Chapter 8 Healthcare Systems and Pharmaceutical Industry in Emerging and Developed Economies: China and Poland versus the US and the EU

In: Economics and Mathematical Modeling in Health-Related Research
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Arkadiusz Michał Kowalski
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Abstract

The chapter focuses on the development of healthcare and pharmaceutical industry analyzed from the perspective of the innovation divide in the world economy, as there are traditionally countries with developed national innovation systems, playing the role of technology leaders, and those with developing innovation systems, acting as innovation followers. However, together with significant structural changes taking place in the world economy, we observe a gradual shift of high-technology industries, such as the pharmaceutical industry, to emerging economies, among which China is making a considerable progress in innovation performance. The objective of this research is to measure the development of healthcare and pharmaceutical industry in economies traditionally playing the role of technological followers, that is, China and Poland, and economies positioned as innovation leaders, that is, the EU and the USA. According to the results, the development of the healthcare sector in emerging economies, in particular China, is positively associated with economic growth, and innovations in the pharmaceutical industry are critical to the present and future advances in healthcare.

1 Introduction

The pharmaceutical industry is classified as high-technology industry, which is a science-based sector that manufactures products while performing above-average levels of R&D. Development of the pharmaceutical industry in a country requires high innovation capability. Hence, the question arises if emerging economies such as China or Poland have enough potential to develop this type of innovative sector. Historically, the majority of innovations were generated in developed countries. Thus, the sources of economic advantages for the Triad economies – the USA, Western Europe and Japan – throughout the last decades have been variables such as knowledge and innovation, as these countries have played the roles of technology leaders in the global economy and they specialized in medium-high and high-technology industries, such as pharmaceuticals. At the same time, the developing countries have drawn on cheap resources as primary source of their economic advantage, which has resulted in specialization in labor-intensive industries. While traditionally research and development (R&D)-led technological progress was concentrated in developed countries, nowadays we are witnessing the emergence of innovation hubs in developing economies. Two countries from the latter group are analyzed in this chapter, China and Poland, and their healthcare systems and pharmaceutical industries are contrasted and compared with countries positioned as innovation leaders, that is, the EU and the USA.

Nowadays, when societies are facing so-called Grand Challenges connected, for example, with the ageing of society and civilization diseases, and the problems of the COVID-19 pandemic, a special role in people’s well-being and nations’ economic development is played by healthcare systems and the development of innovations in pharmaceutical sectors. Traditionally, pharmaceutical innovation has been organized in a linear fashion. This paradigm has lost its meaning over the last two decades as a result of growing expenses, increased competition, new scientific advances, and demanding users. The linear model is inadequate to accommodate these new actors. This provides the rationale to discuss, in addition to the analysis of different indicators related to healthcare systems and the development of the pharmaceutical industry, the role of clusters in this sector. In particular, China’s pharmaceutical sector has grown significantly in terms of breadth and volume of manufacturing, which was accompanied by the creation and development of local pharmaceutical and biotechnological clusters.

2 Healthcare System Characteristics and Investments

The pharmaceutical industry plays a critical role in the development of the healthcare systems. Another crucial factor is related to health expenditure, which has a significant impact on people’s well-being and on the economic growth of countries (Fogel, 2004) and is strongly and positively associated with economic growth in both developed and developing nations (Lopreite & Zhu, 2020). However, comparing health expenditures in different economies is difficult since each country has its own set of political, economic, and social characteristics that influence its expenditures. Healthcare systems feature a range of insurance organizational structures and regulatory frameworks, as well as payment mechanisms for hospitals and physicians. Moreover, the relationship between expenditure on healthcare goods and services and total spending in the economy fluctuate over time as a result of variances in the growth of health spending compared to overall economic growth (OECD/WHO, 2020).

One of the crucial factors affecting healthcare capacity in different countries may be attributed to the level of health expenditure as a percentage of GDP (e.g., Khan, 2020; Ray & Linden, 2020; Wang et al., 2021). Long-term comparisons of current health expenditures as a share in GDP and per capita in China and Poland, in relation to the United States and the European Union, are presented in Table 8.1.

Table 8.1
Table 8.1

Current health expenditure, 2000–2018

Source: Author’s calculations based on data extracted from World Bank (2021)

The highest level of current health expenditure as a share in GDP, as well as per capita, takes place in the USA, followed by the European Union analyzed as a whole. It confirms that wealthy countries tend to spend more per person on healthcare and related expenses than lower-income countries. However, a strong increase can be observed in health expenditure in all the analyzed economies. The reasons include so-called grand challenges, which are connected with a collection of activities fostering innovation to address critical global health and development issues, including the ageing of society or lifestyle diseases. With this respect, Lopreite and Zhu (2020) observed a strong correlation between the ageing index and life expectancy in the United States and China, as well as between health spending per capita and GDP per capita, whereas China’s ageing population induces a relatively strong correlation between health spending per capita and GDP per capita.

Health expenditures include all costs associated with preparing for and maintaining an individual’s health, and they are conceptually distinct in each country. In general, they may be divided into two categories: public and private. Public health expenditures include social security contributions, taxes on the private and public sectors, and borrowings and subventions from foreign governments. Private health expenditures, on the other hand, include private health insurance, out-of-pocket health costs, and so on (Poullier, Hernandez, & Kawabata, 2003). The general tendency in the world economy is that with the exception of few countries, public expenditure largely replaces private spending, especially in high-income countries (Vrijburg & Hernández-Peña, 2020). A comparison of domestic general government health expenditure as % of GDP in all the analyzed economies is presented in Table 8.2.

Table 8.2
Table 8.2

Domestic general government health expenditure (% of GDP)

Source: Author’s calculations based on data extracted from World Bank (2021)

Domestic general government health expenditure as % of GDP is at the highest level in the European Union, but the fastest increase during analyzed period took place in China. From the organizational point of view, an increase in current health expenditure in China in the last decade can be attributed to the fact that this country formally initiated the New Health System Reform (NHSR) in 2009. The goal was to provide inexpensive healthcare to all Chinese citizens through the establishment of a basic universal provision of safe, effective, convenient, and low-cost services (Zhao et al. 2020). This comprehensive reform increased health insurance coverage significantly, with 95.7 percent of the Chinese population covered by three major social health insurance: the Urban Employee-Based Medical Insurance (UEBMI) program, the Urban Resident-Based Medical Insurance (URBMI) program and the New Rural Cooperative Medical Scheme (NCMS) (Meng et al., 2015). However, the growing proportion of the population aged 65 or over has resulted in a global increase in health spending as a result of increased demand for medical and long-term care services, posing a growing threat to the sustainability of national public budgets. This tendency is particularly pronounced in China, which has seen both economic growth and population ageing increase over the last four decades (Lopreite & Zhu, 2020).

The open research question is if public or private health expenditures have the most important effect on health outcomes. According to the findings of Crémieux et al. (2005), private health expenditures have a greater impact on health outcomes than public health expenditures in countries with mixed healthcare systems and traditional sickness insurance. Additionally, Berger and Messer (2002) indicate that the impact of public health spending is less than that of private health expenditures, or that these expenditures are insignificant in general. Moreover, public health expenditure has been hypothesized to crowd-out private healthcare expenditure (Ying, Chang 2020). On the other hand, according to some other studies (e.g., Novignon et al., 2012; Rad et al., 2013; Akinci, 2014), the effect of public health expenditure is greater than the effect of private health expenditure, which is due to the private sector’s lower responsibility for healthcare in comparison to the public sector. The comparison of domestic private health expenditure as % of current health expenditure in the analyzed countries is presented in Figure 8.1.

Figure 8.1
Figure 8.1

Domestic private health expenditure (% of current health expenditure)

Source: Author’s calculations based on data extracted from World Bank (2021)

The European Union, including Poland, has a lower share of domestic private health expenditure as % of current health expenditure in comparison with China and the USA. In China, individuals are increasingly responsible for the majority of healthcare financing as part of China’s economic change. This reflects a rapid transition from a centrally-planned economy to a market-oriented one with fast economic growth and a laissez-faire approach to healthcare that emphasizes self-reliance and out-of-pocket payment (Song et al., 2020). The United States has a healthcare system that largely consists of private providers and private insurance, but as healthcare has become a larger part of the economy, a higher share of healthcare funding has been provided by government (it increased by 16% in 2000–2018). It confirms the findings of Nunn, Parsons, and Shambaugh (2020), who note that some of the rise is due to increased spending as per capita income increases, while some is due to innovations that provide new healthcare services and products. They also document that the United States pays higher prices than most countries because of a lack of competition and high administrative costs. This is connected to the phenomenon of Baumol’s cost disease, which describes how sectors with relatively low productivity growth, such as healthcare, tend to experience rising costs (Baumol & Bowen, 1965; Baumol et al., 2012).

Advocates for pro-government policies stress market failings in the health sector and place a premium on equity. Proponents of free markets believe that the government also makes important mistakes and that market forces continue to work to improve efficiency in the health sector. However, the public sector does not cover all household health expenditures unconditionally on a global scale. If households are unable to meet the public standards for covering some of their health expenditures, they will be forced to cover the costs by themselves. This may result in financial difficulties for people due to their payment capacity being limited, not only in low-income countries, but also in high-income countries (Xu et al., 2003). Such a situation means a financial catastrophe due to health expenditure, which is referred to as catastrophic health expenditure. The risk of catastrophic expenditure for surgical care in the analyzed countries is presented in Table 8.3. Catastrophic expenditure is defined in the World Bank database as direct out-of-pocket payments for surgical and anesthesia care exceeding 10% of total income.

Table 8.3
Table 8.3

Risk of catastrophic expenditure for surgical care (% of people at risk)

Source: Author’s calculations based on data extracted from World Bank (2021)

The lowest proportion of people at risk of catastrophic expenditure for surgical care is found in Poland, followed by the United States and the EU. On the other hand, it is at the highest level in China, which is in line with the findings of Boz et al. (2020) that catastrophic health expenditures are more likely to occur in developing countries where health insurance coverage is insufficient, and in low-income regions. On the other hand, when high-income countries such as the US are considered, the cost of surgical treatments increases due to innovation and the advanced technology used. Technological progress and new treatment procedures that involve advanced technology result in improved health outcomes but also increase expenses. Thus, these countries face the possibility of catastrophic health expenditure. Moreover, Boz et al. (2020) showed that increased public health spending as a percentage of total health spending minimizes the likelihood of catastrophic health expenditure for surgical procedures.

3 Development of the Pharmaceutical Industry, with Focus on Clusters

The nature of the pharmaceutical industry is such that the key driver for its growth is innovation (Schuhmacher 2013). Innovations in pharmaceuticals are critical to the present and future advances in healthcare, and their role has been increasing during the COVID-19 pandemic. The pharmaceutical industry is classified among high-technology industries in the OECD classification (Hatzichronoglou, 1997) of manufacturing industries based on technology, according to their R&D intensity defined as direct R&D expenditures as a percentage of production (gross output), calculated after converting countries’ R&D expenditures and production using GDP PPPs.

The pharmaceutical industry has a long history of innovation. It has maintained a tight and successful two-way relationship with academic research institutes in chemistry, pharmacology, life sciences, and medicine. The succession of technologies generated ripples rather than waves of creative destruction because leading firms were adaptable enough to the demands of new regimes and even prospered as a result of them. A flourishing and very profitable business was founded, with many of its innovations becoming household names for over a century and others having a profound effect on our society’s nature, structure, and morality. In fact, there is no other industry with a comparable impact (Achilladelis & Antonakis, 2001).

Foreign trade can be a substantial stimulant for innovation, as it promotes increased effectiveness through the development of a country’s specialization in those fields where the country is relatively more efficient. Additionally, participation in foreign markets indicates the necessity of contending with international competition, which serves as a motivator for searching for and implementing R&D outcomes. Thus, foreign commerce can influence an economy’s innovation system by encouraging the imitation or adaption of foreign ideas or by stimulating the development of wholly new solutions (Weresa, 2014). A comparison of the export market share of the pharmaceutical industry in the analyzed economies is presented in Table 8.4.

Table 8.4
Table 8.4

Export market share: pharmaceutical industry

Source: Author’s calculations based on data extracted from OECD (2021)

The highest level of export market share of the pharmaceutical industry is reported in the USA, which confirms the US economy’s advancement in this sector, and innovativeness of the American economy. However, in a dynamic perspective, the US export market share of the pharmaceutical industry is slightly diminishing, whereas we can observe an increase of Chinese economy in this respect. Poland is lagging behind the analyzed countries and it does not exhibit specialization in the pharmaceutical industry. This confirms the general specialization of the Polish economy in the low-and medium-low technology industries, with a minority of companies being involved in high-technology sectors, e.g., as presented by Kowalski and Weresa (2014).

One of the most important drivers of technological advancement of the pharmaceutical industry is biotechnology, which is intensively used to develop new products, new processes, methods and services and to improve existing ones. Biotechnology has led to a considerable progress in the healthcare sector by driving the development of drugs that are optimized for therapeutic efficacy. A comparison of the number of patents in the biotechnology sector between the analyzed countries is presented in Table 8.5.

Table 8.5
Table 8.5

Number of patents in the biotechnology sector – applications filed under the PCT (priority year) per billion GDP (constant prices, constant exchange rates, OECD base year)

Source: Author’s calculations based on data extracted from OECD (2021)

The leading position in the number of patents per billion GDP in the biotechnology sector is taken by the US, followed by the EU, but in the dynamic perspective these two economies experience a decline in this indicator. On the other hand, China is making very fast progress, with a 324% increase in the number of patents per billion GDP in the biotechnology sector.

China’s pharmaceutical sector has grown significantly in terms of breadth and volume of manufacturing. Nonetheless, it was just one type of progression to commercialization of imitation drugs, whereas basic research remained severely inadequate. There were few new medications and little investment in creative research and development. China’s pharmaceutical sector is very undeveloped compared to the United States and Japan (Wang et al., 2009). Hence, the Chinese government takes actions aiming to transition the industry away from simple pharmaceutical production and toward pharmaceutical innovation (Prevezer, 2008). It also takes measures to enhance the pharmaceutical industry’s competitiveness through the establishment of clusters. The rationale for this drew on successful policy actions supporting export-oriented production clusters, which has compelled the Chinese government to replicate the cluster-based strategy by attracting enterprises in high-technology sectors to special economic zones or science and innovation parks. However, Hanel et al. (2020) question if cluster policies exploiting economies of agglomeration and scale in labor-intensive industries are likely to be as successful in high-technology sectors such as biotechnology or the pharmaceutical industry because of the need for skilled employees. While the Chinese central government has implemented a series of policies to promote the development of a pharmaceutical cluster, local governments have also implemented policies to promote the development of local pharmaceutical industry clusters, taking into account their own interests as well as local resources and the environment (Conle & Taube, 2010). Additionally, the promotion of cross-border cluster cooperation takes place under the Belt and Road Initiative, which is also used by China to promote more balanced regional development by opening up the western region in the country. This initiative also includes the Silk Road Cities Network concept, presenting the idea of a system of cities clustered along the New Silk Road into a network complex. This network will also include Polish cities, including three important players in the Belt and Road Initiative framework: Warsaw, Łódź, and Kutno (Kowalski, 2019).

As a result of diverse growth paths, resource constraints, and historical factors, the pharmaceutical sector in China has distinct regional features. The distribution of resource endowment has largely provided the background for the creation and growth of Chinese pharmaceutical clusters (Conle & Taube, 2010). Because the traditional Chinese medicine business is significantly more developed in China than the other pharmaceutical industries, clusters in this area were the first to be established. They are mostly concentrated in areas with an abundance of Chinese herb resources, such as the Changbai Mountains and the Sichuan Province. Chemical medicine production clusters are mostly developed in the Jiangsu and Zhejiang Provinces, which are renowned for their abundance of chemical raw materials and production capacity. Cluster formation also results in organizational and network changes through mergers and acquisitions and collaboration. Apart from the natural resources, the Chinese government played a critical role in the establishment, development, and distribution of pharmaceutical clusters (Yu et al., 2014). Different strategies are implemented by local governments in China to encourage the establishment of clusters and to improve the long-term competitiveness of their economies. In the creation and growth of clusters, the role of the local government is beneficial as long as the local government implements appropriate policies and pays more attention to the actual needs of clusters (Prevezer, 2008). As shown by Yu et al. (2014), China’s local strategy for pharmaceutical clusters serves two objectives:

  • 1) to maximize the use of local resources, such as natural resources, infrastructural facilities, and industrial base, in order to effectively create industrial clusters that will support industrial emergence and improve industrial competitiveness. While the particular local strategy may vary depending on the type of cluster resources, encouraging internal dynamics within clusters is usually stressed as a means of improving long-term competitiveness.

  • 2) to complement the relationships and interactions between innovation actors. The similarities in local governments’ policies promoting collaboration between innovation actors demonstrate that local governments in China have made significant efforts to not only establish industrial clusters but also to strengthen industrial competitiveness by enhancing interactions between firms within industrial clusters and between clusters and the outside world, which is particularly important during the economic downturn.

As shown by Kowalski (2020), the key to development success in China lies in closing the technological gap by importing existing technology (e.g., through foreign direct investments, which are concentrated mostly in eastern provinces, and associated technology transfer), and strengthening internal capabilities to utilize and improve on those technologies (e.g., through science, technology, and innovation policy, investment in research and development, and emergence of innovative regional clusters). The first factor was of particular importance for the development of the pharmaceutical industry in China and related transfer of technology. Pharmaceuticals were one of the first sectors in China to open up to foreign investors. Direct foreign investment has poured into the pharmaceutical industry since 1980, when the first Sino-foreign pharmaceutical joint venture was established. Since then, China has attracted huge amounts of inward FDIs as a result of both spontaneous market dynamics and place-based preferential policies at the regional level. However, there are significant differences in FDI geographical distribution among territories in the Chinese market (Li et al., 2017). Nevertheless, foreign investment and advanced technologies have fueled the modernization and expansion of China’s domestic pharmaceutical companies. They transfer to China modern production lines and production technologies, cutting-edge management skills and strategies, as well as more opportunities for information exchange and training.

4 Conclusions

Special attention is put in this chapter on healthcare systems and development of innovations in pharmaceutical sectors. Healthcare expenditure is a factor significantly effecting people’s well-being and nations’ economic development. The analysis here finds the highest level of current health expenditure as a share in GDP, as well as per capita, in the USA, followed by the European Union. It indicates that rich nations spend more on healthcare and associated costs per person than low-income ones. However, we find a significant rise in health spending across all the economies studied. One reason is what are known as great challenges, which refer to a set of actions aimed at encouraging innovation in order to solve major global health and development problems, such as population aging or lifestyle illnesses. This is especially concerning in China, where fast economic development together with an aging population results in a high correlation between health expenditure and GDP per capita.

Different studies investigate the effectiveness of public and private health expenditures, with different research outcomes. When compared to China and the United States, the European Union, including Poland, has a lower share of domestic private health spending as a percentage of total health spending. In China, as a result of the country’s economic transformation from a centrally planned to a market-oriented economy, a laissez-faire approach to healthcare that promotes self-reliance and out-of-pocket expenditure dominates. The United States has a healthcare system that is mostly composed of private providers and private insurance, but as healthcare has grown in importance as a sector of the economy, the government has contributed a greater amount of healthcare funding. Some of the growth of healthcare expenditure results from increased spending as per capita income increases, while some is attributable to innovations that supply new healthcare services and products.

Innovations in the pharmaceutical industry are critical to the present and future advances in healthcare. The pharmaceutical sector has a long history of innovation, with close and productive collaboration with university research institutes in chemistry, pharmacology, life sciences, and medicine. The largest export market share of the pharmaceutical industry is in the United States, indicating that economy’s advancement in this area and the innovativeness of the American economy. However, from a dynamic standpoint, the US pharmaceutical industry’s export market share is slightly declining, whilst the Chinese economy is dynamically growing in this respect. Similarly, China is making very fast progress in the number of patents per billion GDP in the biotechnology sector, despite the leading position taken by the US. An important role in developing the Chinese innovation potential in the pharmaceutical and biotechnological sector is played by the local strategy for the development of clusters in these industries. It aims to maximize the utilization of available local resources and to complement the relationships and interactions between innovative actors. China has successfully leveraged financial resources produced by low- and medium-tech industries, and the strength of its massive internal market to build its high-technology industries, including pharmaceuticals.

Acknowledgements

The author acknowledge the support of the National Science Center, Poland (Grant No 2016/21/B/HS4/03025 “Dynamics and factors of innovation gap between Poland and China – international and regional dimensions”).

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