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Pharmacist with a customer.

What are the lessons learned from pharmacy reforms in the Nordic countries?

What has been the impact of pharmacy reforms in the Nordic countries - and could lessons from one country be learned by others where such reforms are currently discussed? The first Nordic webinar on pharmaceutical policy generated a lively debate.

Organised by researchers of social pharmacy, the webinar showcased changes implemented particularly in Sweden, but also in the other Nordic countries and Estonia, and looked at research findings on their impact. The topic attracted interest, with a total of 300 participants registering for the webinar.

“The reforms are currently being discussed in Finland, so now is a good time to learn from the experiences of other Nordic countries. We also need to collect research data on the current situation so that we can assess the impact of the changes, if such a reform is implemented," said Katri Hämeen-Anttila, Professor of Social Pharmacy at the University of Eastern Finland, who chaired the webinar.

Pharmacy systems and reforms vary widely

Development Specialist Leena Reinikainen from the Finnish Medicines Agency Fimea highlighted the differences in pharmacy systems and pharmacy regulation in the Nordic countries and Estonia, among others. There are differences, for example, in who can own a pharmacy, how the location of pharmacies is regulated, how medicines are priced, whether over-the-counter (OTC) medicines can be sold outside a pharmacy and who is allowed to give counseling on medicines. “Changes to pharmacy systems have also been made in different countries from different starting points and with different objectives.”

In Sweden, new pharmacies were concentrated in cities

In Sweden, the state monopoly on pharmacies was abolished in 2009. The state sold a large share of its pharmacies to private operators, and new ones can be established relatively freely. At the same time, many OTC medicines were allowed to be sold to people aged 18 and over, for example in shops, kiosks, and service stations.

According to Ulrika Winblad, Professor at Uppsala University, no studies at the time found any need for reform. "The moderate coalition government wanted the pharmacy system to be marketised for ideological reasons. Ultimately, the rationale was to promote diversity and entrepreneurship.”

What was the result of deregulation? In 2009, there were 924 pharmacies, and  1,400 in 2023 . “There are more pharmacies, and they are open longer, but they are also smaller and concentrated in big cities.”

One third of Sweden’s 290 municipalities continue to have only one pharmacy, and 115 municipalities have one pharmacy chain. Rural pharmacies receive separate state subsidies. Sweden has four large pharmacy chains and 40–50 smaller pharmacy companies.

In the 2020s, the number of pharmacies has stopped increasing. According to Winblad, the future of brick and mortar pharmacies could also be influenced by online pharmacies, which now account for 22% of the market.

OTC medicine sales up, prescription availability down

20% of over-the-counter medicines in Sweden are now sold outside pharmacies. "Availability has improved, but only for a few products. In most cases, only a few original products are sold outside pharmacies," said Sofia Kälvemark-Sporrong, Professor at Uppsala University.

 “More people are buying over-the-counter medicines. It is difficult to say whether they are bought for a real need. Medication counseling is not available in shops selling OTC medicines and there is a debate about whether people are aware of the appropriate use of OTC medicines.”

The expansion of pharmaceutical sales to thousands of outlets outside pharmacies has also called for new regulation and supervision.

The number of prescriptions written is the same as before, so there are fewer prescriptions per pharmacy. The availability of prescription medicines has deteriorated as small pharmacies are unable to stock a sufficient range. In 2009, the rules on substitution were also tightened, and it became more expensive for patients not to switch to a cheaper generic.

 “Questions have been raised about the necessity of the reforms and whether patient safety has been sacrificed to competition," Kälvemark-Sporrong said.

According to her, customer satisfaction is not a valid measure of the success of the reforms. "The vast majority of customers are typically satisfied.”

Sufficient information on the pharmacy system is needed to inform decision-making

Since 1996, Iceland has not regulated the ownership or location of pharmacies. “This has led to an increase in the number of pharmacies in the capital area and larger cities and decreased the number of rural pharmacies. Just after deregulation, there was price competition on the patient’s out of pocket costs with large commercials offering zero payment to customers on prescription drugs. This was countered by authorities in 1997 with a regulation to increase cost sharing. This did not have an effect on costs to the health insurance," said Professor Anna Birna Almarsdottir from the University of Copenhagen.

“In Norway, too, deregulation in the 2000s has not improved access to pharmacies for all, as shown by two researchers' mapping of access,” said Associate Professor Ingunn Björnsdottir of the University of Oslo.

In Estonia, the ownership of pharmacies was not limited to pharmacists for approximately 30 years, and the majority of pharmacies was owned by pharmacy chains connected to wholesale companies.  From 2020, the main owner of a pharmacy is required to be a pharmacist. “In practice, however, the majority of new owners franchised with previous owners and continue using existing ready-made brands and support for pharmacy operations and staff recruitment”, said Associate Professor Daisy Volmer from the University of Tartu.

The webinar concluded with small group discussions on the topics of the presentations.

 “There was much discussion about the need for reforms to have clear objectives. Decision-makers need to be well informed about the pharmacy system, what can be achieved through its reforms," said Hämeen-Anttila.

The webinar launched an annual series of webinars on various pharmaceutical policy issues. The webinar was organised with the support of the Nordic POP consortium of Nordic universities.