by Yannis Natsis, TACD advocacy officer
Is there an access to medicines crisis in Greece? Yes, and if nothing changes radically, the worst is yet to come!!
This rather pessimistic note summarizes the state of public health in crisis-hit Greece as the country just elected a new government. Some overall macroeconomic figures may have improved but if one looks beyond the numbers, it is evident that the crisis is more present than ever. The public health sector has been particularly hit. It is true that in the pre-crisis era, important amounts of money were wasted in fraud and mismanagement as health is indeed a profitable business. The drastic horizontal spending cuts agreed and implemented in the context of the Troika-dictated policies have however created serious obstacles to peoples’ access to medicines and health services.
In Greece, health insurance is linked to one’s employment status. Since spring 2010 and the signing of the first memorandum of understanding with the country’s international lenders, the so-called Troika (the International Monetary Fund, the European Central Bank and the European Commission), unemployment skyrocketed to almost 30% in the general population and 60% among the youth. This means that over the past five years millions of people lost their jobs and more importantly lost their health coverage. There have been numerous public statements that put the number of the uninsured between 1.5 & 2.5 million in a country of 10,5 million. It is worth noting that national legislation guarantees some social protection for a maximum of two years following the end of one’s employment. But who are these millions of uninsured and what happens to them if they get sick? They mostly belong to the middle-class or what used to be the middle-class in the country; in other words, people in their 30s, 40s and 50s, SMEs’ owners, self-employed and others who were forced out of business while never reaching retirement age. It is important to remember that in many cases, losing their health coverage meant that their family members fell off the social safety net too. The younger generation is the second vast category of people who never managed to find employment and are regarded as chronically unemployed. Ironically, for the moment, the latter are better off thanks to their young age and good health. This probably explains why the consequences of the crisis on public health are not fully felt yet. There are nonetheless numerous worrisome signs that lead to the conclusion that the status quo resembles a time bomb waiting to explode.
Experts and people from the field such as pharmacists, patient groups, doctors, civil society stakeholders who have set up social clinics & pharmacies -another symptom of the crisis- as well as several hospital directors concur that 2014 was the year where the number of uninsured patients went up dramatically. This adds up if ones take into account that the aforementioned 2-year social safety net has by now lapsed. In the meantime, data collected by social clinics and pharmacies point to the fact that the health conditions they are dealing with are becoming more and more serious. Even patients with advanced cancer seek their help as they cannot afford their treatments anymore. This brings us to one of the cores of the access to medicines problem in Greece today: patients are increasingly becoming their own doctors, self-managing their condition and selecting treatments based on what they can afford and not what is right for them. This is the case not only for the uninsured but also for those who still enjoy some sort of social coverage; for example the pensioners with their considerably reduced income. This category includes all those affected by the significantly increased co-payment percentages and out of pocket expenditure. Moreover, social clinics are reporting numerous cases of both uninsured and insured patients whose health has worsened because of this treatment self-management. These policies contribute to worsening health conditions on one hand and on the other hand; higher cost for the public health system which will eventually be forced to deal with more serious health conditions.
But what happens to an uninsured person who gets sick or suffers from a chronic disease in Greece today? In June 2014, under growing pressure the government came up with a long overdue ministerial decision to guarantee that no uninsured will be left without health coverage. In essence, this decision puts the responsibility squarely on the public hospitals. It foresees the establishment of a hospital committee that will examine on a case by case basis whether a patient falls under the category of “uninsured” and can thus be hospitalized and benefit from all the services for free. It all sounds very good on paper but several state hospital directors already complain and emphasize that the reality on the ground is very different as: a) the procedure is heavily bureaucratic and time-consuming making it practically impossible for the uninsured to gain access to the treatments they need, b) red-tape always discourages adherence; not to mention c) every public hospital has a very specific budget and cannot bear the additional cost. It is therefore not surprising that patients choose to visit the hospitals’ emergency care units where treatment cannot be denied and is provided irrespective of one’s insurance status. A similar trend has been well documented in Spain.
According to the OECD, health spending in Greece has dropped in each of the years since 2009, driven by a sharp reduction in public spending as part of government-wide efforts to reduce the large budgetary deficit. In 2015, state pharmaceutical spending is capped at 2bn euro or 1% of the GDP (it stood at almost 6 bn in 2008).
The typical line of argumentation used by Greek government and Troika officials in responding to the access to medicines concerns is that there is no statistical data and most stories are based on anecdotal information. This has paved the way for them to embark on a denialism campaign claiming that the storm is abiding and the crisis fades away. Clearly, this is not true.
There are some short-term, medium-term and long-term options that the new government can implement so as to effectively address the access to medicines crisis the country faces. Firstly, it should strive for further price reductions with an emphasis on expensive life-saving treatments for chronic diseases such as cancer, Hepatitis C, HIV, diabetes and others. It is a common secret that the pharmaceutical industry is charging immoral prices for medicines that are not always innovative. Secondly, it will have to guarantee transparency and unconditional accountability on all levels of policy-making in the public health sector especially concerning pricing & reimbursement policies. To this end, it would be worthwhile to publish detailed information on state pharmaceutical expenditure (both in volume & value). Moreover, since the start of the crisis, there have been efforts to increase the use of generics in the country. These efforts will have to be strengthened as a healthy generics competition leads to affordable treatments for more patients. At the same time, public authorities ought to inform and reassure public opinion about the quality and safety of generics. Health policies particularly with regards to the pharmaceutical expenditure should be dictated by comprehensive impact-assessment studies along with health indicators taking into account the real needs of patients as well as the sustainability of the public health system. It is important to note that new medicines should be evaluated based on their real added therapeutic value. Once more; a maximum degree of public scrutiny needs to be ensured during the negotiations with the pharmaceutical industry. Patient engagement in decision-making bodies such as the national medicines organization (EOF) is another key parameter and common practice in many European states. The next government will have to reexamine the increases in the co-payment percentages that caused the damaging for patients treatment self-management. Keeping in mind that unemployment does not show any sign of being significantly lower in the near future, it is imperative that the Greek government shifts away from the current employment-dependent health coverage system towards a new national insurance scheme that will guarantee access to medicines and health services for everyone.
Additionally, the Greek government could explore the possibility of using the tools offered by international trade rules i.e. the TRIPS flexibilities and price controls such as compulsory licensing in order to enable the breaking of the license, asking other laboratories to develop the medicine and reduce its price by means of generics competition.
On the European level, the future Greek government should join forces with its European partners in questioning the current patent-based model of medical innovation (development of new drugs) and pricing which is the root cause of the problems most countries are faced with. Numerous public health systems cannot afford the exorbitant prices that pharmaceutical companies are demanding and patients are left without their medicines. It is a matter of political will and determination; the EU should allow for the development of alternative mechanisms to stimulate medical innovation such as patent pooling & equitable licensing, open data, collaborative data sharing and innovation prizes to name a few. This is a praiseworthy painstaking long-term objective and requires collective action at the EU Council level. Furthermore, more public investment is necessary as public budgets dedicated to health are rapidly declining across the Union. It is oxymoron that most medical research is publicly funded, yet the question to ask is what do we get in return? EU investment should be with strings attached in transparency, affordability and access.
Even if health does not fall under EU competence, there is ample space for governments to define the parameters of European research and innovation, rules of transparency, intellectual property rules enforcement and many other areas at an EU scale. Governments in Europe today find themselves in a far weaker place than pharmaceutical companies who benefit from the obscurity that prevails in the sector and is conducive to dealings under the counter. To this end, it is worthwhile examining the prospect of activating the joint procurement mechanism in order to maximize states’ negotiating capacity towards the pharmaceutical industries.
Last but not least, Greek patient groups and civil society have a key role to play. They should not be taken for granted as simple solidarity-support mechanisms that can substitute state health services. Should this volunteer movement develop into a parallel health system, this will be a major step backwards for the country. On the contrary, these much-needed organisations should invest in their advocacy capacity. They should aim to foster social dialogue among stakeholders (pharmacists, doctors, pharma industry) and shape policy-making while striving for the highest degree of transparency and public scrutiny in the Greek public life. To this end, it is essential that they prioritise as well as elaborate on concrete policy asks and recommendations. This way they can fulfill their potential and help the newly elected government move in the right direction.
Policy makers in Greece and in the EU need to show a lot more political will in facing the worsening access to health-care crisis. Let´s all hope that the worst in not yet to come.