The horrific reality facing patients
Patients with critical illnesses are finding themselves in serious predicaments after the recurring foreign currency shortage began to affect the manufacture and import of medicines. Families are being increasingly forced to turn to unregulated informal market sources to find life-saving medicine now, even as importers and health institutions look for solutions to the problem. However, it may be easier said than done. EBR’s Ashenafi Endale explores the causes of the shortage and what awaits patients in the future.
Mestawet Degefaw, a mother of seven children, all under age 14, became a widow after her husband passed away three months ago. Tollera Dagne was in his early forties and struggled with cancer for almost a year.
Six months ago, doctors at the Tikur Anbessa Hospital prescribed medication to slow the spread of the tumor and gave him an appointment for surgery to remove it. But Tollera was unable to afford the medicine after the second week.
“It cost ETB16,000 a week to buy the medicine. My husband used to earn a living as a building painter, and I am unemployed. How could we afford to buy such expensive medicine?” asks Mestawet.
Two weeks after Tollera stopped taking the medicine, his neighbors and friends raised ETB100,000 to cover his medical expenses. But by the time the money was collected, the medicine couldn’t be found on the market. “We searched everywhere ,even on the black market, but we could not find the medicine,” Mestawet recalls. As the result, her husband’s health deteriorated, until he finally passed away.
This is not an exceptional story in Ethiopia. Rather, almost every day people run from hospitals to pharmacies and then to black market sources to find medicines for themselves or their loved ones. Patients like Tollera have to rely on luck if they are looking for imported medicines for critical illnesses. They either need the right connections to the informal market, or they need sources that can access medication from abroad. Gebremedhin Be’edemariam, an assistant professor at the Pharmacoepidemiology and Social Pharmacy Department at the Addis Ababa University College of Pharmacy, underlines that failing to access medicine on time has severe consequences. “Even the price of standard medication suddenly jumps, and at the same time, it becomes challenging to find medications such as diabetes medications, and anticoagulants.”
Some doctors have been forced to turn to other sources to find medicines for their patients. “We sometimes have to give medicines bought from the informal market, especially to cancer patients,” explained a doctor who works at Tikur Anbessa. “The availability rate [ at the hospital] fluctuates between 60Pct and 90Pct.”
The annual pharmaceutical market in Ethiopia is estimated to be worth one billion dollars in 2018. In fact, the demand for pharmaceutical products grows by 25Pct annually. Steady economic growth, improvements in the delivery of health care and the introduction of social health insurance coverage across the country all lead to increased demand.
Though there is a growing need, there are problems with the supply of pharmaceutical products in Ethiopia. According to the Ministry of Health (MoH), there are 22 companies licensed to manufacture medicine locally; and just 14 of them are actively involved in manufacturing pharmaceuticals. Most of the manufacturers operate below their capacities and supply only about 20Pct of the local demand. They have limited product portfolios; in 2015/16 they supplied only 125 of the more than 380 products on the national essential medicines list.
Close to 80Pct of the annual demand for pharmaceutical products is satisfied through imports. Around 70Pct of imported medicines enter the country through the state-owned Pharmaceutical Fund and Supply Agency (PFSA).
Medicine supplies and prices have fluctuated wildly due to the lack of foreign currency, especially over the last two years. “It is becoming difficult to allocate enough foreign currency, even for medicines,” said an official at the National Bank of Ethiopia (NBE), who is not authorized to comment to the media. Loko Abraham (MD), director general of PFSA, admits the agency can not supply medicine continuously, due to lack of foreign currency as well as capacity limitation.
“We wait five to six months to get foreign currency approval. CBE takes time to release it, even after the NBE approves. Then the procurement and shipment takes additional time. All in all, the supply of medicine is currently disrupted for four to five months, due to lack of foreign currency. We get the hard currency we request, at the end of the day, but at critical time, after it is too late.”
In the last six months, the PFSA has imported medicines, health materials and chemical reagents worth ETB6.1 billion. According to the Agency, the last financial years’ total import costs were ETB13.5 billion. “Imports are increasing, but we are unable to fully address the demand,” Adna Berhe, communications director of PFSA said. “We have to talk with the banks, transport, and other stakeholders, to stress the urgency of the issue.”
For the 415 private importers of pharmaceutical products and medical consumables, a lack of hard currency is also their main problem.
“We are in limbo,” explains Tsegaye Gebreyesus, general manager of Bicas International Trading, a company that imports medical items from Europe, the Middle East, and India. “It has been six months since we requested a letter of credit; the company needs at least USD100,000 every two months.”
Tsegaye explain the dismal state of affairs, “It has been eight months since the company imported from European and Middle Eastern suppliers, and three months since we imported from India.”
Insiders note that even the big players have not been able to import pharmaceutical products for over a year. As a result, many private pharmacies are leaving the business. “We don’t know if we should continue the business or close under these circumstances,” Tsegaye tells EBR.
The directive the NBE introduced in December 2017 is another headache, according to stakeholders. It states that commercial banks shall not accept Pro-forma invoices for 34 listed items, including pharmaceuticals products, with a price less than the minimum indicative price calculated by the Ethiopian Revenues and Customs Authority. The directive only allows a maximum of five percent price reduction from the indicative price.
Though the directive was introduced because it became necessary to monitor and prevent under-invoicing of imported items, Tsegaye argues that matching the Pro-forma invoices with the minimum indicative price list is impossible. This is because the list prices of most medicines is double the price on the international market.
“There are three flaws with the directive,” explains Tsegaye. “The first is the directive forces importing companies to double their request for foreign currency when it is difficult to obtain even a portion of the original request. Secondly, companies will be forced to pay for items they didn’t import. Finally, the directive makes the price of imported medicines too expensive for patients.”
Tsegaye, who personally spoke with officials from the Food, Medicine and Healthcare Administration and Control Authority about the issue to no avail, says companies have complained to the NBE through the Medicine Importers Association. “The directive can work for other commodities like vehicles, but never for medicines. It is not only damaging to importers but also to patients,” he argues.
Although the extent of the impact varies depending on the types of the disease and the condition of patients, the absence of pharmaceutical products has had devastating effects on people like Tolla. While his case has ended tragically, the fate of patients who are struggling with chronic diseases hangs in the balance.
For the past two years Abebe Weldu, a 58-year-old father of two has been dealing with type-2 diabetes, the most common form of the disease. Abebe has to take medication to regulate his glucose levels. However, the increasing price and the scarcity of the medicine on the market, are putting his life at risk. “I used to buy a week’s worth of the medicine for seven birr two years ago. The price is now ETB263,” a frustrated Abebe tells EBR. “Even worse, the medicine has vanished from the market in recent months, which forced me to ask relatives to bring it from abroad.”
Even children like Bezawit Nahom, six, are being affected. After being diagnosed with type-1 diabetes, doctors prescribed insulin for her, but finding it proved challenging.
“The locally manufactured medicine was not available and for a few days, my child suffered a lot,” recalls her father, Nahom Getachew. “After days of searching, I found imported insulin at a cost three times higher than the locally made one.”
In Ethiopia, diabetes, especially type-2 diabetes, is a leading cause of admission to hospitals. According to a 2015 study entitled Diabetes Mellitus in Addis Ababa, Ethiopia, out of the 8,048 people admitted to Black Lion Hospital between 2010 and 2013, 523 were diagnosed with different types of diabetes. Out of these diabetes patients, 72Pct and 28Pct had type-2 and type-1 diabetes, respectively.
Another common chronic disease, cancer, accounts for about 5.8Pct of total national mortality, according to the National Cancer Control Plan document published by the MoH in 2015. Although nationwide figures are not available, based on the study conducted in Addis Ababa, the yearly incidence of cancer is estimated to be around 60,960 cases while cancer related deaths were over 44,000, annually.
Addisu Melke (MD), head of the Department of Internal Medicine at Tikur Anbessa Hospital sees 7000-8000 outpatients, and up to 200 inpatients coming through his department every month, which treats mostly cases of diabetes, blood cancer, kidney failure and heart disease.
Despite the prevalence of chronic diseases, the unfortunate experiences of patients like Abebe and Bezawit show that the availability and affordability of medicines has reached a critical point. Following the scarcity of medicines in the formal market, people are forced to take smuggled tablets, which are unaffordable especially for average low-income consumers.
Samson Abreham, director of Public Relation Directorate at FMHACA, says informal sales points are an open secret. “We know flight attendants import medicines informally, and there are other ways as well. But since we believe they are helping patients in need, we usually overlook them. However, we have disposed of smuggled medicines worth ETB24.4 million over the last six months, which is a significant rise.”
However, Gebremedhin, the assistant professor at the College of Pharmacy, argues that since informally imported medicines are not enough to satisfy the demand, counterfeit medicines are becoming pervasive on the market. “Often, the risk that comes with smuggled medicines can be even higher than getting no medicine . The content of counterfeit medicines can further complicate the nature of the disease or even cause new issues.”
According to the World Health Organization, counterfeit medicines are drugs manufactured by someone other than the genuine manufacturer, by copying or imitating an original drug with the purpose of marketing the forged medicines as originals. Counterfeit products include drugs that may have the wrong active ingredients or are manufactured without active ingredients using fraudulent packaging. According to a 2015 study entitled Counterfeit Drugs: The Relentless War in Africa, the extent of penetration of fake medicines in Africa is estimated between 30-60Pct.
In Ethiopia, the stagnant growth of local pharmaceutical manufacturers has forced the health sector to heavily depend on imports, leaving it exposed to counterfeit medicines. Despite all the incentives, which include pooled procurement of raw materials, technology acquisition grants, and human resource development facilitation, few companies are investing in the sector while the performance of the local pharmaceutical companies remains low.
Out of the ETB1.2 billion worth of medications the Agency planned to purchase from local manufacturers in 2016/17, only ETB799 million was supplied, while the rest was delayed until the current fiscal year. Furthermore, the Agency planned to procure medicines worth ETB540 million from local manufacturers during the last six months of 2017/18, but only ETB259 million worth of products has been supplied so far.
Stakeholders stress that since local manufacturers have to import the input ingredients, a shortage of the hard currency still affects their performance. “Raw materials needed for most input ingredients are available in Ethiopia, but there has been no investment in developing them,” argues Gebremedhin. “In addition, investigating and assessing the real impact of government incentives is essential.”
According to Gebremedhin, either the private sector must utilize incentives effectively and develop the local manufacturing capacity, or the money must be used to import directly and subsidize patients because the inflated price of medicines is putting lives at risk. “A technical committee has already submitted a draft policy for the MoH. The policy intends to regulate prices that are shooting up uncontrollably.”
“Many of my patients ask me to change their prescription because they can’t find the ones I prescribe,” Addisu explains. However, he has not seen any coordinated efforts to tackle the problem. “It is just perceived as a reality in Ethiopia. I see a defeated state of mind from those who are supposed to solve the problem.”
In the mean time, patients like Tollera are dying while those like Abebe wait in fear of an unknown future. “I am running out of the tablets,” Abebe tells EBR. “I have no idea how to get them.”
6th Year . March 16 – April 15 2018 . No.59