[Ip-health] Patients Pay Price for Albania’s Drug Reform
elizabeth.rajasingh at gmail.com
Thu Sep 24 15:27:36 PDT 2015
Patients Pay Price for Albania’s Drug Reform
A year after the local pharmaceutical market was reformed, essential medicines are running shorter than ever and concern is growing about the quality of drugs that are available.
Esmeralda Keta. Balkan Insight. September 25, 2015.
Hamide Pasha’s life and health depend on a 5-mg capsule of Warfarin, an anticoagulant used to prevent thrombosis. But the drug is nowhere to be found in the Albanian market.
During the last year she only found the drug twice in her local pharmacy. In its absence, she replaces the Warfarin with two other medicaments, which are not as effective.
“I take what I can find because it’s better than nothing,” the 73-year-old pensioner says.
Like all retirees in Albania, Pasha benefits from the state drug reimbursement scheme, which only in 2015 cost the Albanian budget 63.5 million euro.
However, in order to cut costs and expand the number of beneficiaries, in the summer of 2014 Edi Rama’s centre-left government overhauled the scheme, replacing some drugs on the reimbursable list with generics.
Data collected by BIRN including interviews with experts and doctors suggests that one year on, the scheme is failing to supply even basic drugs to pharmacies, leaving many patients struggling.
Pharmacists interviewed by BIRN say the drug market is in chaos, while doctors doubt that some of the drugs supplied through the scheme are effective.
Documents obtained by BIRN also show that a recent audit of the Medical Insurance Fund, FDKSH, uncovered legal breaches and failures to monitor big pharmaceutical importers.
Queried on these findings, Albania’s Ministry of Health failed to respond to detailed questions sent by BIRN.
Market in chaos
For decades, Albania’s public health sector has struggled with the supply and quality of the drugs available on the market.
Reform of the health sector was a major manifesto promise of the Socialist Party during its successful 2013 election campaign.
The Socialists claimed that the reform would free the market of monopolies, reduce the prices of drugs and guarantee a timely supply of drugs to public hospitals.
According to a World Bank report published in June 2014, public spending on healthcare in Albania accounts for only 2.6 per cent of GDP, the lowest rate in the region.
At the same time, private spending on healthcare is equivalent to 3.4 per cent of GDP, the highest rate in the region.
The same report noted that 61 per cent of Albanians take part in the drug reimbursement scheme. This includes everyone with mandatory medical insurance, children, pensioners and the chronically ill.
Although the World Bank promoted reforms to lower the cost of drugs, it questions the scheme imposed by the Albanian government.
The report notes: “It’s unclear if the drugs on the reimbursable list are on the market.”
The 5-mg dose of Warfarin is one of the many drugs missing in Tirana pharmacies. Drugs to treat depression, heart disease and diabetes, also part of the reimbursement list, also cannot be found.
“Our job has turned into a nightmare,” Neda, a pharmacist from Tirana, said. “We are sending away patients empty handed.”
Diana Toma, head of the Union of Albanian Pharmacists, says Neda is not alone in her frustration.
She said pharmacies operate on the basis of two drug reimbursement lists, a real one, on which many drugs are missing, and the “virtual” one supplied by the government.
“Over the 20 years that I have worked in the pharmaceutical system, the last few months have been the worst in terms of supply and legal breaches,” Toma said.
Like the pharmacies, Tirana’s Mother Theresa University Hospital, one of the biggest clients of the drug reimbursement scheme, is also suffering from shortages.
Dr Petrit Vargu, a cardiologist, told BIRN that his wing of the hospital is suffering from basic shortages of drugs needed to treat patients.
“We continue to lack drugs,” he said. “The revolution that was expected in the supply of drugs to the hospital simply did not happen,” he added.
The government now determines the price of the drugs it buys through the scheme using a formula that takes into account the reference price in neighbouring Macedonia, Greece and Italy.
After negotiations with pharmaceutical companies based on the reference price in these countries, the price for Albania is determined.
Experts interviewed by BIRN concede that the scheme has resulted in a drop in the price of many drugs.
But the reform has also pushed many international drug suppliers out of the market, accounting for the present shortages.
In February 2015, the company GlaxoSmith Kline informed the ministries of Health and of Social Welfare that it planned to to dissolve its collective contracts with its staff in Tirana.
In two emails, of which BIRN has obtained copies, the company said it was firing 14 out of its 18 employees, citing chaos in the local market.
Other multinational companies like AstraZeneca, Pfizer or Activis have also withdrawn their drugs from the reimbursement list and are preparing to leave the Albanian market, claiming they have been allocated a dwindling share of public funds.
A representative of Activis crunched the numbers of its reduced share in Albania, noting that in 2014 the company had 78 drugs on the reimbursement list while in 2015 there were only 31.
“The Ministry wants us to reduce our prices to lower than the cost of the drugs and under these conditions many international suppliers are pulling their drugs out of the market,” the Activis employee told BIRN on condition of anonymity. “We won’t compromise our quality,” he added.
In unison with international pharmaceutical companies, regional producers have also abandoned the Albanian market. According to the law passed in 2014, they can only export to Albania if they also export to an EU member state.
The gap left behind by foreign pharmaceutical companies is being filled by the local producer Profarma.
In 2015, the company had 101 drugs as the first alternative in the reimbursement list and 28 others as the second alternative.
Two years earlier, when the Socialist Party came to power, its footprint was much smaller.
However, along with expanding on the market, Profarma has also raised the prices of roughly 40 of its products, which it says is due to tax changes and 30 million euro in fresh investments.
“We only represent 10 per cent of the market and 90 per cent is still made by our many competitors,” Profarma spokesperson Aurela Shota said.
Shota also said the exodus of the multinational pharmaceutical companies was not a good sign.
“The flight of prestigious companies does not translate into the idea that quality drugs are being imported,” she said.
Lack of oversight:
The changes to the pharmaceutical market in Albania have also raised questions about whether some drug importers are being favored over others by the medical insurance fund, FSDKSH.
Police arrested a network of nine officials from FSDKSH and pharmacists in June.
The Tirana prosecutor’s office accuses them of running a fake prescriptions scam that cost the fund more than 150 million lek (€1.1 million).
Documents obtained by BIRN also suggest major problems with the large drugs importers and distributors that have contracts with FSDKSH.
An audit carried out by the anti-corruption unit in the Prime Minister’s office found that many of the contracts that FSDKSH had signed with the drug importers did not respect the law.
The audit, which included contracts signed in 2014 and from January to May 2015, said the fund breached the law in 24 contracts signed in 2014 and in 28 contracts signed in the first five months of 2015.
The report, a copy of which BIRN obtained, says pharmaceutical depots sell drugs in Albania without authorization from the producer, while multi-million contracts signed with FSDKSH lack a signature date.
Another problem identified in the audited contracts is the lack of approved drug lists for import attached to them, which has translated into shortages in the market.
In tandem with problems with the contracts, the audit also found problems with the way the fund oversees the big pharmaceutical depots. It noted that in 2014 only nine controls were carried out and these were based on unclear and less than transparent procedures.
According to the anti-corruption office, the depots audited by the FSDKSH circulate only a small amount of drugs. “It appears that the depots importing the majority of reimbursable drugs in Albania have not been audited,” it said.
Arjan Jaupllari, former head of the pharmaceutical department in the Ministry of Health, told BIRN that the drug reimbursement list had become a farce.
“For years we have been talking of abuses and favours with the drugs on the reimbursement list,” he said. “Everybody knows but everyone acts like they don’t know,” Jaupllari added.
Jaupllari said the cost-cutting envisioned under last year’s reform had been detrimental to patients and had created room for abuse.
Instead of reimbursing drugs based on a prescribed list, he said the fund should instead reimburse treatments and patients.
“We should reimburse diagnosis, not drugs,” Jaupllari said. “The fund should allocate money to the patients who could then choose the drugs on their own,” he added.
Questions about quality:
Along with its new pricing formula, the reform applied by the Ministry of Health in 2014 included a new way for doctors to fill out prescriptions.
Arguing that it would cut the nepotistic ties that exist between pharmaceutical companies and doctors, the latter were asked to not write drug names in their prescriptions but only formulas.
Doctors at Mother Teresa University Hospital argue that this is just a means to camouflage the shortage of drugs in the market.
In interviews with BIRN, hematologist Arben Ivanaj and cardiologist, Petrit Vargu, questioned the quality of the drugs that are on the reimbursement list.
The two doctors support the use of generic drugs - but only when their use is proven to be as effective as the patent drugs.
Ivanaj recalled a recent case with a patient who had suffered for ten years from a chronic disease.
Her blood platelets jumped above the norm in the last six months, after using the reimbursement list drug.
The hematologist questioned the list of the free drugs provided by the scheme, adding: “For myself and my family I prefer to buy them.”
Cardiologist Petrit Vargu has spotted the same problems with his patients, with longer hospital recoveries needed for those who use drugs from the reimbursement scheme.
“Without treating a disease properly, the patient becomes a hostage to the medical insurance scheme,” Vargu concluded.
This article was produced as part of the initiative “Strengthening Cooperation Between Civil Society and Investigative Journalists,” supported by the Open Society Foundation in Albania.
Perls Research and Policy Fellow, Knowledge Ecology International
elizabeth.rajasingh at gmail.com | 410-829-7866
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