Research/text: Kostas Zafeiropoulos, Nikos Morfonios, Janine Louloudi (MIIR)

Data Analysis – Visualizations: Corina Petridi

Illustration: Louiza Karageorgiou 

On the 15th of December 2022 the European Medicines Agency announced that almost every EU country was facing medical replenishment gaps. It was known that a harsh winter was ahead for European countries facing both the Covid 19 pandemic and other seasonal viruses that were testing their health systems anew. However, what actually happened this year surpassed any forecast.

‘’To be honest, what took place this winter was that European countries were taken by surprise with such a large mismatch between supply and demand, especially for antibiotics’’, Steffen Thirstrup admits to MIIR – Health Head of EMA (European Medicines Agency), which is the competent body that guarantees the scientific assessment, supervision and monitoring for medicines safety in the EU.

From 2000 to 2018 there has been a 20-fold increase in recorded drug shortages in Europe. It’s like a disease that gets worse every year without -yet- a cure. The war in Ukraine and the energy crisis were used as a convenient excuse in various countries for political leaders to attempt to cover reality. But the problem seems to have other, timeless causes.

According to the latest 2022 European Pharmaceutical Union (PGEU) report, all EU countries that responded to the survey (including pharmaceutical chambers and pharmacy associations of 29 countries in the European region) experienced drug shortages in pharmacies in the last 12 months. The majority of countries reported that the situation worsened compared to the previous 12 months (75.86%) or remained the same (24.14%). No country recorded an improvement.

‘’Medicines shortages are increasing in Europe and have a huge negative impact on patients. They occur across all healthcare settings and involve both essential life-saving medicines and very commonly used medicines. Community pharmacists are very concerned about this phenomenon, which can compromise patients’ health. Moreover, pharmacies and pharmacists invest a lot of resources dealing with shortages which constitutes not only a financial burden, but also a loss of opportunity to spend time with other patient-centered tasks and to improve the quality of care”, Ilaria Pasarani,  General Secretary of PGEU, tells MIIR. On average, each pharmacy in the European Union spends 6.3 hours a week looking for missing medicines. In some countries this number reaches 20 hours per week.

‘’At present the situation is that most European countries are still reporting shortages. This is observed in 28 out of the 30 countries of the European Economic Area. The result would have been the same if you had also asked me two weeks ago,’’ EMA’s Steffen Thirstrup  points out to MIIR.

Nevertheless, which countries record the greatest drug shortages in recent years? Are the data reliable? What are the real reasons and why are we increasingly unable to find the medicines prescribed by our doctor in pharmacies? Which categories of drugs, which active substances are missing, and above all, why are they missing? The answers are not unequivocal, they are often difficult to find and they are not always common for all countries.

Inhomogeneity in records

At a pan-European level there is not yet a homogenized database recording drug shortages -i.e. in the same language- with data that can be seen in real time. There is not even a definitive European agreement on how a shortage is defined. Several European states have adopted the definition of the European Medicines Agency (EMA, 2019): “A shortage of a medicine for human or veterinary use occurs when the supply does not meet the demand at national level”.

Assessments for the actual duration of medicinal shortages are often difficult to be determined, precisely because of the gaps and inconsistencies in national medical association registries. Many listings do not even provide an (assessed) expiration date for each shortage. Most European countries have only started collecting standardized information on shortages in the last five years. There are also notable differences in the obligations surrounding the reporting of shortages. For example, in Denmark notifications are made only for “severe” shortages, while in Sweden only shortages with an expected duration of more than three weeks are required for notification by the system.

There are countries that do not even provide a registration website, while in others the database includes in parallel human, hospital, veterinary and vaccine medicines. Furthermore, not all countries publish their data in the same way. For example, the Greek National Organization for Medicines (EOF) doesn’t publish the shortages annually, doesn’t mention the classification of drugs, and does not systematically provide data about the duration of a shortage. EU member states are also far from harmonizing standards for recording and reporting shortages, a fact which hinders information-sharing and comparative analysis between countries. 

We asked the European Medicines Agency (EMA) whether it keeps aggregated data for all EU countries, but the answer was negative. Instead, the EMA referred us to the websites of the national medicine’s registries. 

‘’Some states have a very detailed network of information collection from community pharmacies, and from hospital pharmacies. But not everyone has it to the same degree. Some states have sophisticated IT systems to look at supply and demand, and can therefore respond much more quickly”, EMA’s Steffen Thirstrup explains, hoping this gap will be bridged in the future.

In an attempt to partially fill this information gap, MIIR together with collaborating media teams from EDJNET spent a three month period looking for data and managed to create an -as homogeneous as possible- updated database on drug 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, Belgium), from which it was possible to gather reliable data, either by extracting data from published statistics in the national medicine’s associations or by submitting data requests. In many of the above countries, we traced the Anatomical Therapeutic Chemical (ATC) classification, the marketing authorisation holder, the starting & ending date of the shortage and reasons for it being taken off circulation. 

Key Conclusions

From the total of the 9 aforementioned countries over the last five years (2018-2023), when adding up the new shortages of each year, it appears that Italy cumulatively registers the most shortages in absolute number (10,843) for human medicines, quite far from the second Czech Republic (2,699) and the third Germany (2,355). Lastly, Greece (389) is the country with the fewest records of shortages in absolute numbers.

Accordingly, 371 vaccine shortages were recorded in the countries under review in the period 2018-2023, with Italy leading (144 vaccine shortages), followed by Germany (102) and the Czech Republic (57). Belgium recorded the fewest shortages (8).

Nevertheless, the absolute number of medicines and vaccines in short supply is not always the best way to draw safe conclusions, given that not all countries keep record of their stocks with the same consistency and the same criteria. In addition, these are different reference populations, countries with different levels of demand, while the different pharmaceutical import-export balance must also be taken into account. 

The safest recording indicator that best describes the situation in each country is the duration of a shortage. In order to find the average duration of shortages in the European countries that we examined, we excluded extreme values ​​by calculating the median. Of the 22,107 drug entries we processed in total, we had data on shortages’ duration for 16,945.  Based on these, the European average duration of shortages is 94 days, meaning that it takes about three months for a drug to be back on the market. 

From the analysis MIIR conducted on the data collected, it appears that Greece has the longest median duration of shortages (130 days), followed by Germany (120 days) and Belgium (103 days). The Czech Republic may have been second in absolute numbers of shortages, but it registers the shortest amount of time with drugs in shortage (41 days).

The European average of vaccine shortages, again excluding extremes, amounts to 84 days, less than that for medicines.
For vaccines, the longest median duration of shortages is traced accordingly in Italy (111 days), Germany (68 days) and the Czech Republic (66).

The most comprehensive study carried out in recent years on medicine shortages was that of the Technopolis Group consultancy on behalf of the EU (Future-proofing pharmaceutical legislation – study on medicine shortages), which was published in December 2021. In that research, the Netherlands and Portugal turned out to be the “champions” of medicines in shortage in 2019 (over 1600 different drug shortages). In contrast, that year Austria, Croatia, Iceland and Greece recorded fewer than 100 shortages, relating to 60 or less different medicines. 

The same survey ascertained that the average duration across all shortages notices was 137 days and that 66% of all shortages were resolved within the first three months. The minimum duration of the shortage was one day, the maximum duration was about 13.5 years (!) and is related to amoxicillin which was in short supply in Spain from September 2005 until March 2019. Amoxicillin is still today among active substances that are missing mostly from the European market. However, it is noted that in all 9 countries for which data was collected by MIIR, very significant increases in shortages are recorded in 2022 compared to the previous year.

The largest percentage increase in the absolute number of drug shortages from 2021 to 2022 is recorded in Greece, which is due to the possible under-reporting by the Greek National Organisation for Medicines (EOF) or the non-declarations of the actual shortages. Pharmaceutical associations in Greece complain that the real shortages are much more than those declared by EOF.

“The shortages are neither 80 nor 130. They start from 400 and upwards. This is the image I have from running a pharmacy; I don’t care what EOF tells me. I find it reasonable for any government not to want to be exposed. If I were in the position of the respective government, I would do the same. I would call the EOF president and tell him to declare that we have at most 100 shortages. I don’t think you can have an objective view from EOF, its presidents are always appointed by the respective government,” says Konstantinos Lourantos, who has been the president of the Pharmaceutical Association of Attica for 27 years.

For the needs of this report we contacted and repeatedly sent written questions to the president of the Greek National Registry, D. Filippou, without receiving any answer.

Reasons of shortages 

According to the MIIR analysis, in a total of 6 countries (Germany, Spain, Greece, Austria, Slovenia, Czech Republic), the most drugs in shortage are those related to the neural system (1718 drugs, 19.03% of the total), such as anesthetics, psychotropics, antidepressants, anxiolytics, antiepileptics, antiparkinsonian drugs, etc.). In second place we find cardiovascular drugs (1307, 14.48% of all shortages) and in third place the anti-infectives for systemic use – antibiotics (1126 drugs, 12.47% of all). On the contrary, almost zero shortages are recorded in the same sample in the category of antiparasitic, insecticides and insect repellents.

Τhe latest report of the European Pharmaceutical Union PGEU (2022) for all European countries offered similar conclusions, according to which cardiovascular drugs were omitted in most countries (82.76%), followed by drugs for the nervous system and anti-infectives for systemic use – antibiotics (79.31%) and drugs for the respiratory system (75.86%).

In that survey almost all responding countries reported that drug shortages cause distress and suffering to patients (93.10%), discontinuation of treatments (89.66% of countries), increased co-payments as a result of more expensive and alternative solutions that are not reimbursed by the state (72.41%), but also fewer effective treatments (58.62%).

“I have been searching for 8 months and have not been able to find my medicine. The pharmacists tell me to be patient, it may come but we don’t know when”, 25-year-old Eleftheria, who suffers from a rare disease, tells MIIR. “They don’t even give me an explanation as to the reason why it suddenly stopped being available, all I hear is that this medicine is imported and that the multinational company that produces it hasn’t sent it,” she adds. As a substitute she takes another drug that does not fully cover her for the condition, and on the advice of her endocrinologist she has adjusted her diet to make up for the substances she lacks. She works as a babysitter in homes taking care of young children. “Especially this winter, I have been told by parents that not only simple medicines, respiratory and antibiotics for viruses are not easy to find, but even a simple serum,” she says.

The impact of Covid- 19

All researches converge that the problem is growing and concerns millions of patients on the European continent. “During the pandemic, but also in the post-pandemic era, with the post-COVID syndrome to have affected a large part of the population, the need for medicines and treatments increased. This fact led to an increase, to a certain extent, of the shortages of medicines”, underlined  Ioulia Tseti, CEO of the Tsetis Pharmaceutical Group of Companies and general secretary of the Hellenic Federation of Enterprises (SEV).

But this explanation is not enough. As she explains, “the problems of the supply chain and the dependence of the European Union countries on raw materials from third countries, made the problem even more explosive. As well as the fact that countries such as India and China banned the export of raw materials for their own needs – this also aggravated the problem. And it is known that when raw materials are scarce, the price is high. We must not forget that the shortage of raw materials and the increase in energy costs were reinforced by the war in Ukraine, as the (once) rich and sufficient grain silo of Ukraine is a raw material for medicine production. Unfortunately, Europe is dependent on third countries and at some point, it must become independent, acquire sufficiency and self-sufficiency in raw materials.”

The war is not the only one to blame…

The root causes of the problem are generally the result of different economic, structural or regulatory causes, Ilaria Passarani, general secretary of the PGEU, underlines at MIIR. She herself summarizes these as follows:

“o   the increasingly globalized nature of pharmaceutical manufacturing, including Active Pharmaceutical Ingredients (API), with production concentrated in fewer sites distributed around the world;

o   Shifts in demand, resulting from longer term factors such as demographic change, but also short-term factors such as tendering of medicines leading to difficulties in providing sufficient quantities of medicines for some markets;

o   Pricing strategies, both low and high, and regulatory changes that in some cases may have an impact on supply;

o   the imposition of fixed quotas of medicines by the pharmaceutical industry, often not sufficient in relation to patients’ actual needs;

o   the removal of the traditional role of the full line wholesalers as a result of Direct to Pharmacy (DTP) schemes in some markets;

o   the abolition and ineffectiveness of public service obligation/minimum national stock keeping requirements in some countries;

• the lack of priority given to smaller markets;
• The effects of the European internal market dynamics (e.g., exports).”

Dependance and friction point

As it turns out, at European level the over-reliance on a small number of suppliers for active pharmaceutical ingredients and other raw materials has made it difficult for manufacturers to meet current demand. China and India together account for more than 60% of the world’s supply of active pharmaceutical ingredients in 2020. Parallel exports are often seen by pharmacists and the pharmaceutical industry as part of the problem.

“It is a fact that parallel exports magnify the problem as the more expensive prices of the same products in European countries push pharmacies to export in order to take advantage of their price difference and, by extension, increase their profitability”, Ioulia Tseti, CEO of the Tsetis Pharmaceutical Group of Companies, tells MIIR. 

At the same time, however, at the European level, pharmaceutical companies seem to have reduced the stocks they keep in their warehouses. Thus, when a problem occurs in a manufacturing plant, the stocks are not sufficient to meet the needs until the problem is overcome and drug production returns to normal.

“Parallel exports” are a challenging point  between pharmaceutical manufacturers and drug dealers, since through them the pharmacies get a part of the profits of the pharmaceutical industry. For this reason, the multinational pharmaceutical companies strictly control the quantities they give to the domestic pharmacies, in order to limit the chances of exporting their products and the loss of profits in developed markets with high prices. All of this encourages any pharmacists who can obtain drugs directly from the companies to do so, even though this happens at an extremely slow pace.

But what is Europe doing to deal with a problem that looks like a difficult balancing act in an industry with huge competing interests? Within the next few weeks, the European Health Commissioner Stella Kyriakidou will submit the long-awaited proposals for the revision of the pharmaceutical regulations, after a long period of dialogue with the pharmaceutical industry, the relevant government authorities, health professionals, the academic community and representatives of patients. 

“This dialogue and resulting policy analysis showed that shortages of medicines have become a systemic challenge with numerous vulnerabilities, including the increased complexity and specialisation of supply chains, the lack of geographical diversification of sourcing for certain products and perceived regulatory complexity”, a Commission spokesperson admits to MIIR, adding that the upcoming bill will include “stricter procurement obligations, timely notification of shortages and withdrawals and enhanced transparency of stocks”.

* Read the second part of the MIIR investigation: Parallel exports, the EOF and the Greek Statistics of drug shortages.

Research-Text: Kostas Zafeiropoulos, Nikos Morfonios, Janine Louloudi (MIIR)

Data analysis-visualization: Korina Petridi

Illustration: Louiza Karageorgiou

“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 Eleftheria. 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 jointly with the collaborating journalistic teams of the EDJNET 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 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 the present.

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  MoU austerity years in Greece, because of the OECD toolbox that allowed the creation of such ‘’monkey business’’-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 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 is in an opposite direction from the whole 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.

Read the first part of the MIIR investigation:  (Why) Europe is running out of Meds