Edition 31 October 2019, by Phoebe Potter
Following another year of increasing medicine shortages in the Netherlands, health minister Bruno Bruins is asking for radical steps to be taken to address the problem. Pushing much further than previous stockpiling solutions, Minister Bruins has come to the conclusion that more of the raw materials used in medicines must be produced in Europe to solve the shortages.
Medicine shortages are following a worrying upward trend. Where in 2010 there was a shortage of less than two hundred drugs per year, this rose to 769 in 2018 and has sharply increased to 2044 to date in 2019. There are various reasons put forward for these shortages, which are worse in the Netherlands than other European countries. In public, pharmacists are prevented from saying that it is the so-called ‘preference policy’ of insurers that causes the shortages, because KNMP (the organisation that oversees pharmacists in the Netherlands) has an agreement with ZN (the organisation that oversees insurers). But this is what many pharmacists truly believe is driving the shortages. The ‘preference policy’ has been in place since 2008 in the Netherlands. It is driven primarily by financial decisions, boiling down to the simple fact that whoever produces the cheapest drug gets the contract to do so from the insurers.
It is true that since 2008, shortages for common medicines have increased, but a causal link has not been proved. Pharmacists argue, however, that because the prices in the Netherlands are so low, there is no incentive for manufacturers to sell their medicines here. When a manufacturer can get 12 euros in Germany for a drug they would get only 1 euro for in the Netherlands, it is clear where they will head when scarcity occurs.
Insurers are keen, however, for the blame not to fall on their ‘preference policy’. The fault lies with the manufacturers themselves, they say, with disruptions such as the relocation of a factory or temporary software failure leading to shortages. This argument is supported by the fact that the shortages are mirrored across many other European countries, which are affected because they rely on production in Asia for many medicines. The raw materials are now produced in fewer, much larger factories than before, often in China and India. This means that, if there is any problem with production – a contamination of a pill for example – the effects are far greater than they used to be. With the production so centralised, there are fewer and fewer alternative manufacturers who can pick up the slack if one factory is compromised in some way.
It is largely because of these reasons that Minister Bruins is pushing for medicines to start being produced in Europe. Last year, the minister looked into whether it was possible to make it compulsory for manufacturers, wholesalers and pharmacists to maintain a four-month buffer on stocks. This option was criticised by many, including healthcare economist Xander Koolman, who dismissed it as a ‘blunt and costly solution’ to the problem. This is largely because the medicines must be purchased and stored in precise, climate-controlled conditions.
The call for medicines to be produced in Europe has been supported by the health minister’s counterpart in France. He has also called on the intended European Commissioner in this field, Cypriot Stella Kyriakidou, to put the topic high on the agenda for the incoming Commission-Von der Leyen, beginning on 1 November.
Specifically, Bruins is calling for pharmaceutical companies in Belgium to build up large stocks as a buffer against shortages. Brexit could exacerbate the problems – with all traffic from the UK at the border having to be checked, long traffic jams for trucks are expected. Bruins wants lorries with medications to be given priority to get through these delays.
For patients, these shortages cause significant difficulties. Doctors who have to prescribe medications by a different manufacturer or generic medicines (that is, cheaper versions of the same active ingredient, rather than a brand by a well-known producer) have complained about the lack of reassurance they are able to give their patients. They in turn often report adverse side effects from a change in medication, even if the active ingredients are supposedly the same.
Medicines that have experienced shortages range from the very specialist to the very common. In 2018, between September and November there was a crisis in stocks, when many women in the Netherlands couldn’t receive contraceptive pills. The drug levodopa/carbidopa for Parkinson’s disease has also been out of stock on several occasions. But it doesn’t end there – even paracetamol has at times been in short supply.