GREECE: THE NOVARTIS SCANDAL IS JUST THE TIP OF THE ICEBERG
by Dr Antonis Karavas, hospital doctor, unionist, "META" unionist group
Translation: Emmanuel (Manolis) Kosadinos
French language version
Disclaimer: The publication on this blog of some cartoons with provocative or excessive content does not, in any case, support the theses of the websites from which they were reproduced. Any caricature, by definition, forces the line of a situation to stimulate the debate on the subject treated.
Drug industrialists keep the feast going on at the expenses of the Greek working class and people.
The feast of the Pharmaceutical Industry, financed by the growing profits generated by the pharma business, is a permanent situation in Greece taking place at the expenses of the Greek working class and people. Despite the reduction in government spending on pharmaceuticals following the implementation of the memoranda, the collapse of public spending has led to the gradual displacement of the cost of health services to the back of the users; thus the majority of out of pocket payments are directed towards the earnings of the pharmaceutical industry.
The restructuring of the pharma sector in the era of capitalist crisis aims to reduce public pharmaceutical expenditure, without harming the capitalists of the branch while preserving their profits. This change is occurring constantly and necessarily to the detriment of all other participants of the drug market: by a sharp increase of out of pocket payments, by the reduction in the quantity and quality of medicines supplied to hospitals, by brutal cuts in expenditures of the pharmaceutical industry and massive layoffs , by a sharp reduction in the profits of pharmacies, closures of pharmacies in the perspective of converting pharmacists into employees of supermarkets and shopping centers on a 600 euros monthly salary basis.
The withdrawal of the State from pharmaceutical expenditure by the continued reduction of reimbursement by EOPYY/ ΕΟΠΥΥ (1) has led to a dramatic increase of out of pocket payments for medicine of insured persons. During the current governance, supposedly "Left wing" but actually applying Right wing policies, the average rate of copayment has increased from 12% to 28% for generics and more than 50% for drugs under license! The cost of medical drug expenditure has become unbearable for retirees and the poor working class. The result is that thousands of people are no longer able to buy their medicines, so they take them irregularly or even stop them completely!
It is quite widely known that all pharmaceutical companies have sought to establish privileged relationships with senior officials of all governments and that they even keep special departments to develop and cultivate such relationships in order to occupy the best position in the Greek market of pharmaceuticals and the highest prices.
It is significant that, until recently, the Greek Ministry of Commerce was the one competent for fixing the prices of medicines, not taking into account any scientific criterion for making decisions. The case of a Novartis anti-cancer drug is very instructing: it has obtained by agreement the multiple price of that of an equivalent drug, containing a similar active substance. Moreover, in the composition of the official Commission that negociates the prices of drugs the drug manufacturers (through the Association of Pharmaceutical Companies of Greece - ΣΦΕΕ / SFEE) are overepresented, while the employees of the pharma industry and of the Health Services are absent.
In recent years this authority has been transferred to the Greek Ministry of Health. By implementing the latest "all in one" law bill (introducing a large package of neoliberal austerity measures) the Greek government created a commission for "Health Technology Assessment (2) - HTA" (the use of the English term as such by the Greek administration illustrates the country's neoliberal cultural colonization from the memorandum and thereafter) whose function will be "the evaluation and reimbursement of medicinal products for human use", making proposals to the Minister of Health for authorizing access to the market of new drugs, periodically assessing those already in circulation as well, with no involvement of the Greek National Agency for Medicinal Products (EOF / ΕΟΦ), which was until now the competent authority at the scientific and health level for these questions.
Greece is important for the pharmaceutical industry not only for its market, but also because, as a country of the European Union, it can influence the prices negotiated by the drug companies in other countries through the "external reference pricing (ERP)" clause (3). It is therefore in the interest of the pharma companies that the prices of their pharmaceutical products remain high in Greece. This explains why the "clawback" clause (4), which in some countries requires the insurance funds to recover part of the margin on sales, is comparatively high in Greece. This is accepted by the pharma companies so that the market price of the drug in Greece is still kept high. It explains why that discount (rebate) can reach 25% in Greece, while in other countries where applied (Spain, Great Britain, etc.) it varies from 5% to 10% . Nevertheless, the benefits of the drug industry are not the least affected because their margin of profit is immense!
The unveiling of the Novartis alleged bribery scandal comes out in the context of a growing alignment of the interests of Greek capitalism with those of American imperialism.
The multinational pharma corporations are empires of immense power that do not yield markets to their competitors and rely on their "mother State" to defend and develop their markets. When Bayer, a German company, seriously threatened to invade the US pharmaceutical market with a very competitive antilipidemic medicine, its rivals, through the US judicial system, attributed to that drug the death of two patients, forcing Bayer to withdraw from this class of drugs.
Novartis, a firm representing German and Swiss interests, quickly rose through the ranks and attracted the attention of US multinationals, which in the past have inflicted to Novartis a series of judicial hassles, followed by fines.
Now, under the Trump presidency, those multinationals intensify their attacks, discovering an unexpected ally, the pretendedly leftist SYRIZA government, which attempts to politically exploit the alleged participation of prominent government officials of the PASOK (Social Democrats) and of New Democracy (Right wing party) pretending to battle against corruption, in an ultimate effort of political self-rescue while sinking in unpopularity because of its austerity policies.
The SYRIZA government, since having rejected the option of confrontation with the capitalists, is condemned to wander between antagonistic capitalistic influences, whose only common denominator is the wish to continually reduce social spending. On the complete opposite of such an option, the building up of a broad social alliance of the working people, the employees and scientists of the Health services , would be the necessary step and instrument to confront the multinationals of the drugs industry, to work out and put to practice, in alliance with a government of the true Left, the popular control over the pharma industry and thus challenge the blackmail of the capitalists. It is in this direction that the Radical Left must today strive.
What should a truly radical Left project stand for
The way to realise this project is to immediately develop public and social services for pharmaceutical care, under workers control at all levels: research, production, wholesale, distribution.
- The pillar of such a reform should be the immediate commissioning of a modern public pharmaceutical industry under social control and the creation of a State Pharmacy which initially would provide basic medicines at low cost, and gradually expand at the expense of private capitalist sector. The chemical and pharmaceutical sector has been highly developed for many decades in Greece. There is a valuable workforce and know-how to move towards a modern national pharmaceutical industry through nationalisation without indemnity of those pharmaceutical companies being in cessation of activity and the over indebted ones.
- This measure should be accompanied by other anti-capitalist measures in order to control the drug companies: audit, reimbursement of debts to the State and to the social insurance funds, end of tax immunity, ban on parallel exports, capital controls, etc. Novartis, for instance, has modern, valuable medicines for multiple sclerosis.
- A truly Left government should not be limited to seek the political responsibilities of the previous governments, but would force Novartis to compensate the Greek State or accept a large drop in the price of these drugs and, in case of non compliance of the company, it should seize the molecule and produce the drug by the State run industry.
- The market of pharmaceuticals and all the activities of the pharma companies should be controlled by public institutions. For that purpose the Greek National Agency for Medicines (EOF / ΕΟΦ) and the Institute for Research and Pharmaceutical Technology (IFET / ΙΦΕΤ) should be further invested and staffed. Research, continuing education and training should be supervised and organised by public foundations and institutions. Actually, those critics who assign responsibility to doctors and other employees of the Health services for the actual misfunctionnings, knowingly conceal that the financing of Congresses by the pharmaceutical companies is subject to agreement of the Greek National Agency for Medicines. This administration, like all other public ones, should require that companies finance really useful training programs taken from the agenda of public research and public educational institutions.
- Restoration of the Labor Rights for the employees of the drug industry (collective agreements, put an end to the layoffs)
The SYRIZA-ANEL government is trapped in the memoranda and the austerity policies that are planned to succeed them. It is trapped in the constraint of serving capitalist interests and promote benefits of the pharma companies, through transferring of Health care costs to users, since it completely integrates the logic of commoditization of medicines. This government, unable to confront the true scandal of the capitalist pharmaceutical industry, will be nothing more able to confront Novartis and corrupt officials of previous governments. The risk would be then, that in its powerlessness, it could choose to scapegoat doctors, health employees and scientists, that is to say those least guilty in this affair.
Regarding the Novartis bribery scandal, the action of the Left, the unions and the popular movement should be essential for the denunciation of both corruption, budget cuts in health and the speculation of the pharmaceutical industry. The aim of this political struggle should be to make pharmaceuticals a common good, not a commodity, and make Health services public and accessible to all.
(1) EOPYY (ΕΟΠΥΥ) : National Organization for the Provision of Health Services, the Greek administration, founded in 2011 under the memorandum, by the unification of the health branches of the 10 main Greek insurance funds. EOPYY is financed by the social contributions of the employees and employers and by the government. It byes health services from public run hospitals and health centers and from contracted private doctors and clinics. It also reimburses pharmaceutical care.
(2) Health Technology Assessment (HTA): the systematic evaluation of properties , effects and/or impacts of health technologies and interventions. It covers both the direct, intended consequences of technologies and interventions and their indirect, unintended consequences. In the field of pharmaceuticals, HTA is used to aid decisions on the reimbursement of pharmaceuticals or recommendations for their use. Pharmaceutical companies have to provide the national authorities a full documentation based on HTA criteria in order to obtain market authorization or reimbursement of their products.
(3) External reference pricing (ERP): the practice of using the price(s) of a pharmaceutical product in one or several countries in order to derive a benchmark or reference price for the purposes of setting or negotiating the price of the product in a given country.
(4) Clawback : a special contractual clause by which money already paid must be paid back under certain conditions. In many drug reimbursement systems (such as in Greece) this clause is applied to pharmacists and wholesalers who are constrained to pay back a percentage of the price of the drugs sold to the Public payer. Parallel to that a regressive mark-up is applied proportionally to the quantities sold.
- Overview of external reference pricing systems in Europe (Cécile Rémuzat et al, in Journal of market access and Health policy, 2015) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802694/
- Evidence summary 4 – Use of external reference pricing - WHO Guideline on Country Pharmaceutical Pricing Policies, 2016 https://www.ncbi.nlm.nih.gov/books/NBK258618/
- Greek pharma industry unites against growing burden of clawback (Brendan Melck, in IHS Markit Internet review, 2016) https://ihsmarkit.com/research-analysis/greek-pharma-industry-unites-against-growing-burden-of-clawback.html
- Pharmaceutical regulation in 15 European countries (Dimitra Panteli, Francis Arickx, Irina Cleemput et al., in Health Systems in Transition, Vol.18, N° 5, 2016)
- Pharmaceutical Regulation in Central and Eastern European Countries: A Current Review (Pawel Kawalec, Tomas Tesar et al. in Frontiers in Pharmacology, December 2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741607/
- Overview of pharmaceutical pricing and reimbursement regulation in Europe (Panos Kanavos, LSE Health and Social care, 2001) http://eprints.lse.ac.uk/21410/
- Qu'en est-il aujourd'hui de la protection sociale et de la santé en Grèce? (Emmanuel Kosadinos in Mediapart blog) https://blogs.mediapart.fr/emmanuel-kosadinos/blog/141217/quen-est-il-aujourdhui-de-la-protection-sociale-et-de-la-sante-en-grece-0
- Novartis bribery claims: Greek MPs vote to investigate top politicians (The Guardian, 02/22/2018) https://www.theguardian.com/world/2018/feb/22/greece-to-investigate-top-politicians-over-novartis-bribery-claims
- Greece rocked by claims drug giant bribed former leaders (The Guardian, 02/12/2018) https://www.theguardian.com/world/2018/feb/12/greek-pm-calls-for-inquiry-into-bribery-claims-against-two-predecessors
- Novartis hit by kickback lawsuits in US (published on Pharmaceutical Market Europe (PME) website, 04/29/2013) http://www.pmlive.com/pharma_news/novartis_hit_by_kickback_lawsuits_in_us_473996
Pricing and reimbursement of innovative pharmaceuticals in France and the new healthcare reform (Alexander Natz, Marie-Geneviève Campion in Fact; Health economics and therapeutic pathways 2012; 13(2): 49-60) https://journals.seedmedicalpublishers.com/index.php/FE/article/view/270/315