Switch from public to private retail pharmaceutical expenditures: evidence from a time series analysis in Italy

OBJECTIVES: To analyse trajectories of retail pharmaceutical expenditures from 2010 to 2019 in Italy to investigate whether there was a switch from public to private expenditure, how the composition of private and public expenditure changed, and whether there are correlations with supply/demand variables. Answering these questions is important to assure pharmaceutical care to all citizens in a public health system where expenditure containment is the issue of pharmaceutical policies. DESIGN AND SETTING: Time-trend analysis was carried out in the Italian National Health System (NHS), between 2010 and 2019. We considered the following: public pharmaceutical expenditure with/without direct distribution of drugs, copayments, household out-of-pocket payments for drugs reimbursable/non-reimbursable by the NHS, and for drugs without prescription requirement. Correlations were tested between expenditure items and relevant statistics (Gini coefficient, resident population demographics, ages and categories of physicians, and current expenditure on health). RESULTS: The switch feared between public and private pharmaceutical expenditures was not found: private expenditure increased (average annual per cent change 1.5%; 95% CI 0.3% to 2.6%), but public spending remained stable (–1.0%; 95% CI –3.0% to 1.1%). Single items of expenditure exhibited significant pattern changes over the study period. A switch from public expenditure without direct distribution of drugs (–3.9%) to expenditure with direct distribution was found (+8.4%). Unexpected increases in household out-of-pocket payments for drugs reimbursable by the NHS (+6.1%) and in copayments (+4.9%) were shown. No notable correlations were found. CONCLUSIONS: This study offers insights into Italian experience that can be applied to other contexts and the results provide policy-makers issues to reflect on. The findings suggest that policies of pharmaceutical-expenditure management may have multiple effects and unexpected combined effects over time that should be considered when they are designed, and suggest that health policies must be adopted with a systematic logic and a broad and unified vision.