Farid Benhamdine discusses the changing role of the hospital pharmacist, and the potential for a new pharmaceutical agency in Algeria. He reveals the issues this is required to solve, and the benefits he sees this bringing to the system.
The role of the pharmacist in a healthcare ecosystem is often underestimated. What more do you feel should be done to address this issue?
The hospital pharmacy is considered the “poor cousin” of the profession for several reasons. First, there is no specific training, but a number of specialty teachings during the students’ sixth year. Secondly, to be appreciated within the hospital, the profession requires a real status. Today, its status is unclear, and hospital pharmacists are not in the loop of the decision-making process in healthcare institutions. They definitely need recognition and a higher hierarchical status.
For now, the overwhelming majority of our hospital pharmacists are young professionals who just passed their diploma. They have never been tasked with hospital management yet must do this daily. They have never learned how to manage a budget, or how to call for tenders. Non-pharmacists staff train them as best as they can, but lacking an awareness of the legal boundaries, they sometimes encounter problems with the justice department.
In specialized hospitals, the pharmacist manages not only the drugs, but also all the medical equipment for the patients, for radiology, prosthetics, etc. Take the case of an orthopedic surgery as an example. The surgeon will need the pharmacists to find him the appropriate pin. The pharmacists will in turn ask the Central Pharmacy of Hospitals (PCH), which has additional budget constraints and administrative processes. As a result, the hospital pharmacist must be trained both in healthcare and in management. Moreover, they need official recognition as the pivotal stakeholder between the medical staff and the PCH. To achieve this, we are implementing multidisciplinary consultation meetings called RCPs, modelling what is done abroad. We can see it with cancer care teams: when a patient has throat cancer, they gather his ENT, his oncologist, his surgeon and the pharmacist in charge of dispensing his chemotherapy. Unfortunately, in Algeria, the pharmacist is not automatically invited yet, as unreasonable as that may seem. The Hospital pharmacist must absolutely be invited for several reasons: quality of treatment, management of costs, management of stocks, and management of risk. So RCPs are capital.
In the National Cancer Plan, we introduced RCP systematization, and we will use cancer as the starting point of RCPs generalization. Pr. Bouzid includes RCPs within hospitals because he has a good team of very well-trained hospital pharmacists who are very knowledgeable in the field of oncology. This is key since new therapies and technologies against cancer have entered the market, and a great part of them carry an inordinate cost, whilst we do not know their comparative efficiency. The hospital pharmacists must know all this because they have a key role in healthcare. They must be associated to every step of the treatment, from the diagnosis to the release. Nowadays, chemotherapies in the world are personalized to each patient by the teams of cytotoxic reconstitution of each hospital. Each mix of drug is prepared in advance, properly identified and dispensed to the patient it was prepared for. This is the future of chemotherapy and thus an entirely different skillset demanded of hospital pharmacist. This is the essential condition for rationalizing the expense in chemotherapy drugs in Algeria.
What is the role of the pharmacist with regards to the financial viability of the Algerian healthcare system, and in terms of drug prescription rationalization?
It is the very definition of his job. The pharmacist rationalizes the expense, he can switch molecules when equivalent and less expensive. Sometimes, there is a difference of 50% in price. Biosimilars arriving on the market also can be interesting. When the pharmacist is associated to the RCPs, he can inform the rest of the team of the various possibilities that he can provide, their advantages and drawbacks. The pharmacist can work with them to find the best medical solution. These meetings ensure that these decisions are both rational and economically optimized. The pharmacist is also aware of the PCH’s stocks, so the patient is sure to receive his treatment in time as well.
Is the government aware of that?
Not only are they aware, but together we are implementing everything we discussed, that is both the training programs and the tools to rationalize the system. There is no other way forward. The Ministry of Health agrees with us, and we are working with straightforward solutions, adapting the American or French systems with the help of their experts. In our group, every medical field is represented. All our work will be gathered and shared soon.
So the Cancer Plan is the first step towards that goal?
This plan is a Presidential priority. The President named Pr. Zitouni as the national coordinator of the plan and the authorities have to implement everything stated in its text. It will be fully in place by 2019. We need to codify the procedures, implement them, and verify the system. Efficiency, Safety, rationality of the expenses will be ensured. Then the Ministry of Health will do the same with the other pathologies. There is a stated commitment of the authorities in that sense. A big part of the money provided by the cancer plan will be spent in medical equipment (accelerators, radiotherapy equipment, etc), and part of it will be spent in implementing these tools. The fact that cancer is a presidential priority gives this plan a real strength.
Pr. Zitouni is a surgeon, he was the Minister of Health, he is a senator, has national and international name recognition, and is very humble. He is the one who leads all 28 groups of specialists, and both young and senior volunteers donating their time to help with this project. He is a remarkable man for the task.
What are the impediments to the evolution of Hospital Pharmacy?
There is no voluntary obstacle, rather a systemic issue. Let us not forget also that Algeria is not a rich country, especially right now, even though we are holding it together. The healthcare budget per year and per capita lies around 80 to 100€. Hospital Pharmacy gets around 20% of that amount. Therefore, we receive the healthcare system that we can afford. The issue is that a lot of people do not contribute to it, because we have a lot of moonlighting. Whilst our social security is generous, as the extraordinary system of solidarity it is and should be, our population is ageing, so the expense is growing. Contributions do not evolve as fast, so our citizens have an important role to play in that system of ours. This is especially true if we want to continue to offer healthcare to everyone, no matter their nationality or their status, as we do it today. In addition to this, diagnosis means and costs have evolved, so our medicine is better but more expensive.
Is the government committed enough to promoting generic drugs?
The Algerian pharmacist has a right to substitute molecules and held that right even before French pharmacists. He can give you, provided certain conditions, a generic equivalent to your prescription. Now when he does give you a generic drug, he receives monetary incentives from the part of the Social Security, and even earns extra money when that same generic was manufactured in Algeria. Thanks to that system, our pharmaceutical industry went from 2 to 3 plants to 85 today, and 40 more plants will soon begin operations. Consequently, we have reached 50% or maybe even more of local coverage, and we are willing to reach 70% in the years to come. Local production is important. The progress is real. The authorities are in on it and the dynamics of the market towards that goal are very good. Even the financial crisis is not a problem because it can induce the right consumer behavior. In terms of prescriptions, we need to discuss and implement RCPs not only in each hospital, but also on a national level. This will provide us with national consensus for each disease and the best therapies associated. Let us take an example: one of my friends went to the USA for a conference. He had some localized problem on his skin, so a doctor who was sitting next to him told him first to identify the disease, and then to refer to the national treatment. He said “medicine is not painting. 3 painters will paint a different tree, but medicine requires a collective decision”. I think we need that in Algeria – a national therapeutic plan for each disease as done everywhere else. It is also good for the patients: when the doctor does not follow the scientific consensus, they can protect themselves from bad medical decisions.
Social Security should, in my opinion, be trusted with financing post diploma training. This is the way to alert the prescribers of the various issues. We need to accept to prescribe the medicine we can afford. There is a nomenclature of drugs and pharmaceuticals in Algeria; the doctors should not prescribe anything that is not on that list. Each list is gathered by groups of experts and corresponding stocks of drugs are ordered by the country. If you are prescribed a drug that is delivered in France or in England, you cannot be treated correctly. Of course, when a physicist believes that a drug should be added to the nomenclature, he is invited to suggest its addition to the expert committee. The process is clear, and the objective is clearly of national interest. We have the means to cure our patients. Let us not do it outside the safety and economic boundaries that have been set in our country.
My wish is that now we have access to all standard molecules, we move forward and add biotechnology. We must create partnerships with the companies that have the patents and know-how and are willing to transfer the technology. There are companies in Algeria that have the GNP agreement, and they can create such partnerships to answer the demand. That way, we will reach 70% coverage of domestic needs by Algerian manufactured drugs sooner than anticipated. All things considered, there are no impediments because we are talking about innovation and bringing here possibilities that already exist.
Most pharmaceutical companies in Algeria are family businesses. They started small and now possess big plants. It is time for mergers and acquisitions in order to mutualize the means, the research, and so on. Let us plan for that now. Saidal signed big partnerships because they have 11 units of production. Other private companies followed suit because they are large companies, yet not big enough to sign biotechnology centered contracts. Foreign laboratories will try, obviously, not to transfer their technology that is so profitable to them, but Algeria can be a strong opportunity.
What is your opinion about the bill that is currently being considered in Parliament? What are its strengths and weaknesses?
I participated in its preparatory works, though I have not had the chance to read it yet. The approach seems better to me than what was in place previously. It is better because participation possibilities will increase. Yet, it seems to me that such a bill should allow the Ministry of Health to rule through implementing decrees. Given the fluctuating character of the context, we should provide flexibility to our structure. The Bill of 1985 froze the system: each time we needed a new bill to modify the various articles. The new bill is also preferable because it allows for more flexibility and a more organic policy that evolves with the context. The new bill re-ensures free health to the people and provides a better framework for the authorities to adapt and move on.
You’ve been campaigning for a long time for the creation of a national pharmaceutical agency…
Indeed, I have committed myself to that since 2007 and I believe it to be vital. Yet, in the new bill, we left the possibilities open. On the one hand it ensures that it will be able to evolve in the right direction. On the other hand, as we learned with the case of France – the State is now funding the operations of the French agency, to avoid the conflicts of interest that led to the “Mediator Gate”. Our new agency will need proper offices, the human resources and the funding from the public sector, together with identified prerogatives and power of decision making. This is the only way for our agency to be sustainable and sheltered from any political storm. Its prerogatives will have to be separate from those of the Direction genérale de la pharmacie in order to avoid any conflict: the Direction genérale de la pharmacie is in charge of the drug policy, and the new agency covers its coordination, with the means to negotiate drug prices and drug registrations. Without this, nothing will come out of it. And clearly the proof is that the bill was voted in 2008, the status quo remained, and then in 2017 they created a new system. Thus, there is a willingness to progress. Moreover, the Minister is committed to creating that agency. He appointed someone to be the head of that future agency, so I am optimistic even if I feel that we are not going fast enough.
What is the strategic vision for SAP?
First, we are going to push forward the National Cancer Plan. Second, we will fight for transparency in the marketing of pharmaceutical products: we need more transparency on conflicts of interests. We would like the government and the Ministry to implement a public platform for everything to be disclosed on, every relationship of interest between the industry and all the stakeholders. This is in the interest of everyone. It is a safety net.