Our findings show the negative impact of medicines shortages over procurement mechanisms and prices in a public hospital in Quito, Ecuador. During the first months of the Covid-19 crisis, the pharmacy service experienced several episodes of shortages of life-saving drugs for ICU patients. The response was to restock the medicines supply by using the quickest procurement mechanism available by law. The use of retail purchasing proven to have the highest impact on medicines prices (up to 819% increase in particular cases). Notwithstanding, the provision of medicines through the so-called electronic catalog did not produce price changes during periods of high demand.
Classically, the issue of the shortage is approached based on two main categories, either there is a problem on the demand side exceeding supply at any point in the supply chain and ultimately creating a 'stock out' at the patient's point of service delivery, or the supply of medicines identified as essential is insufficient to meet public health and patient needs. Recently, Acosta et al. have proposed a more comprehensive framework of analysis bringing up 4 principal causes of shortages episodes: market-, supply chain-, manufacturing- and political and ethical issues-related causes.
During the COVID-19 pandemic, several phenomena within these categories have coincided. Firstly, market changes due to an unexpected change in clinical practice.[8, 9] Previous experiences have shown that medicines supplies are at increased risk of being depleted rapidly during a pandemic.[10, 11] Secondly, the supply chain management has been deeply affected by the strict lock-downs imposed in countries as China, a prominent producer of active ingredients and medicines. Third, global and local political causes. At the beginning of the crisis, several of the leading worldwide producers of essential goods and medicines closed their borders to protect their own demand, already collapsing the global trade system. From the local side, regulations were not adapted to respond to this new global panorama.
To better understand the context of our study, the Ecuadorian healthcare system comprises two sectors: public and private. The public sector includes all healthcare facilities run by the Ministry of Health (MoH) and those from the public social security subsystems for formal workers, police, and the army. Hospital Pablo Arturo Suárez is one of the MoH specialty hospitals in Quito, Ecuador, and was designated as a COVID-19 hospital during the sanitary emergency.
The medicines supply system for public hospitals relies mainly on a centralized procurement process where preapproved manufactures or wholesalers bid downwards. Once a company wins the bid becomes an exclusive supplier during an established period and is also in charge of distribution to the state-owned health facilities. Thus, healthcare facilities can order and pay for the required medicines through a unique national electronic catalog.
If the drugs that the health service needs are not available in the electronic catalog, or there is a shortage, a direct purchase is authorized within limited budgets. As our results show, the drawbacks of these purchasing processes outside the traditional bulk procurement mechanisms (national electronic catalog and hospital reverse auction) are the inability to negotiate better prices by losing the advantages of large-scale purchases.
Shortages of medicinal products are not a recent problem in Ecuador. Among 7 South American countries, Ecuador was the second-highest on reporting shortages of essential drugs, and the Ministry of Health keeps updating a list of drugs already unavailable in the market for several years. Despite antibiotics are among the most affected group by shortages in previous reports from South American countries, in our study, analgesics, psycholeptics, and inotropic medicines were particularly affected by shortages, which could result from the type of patients allocated to COVID-19 critical care units. A better understanding of how different countries managed the shortages during the COVID-19 pandemic represents an opportunity for learning and improving interdisciplinary collaboration between pharmacists, physicians, and healthcare managers.[17–21]
To avoid abusive drug prices, Ecuador implemented a price regulation system with three regimes: a regulated regime for strategic medicines, a controlled regime for non-strategic medicines, and a direct price setting or emergency regime. The price of medicines is under the regulation of an ad-hoc council that sets and reviews medicines' prices. The council establishes ceiling prices for each market segment, and no drug can be commercialized at a retail price above the ceiling price. However, our results show that the ceiling pricing mechanism had no effect in limiting the price escalations of essential medicines during the pandemic, given that even with considerable increases of up to 800% in the price, many of the products never exceeded the ceiling prices set by health authorities.
Another finding of this study is that loan-stock from other public hospitals was one of the main procurement methods to overcome the shortages. We have also shown that the purchase mechanism directly influenced the price. Drugs purchased in small tenders had the most significant price increase, while medicines acquired via the electronic catalog managed by the public procurement service experienced no price changes. These findings should lead us to think that integrating the supply chain through shared information systems and creating a single public supply center for essential drugs could be a mechanism to be strengthened in the coming years. Countries like Chile report good experiences with the creation of a Central Supply Clearinghouse, named CENABAST, that procures products for the public health sector, increasing transparency of the pharmaceutical procurement process.
In conclusion, while barriers to accessing medicines are not new, the COVID-19 pandemic poses an urgent need to reinforce effective management strategies for pharmaceuticals at all levels of the supply chain. Monitoring and responding to drug shortages during a pandemic can be challenging, and governments must adapt quickly, providing specific guidance on how to deal with shortages.