Lebanese pharmacists suffer in silence: a bitter pill to swallow

Policy Analysis by Taleen El Gharib, Staff Writer

July 10th, 2020

All pharmacists in this article were interviewed exclusively by and for The Phoenix Daily. 

Pharmacists have long fought for their recognition as essential workers, with over 12-hour shifts and little to no days off. The profession often faces challenges relating to the the protection of the professional status of pharmacists, as well as drug prices, ethics, policies and profit as a means of sustenance and continuity.

For years, the pharmaceutical sector has been undermined, and pharmacy owners and employees arguably stand in the crossfire between the Ministry of Health’s political agenda and the Lebanese Order of Pharmacists’ (OPL) abandonment of the pharmacist cause. The OPL recorded more than 8,000 registered pharmacists and over 3,000 licensed pharmacies in Lebanon. Even with their prominence in the employment sector, their cries have not yet been heard. With already 200 pharmacies closed permanently and an expected 800 more to follow by the end of this year, the future of the profession during and post-economic crisis seems quite bleak.

Here’s what’s really going on in the pharmaceutical sector

Lucy Aklimos, an employee at a pharmacy in Achrafieh, stated: “Pharmacists are not covered by NSSF (security fund) and my employer is not obliged to enrol me, as an employee, in NSSF. On top of that, pharmacists’ profit margin (جعالة) from selling drugs is only 22%, as appointed by the Ministry of Health. How do they expect us to live?”

Back in October 2019 when the exchange rates reached 1,600 Lebanese pounds to a dollar, panic gripped the country. However, the Central Bank was believed to have "the necessary tools" to maintain monetary stability. Now in July, the exchange rates reached 9,000 and above Lebanese pounds to a dollar in the black market, and the aftermath of this devaluation has rattled the lives of many. Despite the staggering increase in prices of many goods in nearly all sectors, the pharmaceutical sector is the only one selling at an exchange rate of 1,500 Lebanese pounds (apart from government subsidised products such as wheat and fuel).

This has ultimately sparked fear among pharmacists all over Lebanon, as many are no longer capable of supporting their families.

Pharmacist Joe Salloum emphasised that “not only has the Lebanese lira lost four times its initial value, pharmacists have witnessed over the last 10 years a significant decrease in prices of drugs unparalleled by a fair revenue for pharmacists,” he said. “This dangerously low income is forcing some employers to dismiss their employees and ultimately close their pharmacy. Something as simple as paying the electric bill or shop rent is no longer within many pharmacists’ capabilities.”

Health committee head, MP Assem Araji, declared that nearly 2 weeks ago, several medications went missing - specifically heart medications and their alternatives. And although manufacturers and importers have promised their return to the market, their absence persists today. This shortage poses a great threat to not only the sector itself, but to those suffering from serious or terminal illnesses and requiring these particular drugs to survive. Here pharmacist Helen Chammas explained the main reason behind this dangerous shortage in medication. “Pre-crisis, pharmaceutical agencies in Lebanon could order any medication upon its shortage by submitting a request to import to the Ministry of Health. Once permission is granted, the agency is permitted to import the requested medication. A very easy and quick process.” 

However, since the import of drugs is now subsidised by the Central Bank, BDL, (which covers 85% of the price of import at the official rate), agencies need to make the order, claim the receipt from the source and wait until the product is ready for import. The receipt will then be submitted to BDL for approval — a process which could take weeks.

The depreciation of the currency has also posed an even bigger issue: smuggling. Drugs are being bought in gross quantities at official prices, resold at unofficial prices, and smuggled across the border, especially to Syria and Iraq reportedly.

What is the Ministry of Health doing to help?

Well, the truth is…nothing—at least nothing to stabilise the pharmaceutical sector and save nearly a thousand pharmacies from permanent closure by the end of 2020, which ideally, should be of their primary items to focus on right now.

Helen Chammas added, “With prominent losses of reputable pharmaceutical companies and manufacturers caused by the devaluation of the Lebanese lira, in addition to the illegal smuggling, repricing and reselling of some drugs, many companies will decide to remove their products from the market to stop this illegal activity. If this happens, a lot of drugs will no longer be available in Lebanon.” Pharmacists expressed their concerns over the lack of protection by the Ministry of Health against this occurrence. Between various communities within the pharmaceutical industries, speculation has begin to arise that the MoH has been persistent on importing (or rather, inward smuggling) medication from Iran to replace what currently dominates the Lebanese market, but with the current economic collapse and inflation rate, this could be done successfully without any effort or intrusion by the ministry itself. This remains pure speculation, however, is critical to note.

So, why is this a problem?

The reputable pharmaceutical companies and manufacturers that will be removing their products from the market are FDA approved, meaning they are approved by the CDER (Center for Drug Evaluation and Research) to be effective and safe to use. However, medication manufactured by foreign countries, such as Iran, may not be not approved by the above mentioned agency, but rather by companies which may not be internationally recognized.

Many pharmacists fear not only for the quality of drugs that will be forced into the market but also for their effectiveness in treating patients. The effects of such a shift could be disastrous.

What are pharmacists trying to achieve?

“Pharmacists don’t want the prices of drugs to increase. We want a fair and fixed profit (جعالة),” said medical representative, Hussein Daoud. This means that if that for example, every product X being sold at 1,000 Lebanese pound, pharmacists are entitled to a profit of 100 Lebanese pound from the sale. A decrease in price of product X to 500 Lebanese lira should not affect the fixed profit of 100 Lebanese lira for pharmacists. Now, this sector does not follow the basic rules of supply and demand. A decrease or increase in price of any drug will not affect its demand. In any other sector, a decrease in the price of a product is followed by a decrease in the profit margin. However, since pharmacists do not experience an increase in sales upon a drop in price, they request a fixed profit as they are not able to make up for losses with increased sales.

Other pharmacists like Souheil El Gharib stressed on the importance of policy and regulation of the practice. He also emphasised on the importance of Article 80 of the Pharmacy Practice Law that sets the price and the percentage of profits of all medicines. “It is against the law for pharmacists to give patients ‘discounts’, which is something many pharmacies have relied on to gain customers. It inevitably affects my income, as well as the reputation of pharmacists as essential workers. A lot of pharmacists are faced with customers arguing for discounts and a cheaper price for the products they’re buying—this is a pharmacy, not a supermarket.” El Gharib also states that the OPL is being flexible with pharmacists who are violating the Pharmacy Practice Law (specifically Article 80), as they are protected by their political parties that also have representatives on the OPL board.

Our community’s healers have no one to mend their wounds. They continue to prove their strong will, resilience and passion to ensure quality healthcare for their community, despite the many violations they routinely experience in their profession as essential workers. But if no immediate action is taken to save the pharmaceutical sector from collapse, what will be the future of this profession? What are the long-term effects on Lebanon’s quality of healthcare?

References:

Mohamad Alameddine, Karen Bou Karroum & Mohamad Ali Hijazi (2019, June 24). Upscaling the pharmacy profession in Lebanon: Workforce distribution and key improvement opportunities. Retrieved on July 02, 2020, from https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-019-0386-0

فضول, س. (2020, June 27). قريباً.. لا أدوية للأمراض المزمنة.. ولا صيدليات. Retrieved on July 02, 2020, from https://www.lebanese-forces.com/2020/06/27/pharmacy-3/