The summer of 2016 was a bittersweet one for Brazilians. As the country was drawing praise for hosting a generally well-received Olympics, patients in many cities were lining up at pharmaceutical distribution centers for medications that had been unavailable for as long as several months. At Rio de Janeiro’s Rio Farmes, one of the dedicated state pharmacies responsible for the distribution of specialized, high-cost medication for chronic and rare diseases, there were drug shortages of 35 out of the 157 medications it distributes.
Earlier in the year O Dia reported that some 70,000 people in Rio de Janeiro were suffering from drug shortages for chronic diseases, schizophrenia, ulcerative colitis, lupus and pulmonary arterial hypertension. News broadcasts showed patients at distribution centers claiming they were told to “call and wait” for their prescribed drugs. In July 2016, a specialty pharmacy in the state of São Paulo posted at the entrance a list of 17 essential medicines not available. In São Paulo alone, over 21,000 people have faced a shortage of key medications for the treatment of Hepatitis C, Crohn’s disease, Alzheimer’s and cancer. Other states that have reported drug shortages include Minas Gerais, Paraná and Goiás.
“The biggest complaint is the shortage of medication at the state level, the medication that the specialized state pharmacies are responsible for providing,” says César Augusto Paro, a professor at the Institute of Studies in Collective Health at the Rio de Janeiro Federal University (IESC/UFRJ). “There’s a deficit, a difficulty, in managing the distribution of medication to the states.”
Drug shortages aren’t unheard of in Brazil, nor are they unique to this Latin American country. The U.S. has seen drug shortages, as has Great Britain. Shortages have many causes, including changes in the wholesaler contracts with hospitals and state organizations, drops in manufacturer production capacity, increased global demand and even natural disasters. But in Brazil, the shortages are being attributed by many to a combination of political turmoil and economic hardship, along with mismanagement.
Medications are supposed to be provided by Brazil’s National Health System (Sistema Único de Saúde, or SUS), one of the largest publicly funded healthcare systems in the world. But the system is reeling under larger crises gripping the country. President Dilma Rousseff was suspended in May 2016 and has since been officially impeached and removed from office, even as the country contends with a several-years-long economic slowdown.
Other problems are structural within healthcare, says Paro. “Medication is in shortage due to incompetence,” he charges. “The country hasn’t been able to structure an intelligent way of producing medication.” Brazil relies too heavily on importing drugs, he notes. “It’s very expensive, and a huge strain on the whole system,” he explains.
The drug shortages are exacerbated by what Paro calls a “chronic under-financing” of the SUS network on the part of the federal government. He says that even while municipal and state governments are kicking in their required shares of the healthcare budget — 15 percent and 12 percent, respectively — the federal government is not putting in enough of the rest. “The system has become unsustainable,” he says. Brazil’s Minister of Health, Ricardo Barros, has conceded that the country does not have the means to guarantee universal access to healthcare.
Talita Gobbi, a Brazilian-based spokesperson for the pharmaceutical company Novartis, confirms that when it comes to providing mandated drug coverage, at least, the SUS isn’t delivering. “The public side of the healthcare system is deficient,” she says. The only solution she sees is turning to the courts to force the government to pony up the required funding. Other experts agree.
Longer term solutions to drug shortages might be found in stronger public-private partnerships in healthcare, say many. The country is primed for such partnerships: In early 2015, a new law ended restrictions instituted by the federal government “that kept foreign investors from owning private hospitals or investing capital in them,” according to Law Business Research. Brazil’s new president, Michel Temer, also entered office pushing for more activity in the private sector.
Allowing the government to collaborate with private companies to invest and help manage public hospitals might mean giving the private sector more decision-making and managerial power over areas of health that have been poorly managed by the government, including the distribution of pharmaceuticals. “Public-private partnerships in Brazil aren’t simple, but they mostly work,” says Dr. Margareth Dalcolmo, respiratory physician and clinical researcher at the Oswaldo Cruz Foundation (Fiocruz). “SUS is the world's largest health system with its public reach and coverage, but it has been deteriorating, which leads to many parts of the system being open to privatization.”
Still, Paro cautions that talk of government partnerships with the private healthcare industry shouldn’t be allowed to deflect calls to get the government to chip in the needed funding for medications and other critical elements of care. “Partnerships are not a promise that investments into bettering our health system will be made a priority,” he says.
— Tarsilla S. Moura
Tarsilla S. Moura is the managing editor at GHCi.