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. 2025 Oct 6;18(1):2564825. doi: 10.1080/20523211.2025.2564825

An ideological playground? Changes in community pharmacy ownership – a case study from four Nordic and Baltic countries

Katri Hämeen-Anttila a, Anna Birna Almarsdóttir b,c, Daisy Volmer d, Ingunn Björnsdottir e, Sofia Kälvemark Sporrong f,CONTACT
PMCID: PMC12502118  PMID: 41064589

ABSTRACT

The pharmacy systems have undergone fundamental changes in some Nordic and Baltic countries: Iceland, Norway, Sweden and Estonia. The political declared aims of the reforms have included increasing competition and/or effectiveness of the pharmacy market and the availability of medicines or pharmacies. The aim of this commentary is to describe the policy measures taken in these countries changing community pharmacy ownership, the arguments and rationales behind, and the evidence of the intended and unintended outcomes. Furthermore, we discuss the lessons learned for social pharmacy researchers. The aim of increasing the availability of pharmacies has been achieved, if interpreted as more pharmacies. However, the number of pharmacies has increased, mainly in urban areas, with a need to assure the availability of pharmacies in rural areas with regulations and/or subsidies in some countries. There were also unintended consequences. The aim to increase competition and diversity failed, as big domestic and foreign pharmacy chains conquered most of the pharmacy market. Learning for researchers in social pharmacy when studying pharmacy system changes includes considering the social, economic, and political reality in which the sector exists. The intended and unintended consequences of changes need a multi-method approach, often mixing quantitative (epidemiology and economics) and qualitative social science methods. Lastly, if we want evidence-based policymaking, we as researchers need to do better in communicating our research evidence to politicians and to the public.

KEYWORDS: Pharmaceutical policy, Scandinavian and Nordic countries, Estonia, pharmacies, ownership

Introduction

The pharmacy systems have undergone fundamental changes in some Nordic and Baltic countries, whereas in other countries, such developments are currently under discussion. Reforms towards a more liberalised ownership of pharmacies have been made already starting in the 1990s in Iceland, followed by Norway in 2001 and Sweden in 2009 (Anell, 2005; Lovdata, 2000; Wisell, 2019). In Estonia, the pharmacy system was liberalised in the wake of regaining independence in 1991, but became restricted to pharmacist ownership in 2015 (Sepp et al., 2021). It should be noted that Sweden and Estonia went from only state-owned pharmacies to a liberal market, while the other countries had systems with ownership restricted to pharmacists.

The remaining Nordic countries, Finland and Denmark, have not had such radical system changes.

Denmark, although planning to abolish the professional monopoly in pharmacy ownership, did not do so in 2000 (Larsen et al., 2004). The ownership of community pharmacies is still in the hands of the pharmacy profession, where a pharmacist must have a license from the authorities to own and run a pharmacy. However, reforms have been made in the system allowing more horizontal integration where each pharmacy owner can own up to eight physical units that can dispense medicines. In addition, sales of certain Over the Counter (OTC) medicines have been allowed outside pharmacies.

In Finland, the pharmacy system is still traditional with strict regulation, e.g. on the number and location of pharmacies, ownership of pharmacies restricted to pharmacists, and OTC-medicines only sold from pharmacies. However, there is an ongoing heavy lobbying and political discussion towards opening the sales of OTC medicines outside pharmacies and towards liberalisation of pharmacy ownership – the first being a goal in the current Government programme, but the latter not (Finnish Government, 2023).

The pharmacy ownership reforms in Iceland, Norway, Sweden, and Estonia have been studied with the recognition of underlying ideological and political motivations, and results include unintended consequences, i.e. consequences other than those intended by policymakers (Almarsdóttir & Morgall, 1999; Sepp et al., 2021; Wisell, 2019). The aim of this commentary is to describe the policy measures taken in these four countries in the Nordic and Baltic region changing community pharmacy ownership, the arguments and rationales behind the changes, and the evidence of the intended and unintended outcomes. Furthermore, we discuss the lessons learned for social pharmacy researchers when studying pharmacy system changes.

The reforms

The declared political aims of the liberalisation in Iceland, Norway, and Sweden, and the 1991 reform in Estonia, included increasing competition and/or effectiveness of the pharmacy market as well as availability of medicines or pharmacies (Table 2; Supplemental Material). These declared aims did not include concrete explanations, definitions, or indicators for follow-up. The reforms were inspired by liberalism/New Public Management (Anell, 2005; Morgall & Almarsdóttir, 1999; Volmer et al., 2009; Wisell, 2019; Wisell et al., 2015). Interestingly in Sweden, the aims of the liberalisation changed during the process from increased effectiveness, price pressure, improved medicines use, and better availability to more entrepreneurs and diversity in the market with better availability, as it became obvious that the set goals could not be reached (Wisell, 2019). Furthermore, in Estonia, a second reform in 2015 restricted ownership only to pharmacists (Gross & Volmer, 2016; Sepp et al., 2021). This was due to the consequences of the 1991/1996 reform (see below).

Table 2.

Pharmacy reforms in three Nordic countries and Estonia: intended and unintended consequences.

  Estonia (Sepp et al., 2021) Estonia (Sepp et al., 2021) Iceland (Anell, 2005; Morgall & Almarsdóttir, 1999; Anell & Hjelmgren, 2002; Althingi, 2002) Norway (Enhet for tilsyn og narkotikaforvaltning, 2023; Svendsen & Mosher, 2022) Sweden (Myndigheten för vårdanalys, 2014; Wisell et al., 2019; Tandvårds- och läkemedelsförmånsverket, 2025; Sveriges apoteksförening, 2023; Sveriges apoteksförening, 2024)
Year of the reform 1991/1996 2015 1996 2001/2003 2009
Ownership before the reform State owned Free Pharmacist owned Pharmacist owned State owned pharmacy chain
Ownership after the reform Free Pharmacists holding more than 50% of pharmacy shares, otherwise free, excluding pharmaceutical wholesalers, pharmaceutical companies, prescribers Free Free, excluding pharmaceutical companies, prescribers Free, excluding pharmaceutical companies, prescribers
What was changed? Privatisation of community pharmacies from 1991.
Vertical and horizontal integration since 1996.		 Ownership restriction of community pharmacies. Pharmacy ownership with free establishment. Pharmacy ownership with free establishment, location, and to some extent medicines pricing was liberalised.
In 2003, some pharmaceuticals exempt from pharmacy-only sales.		 Pharmacy ownership with free establishment, allowing OTC to be sold outside pharmacies, stricter generic substitution than earlier (to partly fund the ownership reform)
What was the aim of the change set by the politicians?
Ideology behind?		 Increase competition in the pharmaceutical market.
The reasoning was less connected to healthcare and more to economic needs.		 Increase competition in the pharmaceutical market, open the market to new companies.
Limit ownership only to pharmacists. Prohibit vertical integration. Increase independence of community pharmacists.		 Increase competition in the pharmaceutical market and access to medicines.
New Public Management		 Curb prices, increase consumer choices, keep service in the rural areas at an acceptable level, and ensure rational use of resources.
New Public Management		 Originally: increased effectiveness, price pressure, improved drug usage and better availability.
During the preparatory work for the reform, it was seen that all of these goals could not be reached. Hence new rationales (in addition to better availability): more entrepreneurs and diversity in the market.
New Public Management
Intended consequences Rapid growth in the number of community pharmacies, from 239 in 1995–476 in 2015. Pharmacists are independent legal owners of pharmacies.
No vertical integration.		 Access to pharmacies increased:

  • number of pharmacies increased from 43 in 1997–61 in 1999 and 75 in 2024

  • opening hours increased

 Access to pharmacies increased:

  • number of pharmacies increased from approximately 400 in 2001 to over 1 000 in 2024.

 Access to pharmacies increased:

  • number of pharmacies increased from 925 in 2009 to over 1 405 in 2023.

  • opening hours increased, especially in densely populated areas
Unintended consequences Horizontal and vertical chains, approx. 90% of pharmacies operated under chains which were connected to wholesale companies. Most pharmacies (94%) are associated with pharmacy franchises.
Independence is not clear.
Competition in pharmaceutical market is limited, no new competitors entered the market. The number of community pharmacies remained the same		 Establishment of pharmacy chains: in 2024, 54 out of the 75 belong to one of three chains currently operating.
Access to pharmacies and medicines increased only in the urban areas.		 Number of pharmacies, although increased considerably, has mainly increased in the cities, – distances to nearest pharmacy in the rural areas remain practically unchanged. Hence, access has not improved in the rural areas. Most new pharmacies established close to other pharmacies: in 2013 only 10% of the 368 new pharmacies had opened in localities where there were no pharmacies before.
To ensure availability of pharmacies in rural areas, an extra subsidy for these was introduced in 2013; in 2022 approx. 12 million SEK was paid out.
Three pharmacy chains own 91% of the physical pharmacies.
With an oligopoly market diversity is scarce.
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Context and the current pharmacy system regulation in the Nordic countries and Estonia

The Nordic countries and Estonia are often considered similar in terms of social and healthcare systems (e.g. welfare models and national tax-funded healthcare); however, the pharmaceutical systems differ widely, see Table 1 (Airaksinen et al., 2021; Anell, 2005; Hansen et al., 2021; Sepp et al., 2021; Westerlund & Marklund, 2020). Differences exist in the overall regulation of the field, such as pharmacy ownership, whether online-only pharmacies are allowed, and OTC medicine sales channels (Table 1) (Reinikainen et al., 2022).

Table 1.

Current (2022) pharmacy system regulation in some Baltic and Nordic countries (Reinikainen et al., 2022).

  Estonia Finland Denmark Iceland Norway Sweden
1. Number of inhabitants in the country 1 331 796 5 548 241 5 873 420 376 248 5 425 270 10 452 326
2. Number of pharmacies**** 475 823 516 74 1 031 1 411***
3. Number of inhabitants per physical pharmacy 2 804 6 741 11 383 5 084 5 262 7 408***
4. Horizontal integration* Allowed with restriction: max 4 pharmacies in one chain within an area of minimum of 4 000 inhabitants. Not allowed.
One exception: University Pharmacy owned by the University of Helsinki (chain of 17 pharmacies)		 Allowed with restriction: max 8 units that can dispense medicines Allowed Allowed Allowed
5. Vertical integration** Not allowed Not allowed Not allowed Allowed Allowed Allowed
6. Online pharmacies Only a licenced pharmacy can have an online pharmacy Only a licenced pharmacy can have an online pharmacy Online-only pharmacies are allowed Only a licensed pharmacy can have an online pharmacy Only a licenced pharmacy can have an online pharmacy Online-only pharmacies are allowed
7. OTC medicine sales channels Pharmacy only Pharmacy only, except for nicotine replacement therapies which can be sold in retail stores Pharmacy, retail stores***** Pharmacy, retail stores***** Pharmacy, retail stores***** Pharmacy, retail stores*****
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*The possibility for pharmacies to form or be owned by chains.

**The possibility for actors at different levels of the industry value chain to own a pharmacy or pharmacy chain.

***Does not consider e-pharmacy. At the end of 2021, there were 9 e-pharmacies in Sweden having a 20% share of the market.

****By the end of 2021, does not take into account the number of purely e-pharmacies.

*****Selection of OTCs that can be sold out of pharmacies varies and is approved by the medicine authorities. Retail store refers here to a variety of actors, such as grocery stores, kiosks, and gas stations.

Nevertheless, some basic elements of healthcare and pharmacy systems are the same, including universal health coverage with some co-payment, which means that healthcare and pharmaceuticals are available for all and mainly publicly funded by taxes (Airaksinen et al., 2021; OECD, 2023a, 2023b; Westerlund & Marklund, 2020; Vallgårda, 2007).

There is free pricing for all pharmaceuticals at the manufacturer and wholesale (except Estonia) level; however, the prices are indirectly controlled through the reimbursement system. If pharmaceutical companies want to have their pharmaceuticals eligible for reimbursement, which is within the universal health coverage, they must set the prices at a level acceptable to the pricing and reimbursement authorities. The retail price of reimbursed pharmaceuticals is regulated without the possibility for an individual pharmacy to compete with prescription medicine prices. However, the pricing for OTC medicines is less regulated, with some possible price competition.

Intended and unintended consequences of the liberalisation reforms

The aim to increase access to pharmacies was reached partly, as the number of pharmacies increased in all these countries (in Estonia during the 1996 ownership reform), see Table 2 (Wisell, 2019; Icelandic Medicines Agency, 2025; State Agency for Medicines (Estonia), 2024). However, the number of pharmacies increased mainly in the urban areas, and in some countries (Sweden, Estonia), a need to ensure the availability of pharmacies in the rural areas was identified. This was done with some regulation (the 2015 reform in Estonia and/or subsidy (in Sweden)). In Iceland, the availability as in the number of pharmacies decreased outside larger cities (see Figure 1).

Figure 1.

Figure 1.

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Pharmacies in Iceland 1988 and 2025 (Björnsdottir, 1989; Icelandic Medicines Agency, 2025).

There were also other unintended consequences. The aim to increase competition and diversity failed as in all the countries big domestic and foreign pharmacy chains conquered the pharmacy market (Table 2) (Morgall & Almarsdóttir, 1999; Westerlund & Marklund, 2020)., The 2015 community pharmacy ownership reform in Estonia was intended to reduce the oligopoly of existing pharmacy chains and thus make it possible for independent owners to enter the market (Gross & Volmer, 2016). With this measure, the stated aim was to invigorate competition in both retail and wholesale of medicines, to increase pharmacists’ independence, and to reduce the number of community pharmacies.

Learnings for pharmaceutical policy

The liberalisation of the number and location of pharmacies in the countries focused here has led to an increase in the number of pharmacies, and thus, in competition, particularly in urban areas. In all the pharmacy markets (Iceland, Estonia, Norway and Sweden), liberalisation has led to an oligopoly market with a few dominating pharmacy chains. This contrasts with Finland and Denmark, where pharmacy ownership is in the hands of the pharmacy profession in combination with establishment rules. Furthermore, liberalisation has led to vertical integration, i.e. pharmacies owned by pharmaceutical wholesalers (Reinikainen et al., 2022). It is notable that in countries where pharmaceutical wholesalers or international companies have the right to own pharmacies or pharmacy chains, these chains have a significant share of the market (Reinikainen et al., 2022).

The fact that the pharmacy system is liberalised does not mean that there is no need for regulation – on the contrary (Morgall & Almarsdóttir, 1999). Even in countries with liberalised ownership, the possibility for ownership by pharmaceutical companies, medicine wholesalers, and physicians, for example, is often limited by regulations (Table 2) (Reinikainen et al., 2022; Lag om handel med läkemedel, 2009). Furthermore, the person responsible for overall quality and/or the operational activities of the pharmacy must be a pharmacist in most of these countries (Pharmaceutical legislation, 2020; Läkemedelsverket, 2020). Moreover, regulation and/or compensation are also often needed to ensure pharmacy services in rural areas (Reinikainen et al., 2022; Tandvårds- och läkemedelsverket, 2025; Laegemiddelstyrelsen, 2020).

The concept of ‘access' has been used in some countries to describe what is, in essence, the availability of dispensing outlets, most often pharmacies. According to WHO, access to medicines is defined as the combination of availability and affordability (Vogler et al., 2024; WHO, 2022). Availability is the degree to which medicines are present at distribution points in a defined area for the population living in that area at the moment of need. Affordability is the degree to which medicines are obtainable to people at the moment of need at a price they or their health system can pay. If increased availability to pharmacies is aimed for, establishment rules are crucial; otherwise, as can be seen in Sweden, Estonia, Iceland, and Norway, availability does not increase for all (see e.g. Almarsdóttir et al., 2000; Almarsdóttir & Morgall, 1999). Having several pharmacies close to each other in the cities only creates more availability for parts of the population. In Sweden, it has been pointed out that the aim of adequate availability could have been reached much more easily under state ownership, when the authorities could request more pharmacies to be opened in locations where there was a lack of them (Myndigheten för vårdanalys, 2014).

Ideology has played a crucial role in shaping the discourse and implementation of changes in Iceland, Estonia, Norway, and Sweden. In Iceland, Sweden, and Norway, it has been shown that the reforms were driven by a liberal ideology, grounded in the economic belief that a free market would enhance efficiency, for example, lower prices of medicines (Anell, 2005; Gross & Volmer, 2016; Morgall & Almarsdóttir, 1999; Wisell, 2019). Access to medicines was also cited as a key rationale for the changes, with the expectation that more pharmacies would result in greater availability of medicines and services. In Iceland, pharmaceutical care was also incorporated into the legislation, but it was neither clearly defined nor implemented (Althingi, 2002).

This example shows the major impact of political ideologies behind reforms like this. In fact, liberalisation (i.e. New Public Management) was on the political agenda in many Western welfare states in the 1990s, leading to changes without evidence, but rather steered by this ‘trend' (Vrangbaek et al., 2012). It is worth noticing that in none of the liberalisation reforms, patient safety or public health was in focus. Although pharmacies are part of an essential for health care, this aspect was not included. Availability to pharmacies is important, but so is availability to the medicines as such – as well as advice from qualified staff to ensure the desired outcomes, e.g. by ensuring that patients understand how to use their medicines and are motivated to use them.

Learnings for research and evaluation of pharmaceutical policy

Evaluating changes in an entire sector is complex, and it involves multiple perspectives and aspects that should be considered (Almarsdóttir & Traulsen, 2009). As a result, a variety of competencies are required. Ideally, researchers and other stakeholders should have a common strategy and plan to evaluate the system change so that no perspective is ‘over-evaluated' and others are forgotten. This also makes it possible to use each actor’s strengths and competencies – and in the end – resources optimally. Social pharmacy researchers can add knowledge of the pharmacy market and regulation, and together with perspectives from, e.g. health economics, political science, and behavioural sciences, the bigger, complex picture can be captured. The intended or unintended consequences of system changes do not show immediately, hence strategies for long-term follow-up are needed. As can be seen from Estonia, the first liberalisation was followed by another pharmacy sector reform, as the unintended consequences were seen as too serious to pursue the liberalisation (Sepp et al., 2021).

When studying pharmacy system changes, the context of the pharmacy sector should be considered, i.e. the social, economic, and political context in which the sector exists (Almarsdóttir & Traulsen, 2006; Almarsdóttir & Traulsen, 2009). There are variations regarding what stakeholders and developments influence the pharmacy sector. Furthermore, making comparisons is challenging as data may not be compatible. As an example, the number of inhabitants per pharmacy cannot be compared between one country without e-sales of medicines and another with a considerable part of sales conducted via large online pharmacies.

Lastly, for society to learn from research results – also between countries – researchers need to communicate their research evidence to the public, including politicians. The webinar from which this commentary originated was one such activity. We specifically invited people from authorities and other stakeholders, and a large share of participants came from outside academia. Strategies such as policy briefs, media engagement, co-creation of research with policymakers, or use of implementation science approaches to translate findings into practice should be utilised.

Conclusions

As shown above, enormous system changes are implemented driven by ideology rather than scientific evidence. In many cases, there may not be any evidence available for the basis of system change, as the health care and pharmacy systems differ in different countries. However, documented experiences from other countries should be utilised if possible. There is a great need for research on pharmacy system changes.

Supplementary Material

Supplemental Material
JPPP_A_2564825_SM6835.docx (31.4KB, docx)

Acknowledgements

This commentary is based on the presentations and discussions in the annual Nordic Pharmaceutical Policy Webinar conducted on 16 April 2024. The authors want to thank Development Specialist Leena Reinikainen (FIMEA) for the additional information provided for the Comment, and the workshop participants for their input during the discussions.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20523211.2025.2564825.

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