Why Medicine Shortages Are Affecting Health Facilities Disproportionately

MOH, university, and private hospitals manage their drug stocks differently; both MOH and university hospitals also ration prescriptions to deal with shortages.

KUALA LUMPUR, June 20 – Malaysia’s medicine shortage has put the medical community on alert, although overwhelming demands for stock and global pharmaceutical supply chain disruptions are affecting some health care facilities more than others.

While some like Dr Philip Raja, a paediatrician who runs the Children and Heart Specialist Clinic in Miri, Sarawak, are running out of medicines like Ventolin, salbutamol syrups, and nebuliser inhaler solution for asthma, others maintain that there are no significant stock shortages in private hospitals or at the national level.

Medicine shortages have plagued Malaysia for years, but pharmacists are saying that the current situation has reached a “worrying level”, with longer shipment delays and frequent medicine borrowing from nearby health care facilities.

“The shortages are more frequent this time,” a chief pharmacist at a university hospital in Kuala Lumpur told CodeBlue on condition of anonymity, as he was not authorised to speak to the press. “A lot of our generics are from India and somehow we find that a lot of companies that are bringing in (medicine) from India, they have supply problems.”

According to the Malaysia Competition Commission’s (MyCC) “Market Review on Priority Sector under Competition Act 2010 – Pharmaceutical Sector” report published in December 2017, India is Malaysia’s largest source of generic medicines imports.

Other sources of generic imports, though to a lesser extent, are Eastern European and other Southeast Asian countries, like Thailand and Indonesia.

Pharmaceutical manufacturers in Malaysia are also heavily dependent on imported active pharmaceutical ingredients (APIs) and other raw materials sourced from China and India. APIs are the active components of a drug that produce the intended effect on the body to treat a particular condition.

The university hospital chief pharmacist lists antibiotics and intravenous immunoglobulin (IVIg) as two areas of concern that the hospital is monitoring “very carefully”. The latter is used to treat various autoimmune, infectious, and idiopathic (uncertain origin) diseases.

This is in addition to injections like esomeprazole used for gastric or ulcer bleeding, he said.

Previously, a procurement pharmacist who works at a private hospital outside the Klang Valley told CodeBlue about shortages of paediatric drugs like antibiotic syrups, ibuprofen syrups, antihistamines, phlegm thinning drugs, singular sachet and tablets for children, and nebulising solutions, besides throat gargling solutions and sprays, as the reopening of schools leaves many children at risk of infectious diseases.

Other drugs in short supply that she named were Epilim injection used to treat epilepsy (seizures or fits) and bipolar disorder, Rivotril tablets to treat epilepsy and anxiety disorder, Stesolid rectal tubes used for severe anxiety and epileptic and febrile convulsions, and lorazepam tablets used to treat anxiety.

But not all health facilities share the same urgent concerns.

Amrahi Buang, president of the Malaysian Pharmacists Society (MPS), said that the uneven impact of medicine shortages in the country point to a “systemic problem” in Malaysia’s two-tier health care system where public and private health care providers compete with each other in a complex market.

“I’m not saying it (two-tier system) is right or wrong, but this should be addressed with a clear vision in the future.

“When the public and private systems are uncoordinated, that’s why we have this problem,” Amrahi told CodeBlue when contacted. “We have to correct the system,” he said, adding that the matter should be addressed in the government’s planned White Paper on health reform.

A government hospital doctor in Kuala Lumpur described medicine shortages in the country as a “chicken and egg issue” that has persisted for decades.

“The problem is, when a private entity opens up to provide care, they have to be sufficient or self-sustaining to run the hospital. So, GPs at these private clinics or hospitals need to make sure they have the medicines they need – that they are well stocked up as anticipated.

“But sometimes, they don’t see it happening or have a health contingency plan in place,” the doctor told CodeBlue on condition of anonymity, due to the government’s gag order on civil servants. “People are crying wolf because they need medication. But the thing is, the surge in demand for medication and supply chain disruptions weren’t something that was not anticipated.”

“So, it’s the case that nobody is at fault, but everyone’s to blame,” he added.

How MOH Hospitals Manage Their Stock

The government hospital doctor told CodeBlue that inventory issues boil down to two factors – namely, the size of orders and policies to deal with shortages, which the Ministry of Health (MOH) has the upper hand, he claims.

“So, for example, MOH may buy three containers of medicine, but private clinics or hospitals may only need 10 bottles – so this pushes them (private clinics) to the back of the order,” the doctor said.

Bulk purchases also allow the MOH to indirectly control and reduce medicine prices, unlike in the private sector where there are no price control methods. MOH’s three procurement methods are supply by the concession company, national tender, and local purchase.

“On procurement, there are alternatives. Let’s say our main supplier is short on certain drugs, we will always have alternative generic medicines that can be used. There are all these contingency plans at the MOH,” the government doctor said.

Pharmaniaga Bhd, the main supplier of drugs to the MOH, last week said it had ramped up production ahead of anticipated increases in demand for various drugs, with the company having three to six months’ worth of buffer stock for most medicines under its portfolio.

The state-owned company’s diverse supply chain also meant that each product had at least three alternative suppliers in the event of any shortage or fluctuation of API prices.

“Even if there is a shortage at MOH hospitals, it will not be obvious because there are many measures in place. One of the things we do is to ration prescriptions. If the medication is for six months, the medicine will be given to the patient every two months, for example. That’s how the pharmacy units will handle or dispense the medicine to avoid shortages. They won’t give it all at one go,” said the doctor from the government hospital.

The government doctor also pointed to the MOH’s returned medicines programme, where patients are advised to bring their medicines to the hospital when they see a doctor or are admitted to the ward, so that their own medicines will be reused instead of having to dispense new medicines.

Health director-general Dr Noor Hisham Abdullah, in a statement on November 6, 2017, said the programme resulted in savings in medicine expenses worth RM106,394, following a three-month study in a single ward from 40 government hospitals that adopted the programme.

The programme was first initiated in 2010 for proper disposal of unused drugs.

How Private Hospitals Manage Their Medicine Stock

Unlike MOH clinics and hospitals, private facilities tend to have a leaner inventory, making them more vulnerable to supply shocks.

An executive director of a private hospital in Petaling Jaya, Selangor, told CodeBlue that most private facilities manage their inventory of supplies and medications using periodic automatic replenishment (PAR) levels – a system that sets minimum and maximum quantity limits for pharmaceutical items at a given time.

“In an ideal world, we have PAR levels which are adjusted based on activity. This is based on individual organisations. But you can see from annual reports, what the average inventory days are. Most private hospitals will not keep [their stock] more than 40 days.

“In extreme cases if we know in advance, we may stock up but not by much, maybe another month’s worth at most because we will run into issues if we later cannot dispose and then incur write offs,” said the private hospital director, who requested anonymity.

Private hospitals will also try to find substitutes when stocks run low or if they are alerted of potential disruptions by their suppliers.

“With rarer drugs, we will start calling fellow private hospitals in the region to see if they have stock they can loan, which we will return when our own stock arrives. Nowadays, it’s just over WhatsApp,” the executive director said.

“If there is none in private, we will approach public hospitals,” the hospital director added. “It’s based on the rapport we have with them, which depends on the chief pharmacist or hospital director. Usually, [we will approach] the nearest public hospital.”

The Health Ministry last week issued a guideline to streamline the process for government health care facilities to loan medicine supplies to private clinics or hospitals, three days after Health Minister Khairy Jamaluddin announced the policy.

However, it’s unclear if private facilities will take up the offer, given the red tape involved in borrowing from government facilities.

“Absolute last resort,” the private hospital director said.

“The problem can come when the public uses one drug (generic) and private uses another brand, which means though it’s the same drug, I can’t borrow it because I cannot return the same drug. Drug procurement is usually on contract so it’s not easy to buy ad hoc.

“Sometimes it’s just a matter that the drug doesn’t look the same. MOH drugs have ‘kontrak KKM‘ printed on them. When we return, it doesn’t have that print. It may make it difficult for them when audited,” the director added.

In Sarawak, state health deputy director (pharmacy) Nor Anizah Osman told CodeBlue briefly via text last week that no private clinics or hospitals in the state have made any application to borrow medicine from Sarawak’s public hospitals. “Not yet, so far,” she said.

Nor Anizah said while hospital directors have the prerogative to approve the lending of requested drugs to the applicant (private facility), the process is “still under indirect monitoring of the Sarawak state health department and the MOH”.

How University Hospitals Manage Their Stock

University hospitals, on the other hand, operate on a hybrid model, combining practices from both the public and private sectors. University hospitals are under the purview of the Ministry of Higher Education (MOHE).

The chief pharmacist at a Klang Valley university hospital said teaching hospitals also have three procurement methods, similar to the MOH, one of which is a pooling system with the latter where certain medicines are purchased in bulk together.

Orders made by university hospitals, however, make up only about 10 per cent of the order pooling size, with the MOH accounting for the remaining 90 per cent.

“Our purchasing scale cannot be compared to the MOH. The MOH really purchases a lot more than us so sometimes, even though we are in a pool procurement, the suppliers will usually supply to the MOH first,” the chief pharmacist said.

University hospitals typically have a buffer stock of one to two months, depending on the finances of individual facilities. At the height of the Covid-19 pandemic, the chief pharmacist said his hospital had a buffer stock of up to four months for certain drugs.

The average inventory days at university hospitals is about 60 days.

University hospitals also ration prescriptions as a mechanism to deal with drug shortages, while alternatives are considered for medicines that are low on supply.

“We will inform our doctors not to use a certain drug if we have a stock problem. We will tell them to use other similar antibiotics, for example. Recently, we had problems with pantoprazole, which is used for gastric, but we also had esomeprazole, which is another medicine for gastric. We recommended our doctors to use that (esomeprazole) instead and of course, we increased our order for the one that is available,” the chief pharmacist said.

University hospital pharmacists also have “informal networks” with MOH pharmacists to inquire about drugs or medical supplies that can be loaned or borrowed.

“Yes, we do have a WhatsApp group. We can ask if anyone has a certain drug and if they do, whether we can reach out to them,” the university hospital chief pharmacist said.

“We’ve reached out just recently for the IVIg and I think it’s happening a bit more frequently nowadays. Generally, if public hospitals don’t have (the medicine), then they cannot supply. Similarly, it goes both ways. Public hospitals, too, have reached out to us and the policy is the same. If we have it, we will definitely loan it out, but if we don’t, then we can’t loan out.

“Generally, they (MOH) don’t, but sometimes when they have a shortage in antibiotics or rare antibiotics which we may have – sometimes we have a rare antibiotic that they need – then yes, they will borrow from us,” the chief pharmacist said.

“Once the stock stabilises then the borrowed medicines will be returned.”

What’s The Way Forward?

It’s evident that the health industry’s visibility on the medicine supply issue is poor and dissimilar as systems and interests differ.

What’s also evident is that drug shortages are a national security issue, irrespective of where it hits, and requires its own national strategy.

As Amrahi said: “In the end, it’s very important for us to decide what we want in this country. What’s the role of the government? What can the private sector do? But the ultimate question is, are we prepared because this has become a national security issue.”

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