PPrrooppoossaall ffoorr RReesseeaarrcchh

RReevviissiittiinngg PPhhaarrmmaacceeuuttiiccaall

PPoolliiccyy iinn HHuunnggaarryy

Proposal prepared for an application of Central European University Centre for

Policy Studies

by

Gábor Hoffer

i

EExxeeccuuttiivvee ssuummmmaarryy

In my research I hope to revisit Hungarian pharmaceutical policy and to make

recommendations for the further improvement on the basis of careful evaluation of the

transferability of international evidence to the Hungarian context.

The aim of my research is to describe the formulation of Hungarian pharmaceutical

policy (pricing and reimbursement of medicines; access to medicines) in three stages.

The first stage aims to examine how Hungarian pharmaceutical policy has been

formulated (policy content, priority areas, process of decision making on pricing and

reimbursement of pharmaceutical products) and what main actors have participated in

policy process since the foundation of Health Insurance Fund in Hungary. I also wish

to examine what effect cost-containment policies had on the access to medicines in

the past years. In the second stage I wish to describe and assess the present

pharmaceutical policy by reviewing the content, context, process and actors of

pharmaceutical policy in Hungary. In the third stage I plan to review the evidences

about the international pharmaceutical policy initiatives and their transferability to the

Hungarian context. To achieve this aim results of the previous two stages are going to

be evaluated together with the international literature review on pharmaceutical

policy.

In the proposed research I plan to use a mixture of qualitative and quantitative

techniques. The assessment of policy context, content and process will be based on

qualitative data collection (documentary analysis and in depth interviews) and

analytic methods (grounded theory). Stakeholders of pharmaceutical policy will be

assessed through a stakeholder analysis by selecting specific pharmaceutical policy

initiatives. Planning and undertaking of an ecological study with regression modelling

will examine the effect of policy on access to medicines.

Research results are planned to be utilised in the improvement of pharmaceutical

decision-making process in Hungary. Research on access to medicine and the

assessment of transferability of international evidence provides further interesting

results at international level.

CCoonntteenntt

EExxeeccuuttiivvee ssuummmmaarryy ...................................................................................................................................................................... ii

IInnttrroodduuccttiioonn ............................................................................................................................................................................................ 11

Health of the Hungarian population and response of Hungarian health policy .. 1

Main issues of pharmaceutical policy................................................................... 8

SSttuuddyy AAiimm .............................................................................................................................................................................................. 1122

SSttuuddyy OObbjjeeccttiivveess .......................................................................................................................................................................... 1122

MMeetthhooddss ...................................................................................................................................................................................................... 1155

Theoretical frame of the research ....................................................................... 15

Analytical frame of the research ......................................................................... 16

EExxppeecctteedd UUttiilliissaattiioonn ooff tthhee RReesseeaarrcchh RReessuullttss ............................................................................ 1199

PPrrooppoossaall ffoorr FFiinnaall RReesseeaarrcchh RReeppoorrtt .......................................................................................................... 2200

RReeffeerreenncceess .............................................................................................................................................................................................. 2211

1

IInnttrroodduuccttiioonn

In my proposed research I wish to analyse the Hungarian pharmaceutical policy. In

the first part of my proposal I plan to provide short background information of my

proposed research. This includes the description why health and health policy is an

important issue in Hungary and why pharmaceutical policy can be regarded an

important health policy issue. This introduction is going to be followed by the

description of the suggested research topic.

To reach the above described objective my proposal includes the following topics.

Background of the proposed research.

Description of research aim and objectives.

Suggested methods for research.

Utilisation of research results.

Outline of the recommended research report.

In the following part I provide a broad context of the research.

HHeeaalltthh ooff tthhee HHuunnggaarriiaann ppooppuullaattiioonn aanndd rreessppoonnssee ooff HHuunnggaarriiaann hheeaalltthh

ppoolliiccyy

Health of the Hungarian Population

In this part of the proposal I plan to review the literature about the health status of the

Hungarian population and also the response of Hungarian health policy. By

2

undertaking this I wish to argue that health is a very important matter in Hungary and

Health policy has a significant potential to influence health of the population to a

great extent. I also wish to prove that pharmaceutical policy is an important part of

health policy and a potential area of health policy research and analysis.

Health of the Hungarian population is among the worst in Europe. The reasons of this

unfavourable health status have been the subject of extensive public health research

for a few decades 1-17. The main conclusions of above studies are summarised in the

following table.

Table 1 Review of the conclusions of studies about the health status and health needs of the Hungarian population

1. On the basis of analysis mortality data of the Hungarian population the following issues have to be

emphasised.

Mortality from all causes for the total Hungarian population is among the worst in Europe. Although,

there has not been major age group protected from high mortality the population aged 35-64 showed the

most unfavourable trends 1-4.

In 1999 more than ninety percent of the total mortality in Hungary is attributed to five main causes:

heart and circulatory system diseases (49%), cancer (24%), external causes of death (8%), chronic

respiratory diseases (4%) and chronic diseases of the digestive system (8%) 5.

The excess in overall mortality is primarily due to the higher risk of middle aged men in causes such as

cardiovascular diseases, cancers, injuries, suicides and chronic liver diseases. Certain types of

preventable mortality still cause high risk of death (e.g. the cervix cancer among females) 1-3; 10.

Specific causes of mortality have been showing some favourable tendency during the last few years.

The increase of lung cancer mortality and cirrhosis mortality has stopped and mortality in ischaemic

heart diseases shows a stagnant tendency without any increase or decrease 1.

2. There is a lack of reliable information about the burden of morbidity in the population. On the basis of

available data hypertension and diabetes are one of the most frequent chronic diseases1.

3. The control of communicable diseases seems to be effective in the country. Most of the communicable

disease has decreased since 1970. However, control of food borne diseases should be rearranged due to the

unfavourable six-fold increase of incidence of salmonella cases. Control of TB should be revisited, too.

Especially diagnostic and control measures need changes 18.

3

4. The measure of influence of social inequalities on health is unknown. It is assumed that growing economic

inequalities increase existing social gaps, too. This tendency emphasises the increased role of inequalities

in health and the need for more awareness of socially deprived population groups 19; 20.

5. Most important life style factors are smoking, alcohol consumption and diet 1; 9.

6. There is insufficient evidence about the effect of environmental factors on health. Major problems are such

as air pollution, noise exposure, work places, dump and sewage disposal and the problem of workplace

environment 1.

What is the message of poor health status of Hungarians to policy makers?

During the last decade intensive forces that have led to important changes of life of

Hungarians have formulated Hungarian economic, cultural and social life. Political

structure, economy and numerous aspects of social life were able to adapt rapidly to

the new circumstances and produced internationally recognised improvements 21.

However, other important dimensions of Hungarians’ life, which are far behind the

desired state, can endanger this “success story”. Health of the population and health

determinants is still among the poorest compared to economically well-established

countries. Our present knowledge about health and causes of poor health status allows

us to view present health policy strategies addressing health and proposing changes in

a critical way.

On the basis of Dekker’s definition we can identify health policies focusing on the

supply or demand side of health services22. Health policy can have an important

impact on both the demand and supply side of health services, which is further

supported by the evidences about the effectiveness of health policy approach on

improving the health of the population23-27. If we look at the main health policy issues

of the last few years we find that these are 28-31:

How to fix health care budget (emergence of cost-containment policies)

Private and public role in funding health care services

Private and public role in provision health care services

4

Definition of the guaranteed health care package

Introduction of competitive insurance

Remuneration of primary health care physicians

Remuneration of specialised health services

Co-payment system

Diffusion of medical technology with a special attention to

pharmaceutical policy

The importance of health policy and its analysis is further increased by the special

Hungarian context. Hungarian health policy is a white spot on the map of health

policy analysis literature. Up till now very little research is available on health policy

issues. However, health policy analysis could play a dual role as it helps both the

evaluation of the output and outcome of health policies and it also provides a good

basis for the successful implementation of future health policies. Hungarian health

policy has been improperly researched and explained. This area needs more research

that supports the success of implementation of future health policies.

In this part I reviewed why health policy is an important issue. In the following part I

demonstrate the importance of pharmaceutical policy in health policy.

The significance of pharmaceutical policy

5

Health care expenditures have risen since the nineteen seventies in most of the

economically developed countries. Following chart shows how the total health care

expenditures, calculated in US$ purchasing power parity, has changed

in a selection of European countries since the 1970. Neither of the examined countries

avoided the rapidly escalating costs of health care services. Increasing costs of health

services are mainly explained by the following reasons 29-31.

6

Escalating pharmaceutical expenditures was a principal causative determinant of

increasing health care expenditures common to all countries 29-31.

Above graph clearly demonstrates that pharmaceutical expenditures have increased in

all of the examined countries since 1970. It is an interesting observation that while

there was a gap between Hungarian and Western European per capita total health care

expenditures this gap was less significant in the case of per capita pharmaceutical

expenditures. This assumes that Hungarian pharmaceutical policy was less successful

in cost containment polices than in controlling the increase of other health care cost.

This assumption supports the importance of analysis of pharmaceutical policy further.

On the basis of the above information the following conclusions can be drawn.

0

50

100

150

200

250

300

350

400

1970 1975 1980 1985 1990 1995 2000 2004

Austria

Finland

France

Hungary

United Kingdom

992707 Pharmaceutic.expenditure, ppp$ per capita

7

In this part I reviewed the major evidences about the importance of pharmaceutical

policy. In the following part I summarise the main issues of pharmaceutical policy in

developed countries and in Hungary.

8

MMaaiinn iissssuueess ooff pphhaarrmmaacceeuuttiiccaall ppoolliiccyy

Main issues of pharmaceutical policies in developed countries

Pharmaceutical policy in countries with established market economies has the

following three main objectives 29-31:

Containment of costs;

Increasing of efficiency of financing pharmaceutical products;

Keeping the right level of solidarity in access to medicines.

To reach the following objectives different policy measures were introduced. These

policies could be divided into demand oriented policy strategies and supply side

oriented policy strategies. The following table (Table 2) summarises the list of the

different strategies and the place of their application.

Table 2 Demand and Supply Side Strategies

Demand side strategies:

1. Cost sharing (all countries but the Netherlands)

2. Developing market for OTC products

3. Health education program (The Netherlands, UK)

4. Capitation or salary payment for first contact doctor (e.g. Ireland, UK, Sweden, Spain, Italy

etc.)

5. Paying pharmacist on a flat rate, not on a percentage basis (UK, the Netherlands)

6. Fixed budgets for doctors (UK)

7. Indicative budget for doctors (Germany, Ireland)

8. Fixed budgets for pharmaceutical expenditures (Italy)

9

9. Practice guidelines (France)

10. Use of cost-effectiveness studies (UK, France, Sweden)

11. Information and feed back to physicians (UK, Denmark, Sweden)

12. Prescription auditing (several countries)

13. Disease management (France, UK)

14. Encouraging generic substitution (several countries)

15. Promoting the use of generics (the Netherlands, Denmark, Germany, UK)

Supply side strategies

1. Price control (several countries)

2. Reference prices (Germany, Italy, Denmark, Sweden)

3. Profit control (UK)

4. Industry contributions when budgets are exceeded (Germany)

5. Revenue or fixed budget for the industry (Spain, France)

6. Positive and negative list (all countries)

7. Controlling the number of products (Norway, the Netherlands, Denmark)

8. Ceilings on promotion expenditure (UK)

9. Taxes on promotion expenditure (France Sweden)

10. Development of market for parallel imports (UK, Germany, the Netherlands, Denmark)

Source: Mossialos E.: Pharmaceutical Pricing, Financing and Cost Containment in the European Member States; in Leidl R. Health Care and its Financing in the Single European Market, IOS Press: Amsterdam, 1998

Because of the limitation of the present proposal I do not plan to go into details

related to the different polices and their evaluation on the basis of the international

literature. This work is planned to be the part of the recommended research.

10

Present pharmaceutical policy in Hungary

Escalating pharmaceutical expenditures has not avoided the Hungarian health market

either. Similarly to other countries, Hungarian health policy introduced different ad

hoc measures to control rapidly rising pharmaceutical expenditures. Compared to the

opportunities the number of these measures is very restricted. These policies are

reviewed in the following table (Table 3).

Table 3 Demand and Supply Side Strategies in Hungarian Pharmaceutical Policy

Demand side strategies:

1. Cost sharing

2. Developing market for OTC products

3. Capitation or salary payment for first contact doctor

4. Information and feed back to physicians (very limited for a short period of time)

5. Prescription auditing (to a very limited extent)

6. Promoting the use of generics (this happens in political rhetoric only)

Supply side strategies

1. Price control

2. Reference prices

3. Positive and negative list

4. Controlling the number of products

11

Obviously, Hungary has not utilised many of the available pharmaceutical policy

strategies to control expenditures and due to the growing pressure on policy makers it

cannot avoid the introduction of new measures. The successful application of

international experiences is hindered by many circumstances.

There is a very limited knowledge about the success of implementation

of previous and present policies.

Present pharmaceutical policy priorities are not transparent and

explicit.

Requirements and special consideration of the adaptation and

application of new pharmaceutical policies are not explored.

Because of these reasons in my study I plan to review how Hungarian health policy

was formulated during the past ten years and what were those factor, which affected

the successful application of policy initiatives. I also plan to undertake a deep review

of the major international pharmaceutical policy initiatives and to examine the special

needs of their application in the Hungarian context.

12

SSttuuddyy AAiimm

The aim of my research is to describe the formulation of Hungarian pharmaceutical

policy (pricing and reimbursement of medicines; access to medicines) in three stages.

The first stage aims to examine how Hungarian pharmaceutical policy has been

formulated (policy content, priority areas, process of decision making on pricing and

reimbursement of pharmaceutical products) and what main actors have participated in

policy process since the foundation of Health Insurance Fund in Hungary. I also wish

to examine what effect cost-containment policies had on the access to medicines in

the past years. In the second stage I wish to describe and assess the present

pharmaceutical policy by reviewing the content, context, process and actors of

pharmaceutical policy in Hungary. In the third stage I plan to review the evidences

about the international pharmaceutical policy initiatives and their transferability to the

Hungarian context. To achieve this aim results of the previous two stages are going to

be evaluated together with the international literature review on pharmaceutical

policy.

The main aim of this research is to understand an important part of Hungarian health

policy process, content and context and to support the increase of explicitness of

Hungarian pharmaceutical policy.

SSttuuddyy OObbjjeeccttiivveess

1. Stage 1. objectives: Provision of a detailed review of the Hungarian pharmaceutical

policy since the introduction of National Health Insurance system (with special attention

to the identification and description of policy initiatives related to efficiency, cost-

containment and equity in access to medicines). Description of how decisions were made

on pharmaceutical policy priorities during this period (description and assessment of the

decision making process applied related to pricing and reimbursement of pharmaceutical

13

products). Description of the different stakeholders influencing pharmaceutical policy.

Assessment of other contextual factors affecting pharmaceutical policy (e.g. political,

social, legal and economical factors).

2. Stage 2. objectives:

2.1. Assessment of how far cost-containment, efficiency and equity in access to medicines

principles were taken into consideration in formulating pharmaceutical policy.

2.2. Analysis how pharmaceutical policy influenced and still influences the access to

medicines in Hungary.

2.3. Description of the present pharmaceutical policy initiatives and priorities. Analysis

of how the issues of cost-containment, efficiency and equity are addressed by present

policy.

2.4. After the selection of special policy initiatives (e.g. related to pricing or

reimbursement or other supply or demand oriented strategy) description and

analysis of present process of pharmaceutical policy making.

2.5. Analysis of stakeholders’ influence and power on decision making about pricing and

reimbursement of medicines in the cases of selected initiatives.

2.6. Assessment the explicitness (transparency) of policy process in Hungary.

2.7. Description and analysis of the main factors that are considered during setting up of

priorities in formulating pharmaceutical policy. Description and evaluation of how

these factors are prioritised. (E.g. what are the basic principles, which are

considered in reimbursement and pricing decisions? How solidarity and efficiency

are taken into consideration?)

2.8. Description and analysis how far public health needs are considered during making

decisions about reimbursement and pricing of pharmaceutical products?

3. Stage 3. objectives:

3.1. Review of international literature about the evidences of effectiveness of

pharmaceutical policies.

3.2. Definition of a list of strategies, which could be applied in the Hungarian context.

14

3.3. Examination of the transferability of these strategies to the Hungarian context.

3.4. How the question of efficiency and solidarity is handled in pharmaceutical

reimbursement? With special attention to the question that how efficiency is taken

into consideration in reimbursement and pricing decisions?

15

MMeetthhooddss

In my method chapter, first, I introduce the theoretical framework of my research.

Then I describe the analytical frame with the proposed methods.

TThheeoorreettiiccaall ffrraammee ooff tthhee rreesseeaarrcchh

The aim of my research is to describe and analyse different aspects of Hungarian

pharmaceutical policy, such as how the content of policy has changed, which

stakeholders influenced the process, what the main priorities were etc. I evaluated a

group of different frameworks, which have been developed for analysing health

policy 27; 32-34. As a result of this evaluation I selected to use a framework of Walt and

Gilson, which provides the theoretical basis of the research 27. The main strength of

this framework compared to the other ones is that it does not focus on specific aspects

of the investigated health policy issue but it takes a comprehensive approach by

evaluating the content, context, actors and process of policy making and their

interactions with each other in the same model (most of the other reviewed health

policy frameworks focus on the evaluation of specific segments of health policy, such

as the process of decision making, setting priorities, the applied strategies and the

power of certain stakeholders).

By using Walt and Gilson’s framework I provide a complex description of

pharmaceutical policy formulation from a process (decision making process on

pharmaceutical policy issues), actor (stakeholders affecting pharmaceutical policy

decisions), context (economic, social, political and legal factors affecting

pharmaceutical policy) and content (pharmaceutical policy priorities and their effect

on improving cost-containment, efficiency and equity policies) point of view in each

phase of the description. By applying this theoretical frame, not only the activities and

16

outputs of the system become available for description and analyses but those factors

that hinder or facilitate the application of effective pharmaceutical policy, as well.

AAnnaallyyttiiccaall ffrraammee ooff tthhee rreesseeaarrcchh

Research is planned to consist of three stages. Diagram on the following page

provides an overview about the different stages and the recommended methods to

realise objectives of each stages.

In the first stage I plan to overview the Hungarian pharmaceutical policy of the last

ten years. I plan to analyse content by reviewing what the main priorities and policy

initiatives were (by the separate description of demand and supply strategies). Listing

and assessing the main factors affecting pharmaceutical policy in Hungary will

provide a basis for the assessment of context. Main stakeholders influencing

pharmaceutical policy will be reviewed and their power and influence will be assessed

through a stakeholder analysis. In this stage I plan to assess pharmaceutical policy by

reviewing how the access to pharmaceutical products has changed and how policies

could possible affect the access. In this study I plan to use secondary data.

In the second stage, the content of present pharmaceutical policy will be reviewed.

Policy initiatives will be divided into supply and demand side strategies. It is planned

to be examined how the different initiatives aim to maximise cost-containment,

efficiency and equity principles. By selecting special policy initiatives the analysis of

context of policy and the process of decision making is planned to be carried out.

Main stakeholders are going to be examined by undertaking stakeholder analysis.

In the third stage I review international evidence about the effect of different

pharmaceutical policies and I plan to assess the transferability of these policies into

the Hungarian policy context. During evaluating transferability I use the results of the

previous analysis of Hungarian pharmaceutical policy in stage one and two.

Data analysis:

Stakeholder analysis is going to be undertaken according to the ODA guideline 35.

17

Primary data are going to be collected by undertaking in-depth interviews and collecting

documents. These qualitative data will be analysed according to the analytic strategy

described in the given source 36. Triangulation will be used to check validity.

Ecological study will be undertaken by collecting secondary data about access to

medicines and other factors affecting access to medicines (price, reimbursement, socio-

economic factors, needs etc.). Determinants of access will be examined by using

regression analytic modelling 36.

18

19

EExxppeecctteedd UUttiilliissaattiioonn ooff tthhee RReesseeaarrcchh RReessuullttss

Research results are hoped to be potentially used in the following ways:

Results of this research provide a basis for stakeholders to initiate the further

improvement of pharmaceutical decision making. Description and analysis of

the near past and present Hungarian pharmaceutical policy can improve policy

makers understanding of good pharmaceutical policy.

It provides a list of alternative policies that can be used in the Hungarian

context after careful adaptation. One of the aims of the research is to provide a

list of alternative strategies to improve Hungarian pharmaceutical policy. The

goal of this is not the provision of a cookbook method of good pharmaceutical

policy but the laying down of a good basis for discussion of further

improvement of Hungarian pharmaceutical policy.

It hopes to show further areas of policy studies to improve the basis for policy

making. It is an important goal to show those areas where further research is

essential and can support the efficiency of decision making to a great extent.

The examination of transferability of international evidences on

pharmaceutical policy into the Hungarian context could contribute to the

knowledge and understanding of the emerging scientific issue of adaptation of

technologies and methods in different contexts.

The results of this research are hoped to encourage international comparison,

which can improve our further knowledge at international level. It is also

hoped that knowledge should be global, too. And the internationally relevant

aspects of the analysis are planned to be emphasised.

20

PPrrooppoossaall ffoorr FFiinnaall RReesseeaarrcchh RReeppoorrtt

In this part I plan to propose the outline of the final research proposal.

Chapter 1. Introduction

Chapter 2. Methods

Chapter 3. Review of the Past of Hungarian Pharmaceutical policy

Chapter 4. Present Hungarian Pharmaceutical policy

Chapter 5. Lessons to learn from international evidence

Chapter 6. Recommendations for the improvement of Hungarian

pharmaceutical policy

Chapter 7. Potential areas of future policy studies

21

RReeffeerreenncceess

1. Adany R., Hajdu P. Szeles Gy. Kosa K. Hoffer G. Report on the health status of the Hungarian

population. 1999. Debrecen, Hungarian School of Public Health. (GENERIC)

Ref Type: Report

2. Bobak M.Marmot M. East-west mortality divide and its potential explanations: proposed

research agenda. British Medical Journal 1996;312:412-25.

3. Bobak M.Skodova Z.Pisa Z.Poledne R.Marmot M. Political changes and trends in

cardiovascular risk factors in the Czech Republic, 1985-92. Journal of Epidemiology and

Community Health 1997;51:272-7.

4. Bojan F.Hajdu P.Belicza E. Avoidable Mortality. Is it an indicator of quality of medical care in

Eastern European countries? Quality Assurance in Health Care 1991;3:

5. Bojan F.Kertai P. Nepegeszsegugy Idoszeru Kerdesei (Current Issues in Public Health).

Budapest: Literatura Medica, 1992;

6. Central Statistical Office. Health Status and Life Style in Hungary on the basis of microcensus

carried out in 1984. Budapest: Statisztikai Kiadovallalat, 1987;

7. Central Statistical Office. A halandosag jelenlegi szintje es alapiranyzata Magyarorszagon

(Trends and present status of mortality in Hungary between 1945-1985). Budapest: Central

Statistical Office, 1988;

8. Central Statistical Office. A halalozasi viszonyok alakulasa Magyarorszagon 1980-92 (Mortality

trends in Hungary between 1980-92). Budapest: Central Statistical Office, 1994;

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11. Expert Group from WHO Regional Office for Europe and the European Committee for Health

Promotion Development. Investment for Health in Hungary. 1997. (GENERIC)

Ref Type: Report

12. Feachem R. Health decline in Eastern Europe. Nature 1994;367:13-14.

13. Foster DP.Jozan P. Health in Eastern Europe. Lancet 1990;335:

14. Hajdu P.Belicza E.Jozan P.Jan F. (Analysis of mortality trends in Hajdu-Bihar county and

Debrecen 1985-1988). Nepegeszsegugy (Public Health) 1991;73:169-226.

15. Hajdu P.Belicza E.Jozan P.Bojan F. (Analysis of spatial characteristics of mortality in Gyor-

Moson-Sopron county). Nepegeszsegugy (Public Health) 1992;73:169-226.

16. Hajdu P.Jozan P.Bojan F. (Social, economical and mortality differences in Gyor-Moson-Sopron

and Hajdu-Bihar counties). Nepegeszsegugy (Public Health) 1993;74:157-170.

17. Magyar Tudomanyos Akademia SKHAoSSRD. (Mortality Trends in Hungary between 1980-

1992). Budapest: 1988;

18. McKee M.Bojan F. Reforming Public Health Services. In: Saltman R.Figueras J.Sakellarides C,

ed. Critical Challenges for Health Care Reform in Europe. Philadelphia: Open University Press,

1998;

19. Orosz E. The Hungarian country profile: inequalities in health and health care in Hungary.

Social Science and Medicine 1990;31:847-57.

20. Szivos P. (Vertical and Horizontal Inequalities in Hungary in the early 1990s). Demography

1993; 36:224-237.

21. The Economist Intelligence Unit. Country Profile: Hungary. 1997. London, The Economist

Intelligence Unit Ltd. (GENERIC)

Ref Type: Report

22. Dekker E. Health care reforms and public health. European Journal of Public Health 1994;4:

23. de Jonge GA.Engelberts AC.Koomen-Liefting AJ.Kostense PJ. Cot death and prone sleeping

position in the Neatherlands. British Medical Journal 1989;298:

23

24. De Kadt E. Making health policy management intersectoral: Issue in information analysis in less

developed countries. Soc.Sci.Med. 29:503-514.

25. Ebrahim S.Smith GD. Systematic review of randomised controlled trials of multiple risk factor

interventions for preventing coronary heart disease. British Medical Journal` 1997;314:1666-

74.

26. Frenk J. The New Public Health. Annual Review of Public Health 1993;14:469-490.

27. Walt G GL. Reforming the health sector in developing countries: the central role of policy

analysis. Health Policy and Planning 1994;9:353-70.

28. Saltman R., Figueras J. European Health Care Reform. Copenhagen: World Health Organisation

Regional Office for Europe, 19970;

29. Leidl R. Health Care and its Financing in the Single European Market. Amsterdam: IOS Press,

19980;

30. Normand C., Vaughan P. Europe Without Frontiers, The Implication for Health. Chichester:

Jhon Willey&Sons, 19930;

31. Schwartz F., Glennerster H., Saltman R. Fixing Health Budgets. Chichester: Willey&Sons,

19960;

32. Bill Jenkins. Policy analysis: Models and approaches. In: Michael Hill, ed. The Policy Process.

London: Prentice Hall, 1998;

33. Durning D. Participatory policy analysis in social service agency: a case study. Journal of

Policy Analysis and Management 1993;12:297-322.

34. Parson W. Public Policy: An Introduction to Theory and Practice of Policy Analysis.

Cheltenham UK: Edward Elgar, 1995;

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of aid projects and programs. 1995;

36. Robson C. Real World Research. Oxford: Blackwell, 1996;

24

25

AAppppeennddiixx II.. –– EExxaammiinnaattiioonn ooff HHuunnggaarriiaann pphhaarrmmaacceeuuttiiccaall

sseeccttoorr iinnddiiccaattoorrss tthhrroouugghh iinntteerrnnaattiioonnaall ccoommppaarriissoonn

Objectives

The main objectives of this part of the study is the systematic comparison of

Hungarian pharmaceutical sector indicators (by using secondary data) at an

international level.

Hypothesis

1. Hungarian pharmaceutical expenditures are higher than it would be expected on

the basis of the level of distribution of determinants of pharmaceutical

expenditure.

2. Pharmaceutical consumption is higher than it would be expected on the basis of

the level of distribution of determinants of pharmaceutical consumption.

Data sources

HfA database

OECD database

Applied statistical method

Regression modelling.

26

List of used indicators

The following table reviews those indicators which are planned to be used through the

analysis:

Dependent Variables Independent Variables

Pharmaceutical expenditures Mortality indicators

Pharmaceutical consumption Morbidity indicators

Macro Economic Indicators

Health Service Resources Indicators

Public / private mix in financing pharmaceuticals

Demographic indicators (age and gender distribution)

27

AAppppeennddiixx IIII.. –– MMooddeelllliinngg HHuunnggaarriiaann pphhaarrmmaacceeuuttiiccaall

eexxppeennddiittuurreess aanndd ccoonnssuummppttiioonn

The main objectives of modelling are:

1. To examine Hungarian pharmaceutical consumption data through using

different indicators.

2. To examine which factors affect pharmaceutical expenditures at population

level in Hungary through modeling.

3. To examine how the introduction of different policy initiatives could affect

pharmaceutical expenditures.

4. To model future pharmaceutical expenditure

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