Pharmaceutical Industries and Associations (EFPIA) discounting and price cuts contributed to over €7 billion in savings in five European countries alone (Greece, Ireland, Italy, Portugal and Spain) in 2010 and 2011. The situation is exacerbated by other factors such as difficulties, and in some instances, failure of governments to pay their drug bills. At the end of 2011, EFPIA estimated that the pharmaceutical industry was owed over €12.5 billion by Greece, Italy, Portugal and Spain, with the majority of debt owed by hospitals and local governments.4

Governments are adopting aggressive pricing strategies and changing policiesContinued austerity in Europe is driving governments to seek greater value from their stretched healthcare budgets, ideally measured on the basis of improved patient outcomes. This has resulted in European governments implementing a number of pricing strategies, prescribing policies and other mechanisms aimed at reining in or reducing spending on pharmaceuticals. These are explored in more detail in Part 2.

EU countries are experiencing different levels of pressure to rein in their pharmaceutical spendingAccording to Eurostat, in 2010 the proportion of GDP consumed by total healthcare spending ranged from approximately nine to 12 per cent across major Western European economies. There was a much wider variation between countries in terms of pharmaceutical spending as a proportion of overall healthcare spending. This ranged from approximately eight to 20 per cent. Differences between countries are further highlighted when the proportion of GDP spent on pharmaceuticals is considered:

• the average spending on pharmaceuticals across all OECD countries was 1.6 per cent of GDP

• ten eurozone countries (highlighted in Figure 2) had an expenditure in excess of this benchmark.

Of note is Greece, which of the eurozone countries recorded the second highest expenditure on pharmaceuticals as a percentage of GDP in 2010. Since 2012 the package agreed with the Troika (comprising the country’s three major creditors the European Central Bank, European Commission and International Monetary Fund) has focused on reducing pharmaceutical expenditure. Its target is a reduction in pharmaceutical expenditure to just one per cent of GDP by 2014, well below the current OECD average.5

The OECD data highlights the differences in pharmaceutical spending across member countries. With several countries having similar population and patient demographics, it appears that two of the key drivers of these differences are pharmaceutical pricing and reimbursement policies, and prescribing behaviour. Interestingly, the EU countries experiencing higher levels of pharmaceutical spending as a proportion of GDP are those that are currently implementing aggressive cost-containment policies (see Figure 2).

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Figure 2. Expenditure by OECD countries on pharmaceuticals as a percentage of GDP, 2010

Hungary

Slovak Republic

United States

Greece

Japan

Portugal

France

Canada

Spain

Belgium

Mexico

Ireland

Germany

Slovenia

Poland

Italy

OECD AVERAGE

Iceland

Czech Republic

Korea

Estonia

Australia

Sweden

Finland

Switzerland

United Kingdom

Netherlands

Chile

New Zealand

Denmark

Norway

Luxembourg

0 0.5 1.0 1.5 2.0 2.5 3.0

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Eurozone countries with a higher than average proportion of GDP spending on healthcare

Percentage of GDP

Source: OECD, Health at a Glance: Europe 2012

Note: Pharmaceuticals comprise PoM and OTC drugs. In some markets they also include other medical nondurables (approximately 5%). Pharmacist remuneration has been added where it is separate from the price of medicines. Excludes medicines consumed in hospitals; includes wholesaler and retail margins, and value added tax.

… the EU countries experiencing higher levels of pharmaceutical spending as a proportion of GDP are those that are currently implementing aggressive cost-containment policies.




A price reduction in one country can exert significant downward pressure on prices elsewhereInternational reference pricing (IRP) is a tool used by governments, to ensure that the price of a pharmaceutical drug is moderated or benchmarked in line with prices in other geographies. Typically, IRP is used to cap the local reimbursement price of a drug in a specific country. It is a tool that has been implemented widely across Europe, for example:

• 25 per cent of world pharmaceutical markets benchmark the prices of drugs in the UK

• 26 countries inside and outside of Europe reference prices to Greece in some way.6

Therefore, any downward pressure on prices within referenced markets presents a significant risk to the revenues pharmaceutical companies can generate globally. In 2011 it was estimated that a ten per cent price cut in Greece cost the industry: €299 million in Greece, €799 million in Europe and €2,154 million worldwide.7 This illustrates that revisions to drug prices in referenced markets such as Greece will have an impact across Europe as well as other parts of the world.

IRP is a widely used mechanism to control drug prices. Financially-challenged countries are therefore altering their reference price benchmarks to target those countries that have lower drug prices. Of greater concern to the pharmaceutical industry is a move to take the lowest price among a group of reference price countries, instead of the average price. The Irish government has proposed such a mechanism, but only for groups of interchangeable drugs for which a generic alternative is available.8

In-market reference pricing mechanisms have existed for several years. Germany has been a leader in terms of introducing systems to benchmark prices of generic drugs and branded originals and, more recently, so called jumbo classes of compounds, deemed similar enough to deliver equivalent clinical benefits. Additionally, linking reimbursement levels to the price of the lowest available drug within a class is an effective way to reduce public drug spending. It is therefore not surprising that similar systems are being implemented in countries that are suffering most from the economic downturn.

Revenues from in-market drugs are important for funding future pharmaceutical innovationA key driver of healthcare improvements has been the development of new and more effective drugs. The development of new drugs requires investment in research and development (R&D), which can be supported by governments but more often than not is funded by the industry itself. The reasons for a declining return on investment in R&D include:

• the cost of developing an asset has remained relatively static over the last few years, while returns from launched drugs are declining9

• losses due to terminations continue to take significant value out of late stage pipeline10

• the industry is increasingly seeking to harness external scientific and medical innovation through collaborations with peers or via innovation hubs, including academia and biotech11,12,13,14

• the introduction of stricter pricing and market access hurdles has made the path to commercialisation more challenging.

The need for governments to drive increased value from their pharmaceutical spending has put renewed pressure on industry to demonstrate more clearly the value and cost effectiveness of new product launches. This has resulted in the introduction of additional pricing and market access hurdles, with premium pricing and, in an increasing number of cases, access being reserved for those drugs that can demonstrate true enhancements over existing therapies.

With new product launches expected to deliver less revenue, the funding pool available for R&D is likely to decline. Decisions being taken by policymakers and fund holders over the last few years are beginning to impact the industry’s ability to invest in R&D. A number of big pharmaceutical companies have undergone cost cutting measures to reduce their R&D footprints, rationalise internal headcount and streamline R&D operations.15,16,17 One likely positive outcome is that companies are now taking earlier and more pragmatic decisions about which compounds are likely to succeed in the clinical environment and, importantly for payers and patients, are focusing on compounds that will deliver true enhancements over existing therapies. However, a potential negative is that continued downward pressure on pharmaceutical pricing could challenge the industry’s ability to invest in the innovative medicines of the future.

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Part 2. Mechanisms for reducing pharmaceutical spending

Different mechanisms are being used across the EU to rein in pharmaceutical spending There are a range of mechanisms that governments are using to rein in pharmaceutical spending (summarised in Figure 3). These are being implemented in various ways across the EU and their impact is being felt at different levels. The mechanisms can be segmented into three broad categories:

• tried and tested strategies, such as reference pricing

• new technology-driven systems, such as electronic prescribing (e-prescribing)

• more aggressive approaches, such as clawback or rebate systems.

This section of the report highlights examples of each mechanism, including where and how they have been implemented.

Mechanisms to reduce

drug spend

Prescribing behaviours

• Introduction of international non-proprietary name prescribing

• Generic substitution, whereby a pharmacist must dispense the lowest-priced ‘interchangeable’ drug from a predetermined list

£Headline price cuts

• Transparent reductions in headline price of drugs• Price cuts tend to be mandatory and differentiated

dependent on patent status

Reference pricing calculations

• Changes to in-market and international reference pricing mechanisms, including:

– changing the countries that are referenced – modifying the calculation method e.g. selecting

the average price of cheapest three countries rather than the average of all countries

Reimbursement controls

• Positive drug lists – where only those drugs included on the positive drug list are reimbursed

• Typically these are drugs that meet strict pricing criteria

Distribution margins• Reduction in wholesaler and pharmacist margins• Level of margin differs depending on the patent

status of a drug

Rebates and clawbacks

• Introduction of rebates from the pharmaceutical industry to the country’s health system – minimising the in-market effect of price cuts on international reference pricing

£Patient co-payments

• Patient pays the excess above reimbursement price for selecting a more expensive alternative

• The reimbursement level is set at the price of cheapest available drug

Tendering• Increased tendering for products at a regional

level within markets

Figure 3. The Mechanisms driver tree

Source: Deloitte LLP research




Adoption of mechanisms to reduce drug spending within the EU

Prescribing behaviours

Greece Portugal Italy

International non-propriety name prescribing and e-prescribingINN prescribing mandates that prescribers should write prescriptions according to the active ingredient, not the brand name.

Greece introduced INN prescribing in 2012 to reduce its drugs bill. The proposal included a series of exceptions and exclusions that may mitigate the effect on patients continuing therapy or with particular conditions. It also allows physicians a 15 per cent allowance by volume for branded prescriptions.18 The pharmaceutical industry in Greece strongly opposed the measures as unnecessary and potentially damaging to patient access.19

One way to promote INN prescribing is to implement an e-prescribing system where the brand name on a prescription automatically reverts to the generic name. Countries that have introduced or reinforced e-prescribing include Estonia, Lithuania and Portugal.20

Since 2011 Portugal will only reimburse for drugs prescribed via an INN e-prescribing system.21

Generic substitutionGeneric substitution is where dispensers are directed to dispense the cheapest identical product ignoring any brand-specific prescriptions. Of 29 countries across Europe, 23 are using generic substitution.22 This has been in place in EU countries since 2003, however there have been adaptations to systems including a requirement for patients to pay the difference should they opt for a more expensive brand, and the introduction of ‘reference groups’ to discern interchangeable products.

Greece and Italy both mandate patient co-payments should a patient choose a branded drug.

£Headline price cuts

FranceGermany PortugalSpainIreland

Headline price cuts are where governments impose a transparent reduction to a medicine’s list price. These reductions can cause significant price declines in other markets due to international reference pricing.

France: The new government pledged to keep drug reimbursements at 2012 levels while seeking efficiencies in the healthcare system. These efficiencies include reductions in the cost of medicines and other healthcare products. Price cuts on originator and generic products are targeted to save €530 million by the end of 2013.23

Germany: In 2010, parliament passed the Pharmaceuticals Market Reorganisation Act (Arzneimittelmarkt-Neuordnungsgesetz – AMNOG), which assesses the therapeutic benefit of a drug versus a comparator and includes a mandate for retrospective assessment of additional benefit for medicines previously deemed to be innovative.24 Existing novel drugs will undergo comparisons with the current market, with price cuts applied should the drug no longer be deemed innovative.25

Portugal and Spain: In 2010, both these countries introduced a wave of mandatory price cuts which reduced the prices of generic medicines by a much larger proportion than branded drugs. Portugal reduced generic prices by 30 per cent and branded drug prices by six per cent,26 while Spain reduced generics by 25 per cent and branded drug prices by ten to 16 per cent.27

Ireland: In October 2012 the Irish Department of Health, Health Service Executive and Pharmaceutical Health Association agreed mandatory price cuts for pharmaceuticals.28

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Reference pricing calculations

Greece PortugalIrelandGermany

International reference pricingGreece: In September 2010, a new reference pricing paradigm was introduced whereby the price set was the average price of the three cheapest EU markets. The new system resulted in average price reductions of 9.5 per cent.29 In 2011 an EFPIA letter stated that a ten per cent price cut lost industry €299 million in the Greek market and €799 million across EU countries that reference Greece directly or indirectly.30

Portugal: In 2011 it altered the EU states that it references to include the Eastern European state of Slovenia.31

In-market reference pricingIreland: On patent expiry, the price to the wholesaler of a medicine will be reduced to 70 per cent of the original price. A year after this reduction the wholesaler price will be reduced to 50 per cent of the original price. For existing patent expired medicines, the price to the wholesaler will be reduced to 60 per cent of the original price, and a further reduction to 50 per cent of the original price will follow a year after.32

Germany: Existing product prices have been amended based on reference to the price of a class of similar or interchangeable compounds (jumbo group) as soon as the first generic is launched.33

Reimbursement controls

Greece Ireland

Reimbursement or positive lists have been in existence for several years. Introduction of such lists in periphery countries will control volumes of premium priced medicines and, importantly for governments and payers, the amount of public sector funding that is used to pay for them. Setting the reimbursement level at that of the lowest priced drug within a group of interchangeable drugs will shift the cost burden of more expensive medicines firmly to patients. If they desire a more expensive brand, then the patient will have to pay the difference. The existence of a positive or reimbursed list also allows payers to choose which drugs and classes of drugs are eligible for reimbursement.

Greece: In September 2012 a drug price schedule (positive list) was reintroduced whereby only products meeting strict pricing criteria will be eligible for reimbursement. The reintroduction of such a list provides an immediate instrument for Greece to reduce drug spending as some drugs will no longer be eligible for reimbursement.34

Ireland: There are plans to introduce a reimbursement list in 2013.35




Distribution margins

Greece IrelandItalyGermany

Distribution margins vary widely throughout the EU. However, the vast majority of countries enforce some form of margin control, with only six countries not enforcing wholesaler margin regulation.36

Greece: In 2012, pharmacy margins for reimbursed medicines were reduced from 26 per cent to 16 per cent, and to €30 on products priced at €200 or more. Wholesaler margins were reduced from 6.5 per cent to 4.9 per cent.37

Ireland: In 2011, the government reduced wholesale mark-up on most drug items from ten per cent to eight per cent. Further reductions in 2011 resulted in additional, on-going savings of more than €34 million.38

Italy: In July 2010 margins for reimbursed drugs were reduced by 1.82 per cent. Originally margins were due to be reduced by 3.65 per cent; however this was reduced to 1.82 per cent with a requirement that manufacturers pay 1.83 per cent of the price of their drugs to regional health authorities.39

Germany: The government has aimed to increase transparency of negotiated pharmaceutical prices throughout the supply chain. To the dismay of the industry, prices are effectively in the public domain as they are disclosed by pharmacists.40

Rebates and clawbacks

Italy FrancePortugalGreece

Italy: Since 2010, rebates must be paid retrospectively when the cap for reimbursed medicine spending has been exceeded, for example drug spending higher than 11.5 per cent of total healthcare spending. The scheme is administered at a regional level and requires repayment of 6.5 per cent of the drugs sold to Italy’s national health service. The industry is responsible for paying 100 per cent of retail overspending and 50 per cent of hospital overspending, with over-budget regional payers also accountable for hospital overspending and mandated to pay the other 50 per cent.41

Payments for the rebate scheme are calculated twice a year based on two, six-month periods.42 The payment required for rebates is based on data collected by the Observatory on the use of Medicines. Companies are provided with an annual budget based on health service purchases of a company’s medicines.43

France: Pricing and reimbursement are determined by price/volume agreements where the manufacturer provides an estimate of the patient population and, therefore, the cost of the new drug to the healthcare system. If this cost is exceeded, the manufacturer has to pay a clawback.44

Portugal: Introduction of a payback system, whereby the pharmaceutical industry will pay the amount of overspending, if drug spend exceeds the 1.25 per cent of GDP target in 2012 or 2013 respectively.45

Greece: In 2012 the pharmaceutical industry offered to set a ceiling on the amount the Greek government would pay for outpatient prescription drugs for the year. In return, the government would pledge that it would pay the €1.7 billion the industry is owed by the healthcare system.46 The clawback brokered by EFPIA set a €2.88 billion ceiling on Greece’s pharmaceutical spending for 2012. Reports indicate that as the government is failing to reduce the debt it owes industry, the system is still under negotiation.47

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The implementation of these mechanisms has impacted the prices of pharmaceuticals in a number of EU countries. Of note are three experiencing severe financial difficulties:

• in 2011 in Portugal, combined sales of branded and generic drugs declined by ten per cent or €312 million compared with 201056

• over the last ten years, the prices of medicines have fallen by 28 per cent in Italy57

• after the introduction of reference pricing in Greece in 2010, average drug price reductions of 9.5 per cent were realised. This was partly due to manufacturers reducing the prices of branded drugs to close to that of the reimbursed price to ensure that their brands are dispensed in preference to a cheaper generic.58

£Patient co-payments

IrelandPortugalItaly

Ireland: The patient co-payment system is being redesigned as part of the July 2012 Health (Pricing and Supply of Medical Goods) Bill. Patients will pay the excess if they choose to have a higher priced drug dispensed instead of a cheaper generic. The bill does not change existing arrangements for the supply of items through community pharmacies. In addition, it provides exceptions on clinical grounds allowing patients to continue to have access to prescribed medicines. Patients will face no additional charge if a particular brand of medicine is required for clinical reasons.48

Portugal: A percentage rate co-payment is applied which is determined by the category of drug prescribed (A,B,C or D). If a generic is dispensed the patient co-payment is 10% less than the co-payment for an equivalent brand.49 Revenues from patient co-payments were expected to double between 2011 and 2012, amounting to an extra €80-90 million.50

Italy: A patient co-payment system was introduced as a flat rate but then changed to a fixed charge plus a percentage of the drug price, to incentivise patients to choose a cheaper drug.51

Tendering

Netherlands Tenders are issued and the lowest price bidder wins the right to supply the market. The terms of the tender can vary and are decided by the body issuing the tender.

Tendering tends to occur more in the generics market, where 52 per cent of global spending is offered for tender, compared with only 14 per cent of branded drug spending.52 A recent survey of 19 EU countries showed that tendering was more popular in countries with a mature generic medicines market (54 per cent of countries) than in countries with a developing generic medicines market (12.5 per cent).53 Tendering and contracting are more widespread in emerging markets, but the growth of tendering is increasing in Western Europe.

The customers who are most likely to tender vary country to country but broadly include governments and hospitals. Tendering programmes can achieve significant savings in the short term. However, programmes have to be well designed to deliver intended savings in the long term.54

Netherlands: In 2008, tendering for 33 off-patent drugs decreased prices by as much as 95 per cent, with immediate price savings achieved. However, Dutch authorities had to balance these savings against losses in the distribution chain because of the retail system’s reliance on discounts.55




Part 3. The future pharmaceutical landscape

The recent financial crisis is not the first to have had an impact on the pharmaceutical industry, nor is it likely to be the last. This part of the report examines some of the lessons from past crises and evaluates the likely impact of the current crisis on the future pharmaceutical landscape.

Lessons from history: How pharmaceutical markets developed in Argentina, Japan and Turkey following prolonged recessionsThere are many examples where financial crises directly impacted the local pharmaceutical industry. Evaluation of historical precedents in Argentina, Japan and Turkey identifies a common pattern of events leading up to, during and after the financial crisis:

1. Currency devaluation

2. GDP contraction resulting in a reduction in public sector health expenditure

3. Policies focus on reducing expenditure on pharmaceuticals for example:

a. introduction of in-market and international reference pricing (IRP) systems

b. an increase in competitive tendering

c. mandatory price cuts

d. promotion of INN prescribing and/or generic substitution

4. Once economic growth returns, drug spending levels return to pre-crisis levels, but generic medicines gain a significant increase in market share.

The following case studies are illustrative of the potential impact an economic crisis can exert on a country’s pharmaceutical industry.

ArgentinaArgentina’s economic crisis started in 1998 and lasted four years, during which the economy shrank by 28 per cent. The government implemented INN prescribing and increased competitive tendering, which decreased the value of prescribed drugs by as much as 45 per cent, and delivered estimated annual savings of $145 million.59 While economic growth returned after two years, it took seven years for pharmaceutical sales to return to pre-crisis levels.

Japan Between 1994 and 2011 Japan suffered a total of six years of negative economic growth, with no year posting growth of three per cent or more between 1992 and 2010.60 Japan traditionally spent heavily on pharmaceuticals, as high as 21 per cent of total healthcare spending in the 1990s. In recent years the government has introduced several reforms to reduce this level of spending including biennial pricing reviews, often resulting in price reductions,61 and measures to expand the use of generic drugs to 30 per cent of the pharmaceutical market, in volume terms, by March 2013.62

TurkeyTurkey underwent a significant recession during 2001 fuelled by two separate, financial crises. GDP shrank from $589 billion to $561 billion and inflation increased by 68 per cent. In 2004, the Turkish Ministry of Health introduced IRP, which is estimated to have saved the Turkish government over $900 million annually. The use of generic medicines was promoted through the introduction of generic substitution laws and mandatory price cuts on generic drugs.63 As a consequence the level of generic penetration in Turkey increased markedly and, by 2005, the generic market was estimated to be worth €1.8 billion, accounting for 51 per cent of the overall drugs market in terms of volume and 35 per cent by value.64

The impact of the crises on the countries’ healthcare systems, and their pharmaceutical industries specifically, has had greater longer-term effects than the recessions themselves. Each country exhibited an increase in total healthcare and pharmaceutical spending, but with higher generic penetration.

However, it is unrealistic to use Argentina, Japan and Turkey as exact proxies for the current situation in Europe, as there are considerable differences between these markets, notably monetary union. Members of the eurozone are prohibited from devaluing their currency (the euro) unilaterally. Hence the first event in the pattern identified above does not hold. However, we have seen events 2 and 3 emerging across many countries in Europe since the start of the global financial crisis.

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Reimbursement prices between innovative and me-too medicines are becoming more widely differentiated The changing pharmaceutical and policy environment is hastening the development of a two-tier market in which innovative and undifferentiated, or me-too medicines are treated very differently in terms of the rules governing their pricing and reimbursement. As well as the mechanisms highlighted in Part 2, there are three trends that are hastening this differentiation:

• the rise of value-based pricing (VBP) being introduced in a number of countries across Europe and due to be launched in the UK from January 2014

• a rise in tendering, not only for generics, but also for drugs within the same class

• an increase in in-market reference pricing for groups of interchangeable drugs.

This differentiation will mean greater competition for drugs within a class and, increasingly, premium pricing only for those drugs with a distinct patient or indication-based value offer. Demand for these innovative products will be high in Europe, but if the prices demanded by manufacturers are to be funded by already pressurised payers, many of the cost savings required to pay for them will likely come from savings in other areas of the healthcare and drug budget.

Implications for pharmaceutical sales and profitability in EuropeThe EIU anticipates that by 2016 the developed European pharmaceutical market will recover the sales value lost since the beginning of the financial crisis in 2008 (See Figure 4). However, sales will likely not exceed pre-crisis levels until 2017. Sales growth is forecast to be low, about 0.9 per cent compounded annually between 2011-17, while over the same time period Datamonitor estimates profitability growth will reach 1.3 per cent for the six largest European pharmaceutical companies.

Companies that are used to operating in a more competitive pricing environment, such as generics manufacturers, will already have developed the operational efficiency necessary to remain profitable in this environment. However, there are several actions that branded manufacturers should consider to adapt to this changing market scenario.

Figure 4. Western European pharmaceutical sales, 2000-17

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Source: EIU Data tool, accessed 23 May 2013

Note: 2000-09 actual, 2010-12 estimates, 2013-17 forecasts

Exceptions: Austria, Denmark, Ireland, Spain, Sweden, Switzerland: 2000-08 actual; 2009-12 estimates; 2013-17 forecasts; Italy, Netherlands, Norway: 2000-09 actual; 2010-12 estimates; 2013 forecasts

US$

bill

ion

The EIU anticipates that by 2016 the developed European pharmaceutical market will recover the sales value lost since the beginning of the financial crisis in 2008.




Part 4. Imperatives for the pharmaceutical industry

The industry needs to become more proactive to survive current austerity With changing healthcare policies across Europe, it is essential for pharmaceutical companies to build the data sets and capabilities to support the operational excellence needed to navigate reference pricing systems and manage any increase in tendering activities. In November 2012, the EIU in collaboration with Deloitte undertook a global study to examine the recent wave of global healthcare reforms.65 The study included a survey to assess pharmaceutical company executive perceptions of how their companies are reacting to these reforms. Two-fifths of pharmaceutical executives interviewed believed that their company is too reactive to drug policy changes (see Figure 5). A minority, 20 per cent of respondents, considered their company response to be part of broader, considered strategic change.

Given the hastening pace of change it is time for a more proactive response both in and across markets. In this section we highlight nine actions, both in-market and across market, companies can take to be more proactive and allow them to remain competitive (see Figure 6). While some of these are already being implemented, greater application at scale and pace is needed.

41%

39%

20%

Agree Neither agree nor disagree Disagree

Source: EIU survey, November 2012

Figure 5. Two-fifths of pharmaceutical executives agree that their company’s response to reform is reactiveQuestion: My company’s response to healthcare reforms tends to be reactive rather than part of broader, considered strategic change

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Figure 6. Across market and in-market actions

Overarching action

Link future pricing models to real-world data and patient outcomes

• Work in partnership with payers and providers to build infrastructure and ensure data is gathered around drug utilisation and patient outcomes

• Allows the gathering of real-world evidence to support drug efficacy and impact statements

Across market actions In-market actions

Effective international reference pricing management

• Enhance pricing models so that price trajectory across Europe can be understood

• Allows company pricing expertise to be directed to those countries which are likely to have greatest impact on IRP

• Informs strategies in countries which allow free-pricing

Improve regulatory affairs and pharmaceutical reputation

• Aim to build relationships with regulators to ensure that payers understand the value of pharmaceutical products and the industry to their local market

Low cost commercial models

• Low cost models could assist companies in a pricing constrained market

• Strategies include reducing sales forces or employing a distribution-only strategy for non-core products

Improve data efficiency to enhance business intelligence

• Improve data efficiency to support internal reference pricing and tendering activities

• This includes improving data analytics, competitive market intelligence and understanding of customer profitability

Pharmaceutical company delivered patient services

• Manufacturers could extend the delivery of therapeutically aligned services, pill-plus service models that reduce financial pressure on health systems

Improve cost transparency across portfolios

• Review portfolio profitability – enhance cost allocation across the portfolio

• Scale up divestment of less profitable brands

Lobby • Membership of industry organisations such as EFPIA increases in value in times where the industry needs to understand its collective bargaining power

Review the role of generics and biosimilars

• Expand or introduce generic or biosimilar products in countries with rapidly growing generic share

• Extend partnerships with biosimilar or generic manufacturers

Source: Deloitte LLP research




An overarching need to link future pricing models to real-world data and patient outcomesThe next generation of innovative, targeted medicines, for example in cancer care, will pose a significant cost burden for payers. Targeting these therapies to highly specific patient populations will help to ease this burden and ensure that health outcomes are maximised. However, their high cost may still limit access for patients in western healthcare systems. Payers will increasingly expect reimbursement of high cost, innovative, next generation therapies to link to real-world utilisation and outcomes.

Mechanisms that link price more closely with the real-world value of a therapy, in either specific indications or through actual patient outcomes, will be needed to ensure that patients continue to have access to innovative medicines. Such value-based pricing models should move beyond ‘risk-sharing’ to systems that employ utilisation and outcomes data in a holistic fashion. This will require a fundamental shift in how all healthcare stakeholders work together, including governments, providers, clinicians and pharmaceutical companies.

In addition, the requirement for systems utilising often complex outcomes data could provide significant opportunities for new technology entrants who are able to manage the data required. This is likely to cause a fundamental shift in how information is governed, controlled and shared across stakeholders active within healthcare systems.

Across-market actions aim to decrease the impact of international reference pricing

Effective IRP managementWhile the economic environment remains unstable, prices across Europe will continue to decline. This trend may worsen as those countries that are have relatively strong economies, such as the UK and Germany, recognise the trend across Europe and seek to capitalise on it to reduce public spending on pharmaceuticals and improve government finances.

To tackle this, pharmaceutical companies need to develop the data sets and capabilities required to manage the potential negative impacts of IRP effectively. For example, companies may need to improve their pricing models to understand price trajectory across Europe. Currently many models only look at pricing and monitor expected changes when there is an announced price change in a country. In a situation where the pricing environment is deteriorating, it would be advantageous for business planning to run forward-looking scenarios and stress test the in-market pricing trajectory and the implications of in-market changes on IRP. This will enable a pharmaceutical company to redirect business planning initiatives to the countries where resources can be used to influence the direction of IRP.

Low cost commercial modelsMoving to a lower cost commercial model, such as reducing sales forces or employing a distribution-only strategy for non-core products, can assist in mitigating the profit implications of a market and economic environment in which trading and pricing are experiencing a significant downturn.

Assessing the cost effectiveness of different sales channels helps companies to identify the right multi-channel mix for their medicines and, importantly, how to allocate spending to maximise returns. This type of assessment typically requires upfront investment in channel tracking along with pilot projects in periphery markets. The end goal is to achieve an improvement in the sales effectiveness of different channel spending, measured by change in sales relative to promotional spending. This will facilitate a move to a lower cost sales model.

Patient services delivered by pharmaceutical companiesOver time manufacturers could extend the pace and scale of developing therapeutically aligned services, pill-plus service models that reduce financial pressure on healthcare systems. Examples could include providing a diabetes education service for patients starting insulin therapy. Real-world evidence from local healthcare systems could be used to illustrate the cost savings from pill-plus service models, increasing the value offered to healthcare payers and their willingness to pay for drugs which manufacturers are prepared to support with such services.

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Lobby and improve relationships with payersMembership of industry groups such as EFPIA increases in value in times when the industry needs to understand its collective bargaining power. EFPIA conducts research into the impact on industry of the changing pricing environment in Europe and is able to co-ordinate the industry’s response to understand the options available when negotiating with central government. EFPIA could help to negotiate with governments who are referencing the prices of drugs in markets undergoing financial crisis, to ensure that countries with healthier economies do not benchmark local prices against financially-stressed member states for a set period.

In-market actions to manage the effects of internal reference pricing and tendering Improve regulatory affairs and pharmaceutical reputationThe reputation of the pharmaceutical industry and the relative importance of the industry to a country, for example through R&D investment, will be important as it negotiates price cuts with governments. An increased emphasis on promoting a positive public perception, improving or maintaining good government relations and regulatory affairs will be essential. Decisions dictated by short-term profitability may harm a pharmaceutical company’s reputation and business, therefore a longer-term view will need to be considered.

Improve data efficiency IRP and in-market reference pricing are key policy mechanisms across Europe. Their importance is set to increase and pharma’s ability to maximise sales and profitability will depend on building data sets and capabilities to manage and optimise pricing in this constrained environment. Any rise in tendering practices also requires a similar skill set.

Companies need to have a comprehensive and accurate view of the basics, for example pricing analysis showing where discounts are given and profit is lost starting from list price. They should expand their capabilities in obtaining competitive intelligence and developing an understanding of profitability by customer segment. Ensuring that the systems architecture, data and capabilities are in place locally will provide a foundation for operational efficiency in pricing.

Improve cost transparency across portfoliosPortfolio reviews that include cost allocation by brand enable a complete understanding of the costs associated with marketing a drug and the real profitability of each product. When costs can be matched with income levels, an unbiased decision can be made about whether to continue commercialising products that are delivering less profit versus other drugs in the portfolio. Brands that are identified as poor performers can either be divested completely, withdrawn from specific markets or have their marketing strategy altered.

Review the role of generics and biosimilarsDeveloping biosimilar products or establishing partnerships with generic manufacturers can help manufacturers of branded products maintain market share. However, many branded manufacturers are selective about the markets in which they have generic portfolios, and a number have publically stated that generic medicines are not part of their long-term strategy. This lack of flexibility removes some of the options available to branded manufacturers to offset market share losses in the patented drug market with gains that could potentially be obtained by becoming active in the generics and/or biosimilars markets.

ConclusionClearly, governments will continue to apply downward pressure on pharmaceutical spending. However, there is not a one size fits all solution, cost-reduction strategies will be implemented in varying ways in each country. Branded manufacturers need to take this into account when considering which of the above actions are most appropriate for their organisation and geographic footprint. Adopting proactive strategies both within and across markets will be essential in helping the industry to meet the on-going challenges posed by continuing financial austerity.




Notes

1. Health at a Glance: Europe 2012, Organisation for Economic Co-operation and Development Publishing, November 2012. See also: http://dx.doi.org/10.1787/9789264183896-en

2. Ibid.

3. Ibid.

4. Letter from EFPIA President, Sir Andrew Witty, to European Heads of States and Governments, European Federation of Pharmaceutical Industries and Associations, June 2012. See also: http://www.efpia.eu/sites/www.efpia.eu/files/EFPIA% 20Summit%20Letter%20FINAL%20200612.pdf

5. Greece Memorandum of Understanding on Specific Economic Policy Conditionality, Draft 9 February, 2012. See also: http://www.scribd.com/doc/81233785/Greece%E2%80%94Memorandum-of-Understanding-on-Specific-Economic-Policy-Conditionality-9-Feb-2012

6. The Pharmaceutical Price Regulation Scheme: An OFT market study, Office of Fair Trading, February 2007. See also: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153015/


8. Health (Pricing and Supply of Medical Goods) Bill 2012, Houses of the Oireachtas, July 2012. See also: http://www.oireachtas.ie/documents/bills28/bills/2012/6312/b6312s.pdf

9. Measuring the return from Pharmaceutical Innovation 2012: is R&D earning its investment? Deloitte LLP, December 2012. See also: http://www.deloitte.com/view/en_XB/xb/news/b47f30374ca4b310VgnVCM2000003356f70aRCRD.htm

10. Ibid.

11. Johnson & Johnson Announces Plans to establish Innovation Centers, Johnson & Johnson website, 18 September 2012. See also: http://www.jnj.com/connect/news/all/johnson-and-johnson-announces-plans-to-establish-innovation-centers

12. Innovation and Investment, GSK website, accessed 6 June 2013. See also: http://www.gsk.com/partnerships/ innovation-and-investment.html

13. AZ sets up virtual neuroscience unit in Cambridge, Business Weekly, 2 February 2012. See also: http://www.businessweekly.co.uk/biomedtech-/13519-az-sets-up-virtual-neuroscience-unit-in-cambridge

14. Pfizer Global research and Development, Pfizer website, accessed 6 June 2013. See also: http://www.pfizer.com/lajolla/

15. AstraZeneca to invest £330 Million in new strategic R&D centre and global headquarters in Cambridge, AstraZeneca website, March 2013. See also: http://www.astrazeneca.com/Media/Press-releases/Article/18032013--astrazeneca-to-invest-research-centre-and-global-hq

16. Pfizer site in Sandwich set to retain 650 jobs, BBC, 4 November 2011. See also: http://www.bbc.co.uk/news/uk-england-kent-15584902

17. Roche to streamline research and development activities, Roche website, 26 June 2012. See also: http://www.roche.com/investors/ir_update/inv-update-2012-06-26.htm

18. INN Prescribing in Greece–The New Generic Frontier?, HIS, 29 November 2012. See also: http://healthcare.blogs.ihs.com/2012/11/29/inn-prescribing-in-greece-the-new-generic-frontier/

19. INN RX is not needed says Greek pharma, SCRIP, December 2012. See also: http://www.scripintelligence.com/home/INN-Rx-is-not-needed-says-Greek-pharma-338537

20. Ibid.

21. The current state of the Pharmaceutical Industry in Portugal, European Industrial Pharmacists Group 2012 General Assembly, 5 May 2012. See also: http://www.eipg.eu/records/2012/Pharma%20in%20Portugal.pdf

22. Health (Pricing and Supply of Medical Goods) Bill 2012: Second Stage, House of Oireachtas, 19 July 2012. See also: http://debates.oireachtas.ie/seanad/2012/07/19/00009.asp

23. France to tackle deficit with more price cuts, generic prescribing and promo cuts, SCRIP, October 2012. See also: http:// www.scripintelligence.com/home/France-to-tackle-deficit-with-more-price-cuts-generic-prescribing-and-promo-curbs-335758

24. AMNOG – evaluation of new pharmaceutical, GKV Spitzenverband, 2013. See also: http://www.gkv pitzenverband.de/english/statutory_health_insurance/amnog___evaluation_of_new_pharmaceutical/amnog___evaluation_of_new_pharmaceutical_1.jsp

25. Price cuts loom on latest pre-AMNOG call up, SCRIP, April 2013. See also: http://www.scripintelligence.com/home/Price-cuts-loom-on-latest-pre-AMNOG-call-up-342452

26. Portugal Pharmaceuticals and Healthcare Report Q1 2011, Research and Markets, November 2010. See also: http://www.researchandmarkets.com/research/a948d5/portugal_pharmaceu

27. Spain pharma: Deep cuts, EIU, 17 June 2010. See also: http://viewswire.eiu.com/index.asp?layout=ib3Article&pubtypeid=1152462500&article_id=707209455&fs=true

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28. Policies to Enhance Prescribing Efficiency in Europe: Findings and Future Implication, Front Pharmacol. 2010:1: 141, October 2010. See also: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153015/

29. Ignore our drug prices’ Greece tells Europe, SCRIP, December, 2012. See also: http://www.scripintelligence.com/home/ Ignore-our-drug-prices-Greece-tells-Europe-338216



32. The State Medicines Bill, Irish Pharmaceutical Healthcare Association, October 2012. See also: http://www.ipha.ie/alist/ the-state-medicines-bill.aspx

33. Policies to Enhance Prescribing Efficiency in Europe: Findings and Future Implication, Front Pharmacol. 2010:1: 141, October 2010. See also: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153015/

34. Troika sets new conditions for pharmaceutical savings in Greece, HIS, October 2012. See also: http://www.ihs.com/products/global-insight/industry-economic-report.aspx?id=1065972416


36. The Pharmaceutical Distribution Chain in the European Union: Structure and Impact on Pharmaceutical Prices, Panos Kanavos, Willemien Schurer and Sabine Vogler, March 2011. See also: http://ec.europa.eu/enterprise/sectors/healthcare/files/docs/structimpact_pharmaprices_032011_en.pdf

37. Ministerial Decision Nr. 3/7789: Provisions on the pricing of medicinal products, The Alternate Minister of Health, Greece, January 2013. See also: http://www.sfee.gr/files/story/NEW_Ministerial%20Decision_Pricing_DYG3_a_oik%2097018_2012.pdf


39. Biosimilar policies in Italy, Generics and Biosimilars Initiative, May 2012. See also: http://www.gabionline.net/layout/set/print/Country-Focus/Italy/Policies-and-Legislation

40. Germany pricing and reimbursement, Datamonitor Healthcare, February 2013. See also: https://service.datamonitorhealthcare.com/hkc/strategy/market-access/pricing-and-reimbursement/article95501.ece

41. No dolce vita as Italian pharma faces full monti cuts, SCRIP, July 2012. Available at; http://www.scripintelligence.com/home/ No-dolce-vita-as-Italian-pharma-faces-full-Monti-cuts-332594

42. Elenco Dei Provvedimenti di interesse del settore approvati da gennaio 2011 a maggion 2012 (List of approved measures of interest field of approved January 2011 to May 2012), Farmaindustria, 2012. Available at: http://www.farmindustria.it/ pubblico/in201205.pdf

43. How do you hurt us? Let me count the ways, SCRIP, July 2012. See also: http://www.scripintelligence.com/therapysector/How-do-you-hurt-us-Let-me-count-the-ways-Assobiotecs-Palmisanos-lament-333393

44. French Pharmaceutical System: Focus on pricing and reimbursement, Sophie Delcroix-Lopes, CNAMTS, September 2011. See also: http://whocc.goeg.at/Downloads/Conference2011/PraesentationenPPRIKonferenz/Day2_morning_Sitzungssaal_0945_Delcroix.pdf


46. Drugmakers tell Greece we’ll cap your medicines bill, PharmaTimes, November 2012. See also: http://www.pharmatimes.com/Article/12-11-06/Drugmakers_tell_Greece_we_ll_cap_your_medicines_bill.aspx

47. Greece “drops pharma clawback plan” PharmaTimes, 19 October 2012. See also: http://www.pharmatimes.com/Article/12-10-19/Greece_drops_pharma_clawback_plan.aspx

48. Health (Pricing and Supply of Medical Goods) Bill 2012, Houses of the Oireachtas, July 2012. See also: http://www.oireachtas.ie/documents/bills28/bills/2012/6312/b6312s.pdf

49. Is It Time to Reconsider the Role of Co-Payments in Europe? Office of Health Economics, January 2012. See also: http://news.ohe.org/2012/01/11/is-it-time-to-reconsider-the-role-of-co-payments-in-europe/

50. The Economic Adjustment Programme for Portugal, Sixth Review – Autumn 2012, European Commission, December 2012. See also: http://ec.europa.eu/economy_finance/publications/occasional_paper/2012/pdf/ocp124_en.pdf

51. Italy Healthcare System and Drug Regulatory Analysis, Datamonitor Healthcare, December 2012. See also: https://service.datamonitorhealthcare.com/hkc/strategy/market-access/regulation/article91206.ece

52. Tendering & Contracting for generic & branded medicines across Europe – a comparison and Benchmarking, Nico Bacharidis, November 2011. See also: http://www.ghp.org.uk/ContentFiles/PDIG%20Nico%20Bacharidis%20Presentation%20-%20Nov%202011.pdf




53. Tendering for outpatient prescription pharmaceuticals: what can be learned from current practices in Europe?, P Dylst, A Vulto and S , Simoens, Health Policy 101(2):146-52, July 2011. See also: http://www.ncbi.nlm.nih.gov/pubmed/21511353

54. Ibid.

55. Differences in costs of and access to pharmaceutical products in the EU, European Parliament, March 2011. See also: http://www2.lse.ac.uk/businessAndConsultancy/LSEConsulting/pdf/pharmaceuticals.pdf

56. The current state of the Pharmaceutical Industry in Portugal European Industrial Pharmacists Group 2012 General Assembly, 5 May 2012. See also: http://www.eipg.eu/records/2012/Pharma%20in%20Portugal.pdf

57. Facts & Figures of Pharmaceutical Industry in Italy, Farmindustria, January 2013. See also: http://www.farmindustria.it/pubblico/slide_Brochure_2012_INGLESE.pdf

58. Greece, Pharmaceuticals & Healthcare Report, Business Monitor International, Q3 2012

59. Health policy and planning, Improving access to pharmaceuticals in Brazil and Argentina, Núria Homedes and Antonio Ugalde, March 2006. See also: http://heapol.oxfordjournals.org/content/21/2/123.fullhttp://heapol.oxfordjournals.org/content/21/2/123.full

60. EIU, Data tool, 2013. See also: http://data.eiu.com/default.aspx?geography_id=0&pubtype_id=1383181323

61. Japan: Healthcare and Pharmaceuticals Report, EIU, 2013. See also: http://viewswire.eiu.com/index.asp?layout=ib3Article&article_id=830542267&pubtypeid=1152462500&country_id=1580000158&category_id=775133077

62. Japan: Healthcare and Pharmaceuticals Report, EIU, 2013. See also: http://viewswire.eiu.com/index.asp?layout=ib3Article&article_id=720202456&pubtypeid=1152462500&category_id=775133077&country_id=1580000158&page_title=Forecast

63. Turkey: Health System Review, Health Systems in Transition, Vol. 13, No. 6, 2011. See also: http://www.euro.who.int/__data/assets/pdf_file/0006/158883/e96441.pdf

64. Generic Drugs in Turkey, IEIS. See also: http://www.ieis.org.tr/YAYINLAR/gendruginTr.pdf

65. Health care reform and life sciences: Threat, opportunity or both? EIU, November 2012. See also: http://www.deloitte.com/view/en_GX/global/industries/life-sciences-health-care/health-care/df94ab7450e0e310VgnVCM1000003256f70aRCRD.htm?id=us_twitter_deloittehealth_LS_EIUHCReform_042813

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Contacts

Deloitte LLP

Simon HammettPartner, EMEA Healthcare and Lifesciences Lead+44 (0) 20 7303 [email protected]

John HaugheyPartner, UK Healthcare and Lifesciences Lead+44 (0) 20 7303 [email protected]

Manfred BernersPartner+44 (0) 20 7007 [email protected]

Karen TaylorDirector, Centre for Health Solutions+44 (0) 20 7007 [email protected]

Authors Elizabeth HampsonManager+44 (0)20 7007 [email protected]

Karen YoungSenior Manager, Centre for Health Solutions+44 (0)20 7007 [email protected]

Matthew ChisambiAnalyst+44 (0) 20 7003 [email protected]

ContributorsAlex Cole, Stuart Donald, Hannah Harris, Alex Hermer, Mohit Maheshwari, Abhimanyu Yadav.

Contact informationTo learn more about the Deloitte Centre for Health Solutions, its projects and events please visit:www.deloitte.co.uk/centreforhealthsolutions

Deloitte Centre for Health SolutionsStonecutter Court1 Stonecutter Street 01/09London EC4A 4TR

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