The EU community pharmacy market: The density and its influencing factors

Schwaabe, Selina Research Report The EU community pharmacy market: The density and its influencing factors ifgs Schriftenreihe der FOM, No. 32 Provided in Cooperation with: FOM Hochschule für Oekonomie & Management, ifgs Institut für Gesundheit & Soziales Suggested Citation: Schwaabe, Selina (2025) : The EU community pharmacy market: The density and its influencing factors, ifgs Schriftenreihe der FOM, No. 32, ISBN 978-3-89275-393-3, MA Akademie Verlagsund Druck-Gesellschaft mbH, Essen This Version is available at: https://hdl.handle.net/10419/315650 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ David Matusiewicz / Manfred Cassens (Hrsg.) ifgs Schriftenreihe Band 32 The EU Community Pharmacy Market: The Density and its Influencing Factors ~ Selina Schwaabe i i f f gs gs Institut für Gesundheit & Soziales der FOM Hochschule für Oekonomie & Management Selina Schwaabe The EU Community Pharmacy Market: The Density and its Influencing Factors ifgs Schriftenreihe der FOM, Band 32 Essen 2025 ISBN (Print) 978-3-89275-392-6 ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-393-3 ISSN (eBook) 2569-5274 Dieses Werk wird herausgegeben vom ifgs Institut für Gesundheit & Soziales der FOM Hochschule für Oekonomie & Management gGmbH Verlag: MA Akademie Verlagsund Druck-Gesellschaft mbH, Leimkugelstraße 6, 45141 Essen [email protected] Die Deutsche Nationalbibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliographie; detaillierte bibliographische Daten sind im Internet über http://dnb.d-nb.de abrufbar. 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The EU Community Pharmacy Market: The Density and its Influencing Factors Selina Schwaabe Contact: Selina Schwaabe Hochschule für Politik/Technische Universität München E-Mail: [email protected] ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market III Preface Community pharmacies deliver high-quality health care and are responsible for medication safety. The goal of the government is to ensure nationwide, accessible, and affordable medical health-care services provided by pharmacies. Therefore, the per capita density of community pharmacies matters. Overall, the density of community pharmacies fluctuates, with slightly decreasing tendencies in some countries. So far, studies have shown that changes in the system affect prices and density. However, an overview of the development of the density of European community pharmacies and its causes is still missing. This research is important to counteract decreasing density resulting in a lack of professional health care delivered through pharmacies. I focus on liberal versus regulated market structures and the regulation of mail-order of prescription drugs. The density of community pharmacies is increasingly becoming the focus of health-care policies. The supply of nationwide health-care services, especially with regard to recent pandemics, is important. Community pharmacies are not just a counter for prescription drugs. They deliver high-quality health advice and, in some cases, can replace a doctor’s visit. Hence, a decline in the density of community pharmacies can affect people’s health (care). During my research, I collected data on the number of community pharmacies per 100,000 inhabitants from 27 EU countries from 2000 to 2021. The motivation for this research comes from both a health-care policy and a personal perspective. I grew up in a pharmacist’s household and worked at the family’s pharmacy. During this time, I learned about the differences in pharmacy market regulations throughout the EU, which led me to question what influences pharmacy density. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market IV I am indebted to my supervisors, Prof. Dr. Tim Büthe and Prof. Dr. Christian Adam, for their continuous help and advice. Thank you. Further, I would like to thank Prof. Dr. Ellen Schaffheutle for her spontaneous, important input on the EU community pharmacy market. In addition, I appreciate the information and advice given by the research group members of the international relations chair at the TUM/HfP. Further, I would like to thank Dr. Isabel Gödl-Hanisch, Julius Schmidt, Charlotte Hummel and David Schweitzer for their feedback on this paper. I would also like to extend my gratitude to the respective European pharmacy associations for providing me with the data on pharmacy density. My gratitude also goes to the ifgs publication series for offering me the opportunity to publish. I am particularly grateful to Prof. Dr. David Matusiewicz and Sarah Berndsen. Munich, January 2025 Selina Schwaabe, M.A. Technische Universität München/Hochschule für Politik ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market V Contents Preface ................................................................................................................ III List of Figures ..................................................................................................... VI List of Tables ...................................................................................................... VI List of Abbreviations .......................................................................................... VII 1 Introduction ...................................................................................................... 1 2 Theoretical Framework .................................................................................... 5 3 Empirical Developments .................................................................................. 9 4 Theoretical Expectations ............................................................................... 11 5 Data ............................................................................................................... 14 6 Method ........................................................................................................... 16 7 Results ........................................................................................................... 18 8 Discussion ..................................................................................................... 22 9 Limitations ..................................................................................................... 25 10 Conclusion ..................................................................................................... 26 References ......................................................................................................... 27 Appendix ............................................................................................................. 37 ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market VI List of Figures Figure 1: Evolution of pharmacy density ....................................................... 45 List of Tables Table 1: Cross-Section Analysis .................................................................. 18 Table 2: Analysis over time (within-effects) ................................................. 19 Table 3: Overview of the definition of general regulations within liberal and regulated EU pharmacy markets with examples .......... 38 Table 4: General overview of regulations within the EU pharmacy market, including all 27 EU countries............................................. 39 Table 5: Overview of regulations and their changes in seven selected countries .......................................................................... 41 Table 6: Total number of community pharmacies in the EU from 2000-2021 ...................................................................................... 42 Table 7: Sources of Data collection ............................................................. 44 ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market VII List of Abbreviations ABDA Bundesvereinigung Deutscher Apothekerverbände e. V. AMPreisV Arzneimittelpreisverordnung DKMA Danish Medicines Agency e-prescription electronic Prescription EU European Union FIP International Pharmaceutical Federation GDP per capita on PPP Gross Domestic Product per capita based on purchasing power parity H Hypothesis INHS Italian National Health Service NNF Nachtund Notdienstfond OTC over-the-counter POM prescription only medicines Rx prescription WHO World Health Organisation ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 7 does not attempt to specify outcomes, a set of objectives that does not perpetuate regulation, but, rather, lets it recede as competition progresses” (Sidak & Spulber, 1998, p. 118). However, it is necessary that “regulators should establish basic rules for an orderly transition to competition that rely on competitive innovation and cost cutting as the sources of consumer benefits” (Sidak & Spulber, 1998, p. 119). Overall, managed competition is “a combination of liberalization with reregulation” more specific: “true deregulation (freer markets and fewer rules)” (Vogel, 2007, p. 33). The assumption of re-regulation by Vogel (2007, p. 34) is as follows: The logic by which liberalization drives re-regulation varies according to the nature of the preexisting regime and the character of the transition toward greater competition. A shift from monopoly to competition typically requires pro-competitive regulation to jumpstart competition (…). A transition from public to private provision of services often requires new regulation to mandate public service requirements such as universal access or interoperability) that were previously met directly by the public corporation. An increase in the number and diversity of market players generally demands a more codified regulatory regime (“more rules” in the literal sense). And an intensification of competition may spur companies to behave worse (to produce greater externalities), therefore requiring more social, environmental, or other types of protective regulation. The application of managed competition with regulations has been particularly relevant in sectors undergoing liberalization, such as telecommunications, energy, transportation, and financial services. In these cases, the gradual dismantling of state monopolies or regulatory barriers has been accompanied by the implementation of regulatory frameworks to ensure fair competition and protect public interests (Vogel, 2007). It is also important to know what managed competition is not. For example, Enthoven (1993, pp. 44-45) explains that it is not deregulation, it is not a free market, and “it is new rules, not no rules”. Managed competition controls the entry into a liberalized market, ensures fair conduct by all market players thus acting in the (end) consumer’s best interest. Entry barriers to the pharmacy market are ownership licenses, geographic and demographic rules, minimum and maximum Rx drug prices, retail concepts (workforce requirements), and provided services (vaccinations, diabetes counseling, expanded assortments such as cosmetics, and more)16. One specific 16 Which are not considered in this analysis. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 8 market that has recently witnessed the application of managed competition through regulations is the pharmacy market. The Swedish pharmacy market has changed from a regulated market to a market with managed competition. Sweden’s pharmacy market went from a state monopoly to a more liberally regulated market where a broader service, new selling places for fair competition, and an improvement of service exist (Wisell, 2019; Wisell et al., 2016). As governments explore avenues to liberalize this traditionally regulated sector, striking the right balance between competition and regulatory oversight becomes crucial. The implementation of managed competition principles, combined with targeted regulations, presents a promising approach to fostering competition while safeguarding patient safety, maintaining access to quality health care, and ensuring the sustainability of the pharmacy sector. The next section briefly presents which regulations and liberalizations exist within several EU countries. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 9 3 Empirical Developments Sweden’s state-monopoly based pharmacy market was liberalized in 2009 to introduce more competition. Parts of the pharmacy market in Portugal were liberalized by removing some regulations regarding the ownership structure in 2007. In Austria, so-called private partnerships can invest in a pharmacy since 2008. However, the pharmacist in charge has to hold more than 50 percent of the business (Österreichische Apothekerkammer, 2020b). Nevertheless, the market has structures of re-regulation (liberalization with more regulation) in the sense of fair competition. Regulation examples include geographic and demographic rules for establishing a new pharmacy to create accessibility and fairness. Further, in 2004, the German government liberalized Rx mail-order without changing existing price regulations within the country (liberalization without new rules for competition) (May et al., 2017). Due to the unchanged restrictions for German pharmacies regarding Rx fixed pricing rules,17 pharmacies could not withstand the price competition because pharmacies from abroad are allowed to discount the additional payment on Rx (usually between 5 and 10 €) of the insured in the amount of 10 percent of the pharmacy dispensing price (Bundesministerium für Gesundheit, 2023). A study by May et al. (2017) concluded that this resulted in a decline in the density of pharmacies in Germany. Due to the international trend of liberalizing regulated markets, the former government of Italy under Prime Minister Mario Monti also discussed liberalizing the Italian pharmacy market. A report by Garattini et al. (2012) highlighted that the liberalization plan of the Italian pharmacies would not change the policy goals of better accessibility, lower prices, and more competition.18 The researchers write: The new law in Italy aims to enhance competition in the pharmacy sector by reducing the historical restrictions through liberalization. However, after careful evaluation, the new regulations do not seem to radically change this tightly regulated distribution channel. One of the major hurdles to a free market (i.e. ownership restrictions) will remain and new shopping forms (e.g. internet pharmacies) will not 17 Every Rx medicine has a fixed price in Germany to ensure that the customer gets the same price in every pharmacy. This price is not discountable at German local pharmacies. 18 Nevertheless, in 2017, the pharmacy market was liberalized by allowing nonpharmacists to own a pharmacy through partnerships or companies (Gallone et al., 2020). ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 10 be introduced. Other limits, such as the demographic and geographic rules for opening a new pharmacy, have not been cancelled, just relaxed. An expected consequence is that many more pharmacies could open, resulting in redistribution of INHS remuneration for approved drugs. In theory, increased supply with equal demand could result in enhanced competition. (Garattini et al., 2012, p. 25) They further agree with other researchers that liberalizing the geographical rules will not expand density (Garattini et al., 2012). It will increase density in the urban areas, but the density in rural areas will remain low (urban clustering) (Garattini et al., 2012). In addition, current literature expresses that liberalizing the pharmacy market has different outcomes: pharmacy chains will have a more significant influence while smaller retail pharmacies have to close (Carballada & Lois-González, 2022). Competition promises positive impacts on the freedom of choice for the public and an increase in the number of community pharmacies (Gallone et al., 2020; Vogler, 2014; Wisell et al., 2016). These positive expectations have not been confirmed in all liberalized pharmacy markets. From the literature one gathers that the liberalization of the pharmacy market is associated with false expectations of more competition due to more players within the market – for example, in Sweden. (Vogler et al., 2006; Wisell, 2019). Wisell (2019, p. 36) argues that the liberalization reform was made “without the necessary research on the possible consequences”. Further, she explains that liberalizing the market was not based on rational arguments but mainly on an ideology. (…) privatization per se seemed to be an important rationale in the abolishment of the monopoly. The idea of how it ought to be was prioritized over what was probably going to be, based on the evidence at hand. (Wisell, 2019, p. 36) While liberalizing parts of the market, other regulations remain strong, such as geographic and demographic rules (Carballada & Lois-González, 2022; Rants, 2014). Using the core ideas of the managed-competition approach, this analysis explains how liberalization of the pharmacy market in the field of ownership and Rx mail-order impacts density. The next part of this paper describes the hypotheses according to the theoretical approach. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 11 4 Theoretical Expectations Higher pharmacy density has been associated with improved19 accessibility to health-care services, enhanced medication availability,20 and increased competition, which may result in lower prices and higher quality of care (Vogler, 2014; Wisell et al., 2016; Wiśniewski et al., 2020). The expectations derived from the discussion above posit that the number of pharmacies within a market will rise by relaxing ownership restrictions and allowing a more diverse range of owners, such as independent pharmacists or non-pharmacist investors. Proponents of this hypothesis argue that liberalization stimulates entrepreneurial activity, attracts investments, and fosters a competitive environment, ultimately leading to an expansion of pharmacy services and increased accessibility for patients (Clara, 2011; Vogler, 2014; Wisell, 2019; Wisell et al., 2016). The tougher the restrictions on opening a pharmacy are, the fewer pharmacies exist. Following the ideas of managed competition, liberal markets (liberal pharmacy ownership)21 can further increase competition. In addition, researchers discuss a higher density when changing from a regulated to a liberal market, with more competition (BWB, 2018; Eilard, 2015; Gallone et al., 2020; Vogler et al., 2006; Vogler et al., 2012; Wiśniewski et al., 2020). Differences between liberal and regulated markets are sometimes hard to spot. The pharmacy market is liberal if the ownership is not restricted to pharmacists. Hence, the pharmacy market is regulated if the ownership is 100 percent restricted to pharmacists. This distinction between liberal and regulated was chosen based on the existing work of the two regulatory markets within pharmacy research (Purcell, 2004; Vogler et al., 2014; Wiśniewski et al., 2020; World Health Organization, 2019). Theoretically, following the debate in previous literature, this analysis expects a correlation between pharmacy density and pharmacy ownership regulations (liberal vs. regulated). Accordingly, following the core ideas of managed competition, a liberal pharmacy market, meaning liberal ownership, is expected to increase pharmacy density. Therefore, the first hypothesis is as follows: 19 By improvement, this analysis means more services available at the pharmacy, a broader choice of products, longer opening hours, digitalization, larger stock of drugs, etc. 20 Licensed pharmacists are also a highly sought-after profession in the pharmaceutical industry. Due to the economic size of the pharmaceutical industry, these pharmacists can be paid better, and the working hours are more flexible than in the retail sector of the pharmacy. 21 In every liberal ownership market, regulations on further market regulations exists. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 12 H1: Liberalizing the ownership structure increases pharmacy density. Pharmacy density refers to the concentration of community pharmacies within a specific geographical area. Density has long been viewed as a measure of healthcare accessibility and the availability of prescription medications (World Health Organization, 2019). With the advent of technology, Rx mail-order services have emerged as an alternative means for patients to obtain their prescription medications conveniently through mail delivery. The next hypothesis suggests that by liberalizing Rx mail-order services, patients may increasingly opt for this convenient option, leading to reduced demand for traditional pharmacies. May et al. (2017) argue that there is a decline in German pharmacy density due to foreign competition advantages regarding Rx mailorder.22 In most EU countries, Rx mail-order is prohibited, regulated with pricing rules, or limited to community pharmacies (not online pharmacies, i.e., pharmacies without an on-site store). The density is more or less stable (for example, in Denmark). It can be assumed that liberalization of Rx mail-order (without new rules) will increase the likelihood that patients buy their drugs where they are cheapest (May et al., 2017; Rohrer, 2021). In Germany, because of competitive disadvantages, Rx drugs at foreign pharmacies are not bound to German Rx pricing rules (May et al., 2017). However, this is a particular case for Germany. Nevertheless, the customer buys the medication where it is cheapest and easiest to buy: in drugstores, supermarkets, gas stations, or abroad. Prescriptions can secure the primary income of a pharmacy. The fewer sales generated by Rx on-site, the lower the gross profit (Deutsche Apotheker Zeitung, 2022). Because of missing rules for competition, the density will decline. Hence, the underlying presumption is a decreasing density of pharmacies due to the mail-order permission for Rx. Thus: H2: Liberalizing Rx mail-order reduces pharmacy density. 22 Rx mail-order only exists in the following EU countries: Sweden, Germany, Denmark, the Netherlands, Malta, Finland, Estonia. I only mention Germany as an example because of the competitive advantages on prices for Rx, which is unique. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 13 Besides the regulation of ownership and Rx mail-order, several regulations could impact pharmacy density. The current literature on community pharmacy research discusses the influence on pharmacy density by the Gross Domestic Product per capita based on purchasing power parity (constant 2017 international $, GDP per capita on PPP), the number of pharmacists per 100,000 inhabitants, the proportion of the number of the population aged 65 and over (+), if there are regulations on geographic and demographic rules, and the number of medical doctors per 100,000 inhabitants (International Pharmaceutical Federation - FIP, 2017; World Health Organization, 2019). A positive correlation in density is expected due to the number of pharmacists because every pharmacy needs a pharmacist who is available during opening hours (Gallone et al., 2020; World Health Organization, 2019; Zelnio et al., 1984). Therefore, the more pharmacists there are, the more pharmacies can exist. This holds true, for example, if the maximum number of pharmacies within a specific area or for a specific number of inhabitants is not fulfilled. Pharmacies are established where doctors or medical centers are in proximity, so patients can be referred to a pharmacy and easily access the pharmacy for prescriptions (World Health Organization, 2019). Hence, more pharmacies are needed if the number of medical doctors increases. Another reason for higher density could be the number of the population aged 65+ because the elderly need more medication (World Health Organization, 2019).23 Finally, geographic and demographic24 rules are discussed to secure competition and regulate density (International Pharmaceutical Federation - FIP, 2017; Vogler et al., 2014; World Health Organization, 2019). The next part presents the data and methods used and analyzes the output. 23 Such as cardiovascular disease, diabetes, Alzheimer’s disease, joint pain, and cancer. 24 This analysis only captures if geographic and demographic rules exists or not. Further definitions are not included due to complexity of the rules regarding each country and each city. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 14 5 Data This study employs a comprehensive analysis to investigate the factors influencing pharmacy density across 27 EU countries during the period spanning from 2000 to 2021. The objective is to explore the determinants of pharmacy density and evaluate the influence of specific ownership characteristics, prescription drug distribution methods, and various socio-economic factors (see more details on sources of data in Appendix 2 Table 7). The data on pharmacy density25 primarily comes from the provided dataset by the Federal Union of German Associations of Pharmacists (“Bundesvereinigung Deutscher Apothekerverbände e. V.”, short: ABDA), which is used for their annual report “Figures Data Facts”. This dataset was supplemented and completed with the help of annual reports on pharmacies from respective pharmacy associations (Apteekkariliitto, 2023; Österreichische Apothekerkammer, 2023; Statistics Poland, 2023). Direct email inquiries were made to the relevant health ministries of all 27 EU countries to obtain additional data on pharmacy density. Due to the lack of data on pharmacy density from 2000 to 2010, there are more observation gaps in the dataset. Information regarding the permission for prescription drug mail-order services was obtained from the annual reports of the ABDA (ABDA, 2020a, 2020b, 2021) and a report by the World Health Organization (WHO) (World Health Organization, 2019). The data on GDP per capita on PPP (constant 2017 international $) is sourced from the World Development Indicators database 2022 (The World Bank, 2023). Furthermore, the number of pharmacists per 100,000 inhabitants was obtained from the WHO European Data Warehouse (2023) and Eurostat (2023), and the number of doctors per 100,000 inhabitants was also taken from Eurostat (2023). The presence of geographical and demographic factors was filtered from the literature (ABDA, 2020a, 2021; Carballada & Lois-González, 2022; International Pharmaceutical Federation - FIP, 2017; Vogler et al., 2014; World Health Organization, 2019). Data on the proportion of the population aged 65 and over was taken from Eurostat (2022) and International Pharmaceutical Federation - FIP (2017). Data on pharmacy density has been collected from all EU countries from 2000 until 2021.26 The key variables of interest are the density of pharmacies for each 25 See Table 6 in Appendix 1 for an overview of the number of community pharmacies per 100,000 inhabitants of 27 EU countries from 2000-2021. 26 I choose the timeframe to cover important changes within the pharmacy market, which could have influenced density like the permission of Rx mail-order, the online sale of drugs, and several market regulation changes. Further, there is no other study, which covers the last 21 years. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 15 EU country over time, the ownership market model, and the Rx mail-order. This paper explains the variation in pharmacy density, using the pharmacy density per 100,000 inhabitants27 in each EU country as the dependent variable. Further, the main two binary independent variables are the pharmacy market model (0 = regulated/1 = liberal), and the Rx mail-order (no = 0/yes = 1). Control variables are introduced for socio-economic factors, including the GDP per capita on PPP (adjusted for purchasing power parity), geographical characteristics (if geographic and demographic rules exist; change from 0, no, to 1, yes), population demographics (specifically the proportion of the population aged 65 and over), and the number of pharmacists and medical doctors per 100,000 inhabitants.28 27 In pharmacy research, it is a standard to analyze the accessibility and coverage of pharmacies through the density per 100,000 inhabitants. 28 Assuming the population is getting older, the need for pharmacies, predominantly medication, is increasing. Further, managed competition will rule the market if demographic and geographic rules exist. An increasing number of medical doctors and pharmacists could positively affect pharmacy density as well. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 16 6 Method This study employs two statistical modeling approaches to examine the determinants of pharmacy density across EU countries: cross-sectional analyses and fixed-effects panel analyses. These methods were chosen to capture both the differences between countries and the changes within countries over time. Together, they provide comprehensive insights into the factors influencing pharmacy density. Four models were developed for the cross-sectional analyses. Model 1 includes a broad range of regulatory and demographic variables, such as third-party ownership allowance, Rx mail-order allowance, and geographic and demographic restrictions. It serves as a baseline analysis to explore general associations between these variables and pharmacy density. Model 2 incorporates GDP per capita and the number of pharmacists per 100,000 inhabitants in addition to the variables in Model 1. Countries with missing data for specific variables were excluded to increase the accuracy of the analysis. This model aims to assess the importance of economic and labor market factors in influencing pharmacy density. Model 3 focuses on variables that were at least weakly significant in Model 2. By reducing the number of variables, the analysis becomes more efficient, examining whether the previously observed relationships are robust. Model 3’ was developed to verify the robustness of the results by excluding Greece due to its specific characteristics. This model helps identify potential outliers and ensure the stability of the findings. The crosssectional analyses provide an overview of country-specific differences and allow for the identification of general trends and relationships between the variables and pharmacy density. In addition to the cross-sectional analyses, fixed-effects panel analyses were conducted to examine changes within countries over time. This method accounts for unobserved country-specific characteristics that remain constant over time, isolating the effect of the variables of interest. Two fixed-effects models were created. Fixed-Effects Model 1 includes variables such as GDP per capita, thirdparty ownership allowance, Rx mail-order allowance, geographic and demographic restrictions, the percentage of the population over 65, the number of pharmacists per 100,000 inhabitants, and the number of doctors per 100,000 inhabitants. It investigates the impact of these variables on pharmacy density within countries over time. The fixed-effects Model 2 excludes non-significant variables (third-party ownership allowed and doctors per 100,000 inhabitants) to increase the efficiency of the analysis. This model checks the robustness of the significant variables from Model 1 and focuses on the main influencing factors. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 23 The fixed-effects within analysis provide a different perspective by focusing on the changes within countries over time, accounting for unobserved countryspecific characteristics. Model 1 (Fixed-Effects) includes GDP per capita, thirdparty ownership allowed, Rx mail-order allowed, geographic and demographic restrictions, the percentage of the population over 65, the number of pharmacists per 100,000 inhabitants, and the number of doctors per 100,000 inhabitants. This model reveals that GDP per capita and the number of pharmacists per 100,000 inhabitants are significant positive predictors of pharmacy density, while the percentage of the population over 65 is a significant negative predictor. The fixedeffects model highlights the importance of economic and workforce factors while controlling for time-invariant characteristics within countries. Model 2 (FixedEffects) refines the analysis by excluding the non-significant variables (third-party ownership allowed and doctors per 100,000 inhabitants). This model confirms the robust influence of GDP per capita and the number of pharmacists per 100,000 inhabitants, with both variables remaining significant. The percentage of the population over 65 continues to show a significant negative association. This refined model, with a higher within R-squared value of 0.3833, demonstrates improved explanatory power and efficiency. Comparing the results of the cross-sectional and fixed-effects within analyses provides a comprehensive understanding of the factors influencing pharmacy density. Both analytical approaches consistently show that GDP per capita is a significant predictor of pharmacy density, underscoring the importance of economic prosperity in supporting pharmacy infrastructure, as wealthier countries are better equipped to maintain a higher density of pharmacies. The number of pharmacists per capita is another consistent positive predictor across both methods, highlighting the critical role of workforce availability in ensuring adequate pharmacy services. The percentage of the elderly population is a significant negative predictor in the fixed-effects analysis, indicating that higher healthcare needs among the elderly are not met by merely increasing the number of pharmacies. The allowance of Rx mail-order shows a potential negative impact on pharmacy density in the cross-sectional models, though the evidence is mixed. This suggests that policies facilitating mail-order prescriptions might reduce the need for physical pharmacies. The exclusion of Greece in the cross-sectional analysis (Model 3’) and the control for country-specific characteristics in the fixed-effects analysis both highlight the importance of accounting for unique national contexts in cross-national studies. These adjustments improve the robustness and significance of the findings. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 24 Summarizing the results shows that market regulations do not play a role in pharmacy density. This analysis rejects H1. Furthermore, this analysis does not accept H2. Rx mail-order does not have a statistically significant influence on pharmacy density. An important result of this analysis is that economic capacity and workforce availability are crucial factors, while demographic and regulatory variables also play significant roles. Combining the liberalization process with the core ideas of managed competition, it becomes clear that without establishing new rules in a liberalized market, goals of more competition, broader service, and higher density are harder to achieve. In conclusion, the combined insights from both analytical approaches emphasize the multifaceted determinants of pharmacy density. Policymakers should consider these determinants to optimize pharmacy services and address healthcare accessibility challenges in different national contexts. Further research should shed more light on new rules after liberalization and how new rules can affect density behavior – for each country individually; especially, how more pharmacists can lead to higher pharmacy density. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 25 9 Limitations The data is limited due to gaps in research data.31 A difference-in-difference design was not possible due to the short observation time before a policy changed and due to gaps in research data. Furthermore, this study is limited to the EU pharmacy market. Additional research might include Switzerland, the United Kingdom, Iceland, Liechtenstein, and Norway. Additionally, only Rx mailorder is analyzed in this study – not OTC mail-order. Further, external delivery services are not included.32 As mentioned above, this paper does not measure the quality of pharmacies or the services they provide. Due to the uniform mandate of all pharmacies to supply the population with medication throughout the country and the fact that there is no competition due to fixed prices, a study of the pharmacies’ health-care quality cannot be carried out within this analysis and should be considered for further research. The range of services offered cannot measure the quality of a pharmacy, as this is determined by various economic factors (location, specialist pharmacy, staff, size, family business, etc.), which are not quantified. This study is limited to the service of community pharmacies to deliver Rx. This study does not consider changes in regulations within the drug market. Likewise, it does not investigate the possible effects of the COVID-19 pandemic (for example an extended online market, influence of vaccination at the pharmacy, distribution of masks and gloves, etc.). 31 After contacting several ministries of health and different lobby groups of community pharmacies in every single EU country, this dataset includes all available data on pharmacy density per 100,000 inhabitants. 32 Rules regarding the delivery service of (OTC/Rx) drugs differ significantly throughout the EU. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 26 10 Conclusion In sum, market regulations like ownership and a ban on Rx mail-order do not significantly support the increase in pharmacy density in this specific study. Policymakers and health-care providers should consider implementing strategies to enhance the availability of pharmacists to meet the growing demand for pharmacy services. This would help to better manage the allocation of pharmacists across pharmacies, thereby enhancing pharmacy density and improving healthcare accessibility. ifgs Schriftenreihe, Vol. 32, Schwaabe: The EU Community Pharmacy Market 27 References ABDA (2020a). Die Apotheke – Zahlen, Daten, Fakten 2020. Retrieved 03.09.2024 from https://www.abda.de/fileadmin/user_ upload/assets/Pressetermine/2020/TdA_2020/Praesentation_TdA_04.06.2 020.pdf. ABDA (2020b). Faktenblatt. Versandhandel mit Arzneimitteln. Retrieved 03.09.2024 from https://www.abda.de/fileadmin/user_ upload/assets/Faktenblaetter/Faktenblatt_Versandhandel.pdf. ABDA (2021a). Die Apotheke – Zahlen, Daten, Fakten 2021. Retrieved 03.09.2024 from https://www.pharma4u.de/fileadmin/ user_upload/pdf/ABDA-Leitlinien/ABDA_ZDF_2021_Broschuere.pdf. ABDA (2021b). Personal communication. ABDA (2022). COVID-19-Impfungen in Apotheken starten am 8. Februar. ABDA. 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Retrieved 15.01.2025 from https://www.pharmacie.lu/pharmacies. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 39 Table 4: General overview of regulations within the EU pharmacy market, including all 27 EU countries33 Country Pharmacy System Digitalization: eprescript ion Vaccination against influenza Rx-MailOrder Prohibition of thirdparty ownership OTC Sale outside Pharmacy Geographic and demographic rules Austria liberal yes no no no yes yes Belgium liberal yes no no no no yes Bulgaria liberal yes no no no yes no Croatia liberal yes yes no no no yes Cyprus regulated yes yes no yes no no Czech Republic liberal yes no no no yes no Denmark regulated yes yes yes yes yes no, only for branches Estonia regulated yes no yes yes yes yes Finland regulated yes no yes yes yes no France regulated no yes no yes yes yes Germany regulated yes Pilot Project yes yes yes no Greece regulated yes yes no yes yes yes Hungary regulated yes no no yes yes yes Ireland liberal yes yes no no yes no Italy liberal yes no no no yes yes Latvia regulated yes no no yes yes yes Lithuania regulated yes no no yes yes yes 33 No data = research gaps because of missing data. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 40 Luxembourg regulated yes no no yes no yes Malta regulated yes no yes yes yes yes Netherlands liberal yes no yes no yes no Poland regulated yes no no yes yes yes Portugal liberal yes yes no no yes yes Romania regulated yes no no yes yes yes Slovakia liberal yes no data no no no yes Slovenia liberal yes no no no yes yes Spain regulated yes no no yes yes yes Sweden liberal yes no yes no yes yes Source: based on ABDA, 2020a, 2020b, 2021; PGEU, 2020; World Health Organization, 2019. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 41 Table 5: Overview of regulations and their changes in seven selected countries Source: data based on ABDA, 2020a, 2021; Balgård, 2012; BWB, 2018; Karttunen, 2020; Mossialos & Srivastava, 2008; Ribeiro et al., 2020; Vogler, 2014; Vogler et al., 2006; Vogler et al., 2012; Wiśniewski et al., 2020; World Health Organization, 2019. EU Country (Case Study) Pharmacy System Regulation change Rx mail-order Regulation change 3rd party ownership Regulation change Regulation on distance Reason why country selected Aus tria liberal yes, 2004 no no yes in 2008 (so-called Personengesellschaften can invest) yes, so-called Gebietsschutz, minimum distance of 500m Regulated pharmacy system including regulation on distance and no RX mailorder. The density is consistanty rising Denmark regulated no yes no data no no yes, for branches Regulated pharmacy system including new rule on expanding branches Finland regulated no yes no data no no no, without minimum distance Regulated pharmacy system but without regulation on distance: Country with highest e-prescription usage in EU Germany regulated no yes in 2004 no no no, so-called Niederlassungsfreiheit Regulated pharmacy system including freedom of establishment and RX mailorder Poland regulated yes, in 2002 and 2017 no no data yes, from 20022017 yes, in 2002 and in 2017 yes, 3,000 inhabitaints to serve and 500m or 1km distance Regulated pharmacy system with two changes in the system since 2002 Portugal liberal yes, in 2007 no no yes in 2007 (no wholesalers are allowed to run and own a pharmacy) yes, 3,500 inhabitaints to serve, minimum distance of 250m Liberal pharmacy system with change in the system since 2007 but without RX mail-order Sweden liberal yes, in 2009 yes in 2001 yes in 2009 (including wholesalers) no Liberal pharmacy system with absolutely no regulations on RX mailorder, 3rd party ownership and distance ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 42 Table 6: Total number of community pharmacies in the EU from 2000-202134 34 Including research gaps due to missing data. Illustration based on my research results; numbers are rounded up. Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Austria 14 14 14 14 14 14 15 15 15 15 15 Belgium 49 48 47 Bulgaria 57 Croatia 25 Cyprus 42 40 40 40 40 40 Czech Republic 19 20 21 21 22 23 23 23 22 23 23 Denmark 6 6666 Estonia 30 30 32 35 35 35 40 39 38 37 36 Finland 15 15 15 15 15 15 15 15 15 15 15 France 38 37 37 36 36 36 35 Germany 26 26 26 26 26 26 26 26 26 26 26 Greece 99 Hungary 24 25 Ireland 31 31 31 31 32 32 37 38 Italy 29 30 30 Latvia 42 Lithuania 48 Luxembourg 18 18 Malta 51 Netherlands 10 10 10 10 11 11 11 12 12 12 12 Poland 25 26 26 27 28 28 28 30 Portugal 24 26 26 26 27 Romania 34 Slovakia 19 25 29 36 36 Slovenia 12 12 13 13 13 14 14 14 14 15 15 Spain 48 48 48 48 47 47 46 46 46 46 Sweden 99999910 910 10 12 Country 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Austria 15 15 15 15 16 16 16 16 16 16 16 Belgium 45 45 44 45 44 44 44 43 42 42 Bulgaria 56 51 50 51 51 51 46 46 46 Croatia 24 26 26 26 26 26 28 28 28 Cyprus 55 55 54 57 60 60 62 62 61 61 63 Czech Republic 23 24 25 25 25 24 24 24 24 24 24 Denmark 6666678889 Estonia 36 35 36 36 35 38 38 37 38 37 38 Finland 15 15 15 15 15 15 15 15 15 15 15 France 35 35 35 34 35 33 33 32 32 31 32 Germany 26 26 26 25 25 25 24 24 23 23 23 Greece 99 99 87 99 87 87 87 88 88 88 Hungary 25 24 24 24 23 23 23 23 23 Ireland 38 40 40 39 39 39 39 38 38 Italy 30 30 30 30 31 31 32 32 Latvia 42 43 37 43 37 37 44 44 44 43 43 Lithuania 47 47 45 47 45 45 47 47 47 47 47 Luxembourg 15 18 17 16 16 16 15 15 Malta 51 51 51 51 51 49 49 49 Netherlands 12 12 12 12 12 12 12 12 12 12 12 Poland 31 32 30 33 30 30 38 38 36 36 36 Portugal 28 28 28 28 28 28 28 28 28 28 Romania 32 43 40 40 43 43 44 44 44 Slovakia 36 28 36 36 28 28 37 37 37 Slovenia 15 15 15 16 16 16 16 16 16 16 16 Spain 46 46 46 47 46 47 47 47 47 47 47 Sweden 13 13 13 14 14 14 14 14 14 14 14 ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 43 Country Source of the numbers Austria Vogler et al. (2012); ABDA (2021b); Österreichische Apothekenkammer (2021) Belgium Belgian Pharmaceutical Association (2021); ABDA (2021b) Bulgaria ABDA (2021b); Ministry of Health Republic of Bulgaria (2021) Croatia ABDA (2021b); Ministry of Health of the Republic of Croatia (2021) Cyprus ABDA (2021b); Ministry of Health of Cyprus (2021) Czech Republic ABDA (2021b) Denmark ABDA (2021b); Vogler et al. (2012); Denmark Chamber of Commerce (2021) Estonia ABDA (2021b) Finland ABDA (2021b); Vogler et al. (2012) France ABDA (2021b); Ordre National de Pharmaciens (2021) Germany ABDA (2021b) Greece ABDA (2021b); Ministry of Health Greece (2021) Hungary ABDA (2021b); Ministry of National Resources of Hungary (2021) Ireland ABDA (2021b), Vogler et al. (2012); Pharmaceutical Society of Ireland (2021) Italy ABDA (2021b); Federfarma.it (2023); Federfarma.it (2025) Latvia ABDA (2021b); State Agency of Medicines Republic of Latvia (2025) Lithuania ABDA (2021b), State Agency of Medicines Republic of Latvia (2025) Luxembourg ABDA (2021b); pharmacie.lu (2025) Malta ABDA (2021b); The Ministry for Health and Active Ageing in Malta (2021) Netherlands ABDA (2021b); Statista (2025); Stichting Farmaceutische Kengetallen (2021) Poland ABDA (2021b); Statistics Poland (2023) Portugal ABDA (2021b); Infarmed (2021) Romania ABDA (2021b); Press centre of the Ministry of Health in Romania (2021) Slovakia ABDA (2021b); Public Health Authority of the Slovak Republic (2021) Slovenia ABDA (2021b); Ministry of Health of Slovenia (2021) Spain ABDA (2021b); Spanish Ministry of Health (2021) Sweden Apoteksföreningen (2021); Apoteksföreningen (2025); Pharmaceutical Pricing and Reimbursement Information (2007); Apoteket (2025); Vogler et al. (2012) ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 44 Appendix 2: Sources of Data Table 7: Sources of Data collection Data on Observation period Source Pharmacy density per 100,000 inhabitants 2000-2021 ABDA (2020); ABDA (2021); Vogler et al. (2006); Vogler et al. (2012); Vogler et al. (2014); PGEU (2020); Apotheket AB (2023) System (regulated/liberal) 2000-2021 ABDA (2020); ABDA (2021); Vogler et al. (2006); Vogler et al. (2012); Vogler et al. (2014); World Health Organization (2019); International Pharmaceutical Federation - FIP (2019) RX mail-order regulation 2000-2021 ABDA (2020), ABDA (2021); World Health Organization (2019); International Pharmaceutical Federation - FIP (2019) Ownership structure 2000-2021 ABDA (2020); ABDA (2021); Vogler et al. (2006); Vogler et al. (2012), Vogler et al. (2014); World Health Organization (2019); International Pharmaceutical Federation - FIP (2019) Number of pharmacies in total 2000-2021 ABDA (2020); ABDA (2021); Apotheket AB (2023); Statistics Poland (2023); World Health Organization (2019); International Pharmaceutical Federation - FIP (2019) GDP per capita in PPP (constant 2017 international $) 2000-2021 World Development Indicators (2022) Number of pharmacists per 100,000 inhabitants 2000-2021 WHO European Data Warehouse (2022) Proportion of population aged 65 and over 2000-2021 Eurostat (2022); WHO European Data Warehouse (2022); International Pharmaceutical Federation - FIP (2019) Geographic and demographic rules 2000-2021 Vogler et al. (2006); Vogler et al. (2012); Vogler et al. (2014); WHO (2019); World Health Organization (2019); International Pharmaceutical Federation - FIP (2019) Number of medical doctors per 100,000 inhabitants 2000-2021 Eurostat (2022) ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 45 Appendix 3: Contributory facts and detailed description of the pharmacy market of case study countries The seven EU countries below have been chosen in order to understand the differences in pharmacy markets and their regulations depending on their density. This part aims to demonstrate the idea behind the hypotheses developed above. As already discussed, the density of the chosen countries increased over time; some even stagnated or did not consistently increase (see Figure 1). Is this due to a market change regarding the ownership structure or Rx mail-order? The case study below clarifies possible differences in density behavior concerning different market regulations. Figure 1: Evolution of pharmacy density35 Sweden From 1971 on, Swedish pharmacies “were expropriated by law and amalgamated into one national pharmacy corporation owned by the state” (Balgård, 2012, p. 23). “Apoteket AB” had a monopoly on drugs until 2009. The market opened for more competition, and the state monopoly was ended (Westerlund & Marklund, 2020). The intention was to get better availability of the pharmacies and lower prices for OTC products (Balgård, 2012). The idea was driven by the right-wing 35 This figure only illustrates the seven selected case countries. Due to missing data, the observation period for Poland starts in 2003. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 46 party, which replaced the social democratic party after the election in 2006. The liberalization of the pharmacy market included three main changes: recreating hospital pharmacies, open market structures, and the sale of OTC outside the pharmacy. The idea behind the liberalization policy was to get better accessibility, better use of drugs, more diversity, and better prices and efficiency (Vogler et al., 2014; Wisell, 2019). No rules were set on ownership. Instead, one pharmacist must be present at all times during office hours. This person has to own a Bachelor’s degree (three years, prescriptionist) or a Master’s degree (five years) in Pharmacy (Westerlund & Marklund, 2020). Before the liberalization, “Apoteket AB” owned over 880 community pharmacies. After the deregulation, almost all existing pharmacies were sold to new chains, and over 200 new pharmacies opened (Balgård, 2012). In 2020, Sweden had around 1,433 community pharmacies, with 14 pharmacies per 100,000 inhabitants (Westerlund & Marklund, 2020). As already discussed, the liberalization of the pharmacy market involved many expectations of improvements such as better accessibility, lower prices, and better service (Vogler et al., 2012). Indeed, better prices of OTC were available, but not at the pharmacy. The pharmacies could not keep up with the prices at gas stations or drugstores because of higher purchase costs from the wholesaler. Furthermore, pharmacies could request the stock in other branches through a networked storage system. Now that each chain has its own system, this access is no longer possible (Balgård, 2012). The liberalization also removed the dependency on “Apoteket AB’s” regulations. Pharmacies became freer to operate without the restriction of the large state-owned group. Now, 97 percent of the community pharmacies belong to chains, 45 independent pharmacies, and “three unmitigated e-commerce pharmacy companies, that are taking medicine orders online only” (Westerlund & Marklund, 2020, p. 3). Further, OTC sale is possible outside the pharmacy. The pick-up of dispensed prescriptions at pharmacy representatives, so-called “Apoteksombuds”, are further opportunities to get medicine, especially in rural areas (Vogler et al., 2012; Westerlund & Marklund, 2020). The medical services provided in Swedish community pharmacies are extensive: medication reviews, blood measure treatments, skincare analysis, allergy tests, smoking cessation programs, vaccination services with the help of nurses, and much more. Westerlund and Marklund (2020) explain that chains focus more on selling medicines, whereas private pharmacies concentrate more on extended services like medication plans. In their view, the reason is that chains have to compete more in the sale of medicines than private pharmacies. Thus private ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 47 pharmacies can better maintain their position in the market by offering more services (Westerlund & Marklund, 2020). Sweden was one of the first EU countries that implemented digital prescribing. Almost all prescriptions are digital, and patients can access their data with their personal identification (ID) card (Kierkegaard, 2013; Vogler et al., 2012). Online sales of OTC started in 2002, and Rx mail-order in 2006.36 Since 2009, the online sale of medicines by internet pharmacies other than “Apoteket AB” has been allowed as well (Vogler et al., 2012). OTC prices, compared to prescription only medicines (POM), are not regulated; therefore, pharmacies sell more OTC products. Further, community pharmacies cannot produce medicine, for example, in Germany or Austria. They do not have a laboratory37 to do so (Vogler et al., 2012). Following Westerlund and Marklund (2020), the reimbursement38 system is mixed. It “is based on a Pharmacy Margin, with a combination of fixed fee and percentage” (Westerlund & Marklund, 2020, p. 4). Discounts on generic drugs are allowed but not on “primary care services” (Westerlund & Marklund, 2020, p. 4). However, generic substitutions are reimbursed “with an increased margin added to all generic drugs” (Westerlund & Marklund, 2020, p. 4). The liberalization process increased the number of community pharmacies across Sweden. Of course, the density is much higher in urban areas. Therefore so-called “Apoteksombuds” exist to cover rural areas. Further, with a high digitalization standard and extended services within the pharmacy, the density remains stable – even with Rx mail-order. However, the main goal of better accessibility throughout the country could not be achieved (Garattini et al., 2012; Vogler et al., 2014; Wisell, 2019). 36 Only within the country, not from abroad. 37 A laboratory at the pharmacy is used by pharmaceutical staff, for example, to test existing anesthetics for any impurities and to prepare ointments or capsules specially prescribed by a doctor. Furthermore, pharmaceutical staff can mix unique prescribed tea flavors and produce disinfectants. 38 By definition: “Pharmacy reimbursement means the amount paid to a pharmacy by a pharmacy benefit manager for a dispensed prescription drug or prescription device” (Law Insider Inc., 2022). ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 48 Denmark The Danish pharmacy market is a regulated one. Only licensed pharmacists, accepted by the Danish Medicines Agency (DKMA), can run and own a pharmacy. The DKMA further limits the number of pharmacies and gives an evaluation of applicants to the Ministry of Health. They then decide who will get the license for a pharmacy (Vogler et al., 2012). Pharmacies, branch pharmacies, and supplementary units are the institutions with the right to sell Rx and some specific OTC products (Vogler et al., 2012). In addition to the 227 pharmacies (1 January 2021), “80 branch pharmacies, 209 voluntarily established branches, 24 pharmacy outlets, about 350 OTC outlets and about 400 medicine delivery facilities – all of which are connected to one of the pharmacies” (Danish Medicines Agency, 2021) exists. OTC outlets are stores approved to sell OTC products outside the pharmacy, for example, supermarkets. They are further allowed to “deliver prescription-only medicinal products that have been dispatched by a pharmacy to the outlet” (Danish Medicines Agency, 2021). In addition, buying POM online is partly prohibited. The only exception is the platform called “Apoteket.dk”. Since 2004, it has been the only online pharmacy with the right to sell POM online. It is an online platform for all pharmacies in Denmark initiated by the Danish pharmacy representative (Kierkegaard, 2013). The density of Danish pharmacies varies over time. Noteworthy is that in 2015, the density increased because Denmark allowed every owner of community pharmacies to open up to seven branches within a radius of 75 kilometers (Danish Medicines Agency, 2021). The change in the Danish Pharmacy Act should increase the accessibility of community pharmacies for the patient – with success. To make the ownership of pharmacies in rural areas more attractive, there are so-called equalization schemes: “Pharmacies with large turnover are obliged to pay a sales tax, which is used to subsidise small scale pharmacies in rural areas” (Vogler et al., 2012, p. 101).39 The Danish pharmacies have to pay special fees to the DKMA (Danish Medicines Agency, 2021). There is no obligation for a 24-hour service – but there is a system specially organized by authorities. Some pharmacies must stay open throughout the night; others have on-call duty services. There are three different categories: 39 Likewise in Germany with the “Nacht-und Notdienstfond” (NNF). ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 55 Pharmacies in Austria have to adapt their opening hours to the local shops. The pharmacies provide emergency and night services, not financed by a special fund as in Germany (NNF), but by the pharmacies themselves. The wholesalers set prices for drugs. Following BWB (2018), reimbursable medicines43 cannot be discounted, whereas a discount can be guaranteed on non-reimbursable medications. Further, pharmacies can set their price on non-refundable drugs, so the competition starts. Pharmacies in Austria deliver medicines, give health advice, and check on notable side effects. The staff can vaccinate against several pathogens and provide health-care support about smoking, blood sugar, cholesterol, and many more (Langer et al., 2018). Despite the regulated market, the density of Austria’s community pharmacies has risen. Due to the so-called “Gebietsschutz”, there is no direct local competition. Without Rx mail-order within the country but dispensing doctors having the right to sell medicine in rural areas, the accessibility to POM and OTC is ensured (Österreichische Apothekerkammer, 2022). Germany After many years of growth, the density of community pharmacies in Germany has declined since 2008. The German case might be challenging because of the hybrid pharmacy market, foreign mail-order disadvantages for community pharmacies, and many bureaucratic hurdles within the business (Schwaabe, 2020). In recent years, the effects or regulatory implementations for the German community pharmacies have led to the so-called “Apothekensterben” – a decline in the number or density of community pharmacies. Due to the German reunification, the number of pharmacies increased significantly. Positive effects were also recorded after the ban on multiple and third-party ownership. However, these were deceptive, as pharmacies were bought up. Since 2008, the total number of pharmacies in Germany has decreased continuously from 21,602 pharmacies to 18,461 pharmacies in 2021 and 18,256 in mid-2022 (Tagesschau, 2022). Some articles repeatedly refer to the competitive advantages of foreign mail-order pharmacies (“ausländische Versandhandelsapotheken”) (Coenen et al., 2011; May et al., 2017; Meyer, 2020). The granting of discounts on prescription drugs 43 Reimbursable medicines are covered by health insurance. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 56 by foreign mail-order pharmacies, the resulting competitive advantage over German pharmacies, the “Mehrund Fremdbesitzverbot” and the e-prescription could be possible causes of a decline in pharmacy density. Nevertheless, the German pharmacies are at a disadvantage due to the German price regulation for prescription drugs (“AMPreisV”), which binds pharmacies to fixed prices when selling Rx. Thus, no discounts will be applicable. This means that the pharmaceutical industry sets a price with the insurance on one active substance. Publicly insured people have to pay a so-called “Eigenanteil”. This is obligated. Online pharmacies from abroad can give a discount on this “Eigenanteil”. The fixed drug prices in Germany are intended to ensure that local German pharmacies can provide comprehensive medical care for the same price. In 2016, this approach was criticized by the European Court of Justice (ECJ) as it could not be adequately justified. The ECJ noted that binding consignors from abroad to the German “AMPreisV” violates European law. Price-fixing constitutes an unjustified restriction on the free movement of goods in the sense of a quantitative import restriction. Therefore, the fixed prices in Germany are for German pharmacies but not foreign (mail-order) pharmacies. The “DocMorris”44 decision in 2003 opened the mail-order market for non-POM and OTC products (Jorge, 2016). Germany went one way further and opened the mail-order market for POM with their “Modernisierungsgesetz” in 2004. In 2021, the pharmacists’ lobby abolished discounts for Rx abroad after lengthy legal battles between several German community pharmacies and “DocMorris”. However, this applies to patients with statutory insurance only. Privately insured patients continue to receive a discount (Rohrer, 2021). In addition, OTC sale is permitted outside the pharmacy within drugstores or supermarkets. Only licensed pharmacists with a so-called “Approbation” can run and own a pharmacy in Germany. No chains are allowed, only so-called “Einkaufsgenossenschafften”45 (“Guten Tag Apotheken”, “mea Apotheken”, and many more). Another remark is that German pharmacists are registered traders. This means that the pharmacy owner is liable for their assets. The average net turnover of a pharmacy in Germany is about 2.78 million euros per year. However, there is a 44 “DocMorris”, an online pharmacy located in the Netherlands, is a Swiss “ZurRoseAG” subsidiary. It is the most prominent online pharmacy provider in Europe. 45 Smaller pharmacies unite to form a cooperative to buy as a more significant customer from the wholesalers or the companies themselves and thus get better discounts on the purchase price. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 57 vast spread. Around 60 percent of pharmacies do not achieve the average turnover, while individual large pharmacies are far above the average. In the end, pharmacies need traffic. They should be located next to a prescribing doctor, within shopping centers, or on shopping streets (Elabed et al., 2016; Österreichische Apothekerkammer, 2022). In other EU countries, it is mandatory to have a dispending doctor close to the pharmacy (Österreichische Apothekerkammer, 2022). Although the German pharmacy market is regulated, freedom of establishment prevails. Therefore, the competition is increasing, having pharmacies close to each other. The pharmacy with the best offers and further services survives. Pharmacies in Germany offer the same services as in Austria except for the vaccination service. Since 2022, German pharmacists have been allowed to vaccinate against Covid-19 but not against influenza (ABDA, 2022). In sum, the density of pharmacies in Germany decreased because of the freedom of establishment, the Rx mail-order, its discounts, and the missing digitalization. Due to new laws that allow pharmacies to vaccinate (only) against COVID-19 since February 2022 and the ban on discounts on Rx abroad, stability of the density could be expected. Nevertheless, the digitalization process, which is much more developed in other EU countries and has become an essential part of everyday pharmacy life, lacks behind. ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 58 Appendix 4: Outlook on pharmacy density in Germany Germany has seen a decline in its pharmacy density, decreasing from 21,592 community pharmacies to 17,571 within the last 23 years. In 2023, there were 599 closures compared to 62 new openings, leading to approximately 21 pharmacies per 100,000 inhabitants – a figure that has been gradually declining (ABDA, 2024). According to the ABDA (2024) “Zahlen, Daten, Fakten” report, this trend is influenced by various factors, including economic pressures, demographic shifts, and regulatory challenges. The report notes the financial strain on pharmacies, particularly independent ones, due to rising operational costs and lower reimbursement rates for medications. Additionally, the growing presence of mailorder pharmacies is changing consumer behavior, with more patients opting for online services, which has impacted the foot traffic in traditional pharmacies. This trend is consistent with broader developments observed in other European countries. For instance, from 2004 to 2023, Belgium’s pharmacy density decreased from 50 to 40 pharmacies per 100,000 inhabitants, while Austria experienced a slight increase from 14 to 16 per 100,000 inhabitants. These changes reflect ongoing shifts within the European pharmacy sector (ABDA, 2024). The findings of this study suggest that market regulations, such as ownership restrictions and bans on Rx mail-order services, do not significantly contribute to an increase in pharmacy density in Germany. Instead, the focus may need to shift towards improving the availability and effective placement of pharmacists. The ABDA (2024) report emphasizes the importance of retaining and recruiting pharmacists, particularly in rural areas, where pharmacy closures can have a more pronounced impact on healthcare accessibility, too. Policymakers may consider interventions such as financial incentives for pharmacists in underserved areas, support for small and independent pharmacies, and potential adjustments to the regulatory framework to better support pharmacy operations. These measures could help stabilize pharmacy density in Germany and ensure continued access to professional healthcare services for all citizens. In the coming years, both policymakers and pharmacies in Germany will need to consider how many pharmacies per 100,000 inhabitants are necessary for the country. It will be important to evaluate whether approximately 22 pharmacies per 100,000 inhabitants were excessive and if this level of competition was ifgs Schriftenreihe, Vol. 32, Schwaabe.: The EU Community Pharmacy Market 59 sustainable. Additionally, there may be a need to assess whether Germany requires demographic or geographic regulations for pharmacies, potentially moving away from the current system of free establishment. Furthermore, the issue of recruiting new licensed pharmacists should be addressed in political discussions. Financial incentives could be considered to encourage more individuals to pursue careers in pharmacies. However, this study highlights that changes in the pharmacy market should not be automatically adopted from other countries. Policies that have been effective in other EU nations may not necessarily produce the same outcomes in the German pharmacy market. Folgende Bände sind bisher in dieser Reihe erschienen: Band 1 (2016) Bihlmayer, Christian / Peric, Christina Maria Beiträge zu Gesundheitswissenschaften und -management ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 2 (2016) Hoppenstedt, Inga Der Nutzen eines betrieblichen Gesundheitsmanagements am Beispiel von Suchtprävention am Arbeitsplatz ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 3 (2016) Schaff, Arnd Betriebliches Gesundheitsmanagement als Investition – Projektmanagement und Wirtschaftlichkeit ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 4 (2016) Hildebrandt, Stephanie Chancen und Risiken einer qualitätsorientierten Finanzierung für die Krankenhäuser in Deutschland ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 5 (2016) Lapczyna, Carmen / Siodlaczek, Claudia Nosokomiale Infektionen und multiresistente Erreger – Hygienische versus wirtschaftliche Faktoren ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 6 (2017) Huppertz, Holger Qualitätsmanagement in Krankenhäusern –eine Betrachtung am Beispiel eines Universitätsklinikums nach Kriterien des Gemeinsamen Bundesausschusses ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 7 (2017) Matusiewicz, David Verbesserung der Therapietreue in Apotheken – eine verhaltensökonomische Studie ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 8 (2017) Kusch, Christina Corporate Governance in Universitätsund Privatkliniken ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 9 (2017) Geißler, Jens Die Digitalisierung von Geschäftsprozessen in der gesetzlichen Krankenund Unfallversicherung als Herausforderung für das Management ISSN 2367-3176) – ISSN 2569-5274 (eBook) Band 10 (2018) Mehmet Ali, Takis Demokratische Planwirtschaft im Gesundheitswesen. Eine verfassungsrechtliche, ordnungsund gesellschaftspolitische Analyse ISSN 2367-3176 (Print) – ISSN 2569-5274 (eBook) Band 11 (2018) Boroch, Wilfried Dimensionen allgemeiner Gesundheitspolitik. Eine modifizierte Anordnung nach Kriterien der engen, weiten und praxisbezogenen Anwendung ISSN 2367-3176 (Print) – ISSN 2569-5274 (eBook) Band 12 (2018) Furtmayr, Angelika Die Entwicklung in Gesundheitsförderung und Prävention im Setting Schule seit Einführung des Präventionsgesetzes ISSN 2367-3176 (Print) – ISSN 2569-5274 (eBook) Band 13 (2018) Dännhardt, Andy Kohärenzgefühl berufsbegleitend Studierender am Einzelfallbeispiel des FOM Hochschulzentrums München ISSN 2367-3176 (Print) – ISSN 2569-5274 (eBook) Band 14 (2019) Kösters, Ines Arteria Danubia – Gesundheitsregionen im Donauraum ISSN 2367-3176 (Print) – ISSN 2569-5274 (eBook) Band 15 (2019) Lakasz, Andrea Führungsaspekte in Universitätskliniken mit besonderem Fokus auf ärztliche Mitarbeiter unterschiedlicher Generationen ISSN (Print) 2367-3176– ISSN (eBook) 2569-5274 Band 16 (2019) Wangler, Julian / Jansky, Michael / Heidl, Christian / Müller, Sebastian / Heckel, Natalie / Zerth, Jürgen Beiträge zu Gesundheitswissenschaften und -management II ISSN (Print) 2367-3176– ISSN (eBook) 2569-5274 Band 17 (2019) Fischer, Philipp Digital Health – Untersuchung zur Akzeptanz der elektronischen Gesundheitsdatenspeicherung in Form der elektronischen Patientenakte (ePA) in Deutschland ISSN (Print) 2367-3176– ISSN (eBook) 2569-5274 ISBN (Print) 978-3-89275-115-1– ISBN (eBook) 978-3-89275-116-8 Band 18 (2020) Brauer, Yvonne Retrospektive Studie zur Ermittlung der Risikofaktoren für eine stationäre Wiederaufnahme nach allogener Stammzelltransplantation ISBN (Print) 978-3-89275-135-9 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-136-6 – ISSN (eBook) 2569-5274 Band 19 (2020) Schädrich, Katrin Mindful Leadership: Wirksamkeit appbasierter Kurzmeditationen auf die Achtsamkeit bei Führungskräften ISBN (Print) 978-3-89275-123-6 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-124-3 – ISSN (eBook) 2569-5274 Band 20 (2020) Behrens, Yvonne / Geremek, Mariusz / Scharfenorth, Karin Europe’s Health System – Presentation of the health systems of Bulgaria, Poland and Germany ISBN (Print) 978-3-89275-137-3 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-138-0 – ISSN (eBook) 2569-5274 Band 21 (2020) Krause, Rabea Bedarfsgerechte Versorgung von neuromuskulär erkrankten Menschen nach dem neuen Pflegebedürftigkeitsbegriff: Eine explorative Untersuchung der Anforderungen ISBN (Print) 978-3-89275-152-6 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-153-3 – ISSN (eBook) 2569-5274 Band 22 (2021) Kokotz, Carolin / Tewes, Stefan Personatypologien im Gesundheitswesen: Lösungsansatz für optimierte Kundenzufriedenheit ISBN (Print) 978-3-89275-170-0 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-171-7 – ISSN (eBook) 2569-5274 Band 23 (2021) Geiger, Inke / Geißler, Jens Digitale Transformation der gesetzlichen Krankenversicherung. IT-Strategie, Steuerung und Sourcing als strategische und operative Herausforderungen ISBN (Print) 978-3-89275-182-3 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-183-0 – ISSN (eBook) 2569-527 Band 24 (2021) Elsenheimer, Laura / Behrens, Yvonne / Wiesener, Marc / Kantermann, Thomas Research Network International: Von Wissenschaft, Vernetzung und Emotionen ISBN (Print) 978-3-89275-230-1 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-231-8 – ISSN (eBook) 2569-5274 Band 25 (2022) Schäfer, Stefanie / Schaff, Arnd Nachhaltiges betriebliches Gesundheitsmanagement im Handwerk ISBN (Print) 978-3-89275-246-2 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-247-9 – ISSN (eBook) 2569-5274 Band 26 (2022) Hein, Katharina Anna-Christina Selbstbestimmtes Sterben – Autonomie und Menschenwürde am Lebensende ISBN (Print) 978-3-89275-258-5 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-259-2 – ISSN (eBook) 2569-5274 Band 27 (2022) Behrens, Yvonne / Macher, Sandra / Kollányi, Zsófia / Morales Moreno, Isabel / Iltchev, Velko / Romaniuk, Piotr / Alcer, Klaudia / Kaczmarek, Krzystof / Brukało, Katarzyna / Morales Hernández, Catalina / Palacios Ramírez, José / Ferrándiz Gomis, Roberto / López Arroyo, María José / Ranchev, Nikola / Amort, Frank M. / Kösters, Ines Competences in Health Network Management – A Textbook for Training Regional Health Network Managers ISBN (Print) 978-3-89275-280-6 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-281-3 – ISSN (eBook) 2569-5274 Band 28 (2023) Schaff, Arnd / Olbrecht, Thomas / Magerl, Niklas / Conrads, Tom / Loch, Fabian / Wolff, Anna / Storch, Fabian / Schultz, Stefan / Paust, Robert / Weiß, Susanne Betriebliches Gesundheitsmanagement – Key Learnings aus herausfordernden BGM-Projekten ISBN (Print) 978-3-89275-314-8 – ISSN (Print) 2367-3176 ISBN (eBook) 978-3-89275-315-5 – ISSN (eBook) 2569-5274 Band 29 (2024) Behrens, Yvonne / Movia, Madlene / Macher, Sandra / Amort, Frank Successful Management of Health Regions – Circumstances, Challenges and Competences in German Health Regions ISSN (Print) 2367-3176 – ISSN (eBook) 2569-5274 ISBN (Print) 978-3-89275-368-1 – ISBN (eBook) 978-3-89275-369-8 Band 30 (2024) Holzkämper, Hilko Auswirkungen der Corona-Pandemie auf die wirtschaftliche Situation von Pflegeheimen ISSN (Print) 2367-3176 – ISSN (eBook) 2569-5274 ISBN (Print) 978-3-89275-366-7 – ISBN (eBook)978-3-89275-367-4 Band 31 (2024) Behrens, Yvonne / Bieler, Kathrin / Keller, Katrin / Busskamp, Mareen / Eilers, Leonie / Shkura, Oleksandr / Kron, Florian / Hennrich, Inga / Friebe, Michael / Hohoff, Christoph Bildung und Qualifizierung im Gesundheitswesen: Ein Einblick in die Projekte der FOM Hochschule ISSN (Print) 2367-3176 – ISSN (eBook) 2569-5274 ISBN (Print) 978-3-89275-358-2 – ISBN (eBook) 978-3-89275-359-9