Increasing Private Spending on Equivalent Medicines Calls for Institutional Campaign

Even in 2023, citizens spent over one billion euros out of their own pockets on price differences to obtain branded drugs instead of their generic equivalent medicines. Cittadinanzattiva advocates for a major institutional campaign to overcome resistance and misinformation. Nearly one in three citizens still doubts that equivalent medicines have the same efficacy as so-called “branded” ones, and one in five reports that doctors only prescribe the latter. While 47% of citizens are inclined to purchase the equivalent, 19% still prefer the brand.

These are some of the findings from an exclusive survey conducted by SWG (Observatory on the Propensity of Italians to Buy and Use Equivalent Medicines), between April and May, on a sample of 2,500 adult citizens representative of the Italian population. The survey was presented at the Ministry of Health during the event “Equivalent Medicines: Know to Choose” promoted by Cittadinanzattiva, as part of the IoEquivalgo campaign, with the unconditional support of Egualia.

In addition to the SWG survey, data from a study by the Scuola Superiore Sant’Anna di Pisa (Private Health Spending in Italian Regions: Focus on Equivalents) were presented. This study, for the first time, included the use of equivalent medicines and the price difference paid out of pocket by citizens as performance evaluation indicators for regions and companies. In 2022, private spending by citizens, including co-payment (regional tickets and differences), private purchase of class A medicines, and spending on class C drugs, amounted to 9.9 billion euros, an increase of 7.6% compared to 2021. Notably, co-payment spending is generally higher in low-income regions.

IoEquivalgo Campaign Highlights Disparities in Use of Equivalent Medicines Across Italy

The IoEquivalgo campaign, launched by Cittadinanzattiva in 2016, has reached all regions of Italy in its five editions, with its villages set up in squares and universities where people could receive information through direct consultation with health professionals, leaflets, the website http://www.ioequivalgo.it, and especially the app, a valuable and easy-to-use tool constantly updated by technical partner Farmadati. The current edition of the campaign investigated why the use of equivalent medicines is so low in the South, particularly in the pilot regions of Campania and Sicily, despite the lower per capita income compared to the North, where the use of equivalents is now a common practice.

As highlighted by the latest report from the Egualia Study Center, in 2023, citizens spent 1.029 billion euros out of pocket on the price difference to obtain the more expensive off-patent brand instead of the lower-cost fully reimbursed generic equivalent by the National Health Service (SSN). The use of equivalent medicines continues to be more prevalent in the North (39.8% of packages sold) compared to the Center (29%) and the South (23.7%), with a national average of 32%. The highest consumption rates are in Trento (44.7%), Friuli Venezia Giulia (41.9%), and Piedmont (40%). The lowest are in Sicily (22.7%), Campania (21.9%), and Calabria (21.7%).

“With the itinerant villages of the IoEquivalgo campaign, we have visited 22 cities, touching all regions of Italy, and we have involved students from some schools in Campania, Lazio, Piedmont, and Umbria. Additionally, we have signed individual memoranda of understanding with some regions, including Campania, Sicily, Marche, and Sardinia, to build alliances aimed at simplifying access to equivalent medicines. We believe that a major institutional information and communication campaign aimed at citizens and healthcare professionals (doctors, pharmacists, nurses) is now necessary to overcome cultural resistance and practical obstacles in the demand and supply of these medicines,” said Valeria Fava, head of health policy coordination at Cittadinanzattiva.

Cittadinanzattiva Proposes Measures to Promote Use of Equivalent Medicines in Italy

Cittadinanzattiva has made several concrete proposals in various areas:

In terms of communication and information:

• Launch qualitative surveys on user preferences regarding medicine consumption, analyzing factors associated with potential prejudices against equivalent medicines, to plan specific and personalized interventions with the support of civic organizations and patient associations.
• Conduct an institutional information campaign aimed at citizens and healthcare professionals (doctors, pharmacists, nurses) focusing on rights and responsibilities.
• Integrate health education into schools, creating a synergy between the educational and health systems; promote and support the activities and contributions of patient associations and civic organizations through community information sessions.

In terms of staff training:

• Develop training plans on equivalent medicines within pharmacy, medicine, and nursing degree courses.
• Enhance continuing medical education (CME) courses on the value of equivalent medicines and optimal management of this resource as a clinical and economic value for citizens and the SSN.

In terms of technical management of prescriptions:

• Extend the use of electronic prescriptions to all SSN-affiliated doctors operating in various public and private settings.
• Systematically monitor prescriptions by healthcare professionals and the appropriateness of non-substitutability clauses, initiating a regional dialogue on potential overuse or inappropriate use of “non-substitutability.”
• Promote a regional Technical Table involving doctors, pharmacists, nurses, health districts, representatives of scientific societies, and civic and patient organizations to initiate synergistic actions to improve access to equivalent medicines based on monitoring data and citizen behavior.

The study, presented by Riccardo Grassi, updates a previous 2021 survey by analyzing general attitudes toward health, information levels, trust in stakeholders, relationships with medicines, knowledge of generic/equivalent drugs, and purchase criteria.

Italians’ Health Attitudes and Trust in Equivalent Medicines Remain Steady

It shows that Italians’ attitudes towards health issues remain largely unchanged: 56% of the sample considers themselves health-conscious, 52% regularly undergo routine exams (61% among those over 64), and the majority report feeling well (44%) or very well (37%), but three out of five complain of fatigue, and nearly half report osteoarticular pain and insomnia. Minor ailments are mostly addressed by consulting a doctor (31%), a specialist (16%), or a pharmacist (10%), and by purchasing over-the-counter medicines (31%).

72% of the sample is well-informed about equivalent medicines, having heard about them from pharmacists (58%) or doctors (41%): 83% know that the equivalent contains the same active ingredient as the brand, 69% know it contains the same amount of medicine, but nearly a quarter of the population does not consider generics and equivalents to be the same. Almost 30% of respondents still have doubts about their efficacy.

When purchasing, almost two out of three Italians (64%) rely on doctors’ recommendations, especially among those over 64 and residents in the Northeast, but there is also trust in pharmacists’ recommendations (23%), particularly among young people. The study also focused on doctors’ prescribing habits: 20% of the sample says that doctors only prescribe branded drugs; 36% say they indicate both the active ingredient and the brand; only 31% report that doctors prescribe only the active ingredient, leaving the choice between equivalent and brand to the patient. Nonetheless, 47% of the sample is inclined to purchase an equivalent medicine, 34% the medicine recommended by the doctor or pharmacist, and 19% the branded medicine.

Highlighting Growing Private Health Spending and Importance of Equivalent Medicines

Milena Vainieri, a professor of management at the Scuola Superiore Sant’Anna di Pisa, highlighted the issue of equivalent medicines. She focuses on the performance evaluation of healthcare services, and since 2008, a network of regions has been systematically analyzing their respective performances to provide a comparative evaluation system. The network currently includes 11 regions, which have selected numerous indicators for a systematic and comparative performance evaluation process. These indicators describe and compare various dimensions of the healthcare system’s performance: population health status, capacity to pursue regional strategies, socio-health evaluation, citizens’ and employees’ experience evaluation, and economic-financial dynamics and operational efficiency.

This year, Sant’Anna introduced indicators for the use of equivalents and out-of-pocket price differences paid by citizens for branded drugs versus equivalents, due to growing private health spending. According to State Accounting Office data, private health spending in 2021 increased significantly to 37.16 billion euros (+20.7% compared to 2020) after a decline in 2020 (-11.6% compared to 2019). OECD data for the same year confirm that Italy’s private health spending (voluntary or out-of-pocket) was 26% of total health expenditures, compared to the OECD average of 24%.

Major reasons for private health spending include specialist visits and surgical interventions, predominantly dental (46.1%), medicines (17%), co-payments (7%), and other expenses. The same trend continued in 2022, with citizens’ out-of-pocket spending, including co-payments, private purchase of class A medicines, and class C drug expenses, amounting to 9.9 billion euros, a 7.6% increase from 2021. Co-payment spending is generally higher in low-income regions.

Resource: EGUALIA, May 22, 2024

Zahra Ahangar Atashi