Studie - Pricing & Reimbursement in Emerging Markets: Analysis of pricing mechanisms and the influence of public and private sector health insurance provision

Over the past few years, pharmaceutical sales in the emerging markets have regularly been growing at double-digit rates, albeit in some of the markets there has been a temporary blip caused by the global credit crunch. Much of the recent growth has been fuelled by an expansion in public sector health insurance coverage, which means that drug reimbursement is much more widespread than in the past. However, the growth of reimbursement systems, combined with the ongoing global economic difficulties, has put pressure on governments to introduce more rigorous price-control mechanisms than in the past.

This report provides a concise examination of the pricing and reimbursement environment in seven of the most important emerging markets. In doing so, it highlights differences in the pricing methodology used in the public and private sectors, and it also focuses on differences in the pricing structure for originator drugs and generics.

The report does not limit itself merely to what is happening currently, but also explores how government policy in each of the individual emerging markets is likely to shape the P&R environment in the future. The seven key emerging markets covered in this report are Brazil, China, India, Mexico, Russia, South Korea, Turkey

Key features of this report

• The report tracks the development of the health insurance system (both public and private) in each of the seven emerging markets, and explores issues such as sources of funding and population coverage.
• The report provides a detailed analysis of the reimbursement environment in each of the seven emerging markets, paying particular attention to how it relates to the market’s health insurance system.
• The report provides a detailed analysis of the pricing structure in each of the seven emerging markets, differentiating between the structure that is in place for originator drugs and generics. Where applicable, it also examines how the pricing mechanism differs for the private and public sectors.
• The report provides a unique insight into the role that is played by the distribution chain from a P&R perspective, examining both formal and informal distribution margins.
• The report examines government policy in relation to pricing & reimbursement, and looks ahead to what changes in the P&R environment are likely to take place in the future.

Key benefits from reading this report

• Allows marketers to operate with confidence in the often complex pricing and reimbursement (P&R) environment in seven key emerging markets.
• Allows marketers to prepare fully for the impact that the arrival of generic competition would cause from a P&R perspective.
• Provides marketers with vital intelligence about the sometimes murky criteria that are used for the inclusion of drugs on government reimbursement lists.
• Forewarns marketers about rebates on official prices that are sometimes mandatory in the public sector.
• Provides marketers with an insight into distribution practices, including kickbacks and informal margins.
• Allows marketers to plan ahead with confidence by looking ahead to the P&R policies that are likely to help shape these seven markets in the future.

Key findings of this report

Each of the seven emerging markets under review has its own unique P&R environment. Even in those emerging markets where reference-pricing is used, there is a wide variation in the countries that are being referenced.

Despite the expansion of public sector health insurance coverage, a high proportion of expenditure is still derived from out-of-pocket payments by consumers.

The recent global economic upheaval has placed additional stresses on the P&R environment of the emerging markets, and it has encouraged the imposition of new price control mechanisms.

However, despite this economic upheaval, governments in the emerging markets are pressing ahead with previous plans to expand public sector health insurance coverage (and by extension to increase the accessibility of drugs).

The proportion of people using private sector health insurance coverage remains very limited in most of the emerging markets. However, in several markets, the uptake of private sector health insurance is growing rapidly from a small base, mainly in urban areas.

The authorities in several emerging markets have been seeking ways to encourage a greater uptake of generics instead of expensive branded drugs. Nevertheless, in countries such as China there is scope for a higher number of innovative drugs to be reimbursed.

Future growth prospects for all seven of the emerging markets remain strong.

Key questions answered by this report

• What is the precise pricing methodology used by each of the emerging markets?
• What role is played by the distribution chain in the pricing of drugs?
• Are there differences in the pricing structure for local drugs and imported drugs?
• In what way does the arrival of generic competition impact on the pricing of originator drugs?
• Are there any special pricing requirements for drugs used by the public sector?
• Are there any variations in pricing on a regional level?
• How quickly is public health insurance coverage expanding?
• Are reimbursement lists beginning to include a larger number of innovator drugs?
• Are governments maintaining previous commitments to increase healthcare spending?
• In what direction is government policy taking the markets from a P&R perspective?

Pricing and Reimbursement in Emerging Markets

Executive summary 8

Introduction 8

Brazil 9

China 10

India 11

Mexico 12

Russia 13

South Korea 14

Turkey 15

Chapter 1 Introduction 18

Summary 18

Recent historical perspective 19

Growth drivers 20

Access barriers 21

Key pricing and reimbursement factors 24

Reimbursement lists 24

Pricing methodology 25

Role played by distribution chain 26

Future outlook 27

Chapter 2 Brazil 30

Summary 30

Introduction 31

Public sector provision 32

Private sector provision 33

Reimbursement system 34

Pricing mechanism 35

Price revisions 36

Public sector discounts 36

Pricing in practice 37

Future outlook 38

Chapter 3 China 42

Summary 42

Introduction 43

Public sector provision 43

Urban areas 44

Rural areas 44

Private sector provision 45

Reimbursement system 45

Essential Drugs List (EDL) 46

Reimbursement levels 47

Pricing mechanism 47

EDL pricing 48

Hospital margins 49

Future outlook 49

Chapter 4 India 52

Summary 52

Introduction 53

Public sector provision 53

Private sector provision 54

Reimbursement system 55

Pricing mechanism 56

Price revisions 58

Distribution margins 59

Future outlook 59

Chapter 5 Mexico 62

Summary 62

Introduction 63

Public sector provision 63

Private sector provision 65

Reimbursement system 66

Pricing mechanism 66

Public sector 66

Private sector 67

Future outlook 69

Growth factors 69

Further price pressure expected 69

Chapter 6 Russia 72

Summary 72

Introduction 73

Public sector provision 74

Private sector provision 74

Reimbursement system 75

Pricing mechanism 76

DLO drugs 76

Non-DLO drugs 77

Impact of price controls 78

Future outlook 79

Chapter 7 South Korea 82

Summary 82

Introduction 83

Public sector provision 83

Private sector provision 85

Reimbursement system 86

Pricing mechanism 87

Pricing dynamics 87

Future outlook 89

Chapter 8 Turkey 92

Summary 92

Introduction 93

Public sector provision 94

Private sector provision 95

Reimbursement system 95

Prescribing practices 96

Pricing mechanism 97

Future outlook 98

Appendix 100

Methodology 100

Glossary 100



List of Figures

Figure 2.1: Brazil: pharmaceutical sales, 2005-2009 31

Figure 2.2: Brazil: private health insurance turnover, 2003—2009 34

Figure 4.3: India: price structure for price-controlled formulations 58

Figure 5.4: Mexico: number of affiliates of healthcare schemes, 2009 64

Figure 7.5: South Korea: organizational structure of NHI system 84

Figure 8.6: Turkey: breakdown of generic/originator products available on market 94



List of Tables

Table 1.1: Emerging markets: per capita spend on pharmaceuticals, 2008 20

Table 1.2: Emerging markets in global context: health expenditure ratios, 2000—2007 23

Table 2.3: Brazil: average drug price by medicine type, 2007—2008 38

Table 4.4: India: list of scheduled bulk drugs (DPCO 1995) 57

Table 5.5: Mexico: provisional health budget by sector, 2010 65

Table 8.6: Turkey: distribution margins for drugs 97

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