Drug shortage in Germany: would have, would have, painkillers

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Pharmacists: Germany has a good pharmacy system, but it resists many changes

Photo: Joseffson / Westend61 / IMAGO

If you were to name the two most German character traits while ignoring the abysmal parts - you would certainly not be wrong with these: thrift and a fixation on justice.

These two German auxiliary virtues have long been found throughout politics, culture and everyday life.

The German inventions of Marxism and social democracy bear witness to this, as does the difficult and sexist image of the »Swabian housewife« as a political guideline.

But as is the case with virtues, they sometimes tend to become rigid or take on a life of their own to the point of being counterproductive.

Justice then becomes self-righteousness.

And thrift turns into avarice or radical preservation of vested interests.

When thrift and a sense of justice come together and possibly even escalate together, then things sometimes get very gloomy.

In German minds, for example, there is a perceived price structure that literally nobody can beat.

The core question is: What can a product cost?

But shopping Germany quickly gets frustrated when 100 grams of Quippendudel cost more than 1.29, hello.

An example that is as impressive as it is depressing is the highly climate-relevant question of what meat can cost.

Anyone who is seriously concerned with it for just three milliseconds knows that meat is far too cheap in Germany.

A cutlet for 99 cents is a farce in every respect, the climate is groaning, the animal is being tortured, the people who produce it are being exploited, the meat is expected to be of inferior quality and stuffed with antibiotics and is therefore not a suitable argument in the sense of »enjoyment must also be for poor people be possible« – but: thrift, justice, cheap cutlet.

Antibiotics, however, fantastic cue, because they are scarce at the moment.

At least some important ones.

Stories abound, like the one linked here, of a woman named Bella who was lucky and panic-stricken to snag a replacement drug for her severely strep-infected child.

From another mother who she even found out about through private detours.

Not a single accessible pharmacy had the drug or a substitute, or even the information as to when it could be ordered.

There is a shortage of medicines in Germany, a situation that just a few years ago would at best have been associated with much poorer, poorly organized countries.

The question of why medicines are scarce in Germany does not have just one answer.

Structurally, the healthcare system in Germany is one of the best in the world, really true.

The basic health care is unparalleled and mainly because of the ultimately good health system, people in Germany are reasonably healthy on average, despite the relatively old population.

And yet, now, in the winter of 2022, children's lives are in danger, on the one hand due to a complete overload of staff in hospitals, for example, and on the other hand due to the shortage of medicines.

When it comes to efficiency, the German healthcare system is poor

The Federal Office for Drugs and Medical Devices BfArM publishes a database on a website called »Published Delivery Bottleneck Notifications«.

There are currently 343 drugs on it, from cancer drugs to antibiotics to children's cough syrup.

The table also contains the column "Type of reason", so that should actually be the answer to the question: Why is the drug scarce?

Actually.

In fact, there are only two different answers for all 343 drugs, but they are entered with about the same frequency.

The first is: production problem.

The second is: Other.

German precision.

The German healthcare system proclaimed justice and thrift as goals a long time ago.

The reasons for this are easy to understand.

On the one hand, costs must not get out of hand any more, because quality costs and the German healthcare system is already quite expensive.

On the other hand, it has to be fair between health insurance companies, hospitals, doctors and nursing staff, pharmacies, some others - and of course the patients.

Especially for them, that's what it's all about.

In 2013, the author Kathrin Passig wrote very entertainingly about the fact that justice can often only be achieved by making a system more complicated.

Sure, "one size fits all" is very simple, but understandably often unfair.

Being able to specifically address every conceivable case would be very fair, but extremely complicated.

That is why the German healthcare system has not only become good for many decades, but also extremely complicated and, as a result, extremely bureaucratic.

And when it comes to efficiency, the German healthcare system is bad.

According to the OECD, Germany has by far the highest per capita spending on health in Europe, at an impressive 11.2 percent of total gross domestic product in 2018.

The lack of efficiency now also has a lot to do with the downright lousy digitization of the healthcare system.

If Germany had digitized its healthcare system better or at all, the ever-increasing complexity might have been manageable.

Had, had, painkiller.

In addition to thrift and a sense of justice, a third German characteristic comes into play here – lobbyism.

For example, the lobbying of the pharmacies.

The same applies here: Germany has a good pharmacy system.

But like many well-functioning, highly regulated systems, it resists all sorts of changes with great persistence.

And it costs a lot of money.

As far as the shortage of medicines is concerned, there is an almost bizarre political issue that has a lot to do with maintaining the pharmacies' vested interests.

By default, doctors in Germany cannot access a database that shows which medications are currently available, except for the really very rough, public one linked above.

With a paper prescription from the practice to the pharmacy and back again

In an interview, the Berlin doctor Malik Böttcher explains what that means in everyday practice: When doctors prescribe a preparation, they don't know for sure whether it is currently available or not.

That's why patients sometimes have to drive back and forth between the practice and the pharmacy to find out what a click should actually be.

And with a paper prescription that has not yet been replaced by an e-prescription across the board in Germany, one reason here: also lobbying.

And of course data protection, as is so often the case in healthcare, which the chairwoman of the German Ethics Council, Alena Buyx, was right to say in a clever interview recently (even if data protectionists swear with burning pitchforks that it really has nothing to do with it).

The so-called fixed-amount system was adopted in 1988 because many years ago the aim was to reduce the costs for the super-expensive German healthcare system, and especially for the then constantly increasing expenditure on medicines.

It should not only save money, but also make the health system and especially the supply of medicines fairer.

In simple terms, this means that the Central Association of Statutory Health Insurance sets an amount for most medications.

This will be refunded.

It is somewhat surprising that, to a certain extent, the paying customers of the drug manufacturers, the health insurance companies, more or less set the prices they intend to pay themselves.

And it didn't work out particularly well, at least in the long term: shortly before the pandemic, a British study was published, according to which Germany has the second most expensive drug prices in the world (after the USA).

Nevertheless, the economy and justice-oriented spirit of the fixed price system is partly responsible for the current shortage of medicines.

We only noticed that when a few other factors came along unfavorably.

Because of this system of unit prices - as was intended - fierce price competition among drug manufacturers emerged.

Because the revenue from the maximum price was fixed to a certain extent, the companies tried to save wherever possible.

Corona came first, then inflation

As a result, so little money could be made with a large number of standard medicines that one company after the other stopped delivering to Germany or even producing them at all.

Until finally there were often only one or two left.

And more importantly, they were forced to produce as cheaply as humanly possible.

So in India or China.

As a result, almost all production capacities in Germany and Europe have been closed for an amazing number of drugs.

And often also for the components of the medicines.

And the packaging.

And so on.

This went reasonably well (in the sense of: the public didn't notice) as long as there was no disruption.

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But then Corona came and shot up the supply chains.

Actually, one could assume that at some point everything will straighten out again.

But in fact, globalization has made the same mistake on a large scale as the German healthcare system on a small scale (albeit for different reasons): the machinery has been radically trimmed for efficiency and all resilience has been forgotten in the process.

The consequences of Corona and the Corona containment measures can still be felt, through delays, postponements, through the processing of pent-up tasks.

And then came inflation, which was and is above all energy cost inflation due to Russia's invasion of Ukraine.

And suddenly the intentional, small profits in the fixed price system became unprofitable business models due to higher energy and transport costs.

Many manufacturers then sell to other countries where they can still make money.

And Germany no longer gets any medication.

It's not that the greed of some corporations doesn't play a role.

The USA, with its insane drug prices, shows that too little regulation is simply catastrophic and costs lives.

But the bitter drug shortage in Germany in 2022, which will certainly cost lives, is also the result of mismanaged globalization, a substance-threatening savings hubris in the health system and a policy that insisted so much on highly complicated justice that it became self-righteous.