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For physicians and pharmacists, drug shortages are proving to be an increasingly bitter pill to swallow.

Mohammed Sallam is a pharmacy manager at Welcare Hospital, Dubai. In recent months, Sallam's pharmacy has stopped supplying customers with the hormone therapy Premarin, has struggled to import adrenaline (epinephrine), and is bracing itself to manage gaps in its inpatient stocks.

It's a scene duplicated in private hospitals and pharmacies across the UAE. Drug shortages have become an all too familiar phenomenon, sending healthcare professionals scrambling to find alternatives when key medications are in short supply.

"From an end user's point of view, as a clinician, I find it very frustrating because I can't get the drugs that I want," says Dr Andre Wessels, Welcare's medical director.

He is one of a number of physicians expressing concern over what is widely seen as an ineffective pharmaceutical supply chain. Essential drugs are either not imported or are commonly out of stock, while kinks in the supply chain and poor market forecasting leaves additional gaps on the pharmacy shelves.

"Patients are being compromised," Wessels says bluntly. "We have to go to an importing company [which] functionally is very difficult. Many of these are essential drugs and it can take between six weeks and three months to get them."

Kill the competition

While the system might not be in crisis, Sallam suggests, the stuttering supply chain serving the UAE is compromising the way in which healthcare is practised in the region. The problem largely stems from the UAE's single agent system. Historically, almost all multinational drug companies are tied to a single local distributor, which is registered by the Ministry of Health to supply the product at a fixed price.

While this monopoly system allows for strict regulation of both the quality and cost of drugs entering the country, the setup has one obvious flaw: the lack of competition. If an agent runs out of stock, or chooses to stop supplying a certain drug, physicians are left without a safety net. "It doesn't make for smooth running," Wessels admits.

The situation is doubly complicated as, while government-appointed, agents are not government-run, and their focus is - understandably - profit. With no competition, agents are in the privileged position of being able to ignore market demands, and can choose to only stock medicines that guarantee a high return on investment.

For both general practitioners - who frequently prescribe common, low-cost drugs - and physicians in specialties with a small patient base, such as dermatologists, it's a practice that can lead to frustrating searches for alternative therapies.

"If there is a market shift, a change in price or in the cost of the raw materials, then the drug is not supplied to the market," Sallam agrees. "And it's not just rare medicines either. At any one time there are many essential, life-saving drugs not on the market."

"Pharmacists can be out of stock for several drugs at any one time and the new drugs you read about in the literature - you never see them over here," explains a Dubai-based dermatologist, who asked not to be named. "I recently had to treat someone for chronic urticaria and of the three options I could have offered him, they were all out of stock."

The supply situation is damaging the UAE's reputation as a medical tourism destination, she continues, adding that shortages are hampering the region's ability to offer competitive care. "If the UAE is serious about being a centre of excellence, then they need to sort out the supply of pharmaceuticals. You need medicine if you want to provide healthcare."

And the race to source alternative medications can have more serious repercussions than mere inconvenience. When drugs are switched, the risk of medication errors and adverse drug reactions is increased.

Physicians and pharmacists may be unaware that substitute drug products, even those within the same therapeutic category, have differences in strength, dosage, and time to onset of action, among other variables. Patients who regularly struggle to find particular medications may be compromising their safety.

"Even if you are able to successfully sort out the supply of one item, another 10 will suddenly be out of stock and you have to start again," Sallam admits.

The UAE is not alone in facing supply issues. Drug shortages are duplicated across the GCC. Mr Ph TG Kini is chief of pharmacy at Muscat Private Hospital. Earlier in his career, Kini was the chief pharmacist at Kasturba Medical College Hospital, Manipal, and says the difference between a single agent system and an open market is massive.

"In India everything is available - there is nothing that I cannot get. They have competition there so, for one product, there are many agents - if you tell your supplier that you need it, then the next day you will probably have it. Here there is only one agent and we are at his mercy."

Life's a batch

But the idea that fat cat agents are solely responsible for drug shortages is too simplistic. Both America and Europe, which have open, competitive markets, struggle with bottlenecks in their supply chains. Industry experts argue that the UAE's low ranking on the global pharmaceutical chain plays a significant role.

"A manufacturer has to have a minimum batch size," reasons George Vargehese, assistant general manager of UAE pharmacy chain Community Health Solutions. The country's small patient base and piecemeal ordering from the private sector means agents often wait to accumulate a minimum batch size before import, he explains.

"A batch size can be 50,000 or 100,000 but this is a small market - your order may only be 3,000. They will not manufacturer an entire batch just for your order, so they wait for additional requests to come in."

The UAE also falls behind countries with bigger orders, acknowledges Adel Djalal, director of supply chain for Gulf countries at Sanofi-Aventis. "The process is complicated...we produce all over the world, in something like 80 sites, and there are big orders from countries like the US and Germany."

Sanofi-Aventis has attempted to tackle the issue by setting up a supply warehouse in the Jebel Ali free zone. "We have more flexibility," Djalal explains. "It can take three or four weeks to get the goods from Europe, [so] we have extra stock to avoid shortages."

Economic factors also play their part, says Djalal. Because the dirham is pegged to the dollar, its decreasing value in overseas markets, coupled with the fixed price of drugs in the UAE, has seen agents' profits slip in recent years. This, when balanced against the strength of the euro, has seen the overall cost of importing drugs from Europe creep up.

"The [MoH] prices have been fixed since 2005," Sallam says. "This has meant they have become relatively more expensive. Most companies are from Europe and deal in the euro, which has become a lot stronger in the past few years."

It's no wonder, Djalal adds, that agents are consequently reluctant to ship small quantities of medications.

"The rate of the euro and the pound is affecting everything for us, but we just have to work within the [MoH] agreed CIF (cost, insurance and freight) price."

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