Country Attractiveness for Conducting Clinical Trials – A Literature Review

Tomislav Geršić; Nenad Vretenar; Jelena Jardas Antonić

doi:10.17573/cepar.2025.2.04

Authors

Tomislav Geršić University of Rijeka, Faculty of Economics and Business, Croatia https://orcid.org/0009-0005-0916-8189
Nenad Vretenar University of Rijeka, Faculty of Economics and Business, Croatia https://orcid.org/0000-0003-4689-0865
Jelena Jardas Antonić University of Rijeka, Faculty of Economics and Business, Croatia https://orcid.org/0000-0001-6872-9293

DOI:

https://doi.org/10.17573/cepar.2025.2.04

Keywords:

clinical trials, country attractiveness, factors, regulation, costs

Abstract

Purpose: Clinical trials are a big business worldwide, bringing benefits to patients and the healthcare systems of the countries that attract them. However, despite the extremely high scientific interest in clinical research in the medical literature, there is very little economic literature on clinical research and, in particular, on the factors that influence a country's attractiveness for clinical research. The purpose of this paper is to provide a review of this literature and the main approaches and findings used.
Approach: For this paper, the WoS CC database was first searched and papers on clinical trials published in 2015 or later were analyzed, with a focus on papers from the research area of business economics and public administration. Subsequently, an overview of the most important published papers on the study of the attractiveness of countries is then provided, and the methodological principles and results of the analyzed papers are explained.
Findings: A review of the literature shows that there are few studies investigating the attractiveness of countries for clinical research. Furthermore, the published papers are often small and examine individual cases or small samples of countries. However, the most important factors identified are the speed, reliability and efficiency of the hospital system and the predictability of regulations. The cost of research in each country, although not unimportant, is secondary to the key factors highlighted.
Practical Implications: Clinical trials are of great importance for human health. However, they are also important for economic reasons but are underrepresented in the scientific literature dealing with them. This paper provides researchers with a framework for future scientific research. However, as it focuses on the study of the attractiveness of clinical trials, it is also useful for regulators and policy makers to gain a better understanding of this field.
Originality/Value: This paper offers an overview of an important but neglected scientific field and, by systematizing and interpreting the research and its results, enables further development and facilitates future research.

Metrics

Metrics Loading ...

Downloads

Download data is not yet available.

References

1. Alemayehu, C., Mitchell, G. and Nikles, J. (2018). Barriers for conducting clinical trials in developing countries- a systematic review. Int J Equity Health, 17, p. 37. https://doi.org/10.1186/s12939-018-0748-6.

2. Alvarenga, L. S. and Martins, E. N. (2010). Biopharmaceutical industry-sponsored global clinical trials in emerging countries. Rev Assoc Med Bras (1992), 56(4), pp. 428–433. https://doi.org/10.1590/s0104-42302010000400015.

3. Amato, A. et al. (2017). A harmonized and efficient clinical research environment would benefit patients and enhance European competitiveness. Commentary. Annali dell'Istituto superiore di sanita, 53(2), pp. 104–107. https://doi.org/10.4415/ANN_17_02_05.

4. Avetisyan, A. (2020). Country Attractiveness: Analysis of the Main Factors. Finance: Theory and Practice, 24, pp. 58-74. https://doi.org/10.26794/2587-5671-2020-24-4-58-74.

5. Bansal, N. (2012). The Opportunities and challenges in conducting clinical trials globally. Clinical Research and Regulatory Affairs, 29. https://doi.org/10.3109/10601333.2011.647034.

6. Benisheva, T. et al. (2023). Conducting clinical trials in five Eastern European countries (EU-EECs) with a focus on Bulgaria. Biotechnology and Biotechnological Equipment, 37, 1. https://doi.org/10.1080/13102818.2023.2226741.

7. Bordet, R. et al. (2015). Early results from a multi-component French public-private partnership initiative to improve participation in clinical research - CeNGEPS: A prospective before-after study. BMC Medical Research Methodology, 15(1). https://doi.org/10.1186/s12874-015-0044-8.

8. Carvalho, M. et al. (2021). Clinical Trials in Portugal: How Can we Improve? Acta medica portuguesa, 34(2), pp. 80–83. https://doi.org/10.20344/amp.15155.

9. D'Ambrosio, F. et al. (2020). Clinical trials and drug cost savings for Italian health service. BMC health services research, 20, p. 1089. https://doi.org/10.1186/s12913-020-05928-6.

10. Dilts, D. M., and Sandler, A. B. (2006). Invisible barriers to clinical trials: the impact of structural, infrastructural, and procedural barriers to opening oncology clinical trials. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 24(28), pp. 4545–4552. https://doi.org/10.1200/JCO.2005.05.0104

11. Djurisic, S., Rath, A., Gaber, S. et al. (2017). Barriers to the conduct of randomised clinical trials within all disease areas. Trials, 18(1), p. 360. https://doi.org/10.1186/s13063-017-2099-9.

12. Dombernowsky, T. et al. (2017). Clinical trial allocation in multinational pharmaceutical companies – a qualitative study on influential factors. Pharmacology Research and Perspectives, 5(3). https://doi.org/10.1002/prp2.317.

13. Dombernowsky, T. et al. (2019). Criteria for site selection in industry-sponsored clinical trials: A survey among decision-makers in biopharmaceutical companies and clinical research organizations. Trials, 20(1). https://doi.org/10.1186/s13063-019-3790-9.

14. Garattini, L. and Finazzi, B. (2022). Pharmaceutical Patents in Europe: Radical Reforms Rather Than Getting Rid?. Applied Health Economics and Health Policy, 20(4), pp. 453-455. https://doi.org/10.1007/s40258-021-00697-7.

15. Gehring, M. et al. (2013). Factors influencing clinical trial site selection in Europe: the Survey of Attitudes towards Trial sites in Europe (the SAT-EU Study). Open, 3, 2957. https://doi.org/10.1136/bmjopen-2013.

16. Gehring, M. et al. (2015). Towards a more competitive Italy in clinical research: The survey of attitudes towards trial sites in Europe (the SAT-EU studyTM). Epidemiology Biostatistics and Public Health, 12(1), pp. 1–9. https://doi.org/10.2427/10246.

17. Glass, H. E. et al. (2016). Trends in the Location of Phase 3 Clinical Trials Between 2008 and 2012: A Retrospective Review Utilizing ClinicalTrials.gov. Pharmaceutical Medicine, 30(2), pp. 109–115. https://doi.org/10.1007/s40290-015-0135-1.

18. Glickman, S. W. et al. (2009). Ethical and Scientific Implications of the Globalization of Clinical Research. New England Journal of Medicine, 360(8), pp. 816–823.https://doi.org/10.1056/nejmsb0803929.

19. Górecka, D. and Szalucka, M. (2013). Country market selection in international expansion using multicriteria decision aiding methods. Multiple Criteria Decision Making, 8. pp. 31-55.

20. Ippoliti, R. (2013). Economic efficiency of countries’ clinical review processes and competitiveness on the market of human experimentation. Value in Health, 16(1), pp. 148–154. https://doi.org/10.1016/j.jval.2012.09.010.

21. Jeong, S. et al. (2017). Current globalization of drug interventional clinical trials: Characteristics and associated factors, 2011-2013. Trials, 18(1). https://doi.org/10.1186/s13063-017-2025-1.

22. Kaló, Z. et al. (2014). Contribution of clinical trials to gross domestic product in Hungary. Croatian medical journal, 55(5), pp. 446–451. https://doi.org/10.3325/cmj.2014.55.446.

23. Kramer, J. and Schulman, K. (2012). Transforming the Economics of Clinical Trials. NAM Perspectives. 2. https://doi.org/10.31478/201205e.

24. Lee, K. H. (2016). The conceptualization of country attractiveness: a review of research. International Review of Administrative Sciences, 82(4), pp. 807–826. https://doi.org/10.1177/0020852314566002.

25. Moscicka, K. et al. (2013). Western Eastern Europe – New Region on a Global Map of International Clinical Trials. Journal for Clinical Studies, 5, pp. 42-47.

26. Murthy, S., Mandl, K. D. and Bourgeois, F. T. (2015). Industry-sponsored clinical research outside high-income countries: An empirical analysis of registered clinical trials from 2006 to 2013. Health Research Policy and Systems, 13(1). https://doi.org/10.1186/s12961-015-0019-6.

27. Nedelcheva, Y. (2019). Competitiveness in the Pharmaceutical Industry: A Historical Overview. Entrepreneurship, VІI (1), pp. 36–47

28. Silva, R. et al. (2016). Globalization of clinical trials: ethical and regulatory implications. International Journal of Clinical Trials, 3(1). https://doi.org/10.18203/2349-3259.ijct20160472.

29. Stergiopoulos, S. et al. (2019). Evaluating the Completeness of ClinicalTrials.gov. Therapeutic Innovation and Regulatory Science, 53, p. 216847901878288. https://doi.org/10.1177/2168479018782885.

30. Strüver, V. and Ibeneme, S. C. (2021). Why are emerging countries popular for clinical research? South African medical journal, 111(5), pp. 453–459. https://doi.org/10.7196/SAMJ.2021.v111i5.14870.

31. Varmaghani, M. et al. (2020). At a glance: economic impact of industry-sponsored clinical trials of pharmaceutical products. Journal of Medical Economics, 23(10), pp. 1193–1195. https://doi.org/10.1080/13696998.2020.1787419

32. Viergever, R. F., Terry, R. F. and Karam, G. (2013). Use of data from registered clinical trials to identify gaps in health research and development. Bulletin of the World Health Organization, 91(6), pp. 416–425C. https://doi.org/10.2471/BLT.12.114454.

33. Walter, E. et al. (2020). Economic impact of industry-sponsored clinical trials of pharmaceutical products in Austria’, Journal of Medical Economics, 23(6), pp. 566–574. https://doi.org/10.1080/13696998.2020.1728977.

34. Fortune Business Insights, Clinical Trials Market Size, Share & Industry Analysis, By Phase. At <https://www.fortunebusinessinsights.com/clinical-trials-market-106930>, accessed 27 July, 2025.

35. UN: World Population Prospects. At <https://population.un.org/wpp/>, accessed March 12, 2025.

36. Worldometer: Countries in the world by population (2025). At <(https://www.worldometers.info/world-population/population-by-country/>, accessed 27 July 2025.