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The Impact on Big Pharma’s Production Model of Medicine Policies in a Context of Austerity in France and the UK

Philippe Abecassis et Nathalie Coutinet
p. 197-215

Résumé

The austerity policies implemented by France and the United Kingdom since the 2008 crisis have led to a drastic rationalisation of health spending in both countries. This is especially true for spending on medicines, which is an important part of the health budget. Even though health policies in the two countries seem to be very different, given the specificities of each health system, this rationalisation has expressed itself through greater privatisation, a hardening of mechanisms for controlling the prices of the most expensive drugs and incentives to use the cheapest drugs when possible, such as generic drugs. The pharmaceutical industry has not suffered much from these measures. It first reacted, at least provisionally, by accepting to develop generic drugs. As of 2012, Big Pharma companies have started to implement a new model for producing innovation and highly expensive drugs, grounded in biotechnology and customised medicine. This strategy is based on highly outsourced industrial organisations which have allowed the industry to benefit from healthcare systems, to reduce risks and to make large profits.

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Texte intégral

Austerity is medicine intended to reduce systems of debts and deficits, and to cure recessions. It cuts government spending on healthcare coverage, assistance to the unemployed, and housing support.

  • 1 Stuckler, D. and Basu, S., The Body Economic: Why Austerity Kills - Recessions, Budget Battles, and (...)

Stuckler and Basu,1 foreword.

Introduction

  • 2 Reynaud, M., et al., Rapport annuel du Haut Conseil pour l'avenir de l'assurance maladie, Paris, HC (...)
  • 3 Tabuteau, D., Démocratie sanitaire: les nouveaux défis de la politique de santé, Odile Jacob, 2013.

1The French health system encompasses compulsory health insurance, social security (la Sécurité sociale), financed by employers’ and employees’ social security contributions (64% in 2014), dedicated taxation (28.8%) and direct contributions from the State (7.2%). This compulsory health insurance is supplemented by private insurance covering more than 94% of the population. Other costs are borne by households. Policies in France during the 1990s and 2000s led to a change in the financing structure of the compulsory insurance, resulting in increased contributions by the State (l’Etat, France’s central government), a decrease in the share of employers’ social contributions as well as a rise in private financing. Compulsory health insurance now covers almost 76% of household health expenditure (92.4% of hospital expenditure and 67.7% of ambulatory expenditure).2 However, when patients suffering from a pathology that is fully covered are excluded from the figures, the share of outpatient expenditure covered by the compulsory system is about 50%.3 As a result, private expenditure has risen significantly, either directly borne by households or by complementary insurance.

  • 4 Haut Conseil du financement de la protection sociale, Analyse comparée des modes de financement de (...)
  • 5 Dalingwater, L., “The NHS at the Heart of the Election Campaign”, Revue Française de Civilisation B (...)
  • 6 Surrender, R., et al., Health system of United Kingdom Reference Module in Biomedical Sciences, Els (...)

2In the United Kingdom, the health system receives more public funding than the French system (nearly 79.5%). The National Health Service (NHS) is mainly tax-financed (76% in 2014) and by social contributions (National Insurance) also collected by HMRC (18%).4 Funding is complemented by supplementary and substitutive private insurance. Although public funding increased from 1997 to 2010, the NHS has suffered from chronic underfunding since the early 1990s. After 2010, the Conservative Liberal-Democrat coalition government dramatically reduced resources. The NHS is severely underfunded and hardly fulfils its role. This has an impact on the quality of services provided, which has led, for example, to an increase in hospital waiting lists, to higher avoidable mortality rates for people under 75 compared to other countries (about 25% in the United Kingdom compared with 18% in France), and to inequalities in access to health care.5,6 The main reforms that were aimed at compensating budget cuts have generally resulted in the introduction of competition, leading to an increase of private care funding by the NHS (from 2.8% of the NHS budget in 2006 to 6.1% in 2013, according to the Department of Health or DoH). It has also resulted in a decentralisation leading to increased autonomy of the NHS vis-à-vis the government and the creation of local groups of autonomous managers responsible for the coordination and provision of care within a geographic area.

3Thus, since the 2008 crisis, austerity policies implemented in France and the United Kingdom have led to an increased rationalisation of healthcare spending, coupled with a strengthening of market mechanisms. Drug policies have had a central role to play in the implementation of these measures. While trying to accommodate the pharmaceutical companies, these policies have aimed at better controlling the price explosion of new molecules, lowering the prices of princeps (brand name molecules protected by patent) already on the market, and promoting the least expensive drugs: generics (copies of princeps which are no longer under patent). To this end, drug policies have increased efficiency requirements, designing complex mechanisms to refine the price-effectiveness of medicines. They have also ensured that the pharmaceutical industry does not profit too much from its monopoly position and so contributes “reasonably” to austerity efforts. The United Kingdom has thus strengthened its control of profits while France has established direct contributions from the industry based on the firms’ turnover growth rates.

4These measures have had an impact on the drug production model in a period when large pharmaceutical companies (big pharma) were faced with a broader structural transformation process of their business model.

5The objective of our research is to show how reforms resulting from austerity policies have contributed, and even accelerated this transformation process of the production model. This paper is organised in three sections, beginning with a review of the impact public spending austerity on the privatisation of health systems. Section 2 focuses on the particularities of drug pricing policies, and the last section looks at policies’ impact on firm’ strategies and the production model of medicines.

Fiscal Austerity Affects Public Spending on Health

  • 7 Math, A., “La santé au péril de l’austérité”, Chronique internationale de l’IRES, 2014, pp. 22-52.

6As a result of the 2008 crisis, the growth rate of health spending in all OECD countries slowed significantly, or even declined (Graph 1). In France, the decelerating growth of public health spending began in the 1990s and has continued to this day. In the period considered, spending growth has slowed considerably (from almost 3.4% per year between 1997 and 2000 to 0.7% between 2009 and 2012). The United Kingdom shows a different trend. After spending increases of 5.5% per year between 2000 and 2009, expenditure actually fell by 1% annually between 2009 and 2012. The UK is one of the European countries that have made significant cuts in health spending since 2010.7

7

8

Graph 1 : Annual average growth rate (in real terms) of public expenditure on health per capita

Graph 1 : Annual average growth rate (in real terms) of public expenditure on health per capita

Sources : OECD data, cited by A. Math.

9A large proportion of health expenditure goes to the purchase of medicines. OECD countries spent about $ 800 billion in 2013 on ambulatory and hospital drugs, accounting for 20% of total health spending. This total pharmaceutical expenditure (on ambulatory and hospital drugs) declined on average by -2% in OECD countries, in 2012. However, the situation varies between countries. In France, the trend has been close to the average. But in the UK, the growth in overall drug expenditure increased from +2% in 2011 to +6.5% in 2014.

10Until 2005, expenditure on ambulatory drugs in OECD countries increased faster than other health expenditure (Graph 2). After 2005, the trend was reversed. The same development occurred in France and the United Kingdom: expenditure on ambulatory medicines respectively decreased by about -2.5% and -3%, on average annually from 1990 to 2014. They accounted for 15% of total health expenditure in France and 12.2% in the United Kingdom (OECD data, 2015). The differences are likely due to drug policies across countries, particularly in promoting the use of generic medicines (see above).

Graph 2 : Average annual growth in pharmaceutical expenditure and total health expenditure per capita, in real terms, OECD average, 1990-2013

Graph 2 : Average annual growth in pharmaceutical expenditure and total health expenditure per capita, in real terms, OECD average, 1990-2013

Sources : OCDE, 2015.

  • 8 Abecassis, P., and Coutinet, N., “Médicaments génériques : pivot de la reconstruction de l’industri (...)
  • 9 Belloni, A., et al., “Pharmaceutical Expenditure And Policies: Past Trends And Future Challenges”, (...)

11By contrast, spending on hospital drugs, which accounts for between 10 and 25% of drugs expenditure, is growing faster than other drug expenditure. Indeed, generally the growth of drug spending is linked to two opposing factors: the entry of new and innovative molecules, and the expiration of patents. Until 2012, therapeutic innovation was weak and prices tended to fall due to the expiration of many patents. Since 2012 and the introduction into the market of new and innovative drugs resulting from biotechnological research has reversed this trend.8 According to IMS Health, drug expenditures in the five major European markets (including France and the United Kingdom) are expected to have an average annual growth rate of between 1% and 4% over the period 2014-2018. The United Kingdom should see its spending continue to grow while France is expected to stabilise it.9 These forecasts confirm the view that policies favouring the development of generics have reduced expenditures on ambulatory drugs, but also that these savings have been offset by the high price of hospital drugs.

  • 10 André, C., et al., “Health care privatization processes in Europe: Theoretical justifications and e (...)
  • 11 Philippe Batifoulier, Capital santé: quand le patient devient client, La Découverte, 2014.

12One of the more symptomatic aspects of reforms aimed at reducing public spending is that they have led to different forms of privatisation of the health systems. In European countries, the work of André, Batifoulier and Jansen-Ferreira shows that these reforms follow three main trends: privatisation, the implementation of the “new public management”, and decentralisation (the exact nature and extent of these instruments being country-specific).10 Carried out in 14 countries of the European Union (EU-15, excluding Luxembourg), this research made it possible to establish a classification of these countries according to the policies applied (see Figure 1). On this diagram, the horizontal axis ranks health systems according to their role as health care providers (such as the United Kingdom) or as health care funders (such as France for outpatient health). The vertical axis proposes an analysis of privatisation, that is to say the organisation of the transfer from the public to the private sector. The authors put forward a distinction between a process of privatisation imposed on individuals who are subjected to it, “external privatisation”, and a process of privatisation that is carried by the individuals themselves, “internal privatisation”. External privatisation thus focuses on measures that develop either private financing in the case of social insurance or private care services in the case of care provision.11 Internal privatisation refers to measures aimed at enabling patients to adopt entrepreneurial behaviour and, on the other hand, at allowing professionals in the public sector (insurance and healthcare services) to implement a new method of governance based on that of private organisations (management autonomy, financial budget constraint and competition).

Figure 1 : A framework for reform analysis

Figure 1 : A framework for reform analysis

Sources : André, Batifoulier and Jansen-Ferreira.10

13In France, reforms privileged the external financing of health care (quadrant I) by increasing the financial participation of patients and by delegating part of the health coverage to private organisations. The disengagement of compulsory health insurance therefore results in an overall increase in the share of private health financing. The main measures are: the extension of out-of-pocket payment (as of 2008, € 1 has been cut from reimbursements for medical consultations and € 0.5 per box of medicines); the non-reimbursement of medicines deemed insufficiently effective; and the exclusion of certain care services. The transfer of expenses largely concerns private insurance, with the remaining expenses to be paid by patients having gradually decreased (-0.82% per year on average) to the point of becoming one of the lowest in Europe in 2008 (6.8%). However, this figure masks a wide range of disparities. In particular, hospital care is largely reimbursed, while ambulatory care reimbursement is increasingly weak.

  • 12 Abecassis, P., et al., “Les principes mutualistes confrontés aux modalités de regroupement des orga (...)

14One of the consequences of these reforms is an increase in the turnover of the supplementary private health insurance market, which rose from € 17 billion in 2001 to € 33.9 billion in 2014.12

15Health policies implemented in France are also marked by a desire to rationalise expenditure. For drug policy, this is leading to the setting up of the incentivised development of generics (right of substitution, 1999); the compulsory prescription of drugs according to their international non-proprietary name (INN, 2015); the introduction of a reference price (the reimbursement will be based on a flat rate corresponding to the cost of the generic drug, 2004); and the control and the rationalisation of doctors’ drug prescriptions through various quality improvement schemes (pay for performance, P4P). An important aspect in the implementation of such expenditure rationalisation has involved drug pricing, including increased price control of new medicines using medico-economic evaluation techniques when negotiating prices for reimbursed medicines, and conventional discounts (volume control).

16Beginning in 1991, several reforms gradually introduced market mechanisms into the United Kingdom’s National Health Service (quadrants III and IV above). In 2003 and 2004, the NHS introduced control and rationalisation of doctors’ drug prescriptions. Several measures changed the contracts between the Primary Care Trusts (PCTs) and the NHS, in order to introduce target-based bonuses on professional and prescription practices, defined by guides to good practice (P4P). The Health and Social Care Act of 2012, the first reform since the 2008 crisis, marks an important step in terms of privatisation as it reinforces the introduction of private actors, creates competition among healthcare providers, and decreases the role of political regulation in order to increase market regulation. This law also changes the status of the NHS, which is no longer under the Department of Health, but is managed by an independent body, the NHS Commissioning Board. In this context, the PCTs have been replaced by the Clinical Commissioning Groups (CCG), responsible for the provision of care services in their geographical area. They have a budget and the capacity to work together to form purchasing groups. CGCs have the opportunity to have public and private providers compete with each other (hospitals, clinics, etc.).

  • 13 Schweppenstedde, D., et al., “Regulating quality and safety of health and social care”, London, Ran (...)

17Thus, reforms in the United Kingdom initially sought to control spending by reorganising the health system by introducing new independent regulatory bodies to improve care provision.13 These reforms also fostered competition between suppliers and encouraged the involvement of private players. Although spending was more closely monitored, reforms influenced medicine policy less than in France. The United Kingdom has therefore pursued policies to increase the privatisation of its health care offering (quadrant IV) while introducing competition, particularly in the public hospital sector, and some management rules emanating from the private sector (New Public Management, quadrant III). Privatisation in the United Kingdom, however, also stems from the disengagement of the State from the provision of care. The State is interchanging public funding for care with the provision of public health care, thus leaving more room for private actors. These policies have led to private health spending representing 16% of total health spending in 2012. This includes expenditure on over-the-counter drugs, dental care, private hospitals, private insurance and NGO expenditures.

Measures to Control Drug Pricing…

18The measures taken in both countries since the 2008 crisis are marked by a desire to amplify the reduction of public spending by improving the value for price/quality ratio on the basis of higher economic efficiency (for an exhaustive list of measures, Table 1). However, the means to achieve this differ. In France, the princeps’ prices are controlled since the implementation of the compulsory health insurance (1945) but controls have been strengthened and incentives for the consumption of generics have recently been developed. In the United Kingdom, prices are free but, since 1996, approvals are subject to a medico-economic evaluation. This evaluation has gradually been strengthened. These differences reflect the health systems’ differences. In the United Kingdom, public provision of care is more developed and its control has been the subject of many successive reforms. In France, the focus is on controlling spending, and action on prices and reimbursement rates for medicines is a privileged tool in this regard.

19Drug policy involves determining under what conditions a drug should be covered by the health insurance system, i.e. its price and possibly its rate of reimbursement according to different criteria: the anticipated volumes of demand, the resulting profits, and the drug’s relative effectiveness compared to existing treatments. Such policy has been developed both in France and in the United Kingdom in collaboration with pharmaceutical companies because in both countries this industry is a strategic sector in terms of innovation and employment. Four different ways of controlling prices can be used: free pricing (mainly for innovative and patented medicines, princeps), international benchmarking, the internal reference pricing and profit control (or regulation of rates of return):

20- International benchmarking (IB) involves negotiation based on prices set in other countries which limits excessive price differences for the same product. The most referenced countries are France, Germany and the UK.

21- Internal reference pricing (IRP) compares the therapeutic properties of a new product with those of its competitors (which may be a generic). It allows cost-effectiveness comparison to evaluate the budgetary impact of the new drug. The price varies according to the level of innovation. It sets the relationship between price and innovation. These methods take into account the impact of the medicine’s use on quality of life and/or public budgets.

22- Profit control (PC) takes into account the rates of return and the operating margin of the industry when setting prices. This method allows the creation of a model for price determination by limiting the profits of the firms. 

23These tools are used by both countries in varying degrees. France uses IB and IRP to fix the price of innovative molecules (princeps) that are reimbursed. IRP was introduced in 2013 with the creation of a specific commission inside France’s High Authority for Health (Haute autorité de santé, HAS). This price is negotiated between pharmaceutical companies and the Economic Committee for Health Products (Comité économique des produits de santé, CEPS).The first stage in such an evaluation involves assessing a drug’s therapeutic worth by the HAS. Therapeutic value according to the WHO corresponds to the effect on the patient of the administration of a pharmaceutical product which is to restore, correct or modify a physiological function. This therapeutic value is used as a basis for determining the price of the drug. In the second stage, the fixed price is negotiated for a period of five years with a guaranteed price at least equal to that of four countries (IB): the UK, Italy, Germany and Spain.

24For drugs that have a significant budgetary impact, the CEPS may negotiate a discount, mainly based on volume. The price of generics has decreased. In 2013, it was set at 60% of the price of princeps on which they are based. A decrease of 7% is applied after 18 months of commercialisation. For their part, princeps face a 20% price decrease when generic products are first brought on to the market, and a 12.5% decrease 18 months later.

  • 14 Department of Health, The Pharmaceutical Price Regulation Scheme 2014, Department Of Health & Assoc (...)

25In the United Kingdom, the DoH exercises control over medicine policies. The prices of innovative molecules are set freely by pharmaceutical companies when they are placed on the market, but global price negotiations between representatives of pharmaceutical companies (ABPI) and the DoH, within the framework of the Pharmaceutical Pricing Regulation Scheme (PPRS) are held every five years. In 2009 and 2014, the PPRS strengthened spending regulations on princeps already on the market by imposing price cuts and enhancing control of firms’ profits and operating margins.14 The pricing of generic drugs is free under a fixed price cap per drug. At the same time, the National Institute for Health and Care Excellence (NICE) in charge of the medico-economic evaluation published a memorandum on the advisability of its approval by the health system. Since 2013, NICE has been responsible for carrying out a medico-economic evaluation of drugs (IRP). This evaluation of medico-economic efficiency is done by cost per QALY (quality-adjusted life year) which is a cost/benefit analysis where the QALYs are a measure of the therapeutic value of a molecule. The threshold value of £ 35,000 per QALY is used for the selection of acceptable molecules. For some pathologies, this threshold may be higher. The results of this evaluation serve as a basis for future price negotiations between the firms and the DoH in the framework of the PPRS. Molecules deemed acceptable by NICE are automatically supported by the NHS. However, CCGs have the possibility of developing their own list of drugs, which may be narrower or broader than that of the NHS. Thus, the molecules not retained by NICE that are related to certain pathologies (such as orphan diseases or certain cancers) as well as certain highly innovative molecules can receive a different treatment, which is justified by the fact that they are destined for a limited number of patients. In this case, the evaluation method that is used is based solely on therapeutic value.

26Finally, drug policy is indeed a key instrument of health policy. Its repercussions go beyond the strict scope of the medicinal product and affect health expenditure as a whole. Reimbursements (or approvals) and reductions in reimbursement rates modify the perimeter of the health care basket (all reimbursed care) and direct health policies by favouring certain pathologies to the detriment of others. Medicine policy is an element of the privatisation of health systems because it impacts overall reimbursements. Thus, for example, an increase in the price of new molecules weighs mechanically on overall expenditure. This encourages governments to reduce other spending (France, quadrant I) or to devolve their funding to the private sphere (UK, quadrant IV).

Table 1 : Pharmaceutical cost containment measures implemented in the United Kingdom and France, since 2008

Table 1 : Pharmaceutical cost containment measures implemented in the United Kingdom and France, since 2008

… which Affect Big Pharma’s Strategies

27Austerity policies were carried out in a unique context for the pharmaceutical industry, at a time when the model of drug production is still dominated by blockbusters, though they had been showing signs of weakness since the early 2000s. Blockbusters are drugs with a global turnover of more than $ 1 billion. A model of drug production is understood here as the set of strategic choices leading to the commercialisation of a molecule. These include technological, industrial, organisational and financial choices. In the pharmaceutical industry, this is characterised by three pillars: innovation protected by patents allowing firms to have a monopoly position; high and guaranteed prices, combined with aggressive marketing to sell the maximum number of products during the patent protection period; permanent innovations, allowing the pipeline of blockbusters (on which company profits rely) to be renewed regularly. This model was based on the development of international legislation and on the action of the public authorities whose expenditure ensured the financing of innovation through price regulation.8 However, the sustainability of this model became compromised from the early 2000s onward. Three factors explain this change: the development of generics linked to the simultaneous expiry of patent protection for a large number of blockbusters; the drying up of the pipeline linked to the “delay” of biotechnology; and the tightening of financial constraints reinforced by austerity policies since 2008. These policies mark the end of this model and have accelerated the transition to a new production model.

28The companies were then forced to reorient their strategies and turn to the production of generic drugs, which are considered as a last resort until the emergence of another production model based on biotechnologies emerges. These strategies rely on strong growth in the generic market in developed countries and emerging markets (the worldwide market for generics is forecast to increase from $ 168 billion in 2013 to $ 280 billion in 2018). They involve the development of incremental innovations, i.e. the improvement of an existing molecule (generic brands) or switch strategies (transformation of prescription-only medicines into over-the-counter medicines). Pfizer’s strategy illustrates the evolution of big pharma’s decisions. In 2009, Pfizer, which was initially opposed to generics, positioned itself on the market by creating generics for seven of its own molecules and by buying the rights of 39 generics in the United States and 20 in Europe. In the following years, the firm continued its generic-focused activity by carrying out numerous mergers and acquisitions with generic producers: in 2015, Pfizer acquired Hospira.

29However, the production of generics is less profitable than the production of blockbusters. To enhance their profits, firms rely on innovation. Therefore, they have not stopped their research and development activities but have managed to change their innovation model by multiplying patent acquisitions and by outsourcing a growing portion of their research activities. Beginning in 2011-2012, an increasing number of new molecular entities were granted marketing authorisations. In 2012, they reached the 1997 level, and the majority of them came from biotechnologies. These new biotechnological medicines (biopharmaceuticals) have the property of being able to adapt treatments through companion diagnostics using genetic analyses. A companion diagnostics is a medical device which provides information that is essential for the safe and effective use of a corresponding drug or biological product. Such testing helps to determine whether a particular therapeutic product’s benefits to patients will outweigh any potential serious side effects or risks. The biopharmaceuticals used with companion diagnostics allow firms to develop specialised medicines adapted to targeted and identified populations.

30Drug policies, including pricing, encourage or even finance these innovations. Public authorities are under pressure from patients (often via associations) who wish to have access to innovative molecules as well as from the lobbying of national pharmaceutical companies. In this context, public authorities willing to safeguard domestic industries accept to finance the high costs of new molecules and try to compensate this by lowering the prices of old ones.

31Consequently, in France innovative medicines are negotiated on the basis of the price proposed by the firm. The same is true in the United Kingdom where the pricing of drugs that are considered cost-efficient is unrestricted. The examples of Sofosbuvir (to treat hepatitis C) or Opdivo (for advanced melanoma) illustrate these new policies. The treatment cost of the former, considered very innovative in France and cost-effective in the United Kingdom, was € 41,000 in France and € 44,000 in the UK. The treatment cost of Opdivo amounts to € 60,000 to € 79,000 per year in France (following a volume-price agreement without a performance clause), whereas it was refused in the UK in 2015 because of its excessively high cost per QALY, before being accepted in 2016 via an early access procedure with an annual cost expected to exceed € 101,000 per year. The financing of these innovative and particularly costly molecules is subject to specific procedures both in France and the United Kingdom: the “liste en sus” and the “Grey list” respectively.

32Starting in 2012, the companies, with the complicity of public authorities, adopted a new production model: they combined the production of generics in their subsidiaries, often located in countries of the South, with the production of personalised drugs sold on the markets of the countries of the North. This new model is named custombuster, and is similar (or even better) in terms of profitability to the blockbuster model, but contains notable differences with the previous model. First, custombuster production is based on biotechnological technologies while blockbuster production uses chemical technologies. Second, R&D is internalised in blockbuster production but mostly outsourced in custombuster production. Third, for blockbusters, drug use differs according to the pathology, regardless of patient type. By contrast, custombusters are prescribed according to the pathology and patient type on the basis of companion diagnostics. Finally, if treatments are expensive for blockbusters, they are very expensive for custombusters.

Conclusion

33The reforms carried out since 2008 have led to the privatisation of either the financing or the provision of healthcare services in the French and British healthcare systems. They have also resulted in budgetary restrictions requiring public health actors to try to compensate for declines in funding through productivity gains. However, these have not been sufficient and the quality of services offered has deteriorated, as is illustrated by the condition of public hospitals, both in France and the United Kingdom. Tighter drug price controls and generic promotion policies have affected firms’ profits, which are also confronted with the expiry of patents and a decline in innovation. Firms have responded by turning to the production of generics. Nevertheless, new molecules allowing personalised treatments, made available since 2012, are marketed at high prices relying on the benevolence of governments. These benevolent policies have allowed the emergence of a new production model closer to the blockbuster model: the custombuster model. Ultimately, after suffering a short period of declining profits, big pharma companies have been significantly less affected by austerity policies than other health care providers (including public hospitals). Dividends paid by Sanofi to its shareholders, for example, have been steadily rising for 23 years. This increase allowed it to move from the being the third largest distributor of dividends in France in 2015 (€ 3.48 billion) to top place in 2016 (€ 3.79 billion). Similarly, the world’s five largest big pharma companies recorded sales of more than € 200 billion and profits of € 47 billion in 2015.

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Bibliographie

Abecassis, P., and Coutinet, N., “Médicaments génériques : pivot de la reconstruction de l’industrie pharmaceutique”, Revue de la régulation. Capitalisme, institutions, pouvoirs, 2015.

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André, C., et al., “Health care privatization processes in Europe: Theoretical justifications and empirical classification”, International Social Security Review, vol. 69, 2016, pp. 3-23.

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Haut Conseil du financement de la protection sociale, Analyse comparée des modes de financement de la protection sociale en Europe, Paris, HCFi-PS, 2014.

Math, A., “La santé au péril de l’austérité”, Chronique internationale de l’IRES, 2014, pp. 22-52.

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Tabuteau, D., Démocratie sanitaire : les nouveaux défis de la politique de santé, Odile Jacob, 2013.

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Notes

1 Stuckler, D. and Basu, S., The Body Economic: Why Austerity Kills - Recessions, Budget Battles, and The Politics of Life and Death, HarperCollins Canada, 2013.

2 Reynaud, M., et al., Rapport annuel du Haut Conseil pour l'avenir de l'assurance maladie, Paris, HCAAM, 2013.

3 Tabuteau, D., Démocratie sanitaire: les nouveaux défis de la politique de santé, Odile Jacob, 2013.

4 Haut Conseil du financement de la protection sociale, Analyse comparée des modes de financement de la protection sociale en Europe, Paris, HCFi-PS, 2014.

5 Dalingwater, L., “The NHS at the Heart of the Election Campaign”, Revue Française de Civilisation Britannique (French Journal of British Studies), vol. 20, 2015.

6 Surrender, R., et al., Health system of United Kingdom Reference Module in Biomedical Sciences, Elsevier, 2015.

7 Math, A., “La santé au péril de l’austérité”, Chronique internationale de l’IRES, 2014, pp. 22-52.

8 Abecassis, P., and Coutinet, N., “Médicaments génériques : pivot de la reconstruction de l’industrie pharmaceutique”, Revue de la régulation. Capitalisme, institutions, pouvoirs, 2015.

9 Belloni, A., et al., “Pharmaceutical Expenditure And Policies: Past Trends And Future Challenges”, OECD Publishing, 2016.

10 André, C., et al., “Health care privatization processes in Europe: Theoretical justifications and empirical classification”, International Social Security Review, vol. 69, 2016, pp. 3-23.

11 Philippe Batifoulier, Capital santé: quand le patient devient client, La Découverte, 2014.

12 Abecassis, P., et al., “Les principes mutualistes confrontés aux modalités de regroupement des organismes complémentaires d’assurance maladie”, Revue internationale de l'économie sociale RECMA, 2014, pp. 60-75.

13 Schweppenstedde, D., et al., “Regulating quality and safety of health and social care”, London, Rand Corporation, 2014.

14 Department of Health, The Pharmaceutical Price Regulation Scheme 2014, Department Of Health & Association of the Britisk Pharmaceutical Industry 2013.

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Table des illustrations

Titre Graph 1 : Annual average growth rate (in real terms) of public expenditure on health per capita
Crédits Sources : OECD data, cited by A. Math.
URL http://journals.openedition.org/osb/docannexe/image/1935/img-1.png
Fichier image/png, 37k
Titre Graph 2 : Average annual growth in pharmaceutical expenditure and total health expenditure per capita, in real terms, OECD average, 1990-2013
Crédits Sources : OCDE, 2015.
URL http://journals.openedition.org/osb/docannexe/image/1935/img-2.png
Fichier image/png, 29k
Titre Figure 1 : A framework for reform analysis
Crédits Sources : André, Batifoulier and Jansen-Ferreira.10
URL http://journals.openedition.org/osb/docannexe/image/1935/img-3.jpg
Fichier image/jpeg, 24k
Titre Table 1 : Pharmaceutical cost containment measures implemented in the United Kingdom and France, since 2008
URL http://journals.openedition.org/osb/docannexe/image/1935/img-4.jpg
Fichier image/jpeg, 160k
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Philippe Abecassis et Nathalie Coutinet, « The Impact on Big Pharma’s Production Model of Medicine Policies in a Context of Austerity in France and the UK », Observatoire de la société britannique, 19 | 2017, 197-215.

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Philippe Abecassis et Nathalie Coutinet, « The Impact on Big Pharma’s Production Model of Medicine Policies in a Context of Austerity in France and the UK », Observatoire de la société britannique [En ligne], 19 | 2017, mis en ligne le 01 juin 2018, consulté le 18 juin 2018. URL : http://journals.openedition.org/osb/1935 ; DOI : 10.4000/osb.1935

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Auteurs

Philippe Abecassis

Maître de conférences en économie à l'Université de Paris 13 et chercheur au CEPN (CNRS-Université Paris 13)

Nathalie Coutinet

Maître de conférences en économie à l'Université de Paris 13 et chercheuse au CEPN (CNRS-Université Paris 13)

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Droits d’auteur

Observatoire de la société britannique

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