Community Pharmacists ’ Strategies in Greece : An Assessment of the Policy Environment and the Mapping of Key Players

The aim of the study was to form and assess the pharmacists’ strategies in Greece, by analyzing the policy environment and identifying the role of the key players-stakeholders. For collecting and organizing important information about the pharmacists’ policy, the PolicyMaker’s computerized version of political mapping was used, serving as a database for assessments of the policy’s content, the major players, the power and policy positions of key players, the interests of different players, and the networks and coalitions that connect the players. As the research findings show, the initially expected impact of the pharmacists’ policy proved to be very optimistic in most of the implemented strategies, as the majority of the strategies have worsened or minimized their success ratio throughout the time in study. Concluding, either the initially set strategies were at the wrong direction or the actions taken to implement them were inappropriate. Moreover, one can suggest that the shifting ability in both the position and the power of the most key players were over-estimated, while they under-estimated the impact of troika-constitutions meddling in the pharmaceutical policymaking and in the health sector cost-containment measures imposing.

aggregate, GDP contracted by 20%.At the same time, government consumption continued to fall and investment shrank for the fourth consecutive year.The unemployment rate increased by 15 percentage points to almost 24% [1] [2].The economic crisis had a dramatic impact in social life, since the reduction and/or lack of income causes losses in welfare and sets large sections of the population in poverty [3].
As the Greek healthcare system is characterized by a large number of regulatory bodies, several ministries shared responsibilities concerning the pharmaceutical policy (the Ministry of Health, the Ministry of Development, the Ministry of Labour and Social Security, the Ministry of Finance, etc.).The above system apart from being very difficult to monitor it was not efficient.Hence, since May 2010 under the MoU all health-related activities were brought under one ministry; the Ministry of Health in order to rationalise licensing, pricing and reimbursement systems for medicines.In this way, the supply side cost containment measures is expected to be reinforced [4].
Public pharmaceutical expenditure followed an upward trend until 2009 reaching the €5 billion or 2% of GDP, in line with developments in overall health expenditure and GDP.However, in 2010-2011 it fell sharply by 22% to reach €3.98 billion in 2011, €2.88 billion or 1.4% of GDP in 2012, €2.44 billion in 2013 and €2 billion or 1% of GDP in 2014 [2] [5]- [7].
The cumulative decrease of €3 billion in (net) public pharmaceutical expenditure in the period 2009/2014 resulted from reforms in the pharmaceutical market (changes in the pricing system, increases in rebates to social security funds, reduction in regulated wholesale and retail margins, reduction in the VAT rates, etc.) [6]- [8].

The Pharmacy Landscape in Greece
The supply of pharmaceutical products in Greece is defined by the pharmaceutical companies that are active in the sector (engaging in the manufacturing or marketing areas) and the distribution chain.More analytically, medicinal products with the exception of those distributed through hospitals, for which no wholesaler intervenes, follow this course: pharmaceutical company-wholesaler-pharmacy.The population density of pharmacies in Greece is the highest among EU Member States, with a ratio of one (1) pharmacy per 1028 inhabitants, compared with the EU-27 average of one (1) pharmacy per 3300 inhabitants (the total number of pharmacies in Greece is over 11.000) [9].
Today in Greece more than 14,000 pharmacists are employed, with the vast majority of those >80% working in independent-community pharmacies.More than 60% of pharmacists are women, while the central tendency in the age distribution is between 55 to 65 years that is very close to the retirement age.Regarding the structure of pharmacies, they are small sized stores which hardly exceed 50 m 2 .The legal retail mark-up by pharmacies to the wholesale price is currently set to 35% for medicines that are not reimbursed by Social Security Funds (SSFs), 32.4% for medicines reimbursed by SSFs with a wholesale price of up to €200, 16% for drugs under Law 3816 (having a special wholesale price of up to €200 and a fixed amount of €30 along with a regressive percentage of 8%, 7% and 6% for drugs with a wholesale or special wholesale price of €201 -€500, €501 -€1000 and €1001+, respectively), plus VAT at a rate of 6.5%.Based on the composition of consumption (products with a wholesale price of <€200 have a market share of 91%) and taking into account the pharmacy discounts and rebates, the average profit margin of pharmacies is estimated at about 19% [5].In summary, along with other countries such as Spain and Italy, pharmacies in Greece follow by the so-called "Mediterranean" model in contradiction to the "North European" model prevalent in countries of central and northern Europe.Practically this means scattered, many in number, small in size pharmacies in which works only one pharmacist (the owner-the one with the authorization to establish the pharmacy) versus low dispersion, few in number, large in size pharmacies where many pharmacists are working.
Implementation of reforms in pharmaceutical sector has progressed substantially from 2010 and today stands hopefully in the end of a long road.The most remarkable interventions significantly affecting the pharmacy sector refer to the [10] [11]: 1) Implementation of the claw back mechanism (through Ministerial decree) it was set the new-claw back threshold for 2013 (€2.4 bn for outpatient pharmaceutical); 2) New pricing mechanism for medicines (with the new price bulletin the authorities expect a further reduction in prices); 3) Prescription by active substance-Compulsory lowest-priced medicines substitution (since the beginning of 2012, the authorities mandated the substitution of prescribed medicines by the lowest-priced of the same ac-tive substance in the reference category by pharmacies); 4) Increasing the use of generic medicines (the authorities took further measures to ensure that the target of 60% of the volume of medicines used is made up of generics with a price below that of similar branded products and off-patent medicines, will be accomplished); 5) Reduction of profit margins for medicines (the pharmacies' profit margin was readjusted with the aim of reducing the overall profit margin to no more than 15%, including the most expensive drugs); 6) Prescription budget for each doctor (a prescription budget for each doctor and a target on the average cost of prescription per patient); 7) Regulatory restrictions (deregulation measures as licensing or membership of a professional body, of the professional monopoly, requirements regarding ownership and operating requirements, restrictions on horizontal and vertical integration, etc.); 8) Consolidation in EOPYY (the consolidation of all existing health insurance Funds in a single universal social health insurance organisation-EOPYY); and 9) Electronic prescription (electronic prescription constitutes more than 90% of all prescriptions and can provide real-time information for continuous monitoring and assessment of prescription behavior and pharmaceutical spending by the EOPYY and the Ministry of Health).These measures (and many others) have significantly affected the economic and business sustainability of pharmacies in Greece.
The aim of this study was to form and assess the pharmacists' strategies in Greece, by analyzing the policy environment and identifying the role of the key players-stakeholders.The study also presents the opportunities and obstacles of the community pharmacies and identifies the consequences and impact of the policy formation.

Study Design
A list of the main key players-stakeholders (ministries, national & regional pharmacy professional bodies, health professional bodies, universities and research institutes, health insurance funds, the pharmaceutical industry, wholesale drugstores, pharmacy chains, citizens-patients-consumers, the media & press and, finally, political parties) in the pharmacists' policymaking was obtained.The knowledge to identify the key players-stakeholders was created by experts in the field of pharmaceutical policy, by literature review, our previous research expertise in the field and from the opinions of the pharmacists themselves [12]- [16].
For all the above stakeholders, contact details were obtained and a preliminary contact (via email or phone) was performed, in order to identify their willingness and interest to participate in the research.For those accepted to participate, structure interviews were performed or filled questionnaires were obtained [see Appendix 4], based on the PolicyMaker method for collecting and organizing important information about a policy [17]- [19].For those who didn't accept to participate or didn't answer to our invitation, their views and roles were identified through their acts and their opinions publicly expressed in media, conferences and professional bodies.

Data Analysis
PolicyMaker's computerized version of political mapping enhances the flexibility of this method for application to diverse policy environments.PolicyMaker serves as a database for assessments of the policy's content, the major players, the power and policy positions of key players, the interests of different players, and the networks and coalitions that connect the players.The Feasibility Algorithm is used to calculate the indices of support and opposition shown in the Feasibility Graph.The Feasibility Algorithm is a mathematical formula involving players' positions and power.The algorithm is applied to each player included in the analysis, producing a value that is added to the appropriate index (support, non-mobilized, or opposition), to create the Feasibility Graph.When the Feasibility Graph-Future is generated, the program averages the strategy impacts for each player and determines the combined impact.The Feasibility Algorithm is then applied to that impact, resulting in a feasibility value for each player.This value is then added to the appropriate index (for support, non-mobilized, or opposition).The three indices are then shown on the Future Feasibility Graph.The model embodied in the feasibility algorithm inevitably simplifies reality.However, the multiple uncertainties and informed guesses involved in calculating the Feasibility Graph should not be forgotten [17].
In sum, the research method used is intended to help policymakers manage the processes of reform and promote strategic programming as well as strategic thinking [20].
The methodology used, guides the researcher through five analytical steps for assessing the pharmacists' policymaking (Figure 1).
All the participants signed the informed consent section and their anonymity and the confidentiality of the questionnaire content was ensured.

Results
In the first section of the questionnaire, pharmacists defined the strategic goals of their policymaking.The goals are presented in Table 1, along with the proposed achievement mechanism.
The key players-stakeholders in the pharmacy policymaking are presented in Table 2.
For every stakeholder its initial (backdated to December 31, 2011): • territorial Level (national or regional), • Sector (Governmental, Noon-governmental, Political, Media, Commercial, Private, Social) • Position (High Support, Medium Support, Non-Mobilized, Medium Opposition, High Opposition) and • Power (Low, Medium.High) is also identified.Taking in consideration the stakeholders' initial position (backdated to December 31, 2011) from Table 2, a Current Position Map was constructed (Figure 2).
As it is shown in the graphical presentation of the stakeholders' initial position, there is a medium to high opposition from the Governmental sector and the media, a neutral position from the other stakeholders of the   pharmaceutical supply chain and some medium to high support from its professional bodies and-the most promising-the citizens-patients-customers.A more comprehensive graphical presentation of the key players' initial position, but also of the homogeneity of their interests and their grouping is being presented in the Coalition Map in Figure 3.
In the Greek community pharmacy environment we discern several opportunities, which should not be unleashed, but also many obstacles that have to cope with (Table 3).
The community pharmacies' general strategies were therefore analyzed and connected to certain actions, thoroughly specialized and customized to address each key player position and power [Appendix 1].The expected impact of the pharmacists' general strategies, analyzed by each certain strategy and key player is presented in [Appendix 2].The impact is considered as the shift in each player's initial position and power, assuming that pharmacists' certain actions as in [Appendix 1], will have a positive impact on key players' future position and a modification in their power of intervention, so as to develop a more friendly policy environment.
Taking in consideration the stakeholders' initial position from Table 2, a Future Position Map was constructed, expressing the shifts in the key players' position (Figure 4).
As it is shown, in this graphical presentation, the pharmacists expected a significant positive shift in the future positions for all key players.More specifically, the Pharmacy sector expected the Government entities to mild their initial high opposite position to medium or low opposition, while non-mobilized positions of other key players to modified to low support and the majority of the pharmaceutical sector players to move to medium or high support.At the same time the pharmacy sector actions were expected to reduce the high power of intervention of the opposition players, while enhancing the power of the supporting players, as presented above in [Appendix 2].
We finally assessed in two given distinct time moments (December31, 2012 and June 30, 2013) the success of the pharmacy sector strategy implementation, concerning the degree in which it succeeded in accomplishing the expected impact.The results are presented in [Appendix 3], from where it is obvious that the initially expected impact proved to be very optimistic in the most of the implemented strategies.It's worth noting that in the majority of the strategies have worsened or minimized their success ratio throughout the time in study.

Discussion
Community pharmacies traditionally have been acting as primary care service points, significantly contributing to the health of citizens not only in Greece, but worldwide [21]- [30].
With the first stormy clouds over the health (and specially over the pharmaceutical) sector, due to initial austerity measures under the Economic Adjustment Programme for Greece [31], community pharmacies turn to their National and Regional professional bodies, in order to preserve their scientific, financial and business interests.Though the reforms to modernize the health care sector were rather general in the MoU, its later in the 2010 reviews, unveiled the severe interventions to the pharmaceutical sector, with significant impact to the community pharmacies as well.Along with the Second Economic Adjustment Programme for Greece [2] and the Medium-Term Fiscal Strategy 2013-2016 [7], the reforms in the Greek health System seem to focus mainly to the pharmaceutical supply chain (from production to community pharmacies) inducing heavy losses to their revenues and profits [6] [8] [32].Also, the government's drastic measures due to the obligation of the deregulation in the community pharmacies' market, worsen the state of tension in the market [33]- [35].All these, set in question the feasibility of the community pharmacies in Greece, so the formation of a strategic plan for the community pharmacies was therefore required [36].The strategic goals set under the pressure of reaction to the initial reforms, could be seen as realistic, comprehensive and in accordance to the vision and mission of other European community pharmacists' professional bodies, scientific publications and the PGEU [9] [24] [25] [37]- [50].
But, as the research findings show, either the initially set strategies were at the wrong direction or the actions taken to implement them were inappropriate.Moreover, one can suggest that the shifting ability in either the position or the power of the most key players were over-estimated.
Similar misguided and unsuccessfully developed strategic plans, were also implemented before and in many other countries as well, but never with such a deviance from the initial goals and in such a limited time period [50]- [56].

Conclusion
Concluding, on one hand, the community pharmacists proved not to have the ability and the experience to evaluate the current economic and health care environment, while on the other hand, they under-estimated the impact of troika meddling in the pharmaceutical policymaking and in the health sector cost-containment measures imposing.

Strategy and Actions
Citizens-Patients-Customers, Media and Press Hire a professional public relations firm to monitor the opposition or to design a negative public relations campaign directed against the opposition.: Feed the press with negative information relating to the government actions and simultaneously positive news for the Pharmacies' issue Citizens-Patients-Customers, Media and Press, Political Parties Invoke "Crisis" to Justify Policy: Organize a media campaign to create a sense of public "crisis" regarding access to and costs of pharmaceutical products, in order to justify major policy aims and override opposition.

Citizens-Patients-Customers, Political Parties
Use symbols to Increase public support of the policy: Organizing a media campaign or finding sympathetic victims.

Health Insurance Funds
Get Support from Single Payer Proponents: Persuade single-payer proponents that the policy is the best plan they could hope to achieve.
Hellenic Pharmaceutical Association, Regional Pharmaceutical Association, Citizens-Patients-Customers Persuade supporters to strengthen their position: Reminding of the promised benefits compared to other policies.Compromise on the definition of universal coverage, in order to win support from some critics of the reform effort.

Ministry of
Health Insurance Funds: Position weakened to Medium Support 50 25 25 Compromise on the definition of universal coverage, in order to win support from some critics of the reform effort.Compromise on the definition of universal coverage, in order to win support from some critics of the reform effort.

Ministry of Employment and Social
Protection: Position weakened to Low Support and strengthened to Medium 50 25 25 Compromise on the definition of universal coverage, in order to win support from some critics of the reform effort.
Ministry of Finance: Position weakened to Medium Support 75 50 25 Compromise on the definition of universal coverage, in order to win support from some critics of the reform effort.Organize a media campaign to create a sense of public "crisis" regarding access to and costs of pharmaceutical products, in order to justify major policy aims and override opposition.
Citizens-Patients-Customers: Position strengthened to Medium Opposition 100 75 75 Organize a media campaign to create a sense of public "crisis" regarding access to and costs of pharmaceutical products, in order to justify major policy aims and override opposition.
Media and Press: (No position or change) 50 25 25 Organize a media campaign to create a sense of public "crisis" regarding access to and costs of pharmaceutical products, in order to justify major policy aims and override opposition.2) What are the mechanisms that the community pharmacists' implementation policy (must) use to achieve the above mentioned goals?(Note, each mechanism must refer to a certain goal).
Mechanism Goal 1) 2) 3) 3) Please, identify all the players that might be affected by or might affect the community pharmacists' implementation policy, and assess their position on the policy (check the appropriate cell).

Figure 1 .
Figure 1.The five steps of analysis.
of health services Expansion of working hours, Entry of non-pharmacists in the profession, Increase of the delinquency Pharmaceutical Industries -Large reduction in profits, Political and economic circumstances Pharmacy Chains The economic circumstances encourage the pharmacy chains to flourish -Regional Pharmaceutical Association Provision of health services Expansion of working schedule, Entry of non-pharmacists in the profession, Increase of the delinquency Universities Upgrade of the scientific role of pharmacists Restriction of the scientific role of pharmacists Wholesale Drugstores Increase on sales of para-pharmaceutical products -
Health, Ministry of Finance, Ministry of Employment and Social Protection, Ministry of Development & Competitiveness, Health Insurance Funds Compromise on Coverage: Compromise on the definition of universal coverage, in order to win support from some critics of the reform effort.Ministry of Health, Ministry of Finance, Ministry of Employment and Social Protection, Ministry of Development & Competitiveness, Health Insurance Funds Meet with opponents to seek common goals or mechanisms, and thereby reduce the intensity of their opposition.: Regular meetings with government officials Ministry of Health, Ministry of Finance, Ministry of Employment and Social Protection, Ministry of Development & Competitiveness, Health Insurance Funds Reduce the strength of coalitions of opposing groups or individuals, by fostering internal tensions or by winning over a key member.: Appoint their differences in financial and other interests Ministry of Health, Ministry of Finance, Ministry of Employment and Social Protection, Ministry of Development & Competitiveness, Health Insurance Funds, Media and Press Undermine the legitimacy of the opposition, by connecting them to negative social values through negative publicity.: Limited access to pharmaceutical products Universities Persuade non-mobilized to take a position of support, by adding desired goals and mechanisms to the policy: Provide information and evidence, including technical and political information.Wholesale Drugstores, Citizens-Patients-Customers, Pharmaceutical Industries, Pharmacy Chains, Medical Association-Doctors Persuade non-mobilized groups to take a supporting position: Providing incentives, removing objections, or adding desired policy elements.Wholesale Drugstores, Hellenic Pharmaceutical Association, Regional Pharmaceutical Association, Pharmaceutical Industries, Pharmacy Chains, Medical Association-Doctors, Universities Strengthen Public Relations: Involve representatives in the working group process to draft the reform policy.Wholesale Drugstores, Pharmaceutical Industries, Pharmacy Chains, Medical Association-Doctors Reduce the intensity of their opposition.: Provide compensation for real and perceived harms Development & Competitiveness: Position weakened to Non-Mobilized and strengthened to Medium 50 25 25

25 Continued
representatives in the working group process to draft the reform policy Universities: (No position or change) 25 25 Involve representatives in the working group process to draft the reform policy Wholesale Drugstores: (No position or change

Political
single-payer proponents that the policy is the best plan they could hope to achieve Health Insurance Funds: (No position or changeProvide information and evidence, including technical and political information.Universities: (No position or change) 75 50 50 Providing incentives, removing objections, or adding desired policy elements.Citizens-Patients-Customers: (No position or change

Table 3 .
Opportunities and obstacles.

Please, fill in the Interests Table below by estimating each player's level of interest in certain types of interest fields, concerning the community pharmacists' implementation policy debate
(use L (Low), M (Medium) or H (High)).