Sustainability of the Spanish Public Healthcare System

At present, Spain is undergoing rapid changes to streamline its economy and reduce its deficit. The effects of these changes affect not only the man in the street but also the pharmaceutical industry. This article describes some of the changes that are likely to happen and comments on the potential implications that they may have on patients.

The economic crisis in which Spain finds itself has made apparent the need to reorganize the public health expense.  In fact, right now the national government has placed high on the agenda the importance of developing strategies to minimize costs and maximize the efficiency of the resources of the system. Along these lines, some regional governments have already made cuts to achieve a reduction of the budget deficit in the health area and have even considered the introduction of co-payment.

Some of the measures taken are aimed at the restructuring and reduction of the expense in drugs. This expense in itself reaches close to 25% of the total healthcare expense, which for Spain represents approximately € 3,750 million yearly. This comes as no surprise if one takes into account that the pharmaceutical expense in Spain is one of the highest in the world ⁽¹⁾ and much above the average expense of the countries that make up the Organization of Economic Cooperation and Development (OECD).

Some Measures That Aim At Cutting the Expense in Drugs

In keeping with this goal, the Royal Decree 9/2011 has introduced a modification to the law of reference prices. It implies that when a drug loses its patent (>10 years), whenever there is a generic or biosimilar drug the public health system will finance only those drugs which have the “lower price”. Besides, products that have lost their patents will have to lower their prices a 15% in a mandatory way ⁽²⁾ even if there is no presence of generics or biosimilars in the market. 

While these measures tend to exclude from the reimbursement system all those drugs that do not adjust to a given price, there are also actions intended to encourage a more rational use of the drugs -such as the implementation of single doses- and efforts to obtain better conditions in the negotiations with the pharmaceutical industry.

In connection with the latter, the central government put forward the following:

a) A yearly review of the prices of the reimbursed drugs. This would open a window for renegotiating the prices downwards or leaving some drugs out of reimbursement depending on their use and turnover.

b) The instrumentation of a national purchasing centre to negotiate better prices with the pharmaceutical industry for certain kinds of drugs ⁽³⁾.

Other proposals for the sustainability of the system and/or the reduction of the expense have come in some regions from the Entrepreneurial Federation of Spanish Pharmacists (FEFE). One of these consists in excluding from public reimbursement the drugs aimed at minor pathologies which cost under € 2 –the exclusion would not be applicable to chronic or poly-medicated patients. If this proposal were implemented, the patient would take a bigger role in the choice of some drugs.

It is clear that if these changes take place and the trends settled, they will lay the foundation for new game rules, giving a greater role to other actors and modifying power relations.

For the health system, getting out of the crisis will require making difficult decisions and will entail new challenges and opportunities for the pharmaceutical industry. Another reality is taking shape, which will have to be explored. It will impact upon the standards of service that the patients get, the drugs prescribed, the balance between the parties and the way all of it is perceived by the citizens.

By Gimena Rodriguez, Field Director with A Window.

(1) http:/www.elmundo.es/elecciones-generales/2011/propuestas/propuesta78.html
(2)BOE State Official Bulletin Nº314. Friday 30th, December 2011-Sec 1 Page 145936
(3)The products which might come into the purchasing central would be: vaccines incorporated in the common vaccine timetable of the national health system, the seasonal flu vaccines of the winter 2012-2013; the antibiotics of most common use, such as amoxicilin, amoxi-clavulanic acid, cefazolin, gentamicin, and others: the antiviral drugs (zidovudine, aciclovir). Erythropoietins, and the growth hormone, the antineoplasics with generic or copy, such as Paclitaxel, Oxaliplatin and others and the serums and other health products such as alcohol, gauzes, poultices, or urine absorbents.  

AN INTERNATIONAL MARKETING RESEARCH CHECKLIST (*)

Checklists help with major undertakings such as moving across county or preparing for a long vacation. A checklist could be equally helpful for a global marketing research project. This article provides a checklist for such an endeavor.

Have you ever moved across the country with a professional moving company, or taken a long vacation and consulted with AAA or a travel agent? Often, these organizations will give you a checklist to insure success in such a major undertaking.

Well, guess what? A global marketing research project is also a major undertaking! So why hasn’t someone put together a checklist to help marketing researchers and other professionals navigate the rough seas that can threaten the validity and actionability of these projects?

Below please find your checklist, which can be copied for your convenient use and that of your colleagues.

I have written this list from the point-of-view of a researcher who may plan either to use a coordinating marketing research firm or to directly field a study in international markets. In either case, the issues and concerns in the checklist are the same.

General

• Does the local in-market research firm being used to field your study have 10 or more years of experience in fielding research in each country they are responsible for (or, at least six years in markets that weren’t open until ’90—’91, such as Eastern Europe), so that a strong understanding of local cultural variables and appropriate study design is available?
• Has the questionnaire/discussion guide been translated to the local language by personnel who currently speak the local language day-to-day, and who are therefore up-to-date on current meanings, usages and slang, etc.?
• Has the local language questionnaire/discussion guide version been back-translated to English, again by personnel who are current speakers of the local language and English?
• Is your study benefiting from consulting help from your local in-market research firms at the stages of determining local study methodology, questionnaire/discussion guide design, and again during analysis of results?
• Is your study being fielded by local companies that have the correct level of expertise for the study at hand and who have sufficient experience and caring to brief and monitor fieldwork, and to validate the results of the interviewing?
• Have you arranged for translation of briefing materials, respondent stimuli (including any videotapes), etc., into the appropriate local languages? In addition, have you ascertained the appropriate format for any videotaped stimuli (i.e., PAL, NTSC, etc.)?
• If there are study requirements that include the need for certain water temperatures or for amounts of different items such as in a recipe, are these requirements expressed in understandable terms for all countries included in the study (i.e., Fahrenheit versus Celsius, metric versus English measurements, etc.)?
• If a certain study has requirements for electrical equipment, such as a particular computer or an appliance that must be demonstrated, have you determined that appropriate electrical adapters are available so that the equipment can be used in each country?
• Have you checked for recent major weather or other events, such as the large forest fires in Mexico and Indonesia which caused smoke to travel over vast areas of surrounding countries? These events could have a major impact on planned research, especially research that depends on sensory perceptions of taste and smell.
• Have you checked for possible political issues with respect to conducting research in each country? As an example, Indonesia places a moratorium on conducting polling or marketing research three months prior to a national election. Such local regulations may affect your ability to deliver research results on time.
• Have you allowed for possible lengthy delays in customs for certain types of product in certain countries? Again, this can cause major problems in conducting work on time.

Quantitative

• Have you dealt with the actual fielding of the study within each country in terms of the cities that are selected, and assured that each cell of the study is receiving the identical geographic spread within each country (across cities, etc.)?
• If you are conducting a multi-country study, are editing, coding, data entry, and data tabulation functions centralized with consistent decision-making and oversight?
• If you are conducting a multi-country study, have you designed the questionnaire so that different brand lists can be fielded in each country, and so that identical brands can be easily identified and tabulated across all countries where they are found?
• If you plan to view the results of your multi-country study in total, have you assessed the need for the cross-calibration of any scalar data, so that results are able to be combined and analyzed across cultures?
• Have you considered the need to create more than one questionnaire per country, depending on the number of regional dialects or even indigenous languages that may exist?
• Do not automatically assume that a CATI telephone study as it is fielded in the U.S. is also the appropriate method for international markets. You very likely will need to go to door-to-door interviewing or some other type of face-to-face approach, such as hall interviewing with street intercepts. Here is where local consulting advice is critical in getting the job done right.

Qualitative

• Have you secured moderators in each country that have the appropriate language and cultural fit to relate well to respondents and elicit their feedback?
• If personnel are attending who do not speak the local language, have you arranged for simultaneous translation? Have you also arranged for audiotaping of the simultaneous translation, along with videotaping of the interviewing?
• Although you may be used to using one moderator across all cities in the U.S., have you checked for the need to use different moderators within the same country in international markets, due to different cultural situations and languages/regional dialects?
• If you or your colleagues do not attend qualitative work internationally, have you arranged for transcripts of the interviewing to be created and translated to English? And, have you arranged for these English transcripts to be sent to you electronically?
• Have you arranged for briefing of all moderators, either in-person or via long-distance conference call, depending on whether you are traveling to the interviewing sites?
• Have you determined if a viewing room with a one-way mirror is available, or whether a video set-up is available for observing the interviewing?

It is important to review all of these issues when coordinating international/global marketing research studies. Others may arise that have not been included here. If so, I would be very happy to hear about them. Meanwhile, enjoy the opportunities global/international work can provide - and may you do so as successfully as possible.

By Kent Hamilton

Vice president/Director of international services at A&G Research, Inc., New York.

(*) This article was originally published in November 1998 by Quirk’s Marketing Research Review. (Article ID:19981109)