Opinion – Latin America21: Lack of medicines in Brazil: a problem that comes from abroad

Brazilians who look for basic medicines in pharmacies and hospitals, such as antibiotics, antiallergic and analgesics, have come across empty shelves and leave empty-handed. A report published by the São Paulo Regional Pharmacy Council (CRF-SP) endorses this perception by pointing out the lack of medicines in pharmacies. Different ideological fields debate solutions to the problem, but the discussion does not seem to have reached the Brazilian electoral campaign this year.

According to the CRF-SP document, 98.5% of the pharmacists consulted indicated a lack of medicines, especially antibiotics. In July, the National Confederation of Municipalities (CNM) revealed that 80% of municipalities faced a shortage of medicines needed to serve the population. The private network does not escape the high price either: a survey released by the National Health Confederation with 112 private hospitals revealed that 87.6% of them had difficulty acquiring serum, in addition to facing a significant increase in the prices of other items.

The shortage affects even more severely pediatric medicines, intended for the part of the population that is particularly vulnerable to respiratory diseases.

The problem, however, is not a surprise. In the first half of the year, the National Council of Health Secretaries (Conass) and the National Council of Municipal Health Secretaries (Conasems) were already warning about the lack of medicines. In June, several professional entities in the health sector joined in the collection for answers with the Ministry of Health.

China dependency

The immediate reason for the shortage of medicines lies in Brazil’s dependence on imported inputs, especially from China. According to data from the Brazilian Association of Pharmaceutical Ingredients (Abiquifi), the country imports about 95% of the Active Pharmaceutical Ingredients (IFA) necessary for the manufacture of medicines consumed domestically.

The Covid-19 pandemic has disrupted global production chains. On the supply side, the extension of the lockdown measures in China has affected the production capacity of its factories. Due to the pandemic, there were also strong changes in demand patterns for industrialized goods, including medicines.

In the case of the pharmaceutical industry, although the demand for supplies necessary to combat Covid-19 rose exponentially in 2020 and 2021, the demand for other types of medicines fell. With the advancement of vaccination and the return to social life, respiratory diseases returned to circulate, making 2022 an atypical year: cases of respiratory diseases grew even before winter. The demand for medicines grew early and found the pharmaceutical sector unstructured.

As if the shock caused by the pandemic on the pharmaceutical industry were not enough, the War in Ukraine reinforced the inflationary process – which had already been stimulated by the resumption of demand for services –, with the increase in fuel prices on the international market, which made freight and had a widespread impact on prices.

The devaluation of the real also made imported goods more expensive. In other sectors of the economy, prices are passed on to the consumer, as is observed daily in supermarkets. The medicines sector, however, is highly regulated, and depends on state authorization –from the Medicines Market Regulation Chamber (CMED)– to readjust its prices, impacting its profitability.

Who is responsible for scarcity?

Given this scenario, it would be possible to conclude that the shortage of medicines in Brazil is a product of globalization: economic liberalization in the last 40 years has led to the displacement of industrial sectors to China and neighboring countries, where the “world factory” was set up. Thus, the other countries would be at the mercy of problems originating in Asian countries, with their hands tied to respond to unexpected fluctuations in supply.

According to this reading, the drug shortage crisis would not be a Brazilian crisis: different countries such as Germany, France, Canada, Australia, Sri Lanka and Myanmar have also faced drug shortages. However, it is noteworthy that the last two face serious economic crises, while the first three observe the rationing of specific drugs, such as paracetamol, and, in the German case, also ibuprofen and nasal saline. This is not the case in Brazil, which has faced a shortage of a larger list of medicines, including those of indispensable use, such as antibiotics.

inner silence

International crises are mediated internally by domestic institutional arrangements. The articulation between political actors in different coalitions, which manage the available institutional resources, helps to explain governments’ responses to external crises.

In Brazil, despite the more than 680,000 deaths from Covid-19 recorded so far, the Bolsonaro government has never changed course in relation to health policy. The rough lines come out – “I’m not a gravedigger” – and notes from the Ministry of Health come in, but the strategy is the same: to refrain from coordinating the response to the (lack of) supply crisis. In the midst of his reelection campaign, Bolsonaro is silent. The Ministry of Health and Anvisa claim that they cannot intervene on the causes of the crisis, attributed to external restrictions. As a mitigating measure, the CMED authorized an increase in the prices of medicines with a risk of shortages and included dipyrone and saline solution among the items with reduced import tax on inputs.

Despite the successful trajectory of federative coordination in health built since the creation of the Unified Health System (SUS), the Bolsonaro government refrains from mobilizing responses in collaboration with the federative entities to face shortages. It also refrains from intermediating, via Itamaraty, the importation of missing basic supplies, maintaining the inertia observed during the height of the Covid-19 pandemic in the face of the scarcity of PPE and the need to purchase vaccines. Finally, it refrains from helping the most vulnerable strata of the population: instead of expanding subsidies, it proceeds with the dismantling of the Popular Pharmacy and budget cuts in health to meet the spending ceiling.

As a medium/long term response, experts have proposed polar solutions: on the one hand, the resumption of state activism is advocated with a view to creating a cutting-edge pharmaceutical sector, capable of reducing dependence on Chinese inputs. To this end, substantial investments are required in Science and Technology and in the training of qualified personnel.

This proposal has gained strength in developed countries that already have consolidated pharmaceutical industries, such as France and Germany. In Brazil, Fiocruz has signed international partnerships to circumvent dependence on Chinese factories, but its reach is limited by the absence of government support.

On the opposite pole, the liberal camp defends greater deregulation in the sector, considering the price cap on medicines as an impediment to investments by the pharmaceutical industry. The option for one of the alternatives is eminently political, but, so far, this debate has been absent from the electoral campaign.