Author byline as per print journal: James C. Robinson, PhD, MPH

Introduction/Study Objectives: Adoption of biosimilars has fallen below projections, despite the vigorous implementation of economic incentives, thereby highlighting the importance of behavioral factors such as social trust.  This paper analyzes biosimilar adoption across provinces in Italy and Germany, which evince strong variation in social trust, and across nations in Europe.
Methods: Data for 2020 biosimilar adoption for Italian provinces were obtained from the national pharmaceutical organization and for German states from the association of biosimilar manufacturers. Regions were coded as high versus low trust according to historical metrics and, separately, using the Quality of Government Index. The study includes two biologics for chronic immunological conditions, three biologics for acute cancer treatments, and their 20 biosimilars.
Results: Adoption of biosimilars was much lower in regions suffering from low social trust, with penetration falling below the national median in 7 out of 8 provinces in southern Italy and in all 7 provinces in eastern Germany. Rates of adoption are 21.5 percentage points higher in northern than in southern Italy and 5.2 points higher in western than in eastern Germany, controlling for other relevant factors. Provinces with low values on the Quality of Government Index (CQI) had significantly lower adoption than provinces with high citizen trust in government.
Conclusion: Economic incentives to promote adoption of biosimilars must ensure that the benefits accrue to the populations most affected, thereby enhancing social trust and cooperation.

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This manuscript has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record.