Increasing Drug Shortages during Coronavirus Crisis

Hibatullah Obeidat
Thursday, July 02, 2020

Eleven years after her first pregnancy, Rima, the mother of four who lives in Mafraq Governorate, discovered that she suffers from hyperthyroidism, which requires visiting Mafraq Governmental Hospital, for a monthly examination based on which the medication is prescribed and dispensed for a month.

But the announcement of the curfew in the middle of March caused the delay of her examination until the moment, she said, and consequently the delay in dispensing her medicine. “I bought the medicine and took it on my responsibility during the pregnancy,” says Rima, adding that she was suffering before the pandemic from the lack of medication sometimes or the availability of an alternative that does not fit her health condition. “The medicine is called “Carbimazole”. I take two pills daily, and the hospital used to dispense it. Sometimes the medicine was unavailable, I would refuse the alternative as it causes me flatulence, and the doctor knows. They told me to buy it myself,” said Rima.

Although it was announced that specialist clinics would be opened in hospitals affiliated with the Ministry of Health, starting May 31, she was unable to conduct the examination when she visited Mafraq Hospital in early June. “I went to the emergency, and I went to clinics in Al-Mafraq Governmental Hospital (…) and I went to the laboratory, but everything was closed.” This comes after the Ministry of Health, in cooperation with the Health Computing Company (Hakeem), added a service requesting a medical review appointment via the “eMed platform” that allows patients to request an appointment to see a doctor electronically so that applying electronically is a requirement to review the clinics.

Rima complains about the deterioration of the living situation in light of the crisis, as the pandemic caused her husband to stop working in the Aqaba governorate, which is a daily worker, which means her inability to buy the medicine on her own, in addition to the expiration of her health insurance period and her inability to renew it due to the conditions according to what the Health Directorate told her. The Minister of Health, Saad Jaber, had issued a decision on March 18 automatically renewing for a month all health insurance cards need to be renewed, and then extend the renewal on April 15 to May 15.

Khaled* a nurse at Mafraq Governmental Hospital confirms medicine shortages or the lack of them in the hospital, especially antibiotics. It shows the availability of six types of broad-spectrum antibiotics that cover all types of bacteria and are given to all types of bacteria, but the problem is that no bacterial culture examination has been conducted in the hospital’s internal laboratory, which determines, through the result of the examination, the appropriate type of antibiotic, not to mention the lack of prescribed medications, according to the lists approved by the Minister of Health, based on the recommendation of the Central Committee for Pharmacy and Medicines.

“At the end of December last year, there was an interruption of many medications, but they were provided in January,” says Khaled, adding that often the patient is forced to purchase the drug from outside pharmacies, such as cough medicine.

Acetylcysteine ​​is one of the medicines that are not available in Al-Mafraq Governmental Hospital, according to Khaled, and it is an anti-poisoning drug with paracetamol. It is the main ingredient of the Revanin analgesic. Therefore, acetylcysteine ​​is used as an important drug for patients who have taken Revanin in large doses, as the antidote protecting the patient from liver failure. Khaled recounts that upon entering a patient who tried to commit suicide by taking high doses of Revanin, and it was necessary to prescribe the antidote, the patient’s family had to purchase it from King Abdullah University Hospital in Irbid, as it is not available in Mafraq Hospital.

Khaled adds that the matter is not limited to the lack of specific drugs, but rather the absence of devices that affect the efficiency of drug delivery and dosages. According to him, the hospital lacks infusion pumps, which are devices for injecting fluids, medicines, or nutrients into the patient’s blood circulation. Khaled explains that these devices are characterized by accuracy in determining the appropriate dose needed by the patient, which are necessary devices for intensive care units and cardiovascular care, according to his description, as these departments deal with dangerous drugs, which require accuracy in determining the dose of the drug.

The director of Al-Mafraq Governmental Hospital, Dr. Raed Shihab, denied to “7ibr” that there is any shortage of drugs or drug dosage devices at present, but he added that the interruption of the drug is possible in the future. “Two days ago, I was informed by the chief of pharmacy that there is currently no shortage of any medicine, but on the one hand, it is possible. We are now putting in place mechanisms to prevent interruption of medicines supply and we are developing strategies in the short and long terms (..) and therefore there is no shortage even with antibiotics”. According to Shihab, the curfew did not affect the availability of medicines, and all incoming observations were resolved by 99%.

Medicines for chronic diseases during the ban
Umm Anas, 52, from Zarqa Governorate, suffers from diabetes that caused her rheumatism and a nerve problem, but the neurotoxic medications she is taking, Gabatrex and Neurona, have not been available for a long time at Zarqa Governmental Hospital. “This medicine is important, I took it for three years (…) it was missing for months, and I bought it from my pocket (…) it is too expensive”.

Failure to take nerve medicine on time may result in some swelling in the feet, feeling tingling, and heat caused by diabetes, according to what Umm Anas assures.

The curfew increased the problem of medicines availability in government hospitals, especially with the difficulty of seeing doctors dispense drugs for chronic diseases. Where, during the curfew, Umm Anas was unable to visit the hospital, one of the neighbors volunteered to dispense her medicine, except that they lost the prescription paper, and Umm Anas later went to the hospital at the beginning of June, but the medicine was not dispensed as she lost the prescription, but that did not prevent the pharmacist from notifying her that the medication is not available at all.

“I gave the prescription to someone to get me the blood pressure medicine during the curfew (…) they said this too is not available,” says Umm Anas. “Many times, even diclogesic is not available. It is a pain reliever and for rheumatic pain. Between dispensing the medication and the second appointment, there is a month”.

During the curfew, the “Watan Initiative” sprang up from the Physicians and Emergency Committee of the Medical Syndicate, seeking to deliver medicines to beneficiaries through the initiative’s volunteers.

Dr. Laith Alawneh from the “Watan Initiative” explains to “7ibr” that approximately 85,000 prescriptions were dispensed, including at least a quarter of a million boxes of medicine during the curfew. “We started the distribution from Al-Bashir Hospital in full, which is a central hospital and the largest in Jordan as it is responsible for the most dangerous drugs in Jordan,” says Alawneh. “I mean some medicines are not dispensed in Jordan except by Al-Bashir, such as patients with MS, kidney transplantation, thalassemia, and cancer, in addition to other drugs such as pressure, diabetes, and heart”.

The initiative delivered medicines for the University of Jordan Hospital, and 80% of the prescriptions for the National Diabetes Center and the King Hussein Cancer Center, the King Abdullah Foundation Hospital in Irbid, and other government hospitals in Zarqa, Madaba, and Salt. It also undertook the distribution process inside and outside Amman, and comprehensive health centers in Amman, after an official request from them.

Alawneh says that there was no shortage of medicines delivered by the initiative, but «we were facing a problem when we delivered the medicine order to the patient, the patient tells us that there is a shortage in the order, we would not be able to know if it was a mistake in the packing by the hospital pharmacies or the warehouse. We used to go back to hospitals, and in some cases, they would provide them”.

Alawneh is not surprised by the lack of medicines, as he remembers one of the cases he encountered during the distribution of medicines in mid-April when a case came to them to a doctor whose mother had “heart networks”, and he was supposed to spend her fluidized medications, such as “Clavix”, and other medicines through Al-Bashir Hospital. “They told him it was not available, it was a Thursday and the next day was a comprehensive curfew. He went to the pharmacies around Bashir but could not find it. We had to dispense him (Aspirin) on Sunday. Medically, this was dangerous, and to be honest, he had to pay about JOD198”.

Online platform for dispensing medicines
On April 8, the Ministry of Health launched an electronic platform for dispensing and delivering chronic medicines; in cooperation with the Health Computing Company – Hakeem Program. According to the statement of the Ministry of Health, the patient enters through the platform data that includes his full name, his national number, the insurance card copy, the health record number, the name of the hospital or health center he is reviewing, and the address and phone information, until his medicines request is received.

However, several patients encountered limitations, some of which were related to their ability to use the platform, including those related to the time the drug was delivered.

In April, Umm Adel (55), a resident of Zarqa governorate suffering from diabetes and blood pressure, went to spend her medication two weeks after the dispensing date, after she started feeling acceleration in her heartbeat. Upon reviewing Zarqa Governmental Hospital, she was denied entry and asked to apply via the electronic platform, although she told hospital staff that she is an old lady and does not have a smartphone that enables her to apply via the platform, apart from the fact she does not know how to apply online in the first place, she says.

Umm Adel referred to her neighbor to help her submit her request for the medicine via the platform on April 8, but she got the medicine 18 days after submitting the application, which led her to buy the medicine at her own expense before arriving. “I lost hope to receive the medicine (…) I managed myself, Umm Adel says. “Do you think I can buy it, I swear I can’t”.

The CEO of Health Computing (Hakeem), Firas Kamal, said during an interview on the Kingdom Channel on April 14 that the platform had received about 17 thousand requests for medicines, of which eight thousand were delivered.

The lack of medicines is a persistent problem
Medicines shortages in some government hospitals and health centers are not a new or controversial file that appeared during the curfew. Before the curfew, the Director of Prince Faisal Hospital in Ruseifa District admitted during a Parliamentary Health and Environment Committee meeting that he had a shortage of some medicines.

“There is a shortage of 78 medications in Prince Faisal Hospital in Ruseifa district, and we requested a meeting with the Minister of Health, the director of the hospital, and the Directorate of Supplying Medicines to attend and comply before the Health Committee to find out the implications,” Mohammed al-Atayqa, head of the Parliamentary Health and Environment Committee, told 7ibr. “After the meeting, it became clear that there was a severe shortage of medicines supplied to Prince Faisal Hospital in Zarqa, and the issue was addressed”.

Atayqa confirmed the receipt of other complaints of a lack of medicines in the peripheral hospitals in the governorates, and in the primary health centers, which, after being reviewed by the committee, were found to be lacking physicians, and not just drugs. “Even if there are drugs, there is no doctor to dispense medicines, and we are currently working on a solution to this issue”.

Maher Al-Zyoud, director of procurement and supply in the Ministry of Health, does not call the lack of some medicines a “shortage”, but rather “sometimes there are interruptions in some types of drugs, alternatives are provided for them.”

According to the Ministry of Health, the interruption of some types of medicines is sometimes due to supply problems, such as the delay in the supply of medicines by contractors, or the delay in the payment of their financial dues.

According to the Ministry of Health, the interruption of some types of medicines is sometimes due to supply problems, such as the delay of the contractors (pharmaceutical companies that have been awarded bids) in the supply of medicines, because of the delay in the payment of their financial dues, which in turn is due to the delay of the Ministry of Finance in the payment or approval of the budget, which leads to delivery disruption and suppliers abandoning bid. Al-Zyoud also adds that the expansion of the health insurance umbrella expands rapidly and the inclusion of large numbers of citizens in health insurance, which leads to a significant increase in consumption rates and an impact on the quantities required in the tender.

According to Al-Zyoud, the medicines that are interrupted by the Ministry of Health are the drugs that have a single agent, the medicines that are not registered with the Food and Drug Corporation that require permission to import, and drugs for blood factors diseases, i.e. drugs related to genetic diseases, kidney problems and immunity problems, which are often imported from abroad.

As for the most sought-after medications, they are diabetes and blood pressure drugs, and they are bought in bids for less than a quarter of their prices in the local market and private pharmacies.

According to the latest figures issued by the National Center for Diabetes, Endocrinology, and Genetics, last November, approximately two million Jordanians suffer from diabetes, and two million Jordanians suffer from arterial tension or blood pressure.

Causes of medicines shortage and interruption
The head of the Parliamentary Health and Environment Committee, Mohammad al-Atayqa, explains that the lack of medicine is in two forms, either that the drug itself is missing and not available, or that a certain dose of it is missing. “For example, one of the medicines has a dose of 400 mg, (…) of which 200 mg is available, so I have to give the patient two boxes of a 200 mg medicine if his dose is 400 mg.” This means that the lack of doses of some drugs affects the number of drugs available in government hospitals.

Al-Atayqa believes the shortage is due to poor distribution in the supply center, which supplies all hospitals in Jordan, “that is, the unified purchasing department through which drug bids are purchased and referred to the supply department.” This problem arises especially in the peripheral areas far from the center, he said. He adds that pharmacists in some hospitals sometimes overlook the registration of a specific drug shortage or codify medication requests to reduce the tasks of counting and follow-up.

Moreover, the lack of medicines in these peripheral hospitals is reinforced by the lack of specialist doctors who are authorized to dispense certain drugs “and thus the patient suffers as he takes the hardship of coming to Amman, for example, to take and receive this treatment,” according to Al-Atayqa, adding that if the powers of dispensing medications are not granted to specialized and general doctors alike, and the drugs in the peripheral areas are not promoted, then the issue is not to be solved.

According to Article (5) of the amended instructions for the provision of medication to the patient for the year 2010, the prescribed medicine that is not available in the ministry is prescribed by the specialist practicing for his specialization, the administrative doctor, or any specialist doctor in comprehensive health centers, or a family medicine specialist in comprehensive health centers, or a qualified resident doctor after obtaining special approval from the Minister of Health in health centers and peripheral hospitals. As for the unscheduled medication, it is prescribed only by the specialist practicing for his specialization and the administrative doctor.

The Ministry of Health, on the authority of Al-Zyoud, acknowledges that there is a waste rate of medicines estimated at 5- 7%, concentrated in the densely populated governorates, i.e. the central and northern governorates.

Al-Zyoud, in turn, confirms that there is an acute shortage in the number of specialist doctors in Jordan, and indicates that committees have been formed to study the reasons for the interruption of medicines, which came out with recommendations, including the necessity of cooperation between all medical departments and agencies, and the inclusion of all health systems, including doctors and health insurance, the General Organization, food and medicine, and the government procurement department. He added that there are monthly reports submitted by hospitals and health centers with medication deficiencies, and they will be dispensed once bids are submitted.

On the other hand, the Ministry of Health, on the authority of Al-Zyoud, acknowledges that there is a waste rate of medicines estimated at 5- 7%, concentrated in the densely populated governorates, i.e. the central and northern governorates. This waste is due, among other things, to the duplication of health insurance, due to the lack of an electronic link between hospitals and health centers and medical services, the absence of an electronic link to drug stores and hospitals and health centers with central warehouses, lack of physicians commitment to treatment protocols, and the lack of health awareness among patients, which leads to a desire to collect their treatments without using them, according to Al-Zyoud.

Is it possible to go to court in case of medicine absence?
Instructions for the provision of the drug to the patient expressly provide for the provision of the prescribed and non-scheduled medication according to the lists approved by the Minister of Health. Where Article (4) of these instructions states that “the prescribed medicine that is not available under local purchase orders shall be provided by the provisions of the General Supplies System”, provided that the cheaper prescribed drug will be dispensed by pharmacies in the private sector. Whereas “the medicine that is not scheduled and / or not registered to be purchased is provided at the expense of the health insurance fund according to a prescription in the patient’s name”.

In light of these instructions, the question arises about the right of citizens to seek legal redress in the event of a shortage of medicines. Lawyer Hazem Al-Nsour, a specialist in medical cases and medical liability, says that a government-insured citizen has the right to go to court and seek compensation only if the lack of medicine results in harm, impairment, or a health symptom.

However, lawyer Islam Al-Harhashi affirms that the instructions and the health law authorize a citizen who has not received the prescribed medication to go to court and demand compensation for the price of the drug. If the absence of the drug causes health damage, he may also file a case about the harm he has suffered.

Al-Atayqa sees the judiciary as a “long process”, but he says that there are now specialized committees that can complain to, calling for the formation of an investigation committee in the hospital that is experiencing a shortage of medicine, and holding employees accountable if it turns out that their laziness or negligence is the cause of the shortage.

* Alias.
This report was in cooperation with JHR.

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