Comparative analysis of prices, public expenditures, and utilization of biological disease modifying drugs for treatment of inflammatory joint diseases in Bulgaria and Serbia

PCV75 IMPACT of Generic Competition on Reference Price per DDD and Reimbursed Costs on Antihyperlipidemic Medicines

Therapy for inflammatory joint diseases, such as rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis, includes various conventional disease-modifying antirheumatic drugs (DMARDs). These therapeutic agents are termed DMARDs because they have the potential to reduce or prevent joint damage and preserve joint integrity and function. Conventional DMARDs are used as monotherapy or in combination and include methotrexate, leflunomide, azathioprine, ciclosporin, hydroxychloroquine, sulfasalazine, gold and minocycline. Biologic response modifiers, which are based on proteins made by living cells, are newer agents available for the treatment of various inflammatory joint diseases. Biologic therapies now approved for use in inflammatory joint diseases are TNF inhibitors, T-cell modulators and B-cell depleters. They have all been shown to have clinical efficacy and are able to retard structural damage. However, all current immune-modulating therapies also have potential side effects, and the decision to use a particular agent for treatment should be based on a thorough discussion of the benefits and risks with the patient. Newer biologic response modifiers and other immunologic therapies are currently being developed for the treatment of inflammatory joint diseases and are discussed in this review.

The purpose of this paper is the analysis of public expenditures in the education and health sectors in relation to economic development in Kosovo. The work is carried out with the quantitative methodology, which is based on secondary data. The research covers a long-term period with the data from 2000 to 2023. In the analysis of the impact of public spending in the education and health sector on the economic growth of Kosovo, the Autoregressive Distributed Lag (ARDL) model was used, which deals with time series data, in a long-term period of 24 years. Findings from the research show that public spending supports the hypothesis that the policy of public spending on education positively affects the economic growth of Kosovo, emphasizing the importance of sustainable investments in educational initiatives for long-term economic development. However, these findings do not provide sufficient support for the hypothesis that the public health spending policy significantly contributes to the economic growth of Kosovo.

Local and regional governments represent the nearest form of government to the people and their fundamental role in addressing citizens' needs is acknowledged worldwide. In line with the subsidiarity principle, the responsibility of the public good and service delivery is primarily upon the territorial administrations closer to the citizens, with the main advantage of offering more suitable and better tailored solutions at local level. In a context of scarce resources and tight budget constraints exacerbated by the ongoing economic crisis, the achievement of these goals is limited and needs to be pursued in an efficient and effective way. Accordingly, the development of tools to evaluate the performance of local and regional government is required, as well as measures to monitor the progress of the task achievement and instruments to support over time the decisional process, in the interest of all the involved shareholders, specially policy makers and citizens, international and civil society organizations. This dissertation contributes to the knowledge on basic service delivery and public expenditure analysis at sub-national level. Particularly, it deals with the provision of both general and specific services, namely the education and water sector ones. From a methodological point of view, innovative methods are proposed to evaluate the service supply and public spending in terms of efficiency and effectiveness. To show the potentiality of the suggested tools, empirical applications are proposed covering two EU countries, Belgium and Italy, which are interesting study cases for their common and peculiar features and provide complementary insights. In Chapter 2, we propose the innovative use of a composite indicator to measure the multidimensional aspects of the local public provision, encompassing several commonly acknowledged municipal tasks, and to investigate the relationship with the local government size, as the decentralization of public activities to the municipalities calls for a more enhanced service provision analysis at the local level. We suggest a robust conditional version of a directional distance Benefitof- the-Doubt approach with weight restrictions based on the municipal expenditure composition. Specifically, we deal with the presence of undesirable municipal service indicators and with the heterogeneity among the municipalities in their political preferences, priority public activities and operating environment characteristics. To illustrate the applicability of the suggested method, we show the construction of the municipal service provision composite indicator for 307 Flemish municipalities over the year 2006-2011. As a focus on a particular service, in Chapter 3 the environmental efficiency of 96 Tuscan (Italian) wastewater treatment plants (WWTPs) is investigated taking into account the quality of the outgoing water in terms of pollutant. In this regard, the presence of the residual nitrogen in the outgoing treated water is considered as undesirable output. The efficiency analysis is performed by applying a novel integrated AHP/non-radial directional distance function approach. The obtained results are then used to identify the efficiency explanatory variables: among them, the facilities' capacity, the percentage of wastewater discharged by the industrial and agricultural activities and the level of compliance with the pollutant concentration threshold set by the legislator have a significant impact on the WWTP performance. In Chapter 4, a Data Envelopment Analysis model is used to study the efficiency of Tuscan municipalities' public expenditure. Five strategic functions of Tuscan municipalities are first considered carrying out a non-aggregate analysis; then the overall expenditure composition of each municipality and the global spending efficiency are analysed by a proposed composite indicator. The main determinants affecting the municipalities' efficiency are further investigated. In particular, the obtained results may be consistently included in the long-standing debate on the municipal size, proving that the bigger the municipality, the greater its level of public expenditure efficiency. In Chapter 5, we explore whether investment in public school infrastructure affects students' achievement. We use data on extra funding to public high schools after the 2012 Northern Italy earthquake and apply a quasi-experimental design and an instrumental variable strategy. We find that spending on school infrastructure increases standardized test scores in mathematics and Italian language, and the effect is stronger for lower-achieving students and in mathematics. These results provide evidence in favour of a positive impact of capital spending in improving the learning environment and performances of high school students.

In the 1870s and 1880s total public sector expenditure in the United Kingdom, net of transfer payments in the form of subventions paid by central government to local government agencies to defray the costs of providing important services, averaged 10 to 11 per cent of Gross Domestic Product, GDP, the conventional measurement of the size of the national product of the economy in a financial year, customarily 12 months from April to the following March, but this share began to rise in the 1890s to reach 15 per cent during the decade before the Great War after having been somewhat greater during the Boer War, as shown in Figure 1.1. During the Great War, by which term contemporaries described the First World War, public spending rose sharply in response to the war effort, before declining to a new peacetime level that, throughout the interwar years, remained well above the level attained before 1914. For most of this later period, total net government spending ranged between 25 per cent and 30 per cent of GDP but rose above 30 per cent as another great international conflict approached. During the Second World War government spending reached even greater heights than it had during the First World War, and came close to 70 per cent of GDP. When peace was restored, public expenditure found a new and fairly stable level between 35 per cent and 45 per cent of GDP in most years although the trend turned clearly downward towards the end of the 1980s when it fell below 40 per cent of GDP. The decline in the final decades of the century reflected the policy of privatizing public sector housing which was energetically pursued by the Conservative government in the 1980s, the stock being sold on extremely generous terms to existing tenants as an inducementto encourage them to purchase. By 1988–89 total managed public sector expenditure had fallen to 39.3 per cent of GDP although it exceeded 40 per cent again in the mid-1990s before falling to 39.3 per cent in 1997–98, as the newly elected Labour government committed itself as an election pledge to adhere to the public sector spending plans of their predecessors in office for the first two years of the new parliament, so that public spending fell to 38.4 per cent in 1998–99 and to 37.7 per cent in 1999–00 before recovering to 38.4 in 2000–01 by which time the trend was again clearly upwards. [Rodney Lowe, p.455] By the middle of the first decade of the new century public expenditure had, again, passed the level of 40 per cent of GDP.

Good health is both an intrinsic human right and a catalyst for economic development. Increased Public health expenditure is essential to reduce catastrophic out-of-pocket expenses (OOPE), improve poor health outcomes, build critical infrastructure, and achieve Universal Health Coverage (UHC). India's current public health spending, while increasing, remains low compared to global averages and national targets, creating significant gaps in quality and access. This paper examines public healthcare expenditure of India and their implications for economic growth. The study also provides a comprehensive overview of trends in public health expenditure relative to population and Gross Domestic Product (GDP), central state share in public health expenditure, and key health financing indicators. The study is based on secondary data of public expenditure for the year 2010 to 2022 collected from various government publications like Economic survey, National Health Accounts, NITI Aaayog reports, Census data, World Bank database, ministry of health and family welfare etc. Patterns and trends in time series data were analyzed using line graphs. Macroeconomic links with Gross Domestic Product (GDP), per capita public expenditure, and related variables were examined using Compound Annual Growth Rate (CAGR) and correlation analysis. The study found a dramatic increase in public health expenditure and per capita public expenditure on health over the period, as well as a strong positive correlation between public health expenditure and GDP, population, and per capita public expenditure. Although India's public health spending is rising, it remains low compared to global averages and national targets, resulting in significant gaps in quality and access. The study emphasizes the need for collaborative government efforts to increase public healthcare spending, given the low share of government expenditure relative to GDP, the high rate of out-of-pocket expenses, inadequate infrastructure such as doctor shortages, and disparities in access between urban and rural areas.

Over the past two decades, biologics (Bs) have been widely used in the treatment of patients with inflammatory joint diseases (IJD). The treatment of IJD aims at reducing disease progression, improving patients’ physical health and well-being, and achieving long-lasting remission or, at least, minimal disease activity. The introduction of Bs in rheumatology practice has significantly improved patients’ outcomes and prognosis. Their use, however, involves undertaking significant risks and challenges for both patients and medical teams. The purpose of this article is to provide a brief overview of the biological therapies currently approved for this group of diseases in Bulgaria and the indications for administration and monitoring of the most common side effects. The optimal administration of Bs is determined by treatment efficacy, discussion of benefits and risks, prevention of the possible development of severe adverse effects, administration regimens, and routes of administration of Bs. The analysis of major issues during treatment helps summarize the information on the use of Bs, thus increasing the possibility of managing the risks associated with their use by strengthening the engagement of healthcare experts and patients in the process of monitoring the impact of biological agents.

PCV116 THE ANALYSIS OF STATINS USAGE IN CROATIA DURING THE FIVE-YEAR PERIOD

This article aims to define a value-based approach to pricing and reimbursement for off-patent originators using a multiple criteria decision analysis (MCDA) approach centered on a systematic analysis of current pricing and reimbursement policies in China. A drug price policy review was combined with a quantitative analysis of China’s drug purchasing database. Policy preferences were identified through a MCDA performed by interviewing well-known academic experts and industry stakeholders. The study findings indicate that the current Chinese price policy includes cost-based pricing and the establishment of maximum retail prices and premiums for off-patent originators, whereas reference pricing may be adopted in the future. The literature review revealed significant differences in the dissolution profiles between originators and generics; therefore, dissolution profiles need to be improved. Market data analysis showed that the overall price ratio of generics and off-patent originators was around 0.54–0.59 in 2002–2011, with a 40 % price difference, on average. Ten differentiating value attributes were identified and MCDA was applied to test the impact of three pricing policy scenarios. With the condition of implementing quality consistency regulations and controls, a reduction in the price gap between high-quality off-patent products (including originator and generics) seemed to be the preferred policy. Patents of many drugs will expire within the next 10 years; thus, pricing will be an issue of importance for off-patent originators and generic alternatives.

Modeling Health Spending Financial Sustainability

PHP59 - The Impact Of Direct Price Control On Pharmaceutical Prices In Egypt

AB0969 The Role of High Resolution CT Scanning in The Assessment of Patients with Inflammatory Joint Disease (IJD) on Biologics

ABSTRACT: One of the most fundamental yet unresolved health policy issues is whether public expenditure on healthcare leads to improved health outcomes. Given that health reflects one of the critical aspects of human capital, having implications for economic growth and other development goals, there has been enormous advocacy towards investing significantly in the health systems across the countries to improve the overall health status. However, the effect of public spending on health outcomes remains inconclusive. The present paper analyses the impact of public health spending on mortality probability, taking into account the role of governance while treating public spending as an endogenous variable. The study uses individual level data from the National Family Health Survey (NFHS) Round 5 and a few state-level characteristics. For estimation purpose, it uses a two-level mixed effect model to capture the benefit incidence of public spending on Individual mortality probability. The findings reveal that public spending has a significant but differential impact on mortality across the Indian States, whereas the quality of governance is found to be a mediator. Given a level of public spending, States with better government effectiveness and rule of law can translate public health spending more effectively in reducing mortality at the individual level. The study also found heterogeneous mortality status across gender, location of stay, wealth status, and age groups with a differential impact of public spending across gender, wealth, and age groups. The variation in average distance of mortality probability level in each state from the overall mean mortality probability indicates that the states are very different in terms of health challenges that they are facing. The policy options call for state-specific health interventions to reduce the mortality rather than one-size-fits-all health policies. There needs to more unconditional grants/transfers from the Union Government to the States so that states will be able to tailor policy responses to address the unique challenges faced by the respective states. At the same time, states need to adopt output-based conditions with greater flexibility to deliver services and greater accountability to improve transparency, governance quality, and implementation capacity.

To describe the evolution of antidepressant use in primary care in the Valencian region (Spain) from 2000 to 2004 and to analyze the effects of reference-based price and generic drugs introduction on drug utilization and cost saving. Retrospective observational study in primary care using sales data collected from antidepressant group (N06A), corresponding to the period 2000-2004. Defined daily dose (DDD)/1000 inhabitants per day were obtained as consumption data. Cost and cost/DDD rate evolution was related to reference price system implantation. Antidepressant utilization progressively increased by 44.0% from 30.3 DDDs/1000 per day in 2000 to 43.5% in 2004. Selective serotonin reuptake inhibitors (SSRIs) comprised 77% of the total consumption where paroxetine, sertraline and fluoxetine were the most used drugs in 2004. The proportion of relative use and cost of fluoxetine declined after a reference price and the introduction of generic competitors were put into effect in 1999; cost/DDD was reduced by 1.8. Third-generation antidepressants showed a fast rising rate i.e. venlafaxine utilization multiplied by 2.2; this drug with the higher cost/DDD was not subjected to the reference price system. Reduction in citalopram utilization was related to a replacement by its recently marketed enantiomer escitalopram. In 2004, reference price policy and the implementation of generic drugs reduced the antidepressant cost by DDD. However, antidepressant expenditure increased since 2000 due to a continued growth in consumption (SSRIs and novel agents) and a displacement of prescriptions to drugs that were not included in the reference price policy.

We consider a group of frequently purchased consumer brands which are partial substitutes and examine two situations; the first where the group of brands is managed by a retailer, and second where the brands compete in an oligopoly. We assume that demand is a function of actual prices and reference prices, and develop optimal dynamic pricing policies for each situation. In addition to researchers studying pricing strategy, our results may interest retailers choosing between hi-lo pricing and an everyday low price, and manufacturers assessing whether to follow Procter & Gamble's lead and replace a policy of funding consumer price reductions through trade deals with a constant wholesale price. A reference price is an anchoring level formed by customers based on the pricing environment. The literature suggests that demand for a brand depends not only on the brand price, but also whether the brand price is greater than the reference price (a perceived loss) or is less than it (a perceived gain). The responses to gains and losses are asymmetric. Broadly speaking, we find that when enough consumers weigh gains more than losses, the optimal pricing policy is cyclical. Likewise, when they weigh losses more than gains, a constant price is optimal. Thus, we provide a rationale for dynamic pricing which is quite distinct from the three explanations previously offered: (1) decreasing unit variable costs due to learning effects, (2) the transfer of inventory to consumers who face lower inventory holding costs than do retailers, and (3) competitive effects. Our explanations apply even when the other explanations do not, i.e., in mature product categories where learning effects are minimal, when retailer inventories are minimized through the use of just-in-time policies and when competitive effects do not exist, as in a monopoly. Greenleaf (1995) has shown numerically that in the presence of reference price effects, the optimal pricing policy for a monopolist can be cyclical. We first analytically extend Greenleaf's result to a monopolist with a constant cost of goods, facing a homogeneous market where all customers either weigh gains more than losses or vice versa. Using this building block we examine a monopolist retailer managing multiple brands. We assume that demand is a linear function of prices of multiple brands, and together with an expression which reflects the reference price effect. Further, we assume that the retailer maximizes average profit per period. Next, we analyze a duopoly and extend the results to an oligopoly. We assume that the manufacturers are able to set the retail prices, as in an integrated channel. Here, we retain the same demand function as for the retailer and derive Markov Perfect Nash equilibria. We use two alternative processes of reference price formation: the exponential smoothed (ES) past price process which is frequently used in the literature, and for the multi-brand situations, the recently proposed reference brand (RB) process (Hardie, Johnson, and Fader 1993). In the latter, the reference price is the current price of the last brand bought—the reference brand. We adapt the individual level RB formulation in Hardie et al., to an aggregate demand specification. For the ES process, we obtain most results analytically; for the RB process we use simulation. Finally, we extend our results to a population with two customer segments: Segment 1 which weighs gains more than losses, and Segment 2 which does the opposite, i.e., is loss averse. When the market consists exclusively of Segment 1 customers and ES is the reference price process, we find that prices are cyclical in all cases analyzed, i.e., for a monopoly, a monopolist retailer managing multiple brands, a duopoly, and an oligopoly. If the RB formulation is the underlying process, a monopolist retailer managing two brands uses cyclical prices, but in a duopoly, the equilibrium solution is for the brands to maintain constant prices. When all customers belong to Segment 2 (i.e., they are loss averse) constant prices are optimal in all cases for both reference price formulations. When the population consists of both Segment 1 and Segment 2 and the ES process applies, we develop a sufficient condition for cyclical pricing policies to be optimal. The condition is expressed in terms of the proportion of the two segment sizes, the absolute difference between the gain and loss parameters of each segment, and their respective exponential smoothing constants. Interestingly, for reasonable values of the latter two factors, cyclical policies are optimal even when the proportion of Segment 1 is quite small. Similar magnitudes are obtained numerically for the RB case.