Pharmaceutical Reforms in Greece during the financial crisis

Pharmaceutical Reforms in Greece during the financial crisis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pharmaceutical Reforms in Greece during the financial crisis Athanasios Constantopoulos, Athanasios Chantzaras, John Yfantopoulos This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3154303/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract OBJECTIVES: The objective of this study was to study cost containment and cost reallocation and to discern how they burden households and the pharmaceutical industry. METHODS: For the period 2010-2020, we implemented content analysis on 377 statutes that concerned pharmaceutical expenditure. These measures were classified firstly with reference to their character as cost containing or rationing and, secondly, with respect to cost reallocation. RESULTS: The proportion of measures shifting healthcare costs to consumers was 31% and 48.5% to industry. Mean equivalized total consumption between 2008 and 2018 decreased by 31.5% while mean equivalized total health expenditure decreased by 20.5%. During the same period mean equivalized pharmaceutical expenditure increased by 25.56% and the proportion of households with positive expenditure increased by 31 %. Meanwhile pharmaceutical industry’s direct contribution to the total pharmaceutical expenditure increased from 1.5% in 2010 to 30.1% in 2020. CONCLUSIONS: Recent reforms (2010-2020) regarding pharmaceutical expenditure present a clear tendency to reallocate pharmaceutical cost to consumers and the pharmaceutical industry. This shifting of the cost from the public health sector to the private sector endanger the sustainability of the pharmaceutical sector, and the access of patients to quality pharmaceutical treatment. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The economic crisis in Greece has brought unprecedented economic, social and health consequences since 2009. The main negative consequences of the crisis on the well-being of Greek citizens are the significant decline in family incomes, increased unemployment, labor insecurity and deterioration in working conditions, increasing household poverty, and worsening social inequalities. During the years leading to the crisis, the National Health System (NHS) was plagued by informal payments, social contributions evasion, low incentives for hospitals to remain withing budget, delays in social security reimbursements and lack of measures to control pharmaceutical consumption volume, to name a few. The Memoranda of Understanding (MoUs) were aimed at the fiscal consolidation of Greece through the means of reducing such inefficiencies. However, the continuous increase in public healthcare spending before 2009 [ 1 , 2 ] led subsequent Greek Governments to focus on restraint measures.. Taking into account that the health and pharmaceutical sectors had been in an unfavorable position even before the financial crisis [ 2 – 4 ], recent reforms to the NHS are considered defining[ 5 ], while pharmaceutical care in particular, sustained a host of structural reforms and tough funding cuts [ 6 , 9 ]. Although the importance of reducing public pharmaceutical spending has been recognized, the impact of this reduction on the industry, households and society in general has not been thoroughly explored. Each health system can be funded by four main sources: (a) taxes; (b) social security contributions; (c) private premiums; and (d) out-of-pocket payments [ 7 ]. Therefore, the drastic cut in public spending on healthcare forces citizens and private corporations to fill the gap in healthcare financing with out-of-pocket payments. Considering the above, the purpose of this study was to explore the consequences of the crisis and healthcare reforms, with emphasis on out-of-pocket pharmaceutical payments and their impact on household welfare as well as on the rebates and clawback imposed on the pharmaceutical industry. The rest of the paper is arranged in four sections as follows. The first section provides a brief review on reforms regarding pharmaceutical care in Greece. The subsequent section presents our methodology. We used content analysis on the measures implemented since 2010 based on two features. First, we examined the extent to which the reforms shifted the economic burden to citizens and/or the industry and secondly, we analyzed their content as to whether it constitutes rationing or cost-containment. Moreover, we examine the extent of this financing shift on households and the pharmaceutical industry. The final sections provide the results and conclusions of the study as well as its policy implications. Overview of pharmaceutical reforms Greek pharmaceutical spending since 1990 was growing faster than the GDP, placing Greece among EU Member-States with the highest pharmaceutical expenditure. Moreover, even before the onset of the crisis, per capita demand for pharmaceuticals in Greece has been the highest among OECD countries. However, up until 2009 Greek governments, had strived to control pharmaceutical expenditure through price regulation rather than reducing demand for pharmaceutical products. [ 8 , 9 ]. The key policies implemented between 2010 and 2020, also aimed to control pharmaceutical costs, and market rationalization in general. These measures included significant reductions in drug prices, increased patient participation, centralization the procurement process, the introduction of the clawback and the extension of the rebate, as well as significant changes in the pricing and reimbursement of medicines with the introduction of a positive and negative list and an internal reference price system, and, more recently, the adoption of an HTA system for the evaluation of reimbursed drugs [ 9 , 10 ]. Reforms that targeted demand, such as mandatory electronic prescription based on active substance, monitoring, and controlling doctors’ prescribing behavior and the promotion of generics, have not yielded the anticipated results. In the following subsections we present and comment on pharmaceutical measures that have transferred pharmaceutical costs to households and/or the pharmaceutical industry. Pricing The wholesale prices of medicines were horizontally cut twice, in 2010 and 2011, with their weighted average percentage being estimated at 21.5% and 10.2%, respectively[ 5 ]. The pricing of medicinal products follows a reference pricing system based on EU Member States. In addition, products whose patent has expired, may not be priced above 70% of the original protected price (63% for generics)[ 11 ]. Increases in the prices of existing medicines are not allowed[ 12 , 13 ] [ 14 ]. Also, a dynamic price reduction of generics (1–15%) is applied with a retail price of more than € 12, based on sales volume. Along with the reduction in prices, several other measures were implemented with the aim of increasing the share of generics in the pharmaceutical market to 60%, while other regulations stipulate that at least 50% of the volume of medicinal products used in public hospitals should be generic [ 17 , 18 ]. Reimbursement Before the onset of the crisis, there were no cost-effectiveness limits or other guidelines regarding reimbursement decisions[ 19 , 20 ]. Until then, all products were reimbursed, which led to a large volume of prescriptions and, therefore, a higher expenditure [ 16 ]. In 2011 the pricing and reimbursement procedures were separated, with the re-introduction of the positive list, which includes all medicines reimbursed by Social Security Funds (SSFs). Therefore, inclusion in the list is a primary goal of pharmaceutical companies, as this ensures the most effective market penetration of their products[ 9 ]. However, entry in the list is subject to rebates and the clawback mechanism [ 11 , 14 , 21 ]. Moreover, an entry fee is applied, which is paid in a lump sum for each form, potency, and dosage. HTA Commitee Recently, the Positive List Committee, responsible for overseeing the procedure of entry in the list, has been replaced by the Committee for the Evaluation and Compensation of Medicinal Products for Human Use (Evaluation Committee or EC). The EC is appointed by the Minister of Health and consists of 11 experts in areas related to health technology assessment. Basic evaluation criteria are a) the clinical benefit, b) the comparison with other drugs, c) the reliability of the data, d) the cost / effectiveness ratio and e) the impact on the budget. The final EC recommendation may also include specific therapeutic indications for product compensation and mandatory prescribing protocols [ 9 ]. Co-payments Since 1999, a three-tier system of patient cost-sharing has been in place as a cost-sharing rate: a) 0% for life-threatening illnesses, b) 10% for certain chronic illnesses, and c) 25% for all other diseases. If a patient chooses a drug with a retail price higher than the compensation price, they cover the participation percentage as well as the difference between the compensation price and the retail price of the product they have chosen. [ 9 ]. The current limit for patient participation is € 20 per product. If the patient chooses a drug that does not have a corresponding generic, then the difference between the retail and the insurance price is divided in half between the patient and the producer (as a rebate). Additionally, the insured pay to the pharmacists one (1) euro per prescription. Moreover, since 2012, patients with serious diseases were burdened with increased participation rates. Therefore, patients suffering from illnesses such as systemic lupus erythematosus, rheumatoid arthritis, chronic obstructive pulmonary disease, ulcerative colitis, Crohn's disease or cirrhosis of the liver have to contribute by 25% instead of the reduced 10%, while patients with epilepsy and other epileptic conditions, BURGER vascular disease, dementia, Alzheimer's disease, and Charcot disease have to contribute by 10% instead of 0% [ 9 ]. Prescribing Overprescribing or prescribing specific brands or drugs are chronic issues of the Greek pharmaceutical market, observed even from the 1990s [ 11 , 22 ]. Several studies have shown that a significant percentage of doctors (37.5%) is not considering the cost of the drug and the financial burden for the patient when prescribing. Moreover, it has been reported that Greek doctors avoid prescribing generics up to 75% [ 20 , 23 – 28 ]. The main reason has been the cautious attitude of doctors towards generics and the small price difference between generics and patented drugs compared to other countries [ 9 ]. During the crisis, there have been attempts to curb overprescribing. Handwritten prescriptions are no longer valid and have been replaced by electronic prescriptions. Moreover, prescription based on the active substance was implemented in 2012 [ 9 ]. The above measures allowed for close monitoring of doctors' prescription patterns, referrals, and other medical procedures [ 11 ]. Doctors not complying with the current guidelines are subject to financial sanctions. In practice, however, many of them recommend brand-name drugs in the comments section of the prescription, thus eliminating the policy in practice, while avoiding penalties. [ 29 ] [ 9 ]. Rebates and clawback Even before the crisis (2008) pharmaceutical companies were expected to return to the SSFs 4% of the net price of the drugs as a mandatory rebate[ 5 , 30 ]. Since the merging of the Greek SSFs into EOPYY, a rebate was provided for the debts of the pharmacies to the newly established organization. Moreover, pharmaceutical manufacturers and importers offer a mandatory 4% discount for each prescription-product and 5% for each hospital purchase. On top of that, depending on sales volume, a gradual rebate is added on a quarterly basis (2–12%). All drugs included in the positive list incur a further rebate of 2%. In order to control public pharmaceutical expenditure, fixed budgets were implemented in 2012 (outpatient expenditure) and 2016 (inpatient pharmaceutical expenditure) [ 11 ]. Accompanying fixed budgets was the clawback, an automatic mechanism which ensures that expenditures do not exceed the budget, as any additional amount is automatically reimbursed by pharmaceutical companies [ 11 ] [ 9 ]. Additionally, each producer or importer is required to pay a 15% fee on the previous year's retail sales. This additional rebate is adjusted to 11% for drugs in the positive list. For serious diseases medications, a graduated amount of 1.5% is requested for quarterly sales of less than €2,500,000, 3% for sales between €2,500,000 and €5,000,000, and 4.5% for sales of more than € 5,000,000. The calculation of clawbacks is formulated by 90% of the market shares and by 10% of the company's growth share in the previous year. In this way, companies that have shrunk get a discount, while companies with high growth are additionally burdened. As mentioned above, public pharmaceutical expenditure has been a chronic issue that subsequent Greek governments have strived to overcome. However, policies have focused on decreasing the pharmaceutical costs and shifting the financial burden to households and pharmaceutical manufacturers and importers. At the same time, demand for pharmaceutical products in Greece remains high, since measures aiming to curb it have failed to achieve the anticipated results. Through exclusions from reimbursement and increased co-payments households are subjected to increased pharmaceutical costs, reducing available income and/or exposing families to increased health risks. Finally, the adoption of measures such as mandatory rebates and the clawback has led to a significant increase in the participation of pharmaceutical companies in the pharmaceutical expenditure. Materials and Methods Content analysis of pharmaceutical measures We implemented content analysis on policy measures introduced in the period between 2010 and 2020. In total, 377 statutes and regulations (FEK) that concerned pharmaceutical care directly or indirectly were retrieved from the Greek Government Gazette. These measures were first classified with respect to the direction of cost reallocation. We distinguished measures reallocating pharmaceutical costs based on the cοnsequent payer. The possible categories included the tax-funded NHS, the SSFs, health consumers and the pharmaceutical industry. From the above 377 FEK we found that there were 191 measures that resulted in transpositions of expenditure, excluding repetitions or restatements of the same legislation, price lists, and positive list updates. Special attention was paid to the distinction between direct and indirect private expenditure. Indirect measures include increasing contributions. Subsequently, the same measures were classified based on their character as cost containing (white area), rationing (black area) or a mixture of the above (grey area). Cost-containment is defined as a financial control technique which aims to reduce costs. Its consequences can be positive by reducing waste, neutral, but even negative, when operating at the expense of the quality of health care[ 31 ]. Rationing is more relevant to resource allocation than to direct financial control. Since rationing is based on social principle, it encompasses an ethical dimension and is essentially an external intervention in the field of medical science. As a term, rationing refers to all decisions that affect health care provision negatively [ 32 ]. Many health scientists believe that restricting distribution is inevitable, but do not distinguish between it and cost-containment or prioritization. In economically developed countries, the restrictive distribution of health care should be the exception and not the rule. The case of organ transplants is an example of inevitable restrictive distribution[ 33 , 34 ]. Although there is a growing political and scientific interest in prioritizing, little consensus has been reached among stakeholders. Prioritization is a complex process of interaction and occurs either at the macroeconomic or patient care level [ 31 , 35 ]. The components of rationing in a health care system are summarized as follows[ 36 ]: Shortage of resources and need for organized distribution. Long waiting lists for access to specific care. Refusal to provide quality care. Distinction between patients regardless of their condition. Household Budget Survey evidence To make an introductory analysis of the distribution of private household expenditure for healthcare and particularly pharmaceutical care in Greece, data for 51,842 households were derived from the Household Budget Survey (HBS) for the period 2008–2018. The HBS is a survey collecting national information on households’ composition, citizen employment status and income while focusing on the composition of household expenditure on goods and services. One of the purposes of the HBS is to collect sufficient and reliable information to adjust the Consumer Price Index. Since 2008 the HBS has been conducted annually and in a nationwide scale, to revise the Consumer Price Index yearly and for the country to be able to produce reliable and comparable data. The HBS implements two-stage area stratified sampling. During the first stage primary units are drawn (building blocks), while on the second stage the sample of secondary units (households) are selected. Additional data The quantitative evidence used in this study originate from public databases apart from those mentioned above. We implemented the Eurostat database on Health Expenditure, the Greek Statistical Authority’s (ELSTAT) System of Health Accounts (SHA) and EOPYY’s (the single Greek SSF) data to extract information regarding total pharmaceutical expenditure. Furthermore, we extracted household microdata from ELSTAT’S database of the Health Interview Survey (HIS). The analysis was conducted in MS Excel. The microdata from HIS were organized and analyzed using IBM SPSS v25.0. All charts and graphs, including those found in the appendices, pertaining to these correlation and regression analyses were produced in MS Excel. Results Between 2010 and 2020, subsequent Greek Governments have implemented reforms that have resulted in decreasing public expenditure on healthcare from 14,821 mil.€ to 8,591 mil.€ (-42%). However, as seen in Fig. 1 , public pharmaceutical expenditure has been reduced more drastically, from 4,783 mil.€ to 1,936 mil.€, which corresponds to a staggering − 60%. This decrease could either indicate that pharmaceutical expenditure had been exceedingly wasteful during the years leading to the crisis or that pharmaceutical funding has shifted from the government to other payers. Bearing in mind that the European Council has repeatedly underlined the importance of efficiency policies, we sought to examine the focus of reforms implemented during the crisis. Table 1 presents the annual breakdown of the pharmaceutical measures implemented between 2010 and 2020 in terms of cost reallocation (from any operator) to the NHS, consumers, the industry and/or SSFs. Percentages are summed up yearly and reflect the percentage of new measures that transpose part of the financial burden of pharmaceutical spending to the corresponding payer. Thus, as more measures shift the economic burden to households and the industry, the more intense are the signs of privatization of pharmaceutical care. Initially, we note that measures that transfer pharmaceutical costs to consumers exceed at least 17% of the annual total pharmaceutical legislation for most years. In addition, measures burdening the pharmaceutical industry range between 35% and 75% each year. Table 1 Annual breakdown of new measures in the pharmaceutical sector for the shift in financing scheme of pharmaceutical expenditure for the period 2010–2020 Government Social Security Funds Consumers Industry N % N % Out-of-pocket Indirectly N % N % N % 2010 0 0.0% 2 14.3% 4 28.6% 2 14.3% 6 42.9% 2011 0 0.0% 2 11.8% 3 17.6% 2 11.8% 10 58.8% 2012 2 6.1% 6 18.2% 4 12.1% 6 18.2% 15 45.5% 2013 3 13.0% 3 13.0% 2 8.7% 2 8.7% 13 56.5% 2014 5 12.5% 6 15.0% 6 15.0% 5 12.5% 18 45.0% 2015 3 11.1% 1 3.7% 7 25.9% 3 11.1% 13 48.1% 2016 3 17.6% 1 5.9% 5 29.4% 2 11.8% 6 35.3% 2017 0 0.0% 0 0.0% 2 33.3% 0 0.0% 4 66.7% 2018 0 0.0% 1 16.7% 1 16.7% 1 16.7% 3 50.0% 2019 0 0.0% 1 25.0% 0 0.0% 0 0.0% 3 75.0% 2020 0 0.0% 0 0.0% 1 25.0% 1 25.0% 2 50.0% Total 16 8.4% 23 12.0% 35 18.3% 24 12.6% 93 48.7% Source: Greek Government Gazette, authors’ calculations Figure 2 presents the cumulative percentages of Table 1 that appear in its last row. In total, 152 of the 191 reforms shift the burden of spending to individuals, a rate that reaches 79.5%, with 48.6% being to industry and 30.8% to individuals. We are therefore seeing a significant shift in the burden of pharmaceutical spending on pharmaceutical companies and patients, who are being called upon to bear increasing costs at a time when family incomes are being reduced. Table 2 shows the results regarding whether the new measures were cost-containing or distribution-related. Noting that most measures (80.4%). are classified in the White Area (cost containment), we see that rationing reforms (Black Area) are limited to 0.8%, while 18.9% of the measures are in the interim Gray Region. Table 2 Classification based on cost-containment/rationing White Grey Black (cost-containment) (unidentified) (rationing) N % N % N % 2010 12 85.7% 1 7.1% 1 7.1% 2011 23 82.1% 5 17.9% 0 0.0% 2012 8 88.9% 1 11.1% 0 0.0% 2013 23 76.7% 7 23.3% 0 0.0% 2014 11 73.3% 4 26.7% 0 0.0% 2015 7 87.5% 1 12.5% 0 0.0% 2016 4 100.0% 0 0.0% 0 0.0% 2017 4 57.1% 3 42.9% 0 0.0% 2018 4 57.1% 3 42.9% 0 0.0% 2019 7 100.0% 0 0.0% 0 0.0% 2020 110 80.9% 25 18.4% 1 0.7% Total 213 80.4% 50 18.9% 2 0.8% Source: Government Gazette, own calculations Table 3 contains information on the precise targeting category of all new measures. Most reforms are concentrated on reducing prices (50.7%). In fact, price controls went up between 32% and 85.7% of all medicinal measures per year. Following are measures setting thresholds on cost or coverage (14%) and prescription (15.4%), exclusions from coverage (4.4%), waste restrictions (6.6%), increases in turnout (6.6%), reductions in surpluses (1.5%) and waiting lists (0.7%). To summarize, even though most of the measures are indeed of cost-containing character, 16,5% lay in the gray area between cost-containment and rationing. More importantly, measures implemented between 2010–2020 display a tendency to shift pharmaceutical funding, decreasing public participation and effectively privatizing the cost of pharmaceutical care. To examine whether this shift in policy measures corresponds to an actual shift in funding, we must investigate private pharmaceutical expenditure for the corresponding period. Table 3 Classification based on type of measure Pricing Regulation Prescription control Co-payments Waste Avoidance Elimination of Surplus Exclusions from reimbursement Restrictions on volume and benefits Scarcity of resources N % N % N % N % N % N % N % N % 2010 6 85.7% 1 14.3% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 2011 8 57.1% 1 7.1% 2 14.3% 0 0.0% 1 7.1% 1 7.1% 0 0.0% 1 7.1% 2012 9 32.1% 6 21.4% 5 17.9% 2 7.1% 1 3.6% 2 7.1% 3 10.7% 0 0.0% 2013 7 77.8% 1 11.1% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1 11.1% 0 0.0% 2014 15 50.0% 6 20.0% 0 0.0% 2 6.7% 0 0.0% 0 0.0% 7 23.3% 0 0.0% 2015 7 46.7% 3 20.0% 0 0.0% 1 6.7% 0 0.0% 0 0.0% 4 26.7% 0 0.0% 2016 4 50.0% 2 25.0% 0 0.0% 1 12.5% 0 0.0% 0 0.0% 1 12.5% 0 0.0% 2017 3 75.0% 0 0.0% 0 0.0% 1 25.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 2018 3 42.9% 0 0.0% 1 14.3% 0 0.0% 0 0.0% 1 14.3% 2 28.6% 0 0.0% 2019 2 28.6% 1 14.3% 0 0.0% 1 14.3% 0 0.0% 2 28.6% 1 14.3% 0 0.0% 2020 5 71.4% 0 0.0% 1 14.3% 1 14.3% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total 69 50.7% 21 15.4% 9 6.6% 9 6.6% 2 1.5% 6 4.4% 19 14.0% 1 0.7% Source: Government Gazette, own calculations To begin with, we examined the breakup of pharmaceutical expenditure between 2010 and 2020, as shown in Fig. 3 , to discern whether the industry’s contribution to pharmaceutical expenditure has increased and to what extent. During the early years of the crisis total pharmaceutical expenditure is decreasing effectively. However, since closed budgets were implemented (in 2014), total expenditures seem to explode, even though public contribution remains stable. More specifically, public contribution reduces by 73% overall during the years, while industry’s contribution, in the form of claw back and rebates, increases by a staggering 407%. During the same period, OOP payments increase by 13%. Moreover, since the application of closed public budgets, overall pharmaceutical expenditure has increased by 29.3%, indicating that the implemented reforms were not scoping to reduce overall demand and improve the overall efficiency of pharmaceutical care, but only to contain public expenditure. In terms of proportions, Fig. 3 indicates that in 2010 87.5% of the pharmaceutical expenditure was financed by the state, while in 2020 this percentage has fallen to 50.7%. During the interim years, OOP payments’ contribution has increased by 48.6% from 10.9–16.2%. In the same period, industry contribution has increased a staggering twenty times over, supporting more than 33% of the total expenditure in 2020 while its share in 2010 was 1.5%. Policies implemented between 2010 and 2020 have certainly decreased government pharmaceutical budget. However, they have only shifted the burden of financing pharmaceutical care to consumers and the industry, instead of implementing measures to decrease the overall inefficiency of pharmaceutical care. Furthermore, we sought to examine the extent to which households have been burdened by the rising cost of pharmaceutical expenditure attributed to them. Table 4 presents the mean annual equivalized total consumption, the mean annual equivalized out-of-pocket payments for health services and its components for the period from 2008 to 2018. Equivalized total consumption has decreased by 31.5% during the crisis. The equivalized total OOP health expenditure has also decreased by 20.5% which occurred due to an exceptionally large reduction in equivalized outpatient care (61%). On the contrary, out-of-pocket payments for pharmaceutical products and equipment and inpatient care increased by 25.5% and 69.9% respectively. More specifically, the equivalized expenditure on pharmaceutical care rose by 37.2% during the crisis. From 2008 to 2011 it declines steadily while between 2012 and 2016 the slope is reversed. Table 5 describes the evolution of the proportion of households that resorted to OOP payments, for each category of health care. The proportion of households with private health payments is very high over the entire period, reaching 85.8% of all households in 2018, decreased by 4.5% compared to 2008. The proportion of households with outpatient care expenditure decreased by 8.2% during the same period. However, the corresponding percentage for pharmaceutical products and equipment and for hospital care increased by 14.5% and 98.3%, respectively. More specifically, concerning pharmaceuticals the proportion of households with positive expenditure is rising steadily during the crisis, resulting in an overall increase of 31% between 2008 and 2018. It is evident that while total household consumption and total household expenditure in healthcare is decreasing during the period under study, expenditure on pharmaceuticals is increasing by 25.6% while the proportion of households with positive private expenditure increases by a staggering 31%. These changes indicate that the measures presented in the previous section increase household expenditure on pharmaceuticals, in a period that household expenditure in healthcare decreases. Table 4 Mean annual equivalized total consumption, mean annual equivalized OOP payments for health services and its components 2008–2018 (€ in constant 2018 prices) 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Change 2008–2018 Absolute Relative (%) Total consumption 17990.93 17750.01 15546.19 13864.99 12594.14 12339.1 12173.34 12286.14 12118.32 12227.34 12318.32 -5672.61 -31.53 Total health expenditure 996.62 986 843.63 761.14 690.62 736.23 778.11 808.25 791.73 765.54 792.45 -204.17 -20.49 Medical products expenditure Total 243.93 242.43 234.77 224.02 233.18 274.67 306.83 310.82 310.18 307.12 306.29 62.35 25.56 Pharmaceutical products 203.3 198.19 201.59 189.05 208.68 250.29 277.62 284.14 283.46 281.31 279.77 76.47 37.62 Other medical products 10.61 17.71 12.54 12.07 9.45 12.02 18.05 14.84 18.13 17.31 18.5 7.89 74.39 Therapeutic appliances and equipment 30.37 26.57 19.97 21.65 14.16 11.85 10.99 11.85 8.66 8.52 8.02 -22.35 -73.58 Outpatient expenditure Total 605.66 568.88 453.11 365.93 278.59 261.34 255.14 244.45 235.01 230.48 236.32 -369.34 -60.98 Medical Services 215.68 195.38 159.13 132.09 96.89 88.37 85.53 88.41 89 88.32 96.49 -119.19 -55.26 Dental services 285.48 275.64 218.55 164.87 123.64 110.27 111.34 99.1 93.6 98.08 94.97 -190.52 -66.73 Paramedical services 104.5 97.86 75.43 68.97 58.05 62.71 58.27 56.94 52.42 44.08 44.86 -59.63 -57.07 Inpatient expenditure 147.03 174.69 155.74 171.18 178.85 200.21 216.14 252.98 246.53 227.95 249.84 102.82 69.93 Source: Household Budget Survey, own calculations Table 5 Proportion (%) of households with positive private expenditure on health services and its components, 2008–2018 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total health expenditure 89.40% 92.80% 86.00% 83.20% 81.40% 82.40% 86.70% 83.70% 86.10% 85.60% 85.30% Medical products 46.70% 48.60% 48.90% 49.20% 50.40% 62.30% 65.50% 67.40% 65.20% 61.90% 61.20% Outpatient services 77.50% 81.30% 74.20% 66.50% 69.20% 71.90% 72.30% 69.00% 72.70% 69.00% 69.30% Inpatient services 12.00% 12.10% 13.30% 13.80% 16.90% 22.70% 26.70% 24.00% 29.10% 27.20% 23.80% Source: Household Budget Survey, own calculations Discussion Pharmaceutical reforms between 2010 and 2020 present a clear tendency to privatize pharmaceutical expenditure. Health reforms during the crisis reduced overall health and drug payments, but they also reallocated the financial burden of the Greek health system to private individuals, especially in relation to their pharmaceutical care [ 37 ]. We have reviewed the new measures regarding pharmaceutical expenditures in relation to two key features. We first checked in which direction and to what extent new measures create a shifting between payers. Overall, for the crisis period, 48% of the measures transferred costs of pharmaceutical spending to industry and 31% to citizens. Thus, at a time when family incomes are shrinking, patients have a larger share of the cost of pharmaceutical spending. The second feature for which drug reforms were examined was whether the new measures are of a cost-containment or rationing nature. Cost-containment is related to patient participation, price regulation, reimbursement rules, avoidance of waste, etc. Rationing is related to the allocation of health resources. It involves external intervention in the field of medical science and may even involve refusal or delay in receiving necessary and qualitative treatment, discrimination between of patients, lack of resources and waiting lists. However, there is a gray area between cost containment and rationing, with measures that are either twofold or undefined, such as cover exceptions, volume or cost limits, quality problems in care, etc. The analysis showed that 82.6% of the measures limited the cost, and only 0.87% imposed a distribution restriction. However, 16.5% of the measures fell in the intermediate category. Therefore, a remarkable percentage of the new policies, attempting to reduce pharmaceutical costs, intervenes in medical decisions, which would otherwise be based on patients' needs and medical specialists’ informed opinions. The intensity of this shifting between payers cannot be ascribed to the mere determination of the nature of the measures. Therefore, in the second part of this paper we analyzed data from the Household Budget Survey, an annual, nationwide research examining the proportions of household budgets dedicated to each household need. The first major finding is the constant decline in average equivalized total consumption between 2008 and 2015 recording at a total decrease of 35.7% (from € 19.670,77 to € 12.649,60) of the crisis. At the same time, we see a steady decline in the average equivalized total health expenditure by 2012 (from € 1,085.66 to € 731.60), followed by a steady upward trend, with the average share in the total household budget rising from around 5.5% between 2008 and 2012, at 6.6% in 2015 (€ 830.72). The reversal of this trend is due to a sustained increase, of equivalized expenditure on hospital care over the whole period, but also to the steady rise observed since 2012 to the average equivalized expenditure for pharmaceuticals and equipment. This may reflect either unmet outpatient needs or a population trend to visit hospital emergency clinics for economic reasons. To assess the impact of measures on the pharmaceutical industry, we analyzed data from the Greek System of Health Accounts. Our findings indicate that between 2010 and 2018, direct industry contribution in pharmaceutical expenditure has increased by 419%, from 78 mil.€ to 1.37 bil.€. This calculation takes only the rebates and the clawback into account, meaning that the actual difference might be even higher. Moreover, total pharmaceutical expenditure has increased by 41,7%, from 3.03 bil.€ in 2014 to 4.3 bil.€ in 2018. The total increase amounts to 1.26 bil.€ and 75% of it burdened the industry while 25% burdened households. Furthermore, the dynamics of privatizing pharmaceutical care are even more prominent when considering the industry share of total pharmaceutical expenditure. Since total expenditure increases and public expenditure remains fixed, public share of the expenditure shrinks while industry’s share grows ever larger, from 1.5% in 2010 to 32% in 2018. As a result, the pharmaceutical industry constitutes a significant financing pillar of the healthcare system, contributing to almost 1/3 of the total pharmaceutical expenditure in 2018. This suggests that, in a situation of an expanding pharmaceutical demand, due to innovation, chronic diseases and the ageing of population, a significant share of burden of the additional –and not necessarily actual– pharmaceutical needs of the population is resting entirely upon the shoulders of pharmaceutical companies. This unreasonable burden can only discourage any thought of investment, but also it may threaten the very survival of the whole sector. Therefore, the continuance of these market conditions may cause the loss of thousands of jobs and even endanger public health in the long run. Moreover, the excessive amounts of claw back and rebate leads to disinvestment and funding cuts in research and clinical studies, prohibiting the development of new drugs much needed to cover the growing medical needs of the ageing population. On the one hand, this shifting of the cost of pharmaceutical care from the public health system's risk concentration mechanisms to the citizens themselves seems to have a significant negative impact on households in terms of their well-being, health care and, in the future, their health. More specifically, some households may postpone or give up on medical care due to economic weakness. These unmet health needs can be particularly damaging to the health status of citizens, creating a damaging circle where access to health care problems lead to even greater health problems in the future [ 38 , 39 ]. Considering the economic challenges, the Greek citizens are facing, and the already privatized nature of the Greek health system, policies should focus more on improving health system’s efficiency and effectiveness, instead of increasing out-of-pocket payments, which may exacerbate barriers to pharmaceutical access, especially for the more vulnerable groups. On the other hand, public policy relies exclusively on the clawback using it as the only capable and necessary safeguard to achieve fiscal targets regarding pharmaceutical spending. However, the Greek government should not relinquish its responsibilities for institutional reforms aiming at controlling consumption and rationalizing pharmaceutical spending by rendering the pharmaceutical industry as the sole responsible for the pharmaceutical care of the Greek population. This is not only unreasonable, but also it perpetuates the chronic problems of the health system leading to the erosion of social efficiency and to suboptimal health and social outcomes. Structural reforms to rationalize demand and minimize waste based on the actual pharmaceutical needs of the population and to reduce the extent of unfairness and arbitrariness of the retroactive returns by imposing co-responsibility with the State and all parties involved is the only fair and viable solution. Declarations Funding: No funding source Conflict of Interest: No conflict of interest declared. References Economou, C., Girono, C.: Improving the performance of the public health care system in Greece. OECD Economic Department Working Papers. (722):0_1. (2009) Economou, C.: Greece Health System Review Health systems in transition. 12 (7), 204 (2010) Kousoulis, A.A., Angelopoulou, K.-E., Lionis, C.: Exploring health care reform in a changing Europe: lessons from Greece. Eur. J. Gen. Pract. 19 (3), 194–199 (2013) Simou, E., Koutsogeorgou, E.: Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health policy. 115 (2), 111–119 (2014) Economou, C., Kaitelidou, D., Kentikelenis, A., Sissouras, A., Maresso, A.: The impact of the financial crisis on the health system and health in Greece. Economic crisis, health systems and health in Europe: country experience Copenhagen. WHO/European Observatory on Health Systems and Policies (2014) Economou, C., Kaitelidou, D., Karanikolos, M., Maresso, A., Greece: Health Syst. Rev. Health Syst Transit. 19 (5), 1–166 (2017) Chantzaras, A.E., Yfantopoulos, J.N.: Financial protection of households against health shocks in Greece during the economic crisis. Social Science & Medicine (2018) Chantzaras, A.E., Yfantopoulos, J.N.: Financial protection of households against health shocks in Greece during the economic crisis. Soc. Sci. Med. 211 , 338–351 (2018). https://doi.org/10.1016/j.socscimed.2018.06.024 Yfantopoulos, J.N., Chantzaras, A.: Drug Policy in Greece. Value in health regional issues. 16 , 66–73 (2018) Yfantopoulos, J.: Awaiting the “catharsis. Eur. J. Health Econ. (2020). 10.1007/s10198-020-01193-w Yfantopoulos, N., Yfantopoulos, P., Yfantopoulos, J.: Pharmaceutical Policies under Economic Crisis: The Greek case. J. Health Policies Outcomes Res. (2016) Vogler, S., Zimmermann, N., Babar, Z.U.: Price comparison of high-cost originator medicines in European countries. Expert Rev. Pharmacoecon Outcomes Res. 17 (2), 221–230 (2017). 10.1080/14737167.2016.1223543 Atikeler, E.K., Ozcelikay, G.: Comparison of pharmaceutical pricing and reimbursement systems in Turkey and certain EU countries. Springerplus. 5 (1), 1876 (2016). 10.1186/s40064-016-3455-z Vogler, S., Zimmermann, N., de Joncheere, K.: Policy interventions related to medicines: Survey of measures taken in European countries during 2010–2015. Health Policy. 120 (12), 1363–1377 (2016). 10.1016/j.healthpol.2016.09.006 Schweitzer, S.O., Lu, Z.J.: Pharmaceutical Economics and Policy: Perspectives, Promises, and Problems. Oxford University Press (2018) Yfantopoulos, J.: Pharmaceutical pricing and reimbursement reforms in Greece. Eur. J. Health Econ. 9 (1), 87–97 (2008) Xenos, P., Yfantopoulos, J., Nektarios, M., Polyzos, N., Tinios, P., Constantopoulos, A.: Efficiency and productivity assessment of public hospitals in Greece during the crisis period 2009–2012. Cost Eff. Resource Allocation. 15 (1), 1–12 (2017) Xenos, P., Nektarios, M., Constantopoulos, A., Yfantopoulos, J.: Two-stage hospital efficiency analysis including qualitative evidence: A Greek case. J. Hosp. Adm. 5 (3), 1 (2016) Polyzos, N., Karanikas, H., Thireos, E., Kastanioti, C., Kontodimopoulos, N.: Reforming reimbursement of public hospitals in Greece during the economic crisis: implementation of a DRG system. Health policy. 109 (1), 14–22 (2013) Xanthopoulou, S., Katsaliaki, K.: Evaluation of generic drug use in the Greek market during the financial crisis. ARCHIVES OF HELLENIC MEDICINE. 33 (5), 583–595 (2016) Vogler, S., Zimmermann, N., Leopold, C., de Joncheere, K.: Pharmaceutical policies in European countries in response to the global financial crisis. South. Med. Rev. 4 (2), 69–79 (2011). 10.5655/smr.v4i2.1004 Kanavos, P., Vandoros, S., Irwin, R., Nicod, E., Casson, M.: Differences in costs of and access to pharmaceutical products in the EU. (2011) Theodorou, M., Tsiantou, V., Pavlakis, A., Maniadakis, N., Fragoulakis, V., Pavi, E., et al.: Factors influencing prescribing behaviour of physicians in Greece and Cyprus: results from a questionnaire based survey. BMC Health Serv Res. 9 , 150 (2009). 10.1186/1472-6963-9-150 Tsiantou, V., Zavras, D., Kousoulakou, H., Geitona, M., Kyriopoulos, J.: Generic medicines: Greek physicians' perceptions and prescribing practices. J. Clin. Pharm. Ther. 34 (5), 547–554 (2009). 10.1111/j.1365-2710.2009.01037.x Mpogiatzidis, P.: Prescribing behavior on a clinical department leadership level in public hospitals. Clin. Gov. Int. J. 18 (4), 332–349 (2013). 10.1108/cgij-03-2013-0009 Balasopoulos, T., Charonis, A., Athanasakis, K., Kyriopoulos, J., Pavi, E.: Why do generic drugs fail to achieve an adequate market share in Greece? Empirical findings and policy suggestions. Health Policy. 121 (3), 265–272 (2017). 10.1016/j.healthpol.2016.12.011 Wouters, O.J., Kanavos, P.G., McKee, M.: Comparing generic drug markets in Europe and the US: prices, volumes, and spending. Milbank Q. (2017) Skaltsas, L.N., Vasileiou, K.Z.: Patients' perceptions of generic drugs in Greece. Health Policy. 119 (11), 1406–1414 (2015). 10.1016/j.healthpol.2015.09.007 European Commission:. Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. In: Commission E, editor. European Economy Institutional Papers. Luxembourg2016 Siskou, O.C., Kaitelidou, D.C., Litsa, P.S., Georgiadou, G.S., Alexopoulou, H.A., Paterakis, P.G., et al.: Investigating the Economic Impacts of New Public Pharmaceutical Policies in Greece: Focusing on Price Reductions and Cost-Sharing Rates. Value in Health Regional Issues. 4 , 107–114 (2014). 10.1016/j.vhri.2014.07.003 Mitton, C., Donaldson, C.: Health care priority setting: principles, practice and challenges. Cost Eff. resource allocation. 2 (1), 3 (2004) Martin, D.K., Singer, P.A.: Priority setting and health technology assessment: beyond evidence-based medicine and cost-effectiveness analysis. The global challenge of health care rationing. :135 – 45. (2000) Bertram, M.Y., Lauer, J.A., Stenberg, K., Edejer, T.T.T.: Methods for the economic evaluation of health care interventions for priority setting in the health system: An update from WHO CHOICE. Int. J. Health Policy Manage. (2021) Ham, C.: Priority setting in health care: learning from international experience. Health policy. 42 (1), 49–66 (1997) Rumbold, B., Baker, R., Ferraz, O., Hawkes, S., Krubiner, C., Littlejohns, P., et al.: Universal health coverage, priority setting, and the human right to health. The Lancet. 390 (10095), 712–714 (2017) Redwood, H.: Why ration health care? An international study of the United Kingdom, France, Germany and public sector health care in the USA. (2000) Yfantopoulos, J., Chantzaras, A., Constantopoulos, A.: Cost Containment And Privatisation Of Pharmaceutical Care In Greece: A Review Of Policy Reforms Under The Memorandums’ Requirements. Value in Health. 20 (9), A509 (2017) Pappa, E., Kontodimopoulos, N., Papadopoulos, A., Tountas, Y., Niakas, D.: Investigating unmet health needs in primary health care services in a representative sample of the Greek population. Int. J. Environ. Res. Public Health. 10 (5), 2017–2027 (2013) Yfantopoulos, J., Chantzaras, A., Ollandezos, M.: Unmet Pharmaceutical Needs During The Economic Crisis In Greece. Value in Health. 20 (9), A510 (2017) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3154303","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":217485718,"identity":"f15c5822-c3b8-4323-aa8e-2aa573161d11","order_by":0,"name":"Athanasios Constantopoulos","email":"","orcid":"","institution":"National and Kapodistrian University of Athens","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Athanasios","middleName":"","lastName":"Constantopoulos","suffix":""},{"id":217485719,"identity":"8b706a5c-73dc-4893-9dbf-1bdd61177f42","order_by":1,"name":"Athanasios 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Athens","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Yfantopoulos","suffix":""}],"badges":[],"createdAt":"2023-07-09 17:14:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3154303/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3154303/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":40040860,"identity":"74d510b4-1c7a-407f-bf9a-3916ac07546e","added_by":"auto","created_at":"2023-07-14 14:59:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84113,"visible":true,"origin":"","legend":"\u003cp\u003eBreakup of Public Health Expenditure (selected functions) 2010-2020\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: ELSTAT, System of Health Accounts, own calculations\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3154303/v1/88cfbf0d68766c68dc61370d.png"},{"id":40040859,"identity":"0e3ed173-9756-486c-9d53-1e8e719c2b8d","added_by":"auto","created_at":"2023-07-14 14:59:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60825,"visible":true,"origin":"","legend":"\u003cp\u003eBreakdown (%) of new measures in the pharmaceutical sector for the change of financing scheme of pharmaceutical expenditure for the period 2010-2020\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: Greek Government Gazette, authors’ calculations\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3154303/v1/409d33ef078a32c0cd338f15.png"},{"id":40040862,"identity":"36c01d5d-88d8-4283-8d90-72cb51b99966","added_by":"auto","created_at":"2023-07-14 14:59:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":161342,"visible":true,"origin":"","legend":"\u003cp\u003eBreakup of total pharmaceutical expenditure\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: ELSTAT, System of Health Accounts, EOPYY, own calculations\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3154303/v1/b1997788d583436760875274.png"},{"id":40040861,"identity":"b9cd5fe0-8ddb-45c0-9444-782fd59d41e2","added_by":"auto","created_at":"2023-07-14 14:59:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":69322,"visible":true,"origin":"","legend":"\u003cp\u003eShare of total pharmaceutical expenditure by financing scheme\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: ELSTAT, System of Health Accounts, own calculations\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3154303/v1/54fee678c340a8a34cc26d34.png"},{"id":40077834,"identity":"e9014dbe-24ae-44da-a166-b8aeb116b38b","added_by":"auto","created_at":"2023-07-15 20:14:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1030054,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3154303/v1/443e91ef-de07-46e4-9ec2-cae81a49e5fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pharmaceutical Reforms in Greece during the financial crisis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe economic crisis in Greece has brought unprecedented economic, social and health consequences since 2009. The main negative consequences of the crisis on the well-being of Greek citizens are the significant decline in family incomes, increased unemployment, labor insecurity and deterioration in working conditions, increasing household poverty, and worsening social inequalities.\u003c/p\u003e \u003cp\u003eDuring the years leading to the crisis, the National Health System (NHS) was plagued by informal payments, social contributions evasion, low incentives for hospitals to remain withing budget, delays in social security reimbursements and lack of measures to control pharmaceutical consumption volume, to name a few. The Memoranda of Understanding (MoUs) were aimed at the fiscal consolidation of Greece through the means of reducing such inefficiencies. However, the continuous increase in public healthcare spending before 2009 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] led subsequent Greek Governments to focus on restraint measures.. Taking into account that the health and pharmaceutical sectors had been in an unfavorable position even before the financial crisis [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], recent reforms to the NHS are considered defining[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while pharmaceutical care in particular, sustained a host of structural reforms and tough funding cuts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the importance of reducing public pharmaceutical spending has been recognized, the impact of this reduction on the industry, households and society in general has not been thoroughly explored. Each health system can be funded by four main sources: (a) taxes; (b) social security contributions; (c) private premiums; and (d) out-of-pocket payments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, the drastic cut in public spending on healthcare forces citizens and private corporations to fill the gap in healthcare financing with out-of-pocket payments.\u003c/p\u003e \u003cp\u003eConsidering the above, the purpose of this study was to explore the consequences of the crisis and healthcare reforms, with emphasis on out-of-pocket pharmaceutical payments and their impact on household welfare as well as on the rebates and clawback imposed on the pharmaceutical industry.\u003c/p\u003e \u003cp\u003eThe rest of the paper is arranged in four sections as follows. The first section provides a brief review on reforms regarding pharmaceutical care in Greece. The subsequent section presents our methodology. We used content analysis on the measures implemented since 2010 based on two features. First, we examined the extent to which the reforms shifted the economic burden to citizens and/or the industry and secondly, we analyzed their content as to whether it constitutes rationing or cost-containment. Moreover, we examine the extent of this financing shift on households and the pharmaceutical industry. The final sections provide the results and conclusions of the study as well as its policy implications.\u003c/p\u003e \u003cp\u003eOverview of pharmaceutical reforms\u003c/p\u003e \u003cp\u003eGreek pharmaceutical spending since 1990 was growing faster than the GDP, placing Greece among EU Member-States with the highest pharmaceutical expenditure. Moreover, even before the onset of the crisis, per capita demand for pharmaceuticals in Greece has been the highest among OECD countries. However, up until 2009 Greek governments, had strived to control pharmaceutical expenditure through price regulation rather than reducing demand for pharmaceutical products. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The key policies implemented between 2010 and 2020, also aimed to control pharmaceutical costs, and market rationalization in general. These measures included significant reductions in drug prices, increased patient participation, centralization the procurement process, the introduction of the clawback and the extension of the rebate, as well as significant changes in the pricing and reimbursement of medicines with the introduction of a positive and negative list and an internal reference price system, and, more recently, the adoption of an HTA system for the evaluation of reimbursed drugs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Reforms that targeted demand, such as mandatory electronic prescription based on active substance, monitoring, and controlling doctors\u0026rsquo; prescribing behavior and the promotion of generics, have not yielded the anticipated results. In the following subsections we present and comment on pharmaceutical measures that have transferred pharmaceutical costs to households and/or the pharmaceutical industry.\u003c/p\u003e \u003cp\u003ePricing\u003c/p\u003e \u003cp\u003eThe wholesale prices of medicines were horizontally cut twice, in 2010 and 2011, with their weighted average percentage being estimated at 21.5% and 10.2%, respectively[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The pricing of medicinal products follows a reference pricing system based on EU Member States. In addition, products whose patent has expired, may not be priced above 70% of the original protected price (63% for generics)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Increases in the prices of existing medicines are not allowed[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Also, a dynamic price reduction of generics (1\u0026ndash;15%) is applied with a retail price of more than \u0026euro; 12, based on sales volume. Along with the reduction in prices, several other measures were implemented with the aim of increasing the share of generics in the pharmaceutical market to 60%, while other regulations stipulate that at least 50% of the volume of medicinal products used in public hospitals should be generic [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReimbursement\u003c/p\u003e \u003cp\u003eBefore the onset of the crisis, there were no cost-effectiveness limits or other guidelines regarding reimbursement decisions[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Until then, all products were reimbursed, which led to a large volume of prescriptions and, therefore, a higher expenditure [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In 2011 the pricing and reimbursement procedures were separated, with the re-introduction of the positive list, which includes all medicines reimbursed by Social Security Funds (SSFs). Therefore, inclusion in the list is a primary goal of pharmaceutical companies, as this ensures the most effective market penetration of their products[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, entry in the list is subject to rebates and the clawback mechanism [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Moreover, an entry fee is applied, which is paid in a lump sum for each form, potency, and dosage.\u003c/p\u003e \u003cp\u003eHTA Commitee\u003c/p\u003e \u003cp\u003eRecently, the Positive List Committee, responsible for overseeing the procedure of entry in the list, has been replaced by the Committee for the Evaluation and Compensation of Medicinal Products for Human Use (Evaluation Committee or EC). The EC is appointed by the Minister of Health and consists of 11 experts in areas related to health technology assessment. Basic evaluation criteria are a) the clinical benefit, b) the comparison with other drugs, c) the reliability of the data, d) the cost / effectiveness ratio and e) the impact on the budget. The final EC recommendation may also include specific therapeutic indications for product compensation and mandatory prescribing protocols [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCo-payments\u003c/p\u003e \u003cp\u003eSince 1999, a three-tier system of patient cost-sharing has been in place as a cost-sharing rate: a) 0% for life-threatening illnesses, b) 10% for certain chronic illnesses, and c) 25% for all other diseases. If a patient chooses a drug with a retail price higher than the compensation price, they cover the participation percentage as well as the difference between the compensation price and the retail price of the product they have chosen. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The current limit for patient participation is \u0026euro; 20 per product. If the patient chooses a drug that does not have a corresponding generic, then the difference between the retail and the insurance price is divided in half between the patient and the producer (as a rebate). Additionally, the insured pay to the pharmacists one (1) euro per prescription. Moreover, since 2012, patients with serious diseases were burdened with increased participation rates. Therefore, patients suffering from illnesses such as systemic lupus erythematosus, rheumatoid arthritis, chronic obstructive pulmonary disease, ulcerative colitis, Crohn's disease or cirrhosis of the liver have to contribute by 25% instead of the reduced 10%, while patients with epilepsy and other epileptic conditions, BURGER vascular disease, dementia, Alzheimer's disease, and Charcot disease have to contribute by 10% instead of 0% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrescribing\u003c/p\u003e \u003cp\u003eOverprescribing or prescribing specific brands or drugs are chronic issues of the Greek pharmaceutical market, observed even from the 1990s [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have shown that a significant percentage of doctors (37.5%) is not considering the cost of the drug and the financial burden for the patient when prescribing. Moreover, it has been reported that Greek doctors avoid prescribing generics up to 75% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The main reason has been the cautious attitude of doctors towards generics and the small price difference between generics and patented drugs compared to other countries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring the crisis, there have been attempts to curb overprescribing. Handwritten prescriptions are no longer valid and have been replaced by electronic prescriptions. Moreover, prescription based on the active substance was implemented in 2012 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The above measures allowed for close monitoring of doctors' prescription patterns, referrals, and other medical procedures [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Doctors not complying with the current guidelines are subject to financial sanctions. In practice, however, many of them recommend brand-name drugs in the comments section of the prescription, thus eliminating the policy in practice, while avoiding penalties. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRebates and clawback\u003c/p\u003e \u003cp\u003eEven before the crisis (2008) pharmaceutical companies were expected to return to the SSFs 4% of the net price of the drugs as a mandatory rebate[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Since the merging of the Greek SSFs into EOPYY, a rebate was provided for the debts of the pharmacies to the newly established organization. Moreover, pharmaceutical manufacturers and importers offer a mandatory 4% discount for each prescription-product and 5% for each hospital purchase. On top of that, depending on sales volume, a gradual rebate is added on a quarterly basis (2\u0026ndash;12%). All drugs included in the positive list incur a further rebate of 2%.\u003c/p\u003e \u003cp\u003eIn order to control public pharmaceutical expenditure, fixed budgets were implemented in 2012 (outpatient expenditure) and 2016 (inpatient pharmaceutical expenditure) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Accompanying fixed budgets was the clawback, an automatic mechanism which ensures that expenditures do not exceed the budget, as any additional amount is automatically reimbursed by pharmaceutical companies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, each producer or importer is required to pay a 15% fee on the previous year's retail sales. This additional rebate is adjusted to 11% for drugs in the positive list. For serious diseases medications, a graduated amount of 1.5% is requested for quarterly sales of less than \u0026euro;2,500,000, 3% for sales between \u0026euro;2,500,000 and \u0026euro;5,000,000, and 4.5% for sales of more than \u0026euro; 5,000,000. The calculation of clawbacks is formulated by 90% of the market shares and by 10% of the company's growth share in the previous year. In this way, companies that have shrunk get a discount, while companies with high growth are additionally burdened.\u003c/p\u003e \u003cp\u003eAs mentioned above, public pharmaceutical expenditure has been a chronic issue that subsequent Greek governments have strived to overcome. However, policies have focused on decreasing the pharmaceutical costs and shifting the financial burden to households and pharmaceutical manufacturers and importers. At the same time, demand for pharmaceutical products in Greece remains high, since measures aiming to curb it have failed to achieve the anticipated results. Through exclusions from reimbursement and increased co-payments households are subjected to increased pharmaceutical costs, reducing available income and/or exposing families to increased health risks. Finally, the adoption of measures such as mandatory rebates and the clawback has led to a significant increase in the participation of pharmaceutical companies in the pharmaceutical expenditure.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eContent analysis of pharmaceutical measures\u003c/p\u003e \u003cp\u003eWe implemented content analysis on policy measures introduced in the period between 2010 and 2020. In total, 377 statutes and regulations (FEK) that concerned pharmaceutical care directly or indirectly were retrieved from the Greek Government Gazette. These measures were first classified with respect to the direction of cost reallocation. We distinguished measures reallocating pharmaceutical costs based on the cοnsequent payer. The possible categories included the tax-funded NHS, the SSFs, health consumers and the pharmaceutical industry. From the above 377 FEK we found that there were 191 measures that resulted in transpositions of expenditure, excluding repetitions or restatements of the same legislation, price lists, and positive list updates. Special attention was paid to the distinction between direct and indirect private expenditure. Indirect measures include increasing contributions.\u003c/p\u003e \u003cp\u003eSubsequently, the same measures were classified based on their character as cost containing (white area), rationing (black area) or a mixture of the above (grey area). Cost-containment is defined as a financial control technique which aims to reduce costs. Its consequences can be positive by reducing waste, neutral, but even negative, when operating at the expense of the quality of health care[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Rationing is more relevant to resource allocation than to direct financial control. Since rationing is based on social principle, it encompasses an ethical dimension and is essentially an external intervention in the field of medical science. As a term, rationing refers to all decisions that affect health care provision negatively [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany health scientists believe that restricting distribution is inevitable, but do not distinguish between it and cost-containment or prioritization. In economically developed countries, the restrictive distribution of health care should be the exception and not the rule. The case of organ transplants is an example of inevitable restrictive distribution[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Although there is a growing political and scientific interest in prioritizing, little consensus has been reached among stakeholders. Prioritization is a complex process of interaction and occurs either at the macroeconomic or patient care level [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The components of rationing in a health care system are summarized as follows[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eShortage of resources and need for organized distribution.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLong waiting lists for access to specific care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRefusal to provide quality care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDistinction between patients regardless of their condition.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eHousehold Budget Survey evidence\u003c/p\u003e \u003cp\u003eTo make an introductory analysis of the distribution of private household expenditure for healthcare and particularly pharmaceutical care in Greece, data for 51,842 households were derived from the Household Budget Survey (HBS) for the period 2008\u0026ndash;2018. The HBS is a survey collecting national information on households\u0026rsquo; composition, citizen employment status and income while focusing on the composition of household expenditure on goods and services. One of the purposes of the HBS is to collect sufficient and reliable information to adjust the Consumer Price Index. Since 2008 the HBS has been conducted annually and in a nationwide scale, to revise the Consumer Price Index yearly and for the country to be able to produce reliable and comparable data. The HBS implements two-stage area stratified sampling. During the first stage primary units are drawn (building blocks), while on the second stage the sample of secondary units (households) are selected.\u003c/p\u003e \u003cp\u003eAdditional data\u003c/p\u003e \u003cp\u003eThe quantitative evidence used in this study originate from public databases apart from those mentioned above. We implemented the Eurostat database on Health Expenditure, the Greek Statistical Authority\u0026rsquo;s (ELSTAT) System of Health Accounts (SHA) and EOPYY\u0026rsquo;s (the single Greek SSF) data to extract information regarding total pharmaceutical expenditure. Furthermore, we extracted household microdata from ELSTAT\u0026rsquo;S database of the Health Interview Survey (HIS).\u003c/p\u003e \u003cp\u003eThe analysis was conducted in MS Excel. The microdata from HIS were organized and analyzed using IBM SPSS v25.0. All charts and graphs, including those found in the appendices, pertaining to these correlation and regression analyses were produced in MS Excel.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 2010 and 2020, subsequent Greek Governments have implemented reforms that have resulted in decreasing public expenditure on healthcare from 14,821 mil.\u0026euro; to 8,591 mil.\u0026euro; (-42%). However, as seen in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, public pharmaceutical expenditure has been reduced more drastically, from 4,783 mil.\u0026euro; to 1,936 mil.\u0026euro;, which corresponds to a staggering \u0026minus;\u0026thinsp;60%. This decrease could either indicate that pharmaceutical expenditure had been exceedingly wasteful during the years leading to the crisis or that pharmaceutical funding has shifted from the government to other payers.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003cp\u003eBearing in mind that the European Council has repeatedly underlined the importance of efficiency policies, we sought to examine the focus of reforms implemented during the crisis. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the annual breakdown of the pharmaceutical measures implemented between 2010 and 2020 in terms of cost reallocation (from any operator) to the NHS, consumers, the industry and/or SSFs. Percentages are summed up yearly and reflect the percentage of new measures that transpose part of the financial burden of pharmaceutical spending to the corresponding payer. Thus, as more measures shift the economic burden to households and the industry, the more intense are the signs of privatization of pharmaceutical care.\u003c/p\u003e\n\u003cp\u003eInitially, we note that measures that transfer pharmaceutical costs to consumers exceed at least 17% of the annual total pharmaceutical legislation for most years. In addition, measures burdening the pharmaceutical industry range between 35% and 75% each year.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAnnual breakdown of new measures in the pharmaceutical sector for the shift in financing scheme of pharmaceutical expenditure for the period 2010\u0026ndash;2020\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eGovernment\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSocial Security Funds\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eConsumers\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eIndustry\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOut-of-pocket\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eIndirectly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2010\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2011\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2012\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2013\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2014\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2015\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2016\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2019\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003cp\u003eSource: Greek Government Gazette, authors\u0026rsquo; calculations\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the cumulative percentages of Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e that appear in its last row. In total, 152 of the 191 reforms shift the burden of spending to individuals, a rate that reaches 79.5%, with 48.6% being to industry and 30.8% to individuals. We are therefore seeing a significant shift in the burden of pharmaceutical spending on pharmaceutical companies and patients, who are being called upon to bear increasing costs at a time when family incomes are being reduced.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the results regarding whether the new measures were cost-containing or distribution-related. Noting that most measures (80.4%). are classified in the White Area (cost containment), we see that rationing reforms (Black Area) are limited to 0.8%, while 18.9% of the measures are in the interim Gray Region.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eClassification based on cost-containment/rationing\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWhite\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eGrey\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBlack\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e(cost-containment)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e(unidentified)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e(rationing)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2010\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e85.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2011\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e82.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2012\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e88.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2013\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e76.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2014\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e73.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e26.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2015\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e87.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2016\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e57.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e57.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2019\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e110\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e80.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e213\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e80.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003cp\u003eSource: Government Gazette, own calculations\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e contains information on the precise targeting category of all new measures. Most reforms are concentrated on reducing prices (50.7%). In fact, price controls went up between 32% and 85.7% of all medicinal measures per year. Following are measures setting thresholds on cost or coverage (14%) and prescription (15.4%), exclusions from coverage (4.4%), waste restrictions (6.6%), increases in turnout (6.6%), reductions in surpluses (1.5%) and waiting lists (0.7%).\u003c/p\u003e\n\u003cp\u003eTo summarize, even though most of the measures are indeed of cost-containing character, 16,5% lay in the gray area between cost-containment and rationing. More importantly, measures implemented between 2010\u0026ndash;2020 display a tendency to shift pharmaceutical funding, decreasing public participation and effectively privatizing the cost of pharmaceutical care. To examine whether this shift in policy measures corresponds to an actual shift in funding, we must investigate private pharmaceutical expenditure for the corresponding period.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eClassification based on type of measure\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePricing Regulation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrescription control\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCo-payments\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWaste Avoidance\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eElimination of Surplus\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eExclusions from reimbursement\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eRestrictions on volume and benefits\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eScarcity of resources\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2010\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e85.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2011\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e57.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2012\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2013\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e77.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2014\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e50.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2015\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e46.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e26.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2016\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e50.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e75.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2019\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e71.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e50.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003cp\u003eSource: Government Gazette, own calculations\u003c/p\u003e\n\u003cp\u003eTo begin with, we examined the breakup of pharmaceutical expenditure between 2010 and 2020, as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, to discern whether the industry\u0026rsquo;s contribution to pharmaceutical expenditure has increased and to what extent. During the early years of the crisis total pharmaceutical expenditure is decreasing effectively. However, since closed budgets were implemented (in 2014), total expenditures seem to explode, even though public contribution remains stable. More specifically, public contribution reduces by 73% overall during the years, while industry\u0026rsquo;s contribution, in the form of claw back and rebates, increases by a staggering 407%. During the same period, OOP payments increase by 13%. Moreover, since the application of closed public budgets, overall pharmaceutical expenditure has increased by 29.3%, indicating that the implemented reforms were not scoping to reduce overall demand and improve the overall efficiency of pharmaceutical care, but only to contain public expenditure.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003cp\u003eIn terms of proportions, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e indicates that in 2010 87.5% of the pharmaceutical expenditure was financed by the state, while in 2020 this percentage has fallen to 50.7%. During the interim years, OOP payments\u0026rsquo; contribution has increased by 48.6% from 10.9\u0026ndash;16.2%. In the same period, industry contribution has increased a staggering twenty times over, supporting more than 33% of the total expenditure in 2020 while its share in 2010 was 1.5%. Policies implemented between 2010 and 2020 have certainly decreased government pharmaceutical budget. However, they have only shifted the burden of financing pharmaceutical care to consumers and the industry, instead of implementing measures to decrease the overall inefficiency of pharmaceutical care.\u003c/p\u003e\n\u003cp\u003eFurthermore, we sought to examine the extent to which households have been burdened by the rising cost of pharmaceutical expenditure attributed to them. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e presents the mean annual equivalized total consumption, the mean annual equivalized out-of-pocket payments for health services and its components for the period from 2008 to 2018. Equivalized total consumption has decreased by 31.5% during the crisis. The equivalized total OOP health expenditure has also decreased by 20.5% which occurred due to an exceptionally large reduction in equivalized outpatient care (61%). On the contrary, out-of-pocket payments for pharmaceutical products and equipment and inpatient care increased by 25.5% and 69.9% respectively. More specifically, the equivalized expenditure on pharmaceutical care rose by 37.2% during the crisis. From 2008 to 2011 it declines steadily while between 2012 and 2016 the slope is reversed.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e describes the evolution of the proportion of households that resorted to OOP payments, for each category of health care. The proportion of households with private health payments is very high over the entire period, reaching 85.8% of all households in 2018, decreased by 4.5% compared to 2008. The proportion of households with outpatient care expenditure decreased by 8.2% during the same period. However, the corresponding percentage for pharmaceutical products and equipment and for hospital care increased by 14.5% and 98.3%, respectively. More specifically, concerning pharmaceuticals the proportion of households with positive expenditure is rising steadily during the crisis, resulting in an overall increase of 31% between 2008 and 2018.\u003c/p\u003e\n\u003cp\u003eIt is evident that while total household consumption and total household expenditure in healthcare is decreasing during the period under study, expenditure on pharmaceuticals is increasing by 25.6% while the proportion of households with positive private expenditure increases by a staggering 31%. These changes indicate that the measures presented in the previous section increase household expenditure on pharmaceuticals, in a period that household expenditure in healthcare decreases.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMean annual equivalized total consumption, mean annual equivalized OOP payments for health services and its components 2008\u0026ndash;2018 (\u0026euro; in constant 2018 prices)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2009\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2010\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2011\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2012\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2013\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2015\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2017\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eChange 2008\u0026ndash;2018\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAbsolute\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRelative (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal consumption\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17990.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17750.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15546.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13864.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12594.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12339.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12173.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12286.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12118.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12227.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12318.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-5672.61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-31.53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal health expenditure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e996.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e986\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e843.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e761.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e690.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e736.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e778.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e808.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e791.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e765.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e792.45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-204.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-20.49\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eMedical products expenditure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e243.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e242.43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e234.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e224.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e233.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e274.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e306.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e310.82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e310.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e307.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e306.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.56\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePharmaceutical products\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e203.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e198.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e201.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e189.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e208.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e250.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e277.62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e284.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e283.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e281.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e279.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37.62\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther medical products\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.07\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTherapeutic appliances and equipment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-22.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-73.58\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eOutpatient expenditure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e605.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e568.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e453.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e365.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e278.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e261.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e255.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e244.45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e235.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e230.48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e236.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-369.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-60.98\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical Services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e215.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e195.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e159.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e132.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88.37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88.41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96.49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-119.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-55.26\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDental services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e285.48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e275.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e218.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e164.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e123.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e110.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e111.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e99.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-190.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-66.73\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eParamedical services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e104.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75.43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-59.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-57.07\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInpatient expenditure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e147.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e174.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e155.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e171.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e178.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e200.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e216.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e252.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e246.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e227.95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e249.84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102.82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003cp\u003eSource: Household Budget Survey, own calculations\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eProportion (%) of households with positive private expenditure on health services and its components, 2008\u0026ndash;2018\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2009\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2010\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2011\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2012\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2013\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2015\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2017\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal health expenditure\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89.40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92.80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86.00%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81.40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e82.40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86.70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83.70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86.10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85.60%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85.30%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMedical products\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.60%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.30%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65.50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67.40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOutpatient services\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81.30%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66.50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71.90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72.30%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.00%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72.70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.00%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.30%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInpatient services\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.00%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.30%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.00%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27.20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.80%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003cp\u003eSource: Household Budget Survey, own calculations\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePharmaceutical reforms between 2010 and 2020 present a clear tendency to privatize pharmaceutical expenditure. Health reforms during the crisis reduced overall health and drug payments, but they also reallocated the financial burden of the Greek health system to private individuals, especially in relation to their pharmaceutical care [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe have reviewed the new measures regarding pharmaceutical expenditures in relation to two key features. We first checked in which direction and to what extent new measures create a shifting between payers. Overall, for the crisis period, 48% of the measures transferred costs of pharmaceutical spending to industry and 31% to citizens. Thus, at a time when family incomes are shrinking, patients have a larger share of the cost of pharmaceutical spending. The second feature for which drug reforms were examined was whether the new measures are of a cost-containment or rationing nature. Cost-containment is related to patient participation, price regulation, reimbursement rules, avoidance of waste, etc. Rationing is related to the allocation of health resources. It involves external intervention in the field of medical science and may even involve refusal or delay in receiving necessary and qualitative treatment, discrimination between of patients, lack of resources and waiting lists. However, there is a gray area between cost containment and rationing, with measures that are either twofold or undefined, such as cover exceptions, volume or cost limits, quality problems in care, etc. The analysis showed that 82.6% of the measures limited the cost, and only 0.87% imposed a distribution restriction. However, 16.5% of the measures fell in the intermediate category. Therefore, a remarkable percentage of the new policies, attempting to reduce pharmaceutical costs, intervenes in medical decisions, which would otherwise be based on patients' needs and medical specialists\u0026rsquo; informed opinions.\u003c/p\u003e \u003cp\u003eThe intensity of this shifting between payers cannot be ascribed to the mere determination of the nature of the measures. Therefore, in the second part of this paper we analyzed data from the Household Budget Survey, an annual, nationwide research examining the proportions of household budgets dedicated to each household need. The first major finding is the constant decline in average equivalized total consumption between 2008 and 2015 recording at a total decrease of 35.7% (from \u0026euro; 19.670,77 to \u0026euro; 12.649,60) of the crisis. At the same time, we see a steady decline in the average equivalized total health expenditure by 2012 (from \u0026euro; 1,085.66 to \u0026euro; 731.60), followed by a steady upward trend, with the average share in the total household budget rising from around 5.5% between 2008 and 2012, at 6.6% in 2015 (\u0026euro; 830.72). The reversal of this trend is due to a sustained increase, of equivalized expenditure on hospital care over the whole period, but also to the steady rise observed since 2012 to the average equivalized expenditure for pharmaceuticals and equipment. This may reflect either unmet outpatient needs or a population trend to visit hospital emergency clinics for economic reasons.\u003c/p\u003e \u003cp\u003eTo assess the impact of measures on the pharmaceutical industry, we analyzed data from the Greek System of Health Accounts. Our findings indicate that between 2010 and 2018, direct industry contribution in pharmaceutical expenditure has increased by 419%, from 78 mil.\u0026euro; to 1.37 bil.\u0026euro;. This calculation takes only the rebates and the clawback into account, meaning that the actual difference might be even higher. Moreover, total pharmaceutical expenditure has increased by 41,7%, from 3.03 bil.\u0026euro; in 2014 to 4.3 bil.\u0026euro; in 2018. The total increase amounts to 1.26 bil.\u0026euro; and 75% of it burdened the industry while 25% burdened households. Furthermore, the dynamics of privatizing pharmaceutical care are even more prominent when considering the industry share of total pharmaceutical expenditure. Since total expenditure increases and public expenditure remains fixed, public share of the expenditure shrinks while industry\u0026rsquo;s share grows ever larger, from 1.5% in 2010 to 32% in 2018. As a result, the pharmaceutical industry constitutes a significant financing pillar of the healthcare system, contributing to almost 1/3 of the total pharmaceutical expenditure in 2018. This suggests that, in a situation of an expanding pharmaceutical demand, due to innovation, chronic diseases and the ageing of population, a significant share of burden of the additional \u0026ndash;and not necessarily actual\u0026ndash; pharmaceutical needs of the population is resting entirely upon the shoulders of pharmaceutical companies. This unreasonable burden can only discourage any thought of investment, but also it may threaten the very survival of the whole sector. Therefore, the continuance of these market conditions may cause the loss of thousands of jobs and even endanger public health in the long run. Moreover, the excessive amounts of claw back and rebate leads to disinvestment and funding cuts in research and clinical studies, prohibiting the development of new drugs much needed to cover the growing medical needs of the ageing population.\u003c/p\u003e \u003cp\u003eOn the one hand, this shifting of the cost of pharmaceutical care from the public health system's risk concentration mechanisms to the citizens themselves seems to have a significant negative impact on households in terms of their well-being, health care and, in the future, their health. More specifically, some households may postpone or give up on medical care due to economic weakness. These unmet health needs can be particularly damaging to the health status of citizens, creating a damaging circle where access to health care problems lead to even greater health problems in the future [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Considering the economic challenges, the Greek citizens are facing, and the already privatized nature of the Greek health system, policies should focus more on improving health system\u0026rsquo;s efficiency and effectiveness, instead of increasing out-of-pocket payments, which may exacerbate barriers to pharmaceutical access, especially for the more vulnerable groups.\u003c/p\u003e \u003cp\u003eOn the other hand, public policy relies exclusively on the clawback using it as the only capable and necessary safeguard to achieve fiscal targets regarding pharmaceutical spending. However, the Greek government should not relinquish its responsibilities for institutional reforms aiming at controlling consumption and rationalizing pharmaceutical spending by rendering the pharmaceutical industry as the sole responsible for the pharmaceutical care of the Greek population. This is not only unreasonable, but also it perpetuates the chronic problems of the health system leading to the erosion of social efficiency and to suboptimal health and social outcomes. Structural reforms to rationalize demand and minimize waste based on the actual pharmaceutical needs of the population and to reduce the extent of unfairness and arbitrariness of the retroactive returns by imposing co-responsibility with the State and all parties involved is the only fair and viable solution.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding source\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eNo conflict of interest declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEconomou, C., Girono, C.: Improving the performance of the public health care system in Greece. OECD Economic Department Working Papers. (722):0_1. (2009)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEconomou, C.: Greece Health System Review Health systems in transition. \u003cb\u003e12\u003c/b\u003e(7), 204 (2010)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKousoulis, A.A., Angelopoulou, K.-E., Lionis, C.: Exploring health care reform in a changing Europe: lessons from Greece. Eur. J. Gen. Pract. \u003cb\u003e19\u003c/b\u003e(3), 194\u0026ndash;199 (2013)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimou, E., Koutsogeorgou, E.: Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health policy. \u003cb\u003e115\u003c/b\u003e(2), 111\u0026ndash;119 (2014)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEconomou, C., Kaitelidou, D., Kentikelenis, A., Sissouras, A., Maresso, A.: The impact of the financial crisis on the health system and health in Greece. Economic crisis, health systems and health in Europe: country experience Copenhagen. WHO/European Observatory on Health Systems and Policies (2014)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEconomou, C., Kaitelidou, D., Karanikolos, M., Maresso, A., Greece: Health Syst. Rev. Health Syst Transit. \u003cb\u003e19\u003c/b\u003e(5), 1\u0026ndash;166 (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChantzaras, A.E., Yfantopoulos, J.N.: Financial protection of households against health shocks in Greece during the economic crisis. Social Science \u0026amp; Medicine (2018)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChantzaras, A.E., Yfantopoulos, J.N.: Financial protection of households against health shocks in Greece during the economic crisis. Soc. Sci. Med. \u003cb\u003e211\u003c/b\u003e, 338\u0026ndash;351 (2018). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.socscimed.2018.06.024\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2018.06.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYfantopoulos, J.N., Chantzaras, A.: Drug Policy in Greece. Value in health regional issues. \u003cb\u003e16\u003c/b\u003e, 66\u0026ndash;73 (2018)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYfantopoulos, J.: Awaiting the \u0026ldquo;catharsis. Eur. J. Health Econ. (2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10198-020-01193-w\u003c/span\u003e\u003cspan address=\"10.1007/s10198-020-01193-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYfantopoulos, N., Yfantopoulos, P., Yfantopoulos, J.: Pharmaceutical Policies under Economic Crisis: The Greek case. J. Health Policies Outcomes Res. (2016)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVogler, S., Zimmermann, N., Babar, Z.U.: Price comparison of high-cost originator medicines in European countries. Expert Rev. Pharmacoecon Outcomes Res. \u003cb\u003e17\u003c/b\u003e(2), 221\u0026ndash;230 (2017). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14737167.2016.1223543\u003c/span\u003e\u003cspan address=\"10.1080/14737167.2016.1223543\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtikeler, E.K., Ozcelikay, G.: Comparison of pharmaceutical pricing and reimbursement systems in Turkey and certain EU countries. Springerplus. \u003cb\u003e5\u003c/b\u003e(1), 1876 (2016). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40064-016-3455-z\u003c/span\u003e\u003cspan address=\"10.1186/s40064-016-3455-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVogler, S., Zimmermann, N., de Joncheere, K.: Policy interventions related to medicines: Survey of measures taken in European countries during 2010\u0026ndash;2015. Health Policy. \u003cb\u003e120\u003c/b\u003e(12), 1363\u0026ndash;1377 (2016). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.healthpol.2016.09.006\u003c/span\u003e\u003cspan address=\"10.1016/j.healthpol.2016.09.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchweitzer, S.O., Lu, Z.J.: Pharmaceutical Economics and Policy: Perspectives, Promises, and Problems. Oxford University Press (2018)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYfantopoulos, J.: Pharmaceutical pricing and reimbursement reforms in Greece. Eur. J. Health Econ. \u003cb\u003e9\u003c/b\u003e(1), 87\u0026ndash;97 (2008)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXenos, P., Yfantopoulos, J., Nektarios, M., Polyzos, N., Tinios, P., Constantopoulos, A.: Efficiency and productivity assessment of public hospitals in Greece during the crisis period 2009\u0026ndash;2012. Cost Eff. Resource Allocation. \u003cb\u003e15\u003c/b\u003e(1), 1\u0026ndash;12 (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXenos, P., Nektarios, M., Constantopoulos, A., Yfantopoulos, J.: Two-stage hospital efficiency analysis including qualitative evidence: A Greek case. J. Hosp. Adm. \u003cb\u003e5\u003c/b\u003e(3), 1 (2016)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolyzos, N., Karanikas, H., Thireos, E., Kastanioti, C., Kontodimopoulos, N.: Reforming reimbursement of public hospitals in Greece during the economic crisis: implementation of a DRG system. Health policy. \u003cb\u003e109\u003c/b\u003e(1), 14\u0026ndash;22 (2013)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXanthopoulou, S., Katsaliaki, K.: Evaluation of generic drug use in the Greek market during the financial crisis. ARCHIVES OF HELLENIC MEDICINE. \u003cb\u003e33\u003c/b\u003e(5), 583\u0026ndash;595 (2016)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVogler, S., Zimmermann, N., Leopold, C., de Joncheere, K.: Pharmaceutical policies in European countries in response to the global financial crisis. South. Med. Rev. \u003cb\u003e4\u003c/b\u003e(2), 69\u0026ndash;79 (2011). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5655/smr.v4i2.1004\u003c/span\u003e\u003cspan address=\"10.5655/smr.v4i2.1004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanavos, P., Vandoros, S., Irwin, R., Nicod, E., Casson, M.: Differences in costs of and access to pharmaceutical products in the EU. (2011)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTheodorou, M., Tsiantou, V., Pavlakis, A., Maniadakis, N., Fragoulakis, V., Pavi, E., et al.: Factors influencing prescribing behaviour of physicians in Greece and Cyprus: results from a questionnaire based survey. BMC Health Serv Res. \u003cb\u003e9\u003c/b\u003e, 150 (2009). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1472-6963-9-150\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-9-150\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsiantou, V., Zavras, D., Kousoulakou, H., Geitona, M., Kyriopoulos, J.: Generic medicines: Greek physicians' perceptions and prescribing practices. J. Clin. Pharm. Ther. \u003cb\u003e34\u003c/b\u003e(5), 547\u0026ndash;554 (2009). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1365-2710.2009.01037.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2710.2009.01037.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMpogiatzidis, P.: Prescribing behavior on a clinical department leadership level in public hospitals. Clin. Gov. Int. J. \u003cb\u003e18\u003c/b\u003e(4), 332\u0026ndash;349 (2013). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/cgij-03-2013-0009\u003c/span\u003e\u003cspan address=\"10.1108/cgij-03-2013-0009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalasopoulos, T., Charonis, A., Athanasakis, K., Kyriopoulos, J., Pavi, E.: Why do generic drugs fail to achieve an adequate market share in Greece? Empirical findings and policy suggestions. Health Policy. \u003cb\u003e121\u003c/b\u003e(3), 265\u0026ndash;272 (2017). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.healthpol.2016.12.011\u003c/span\u003e\u003cspan address=\"10.1016/j.healthpol.2016.12.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWouters, O.J., Kanavos, P.G., McKee, M.: Comparing generic drug markets in Europe and the US: prices, volumes, and spending. Milbank Q. (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkaltsas, L.N., Vasileiou, K.Z.: Patients' perceptions of generic drugs in Greece. Health Policy. \u003cb\u003e119\u003c/b\u003e(11), 1406\u0026ndash;1414 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.healthpol.2015.09.007\u003c/span\u003e\u003cspan address=\"10.1016/j.healthpol.2015.09.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuropean Commission:. Joint Report on Health Care and Long-Term Care Systems \u0026amp; Fiscal Sustainability. In: Commission E, editor. European Economy Institutional Papers. Luxembourg2016\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiskou, O.C., Kaitelidou, D.C., Litsa, P.S., Georgiadou, G.S., Alexopoulou, H.A., Paterakis, P.G., et al.: Investigating the Economic Impacts of New Public Pharmaceutical Policies in Greece: Focusing on Price Reductions and Cost-Sharing Rates. Value in Health Regional Issues. \u003cb\u003e4\u003c/b\u003e, 107\u0026ndash;114 (2014). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.vhri.2014.07.003\u003c/span\u003e\u003cspan address=\"10.1016/j.vhri.2014.07.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitton, C., Donaldson, C.: Health care priority setting: principles, practice and challenges. Cost Eff. resource allocation. \u003cb\u003e2\u003c/b\u003e(1), 3 (2004)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin, D.K., Singer, P.A.: Priority setting and health technology assessment: beyond evidence-based medicine and cost-effectiveness analysis. The global challenge of health care rationing. :135 \u0026ndash; 45. (2000)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBertram, M.Y., Lauer, J.A., Stenberg, K., Edejer, T.T.T.: Methods for the economic evaluation of health care interventions for priority setting in the health system: An update from WHO CHOICE. Int. J. Health Policy Manage. (2021)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHam, C.: Priority setting in health care: learning from international experience. Health policy. \u003cb\u003e42\u003c/b\u003e(1), 49\u0026ndash;66 (1997)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRumbold, B., Baker, R., Ferraz, O., Hawkes, S., Krubiner, C., Littlejohns, P., et al.: Universal health coverage, priority setting, and the human right to health. The Lancet. \u003cb\u003e390\u003c/b\u003e(10095), 712\u0026ndash;714 (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRedwood, H.: Why ration health care? An international study of the United Kingdom, France, Germany and public sector health care in the USA. (2000)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYfantopoulos, J., Chantzaras, A., Constantopoulos, A.: Cost Containment And Privatisation Of Pharmaceutical Care In Greece: A Review Of Policy Reforms Under The Memorandums\u0026rsquo; Requirements. Value in Health. \u003cb\u003e20\u003c/b\u003e(9), A509 (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePappa, E., Kontodimopoulos, N., Papadopoulos, A., Tountas, Y., Niakas, D.: Investigating unmet health needs in primary health care services in a representative sample of the Greek population. Int. J. Environ. Res. Public Health. \u003cb\u003e10\u003c/b\u003e(5), 2017\u0026ndash;2027 (2013)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYfantopoulos, J., Chantzaras, A., Ollandezos, M.: Unmet Pharmaceutical Needs During The Economic Crisis In Greece. Value in Health. \u003cb\u003e20\u003c/b\u003e(9), A510 (2017)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3154303/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3154303/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eOBJECTIVES:\u003c/strong\u003e The objective of this study was to study cost containment and cost reallocation and to discern how they burden households and the pharmaceutical industry.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS:\u003c/strong\u003e For the period 2010-2020, we implemented content analysis on 377 statutes that concerned pharmaceutical expenditure. These measures were classified firstly with reference to their character as cost containing or rationing and, secondly, with respect to cost reallocation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS: \u003c/strong\u003eThe proportion of measures shifting healthcare costs to consumers was 31% and 48.5% to industry. Mean equivalized total consumption between 2008 and 2018 decreased by 31.5% while mean equivalized total health expenditure decreased by 20.5%. During the same period mean equivalized pharmaceutical expenditure increased by 25.56% and the proportion of households with positive expenditure increased by 31 %. Meanwhile pharmaceutical industry’s direct contribution to the total pharmaceutical expenditure increased from 1.5% in 2010 to 30.1% in 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSIONS:\u003c/strong\u003e Recent reforms (2010-2020) regarding pharmaceutical expenditure present a clear tendency to reallocate pharmaceutical cost to consumers and the pharmaceutical industry. This shifting of the cost from the public health sector to the private sector endanger the sustainability of the pharmaceutical sector, and the access of patients to quality pharmaceutical treatment.\u003c/p\u003e","manuscriptTitle":"Pharmaceutical Reforms in Greece during the financial crisis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-14 14:59:42","doi":"10.21203/rs.3.rs-3154303/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05781b76-6223-4dcb-891a-f32c385c3234","owner":[],"postedDate":"July 14th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-07-15T20:14:20+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-14 14:59:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3154303","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3154303","identity":"rs-3154303","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}