Parallel exports and the problem with Greek drug shortage statistics

“It’s been 8 months since the last time I got my medicine, I can’t find it anywhere, no matter how far I’ve searched. It used to be a so-called rare drug, but now it has become a non-existent one” says 25-year-old Eleftheri. She suffers from a rare form of rickets, which is a metabolic disease of the bones. “I was told to search for it in a warehouse in the center of Athens, but I didn’t find it there either. Pharmacists advise me to be patient. There is no replacement. This situation is very serious for me, I have severe pains and my whole body is straining,” says Eleftheria to MIIR.

In Europe, about 25 million people suffer from a rare disease. The drugs that are needed are called “orphans” because they are not usually adopted by the research programs of the pharmaceutical industry. In Greece, however, as in many European countries, the shortages no longer concern only rare diseases but regular consumed ones, such as antibiotics, respiratory and cardiovascular drugs.

MIIR, in collaboration with other EDJNet newsrooms, searched for data and managed to create a – as homogenized as possible – database of medicine shortages in Europe. We recorded 22,107 different entries over a five-year period (2018-2023) in a total of 9 European countries (Germany, Italy, Spain, Slovenia, Czech Republic, Greece, Romania, Austria, and Belgium). This research indicates that Greece is one of the countries that declared the lowest shortages in absolute number during the last five years. At the same time, however, the Greek official data show that even for these few – in relation to the real depiction – Greece has the longest median duration of shortages.

In the latest related announcement of the Greek National Organization for Medicines (EOF) 148 medicine shortages are reported. “There are much more but they report less. I am just indicatively saying that EOF issued a press release in September 2022 where it was mentioned that in terms of shortages we were in a better era than in 2019. We have already reported for over a year that we have much more (shortages)”, says Ilias Giannoglou, a Board Member of the Athens Pharmaceutical Association.

According to this Association there were over 400 medicines in shortage in mid March 2023.

“EOF is clueless in terms of shortages. It doesn’t know the market. It does not know which warehouses are exporting and which are not. This year was one of the worst, if not the worst ” adds the president of Athens Pharmaceutical Association, Konstantinos Lourantos. The interview at his pharmacy was interrupted by a customer. We heard him say (Lourantos): “this is in short supply, I had 10 boxes, I gave them all today; maybe you will find somewhere, although I think it would be very difficult”. He then turned to us: “Here is a man who tries to find an antibiotic for his child but there is no Augmentin. I had taken many boxes, some 50, I collected them as if I knew, but now I don’t have any. I mean, if I don’t have it, meaning a pharmacist who had stored a lot, who will?” Lourantos wonders.

The CEO of the Greek pharmaceutical companies Uni-Pharma & InterMed and also SG of the Hellenic Federation of Enterprises, Ioulia Tseti, considers the under-registration as given. She highlights to MIIR the typical example of “paracetamol, the lack of which this year, had not been officially notified to the Greek National Organization for Medicines (EOF). This fact is due to the circumstance, that many multinational companies do not inform the Agency and prefer instead to pay the relevant fines. Unfortunately, the Agency does not work proactively in our country and in the interest of public health, except when the private sector appears. And the private sector unfortunately works – with very few exceptions – at its own interest”.

We contacted the President of the EOF, D. Filippou and repeatedly sent our written questions to the organization without receiving any response until the publication of this article.

The Greek “paradox”

The production and distribution of pharmaceutical products is one of the most dynamic branches of the Greek industry. Based on the latest research by the Foundation for Economic & Industrial Research (IOBE) on behalf of the Hellenic Association of Pharmaceutical Companies (SFEE), in 2020 the sales of drugs in pharmacies and drugstores amounted to €4.6 billion, increased by 3.7% compared to 2019, while the sales in the hospitals and pharmacies amounted to €2.4 billion to be increased by 5.0%.

Drug sales have increased by 80% during the last five years, reaching a €3 billion in 2021. According to the Prodcom (Eurostat) survey, pharmaceutical production in Greece in value (ex-factory) approached €1.7 billion in 2020, increased by €287 million compared to 2019, while compared to the average term of the period 2010-2017 is strengthened by 82%. In addition, drug exports in 2020 increased by 48.3% compared to 2019.

So, if all these indicators are positive, why are there so many medicine shortages?

“There are two reasons: one is, the reduced import of products from some multinationals which are obviously not interested in the Greek market. By an audit we carried out over the last three years, we found out that many multinational companies imported smaller quantities of certain products,” mentions to MIIR the general secretary of the Panhellenic Association of Drugstores, Irini Markaki. And she adds, “the second reason – a very important one indeed – is the illegal export – please pay attention because there is also a legal one – that is done by some, in collaboration with pharmacies and some astute people who collect them”.

According to the analysis of MIIR, it appears that the main causes of the drug shortages in Greece for 2022 are manufacturing or product quality problems (45.3%), supply chain delays (33.7%) and increased demand (14%).

Shady dealers and the hoovering

These drugstores usually buy with cash from some pharmacies and then export directly to other countries. According to Ms. Markaki, the problem was created during austerity years in Greece, because of the OECD toolbox that allowed the creation of such “monkey businesses” – pharmaceutical warehouses.

“They create a Private Capital Company and they get easily an approval from the Greek National Organization for Medicines – because they include, for example, a refrigerator – however, without having a high stock of drugs and without having large spaces, while a wholesale pharmaceutical warehouse requires very large spaces. And what do they do? They go and collect medicines from the pharmacies (so in the market they call this “hoovering”) and then they export them, they sell them to each other, they “clean” them, they sell them to large pharmaceutical warehouses that export at the end. Or they sell them in black market outside Greece. There, a great deal of damage is done both to the Greek State and to the public health of whatever State they will end up in, because we don’t know under which conditions they are transferred.”

In mid-winter, EOF imposed a temporary lock down on 3 pharmaceutical warehouses that refused inspection.

However, this is also considered completely insufficient. “A short while ago, the Minister of Health, Mr. Th. Pleuris, issued an announcement about a pharmacy in Athens that had been locked down because the owners refused the inspection. This is not enough, however, as it has been observed that often companies can and do reopen, simply with a different name”, states Ilias Giannoglou of the Athens Pharmaceutical Association.
In fact, those who are “caught in the act” quickly open a new “second chance” warehouse with a different name, just paying a low fee to the Greek state.

However, apart from illegal exports, pharmaceutical manufacturers, traders and pharmacists agree that the low price of the medicine in Greece is part of the problem.

It is noted that only 34% of the total amount of medicines consumed in the country are produced by domestic factories. As Ilias Giannoglou explains, “Greek pharmaceutical companies mainly produce generics. The ones that are exported are the originals. They are multinationals’ products which are imported and re-exported. For example, a company’s insulin comes from Denmark and the company imports 300 pieces and channels them to the Greek market. However, an imported drug is sold by the pharmacy with a multiple profit abroad, than if it is distributed within the country”.

On the other hand, the powerful pharmaceutical industry in Greece – usually immune to the press criticism due to high advertising expenditure – also has a shared responsibility. Despite the inadequacy of checks by the EOF on drugstores, pharmaceutical companies often do not disclose in real time the quantities of drugs they distribute per pharmacy. Some companies do not even disclose the period of the actual shortage, which is critical information needed by legal pharmacies, pharmacies and certainly patients.

In addition, according to the president of the Panhellenic Pharmaceutical Association, Apostolos Valtas,  “fake shortages are created at the responsibility of companies at critical time periods as a bargaining tool to put pressure on the price committee in order to achieve better pricing.”

Under the legislative framework, pharmaceutical companies must have 3 months’ stock (plus 25% for foreigners and tourists) and any shortages must be declared 3 months in advance. “No company does that. And companies have never been audited or fined for that. Let’s not fool ourselves. The pharmaceutical industry always has a huge power towards any government and has a lot of money to push to the market, either directly or indirectly” says Irini Markaki to MIIR.

The blame game among the key players of the pharmaceutical industry can last forever. At the same time, however,  people in need of their medicines feel more insecure.

Eleftheria had not managed to find her medicine until the publication of the present. As a substitute, she takes another drug that does not fully aplly to a proper treatment, while following the advice of her endocrinologist, she has adjusted her diet to cover the substances she is lacking.

Less money for health

The total funding for health expenditure in Greece fell by 25.9% in the period 2010-2020, while in the EU it increased by 20.7% in the same time period (source: IOBE, SFEE, The pharmaceutical market in Greece: Facts & figures 2021). The public out-of-hospital pharmaceutical expenditure suffered a significant decrease of 60.8% in the period 2009-2021.

The funding decrease for health expenditure in Greece goes in an opposite direction from the rest of the EU, but also from the southern Mediterranean countries subset.

The government, unable or unwilling to control the situation, often throws the ball of blame to doctors and patients. Indicative was the statement of the Minister of Health, Thanos Pleuris at the beginning of this year: “some parents buy more non-prescription drugs and doctors may sometimes prescribe antibiotics in excess, providing an incentive for people to stock medecins at home due to fear of shortages”. This statement provoked intense reactions from the opposition and many pharmaceutical associations.

Medicines may indeed be cheaper in Greece compared to the European average (although the continuous decline in purchasing power must be taken into account), may the EU indeed urgently need a bold patient-centred policy based on its needs of public health with the return of production to its territory, but it is the responsibility of the Greek State and the government to ensure transparency in the data of deficiencies and accountability throughout the chain of the pharmaceutical industry.

Before the shortages peak and before accusing parents of stocking medicines, many other actions should have been taken: preventive measures, transparent information with harmonized and detailed benchmarks, imposing deterrent sanctions on pharmaceutical companies and traders and banning parallel exports in time and for as long as it takes.

To the question why this measure is almost always imposed with delay or not at all, a probable answer is that no government wants to reduce the index of exports, which add turnover to the country’s GDP.

As for the patients, especially for those who don’t trust the generics, as usual they are asked to bear the consequences through alchemy and prayers.

This cross-border data-based investigation was organised and coordinated by the Mediterranean Institute for Investigative Journalism (MIIR.gr ) within the framework of the European Data Journalism Network (EDJNet). Data analysis and visualizations were conducted by Corina Petridi.

The research was implemented between January & March 2023 and seven more EDJNET members participated: Deutsche Welle (Germany), Il Sole 24 Ore (Italy), PressOne (Romania), Deník Referendum (Czech Republic), El Orden Mundial (Spain), Pod črto (Slovenia), BIQdata (Poland).