Please... help me get this medicine!

This investigation shows that there is a severe shortage in Moroccan pharmacies, of medicines essential for the treatment of patients with mental illness. As well as these drugs being costly for most Moroccans, importing them via the Internet is against the law, which prohibits the sale of medicines outside pharmacies. In return, the law obliges pharmacies to keep a six-month stock of medicines which they are failing to do..

Ayman (not his real name), now 29, had no idea his life was about to be turned upside down. He was getting good marks at primary and middle school and dreamed of a bright future. But he suddenly turned aggressive, began talking to himself all the time, getting angry with himself, and hating those around him, including his mother. Once he tried to kill her, and another time was on the verge of suicide, while he suffered increasing episodes of hallucinations.

Ruqaya (also not her real name), Ayman’s sister, explains what he went through: “The more we sought help to control his behaviour even seeking the help of self-styled (healers) sheikhs, or sorcerers, thinking he was under some sort of demonic possession, but his condition kept on deteriorating. Even, he would leave sometimes leave the house and stray, we would have to go and look for him. It was a hard job to get him admitted finally to the Arrazi Psychiatric Hospital, which was at maximum capacity.”

Tayeb Hamdi, head of the National Union of General Medicine in Morocco, describes as “shocking” the data on treatment of mental illness in Morocco. “We have only around 350 psychiatrists, which means one doctor for every 100,000 citizens. And we have 6.64 beds per 100,000, that’s one bed for every 15,000 people – a pitiful number.” But even Hamdi seems more optimistic than the 2022 mental health report from Morocco’s Economic, Social and Environmental Council, which said there were only 6.2 beds per 100,000 people. And it is important to note that the population of Morocco stands at over 37.8 million.

Tayeb Hamdi points out that 48.9 percent of Moroccans over 15 years old, are either currently suffering from a mental condition, or have done previously. That means approximately 9.6 million Moroccans have a mental health condition, which is higher than the global average. “A quarter of the Moroccan population suffer from depression, nine percent have anxiety, five percent psychotic conditions, and one percent have schizophrenia. Many Moroccans are therefore suffering in silence and cannot access treatment,” Hamdi adds.

This percentage is confirmed by the Economic, Social and Environmental Council (an official Moroccan institution), which also points to a significant shortage in both human resources (454 psychiatrists) and beds in psychiatric hospitals, and health centres. These figures demonstrate the lack of investment by the Moroccan government in the mental healthcare system.

There are only about 2,431 beds in psychiatric hospitals across the whole Kingdom of Morocco.

According to World Health Organization statistics for 2019, one in every eight people around the world (970 million) have suffered from some mental disorder, with anxiety and depression the most common.

In 2020 there was a major increase in the number of people suffering from anxiety and depression, because of the Covid-19 pandemic. Initial estimates showed a 26 percent increase in anxiety disorders, and a 28 percent rise in depression, in just one year. And although there are effective options available for prevention and treatment, most people with mental health conditions cannot access effective healthcare.

The Study on Mental Health and Causes of Suicide in Morocco, issued by the Economic, Social and Environmental Council in 2022, classifies mental illness as a chronic disease. Psychiatric patients are therefore caught between the rock and a hard place – the shortage of medicines on the market and their high price, against a background of rising poverty levels.

A study conducted by the National Fund for Social Reserve Organizations (CNOPS) during 2020, indicated that prices vary widely between the Moroccan market and that in France for 33 types of medicines, some of which are in frequent use. This means patients are forced to accept a price differential of sometimes over 250 percent, as is the case, for example, with Travatan, a drug used to treat glaucoma.

Even with this shortage of psychiatrists, hospitals, specialised centres and beds, most psychiatric patients do not need to be admitted to hospital if they take their medications regularly. But this is the key problem: the scarcity of medicines supplies in Moroccan pharmacies.

This reporter accompanied Ayman’s sister Ruqaya as she went to ten pharmacies in the city of Rabat, one in Salé, and three in Mohammedia and Bouznika, all of them places where she can sometimes obtain medicine for Ayman. The pharmacists there are well aware of Ayman’s condition and, whenever the drug comes in, they get in touch with her and ask her to come and buy what she needs and can afford.

Throughout March and April of 2023, as our search for the missing medicine went on, there was one thing we heard repeatedly from pharmacists: “It’s not here now, but save up your money so that, when it does come in, you can get hold of the maximum number of medicine packs.”

These words would burn Ruqaya’s heart. She says: “I remember once one of these pharmacies called me, so I rushed down to buy the medicine. But then I saw a well-to-do woman take 40 packs of the medicines, even though her prescription stated a smaller specific number.” The owner of the pharmacy told me sternly: “You should have saved up more money, and then I could have ensured that you would get a larger quantity.”

Ruqaya adds: “I’m prepared to tell you, it makes me cry every time I hear these words and others in the same vein, because they make me feel like I am being negligent. But really, I am doing everything I possibly can to get this medicine.”

It was not hard to find several sufferers prepared to talk about how they were unable to obtain medicines to treat a range of psychiatric conditions, but the difficulty lay in getting them to talk publicly about it. They were afraid that exposing the problem of lack of supply of medicines might have harmful consequences for them, and make the situation even worse, especially since pharmacies are able to control the number of medicine packs they could purchase, regardless of what is stated on the prescription. Such practices are illegal, but it works to the patient’s benefit, since they do not have to go back to square one.

Fifty-year-old Amina says: “I have two people ill at home. My daughter suffers from severe schizophrenia, while her older brother has the same condition, but less severely. After a long course of psychiatric treatment in hospital, the doctors were able to cut down their dose of medication. So instead of needing three medicine packs of Leponex a month, now we only need two.”

Amina also told me: “Every month we need this drug. Sometimes a society that cares for orphans helps me get hold of the medicine, and sometimes I borrow money to purchase the medicine. Often I get it from the psychiatric hospital, which is sympathetic to my children’s condition.” Amina urges the relevant authorities to set aside a quota of some important medicines for poor people, which is not always available in pharmacies.

As time went by, Ayman's condition became more complicated and he developed the most extreme form of schizophrenia – hiding himself behind a wall of silence, which can lead to committing murder, suicide, or living on the streets. He therefore had to stay in a clinic near Arrazi Hospital in Salé for about seventy-five days.

Many people with psychiatric conditions have suddenly lost contact with their families and become homeless, and have suffered a worse fate than Ayman’s, joining the list of people who have disappeared. On Facebook and other social media platforms you can find advertisements placed by those in search of some loved ones saying: “Missing person – suffering from a mental condition.”

Tayeb Hamdi, head of the National Union of General Medicine in Morocco, categorises psychiatric drugs according to the condition they are for: “As doctors, we classify a number of medications as of utmost therapeutic importance. These are drugs that are necessary to ensure a patient’s life is not in danger, or that will stop his condition getting worse, as well as drugs for which there is no substitute. If such drugs are not available in pharmacies, that will definitely be a major problem,” he says, referring to specific medicines for schizophrenia and severe neurological conditions, which are difficult to control without medication.

Hamdi adds: “Psychiatric patients take a lot of drugs when they start treatment, but over the years - as their condition stabilises - doctors reduce the dose of medication. But if patients can’t get enough of the essential medication, then - unfortunately - they will suffer a relapse and complications.”

Ruqaya says that Ayman is now in a “miserable” state: “The longer the medicine is unavailable in the pharmacy, the more of it I will need. That means I have to trust any source to provide me with the drug, even though I don’t want to.”

Hassan Aatich, head of the Union Chamber of Community Pharmacists of Fes, said on television that the pharmaceutical sector was suffering greatly from medicines being sold outside pharmacies, and that this was a dangerous development, because of the effects on medicines as a whole, which are the cornerstone of treatment.

Law 17.04, the legal code governing medicines and pharmacies, stipulates in Article 7 that” “All medicines manufactured, imported or exported, even as samples, are subject to official permission being granted, before they are marketed or distributed, whether for free or for money, in bulk or in retail." This means that the marketing and selling of medicines on the national market is subject to legal control and cannot take place unofficially.

Article 19, of the same law also restricts the wholesale, manufacture, import and sale of medicines to “industrial pharmaceutical institutions.” These are defined in the second paragraph of Article 74, of this law as: “All institutions that have a dedicated manufacturing site, and carry out the bulk manufacture, import, export and sale of medicines and, when necessary, their wholesale distribution.” It also defines wholesale distribution pharmacies as “institutions that engage in activities related to the purchase, possession, and wholesale distribution of medicines to pharmacies and to pharmaceutical stores inside clinics.”

To regulate the marketing and sale of pharmaceuticals, Article 55 of this same law explicitly states that “premises that are allowed to pursue the pharmaceutical profession are: pharmacies, pharmaceutical stores within clinics, and pharmaceutical institutions.”

Although the law itself sets out the penalties for the illegal selling of medicines outside the normal, legally specified premises – in Articles 134, 135 and 136 of Section Four – there is no clear and explicit prohibition on the sale of medicines in the digital space (Internet), in the law governing medicines and pharmacies in Morocco.

Khalid Aït Taleb, Minister of Health and Social Protection, has warned in the past of the risks inherent in the selling and marketing of counterfeit medicines and health products on the Internet, saying: “This has become a phenomenon in which many networks are active, both internationally and within Africa. It will pose a real danger to our country, if it is not completely stamped out.” He indicated that the ministry was fulfilling its duty to combat all forms of fraud and counterfeiting, by monitoring quality and safety in all components of medicines. This starts with the ensuring mandatory bioequivalence of generic medicines, laboratory analysis by the National Laboratory for Drug Quality Control, and pharmaceutical inspection committees with highly qualified staff.

Law 17.04, which codifies medicines and the pharmaceutical industry, was issued in 2006, i.e. about twelve years after the Internet reached Morocco, and after the volume of e-commerce there had grown to approximately $2.1 billion.

Given the increasing risks inherent in the trade in medicines over the Internet, there is a pressing need to adopt a new law that takes into account ongoing societal changes.

For its part, the Public Prosecutor’s office sent a circular to state prosecutors at both the courts of appeal and courts of first instance, calling for the Judicial Police to work together with the regional departments of the Ministry of Health, to look out for any illegal selling and distribution of medicines, and to pass the findings of their investigations to the Public Prosecutor for any necessary legal action.

The kingdom of Morocco’s efforts to reduce the import of medicines via the Internet have not been in vain, and were based on the need for “protection” against counterfeit medicines. This is underlined by the World Health Organization (WHO), which has said that: “counterfeit medicines pose an increasing threat, since the growth of the trade in pharmaceuticals, including online drug sales, opens the door to toxic products.”

Although it is difficult to determine precisely the extent of the problem, WHO’s analysis of 100 studies conducted between 2007 and 2016, covering more than 48,000 samples, shows that 10.5 percent of medicines in low- and middle-income countries are either counterfeit or fail to meet quality standards. The WHO, concerned for the safety of consumers from the harm resulting from such drugs, has warned against them.

In 2020, in response to the high prices, and the frequent absence of important medicines from pharmacies, the Competition Council stressed the need for a radical overhaul of the legal framework governing the whole Moroccan pharmaceutical market, describing the current law as “complicated, outdated, and incomplete.”

The Ministry of Health and Social Protection has highlighted several causes of this problem, the most important of which were: “interruption in the supply to manufacturing plants of raw materials for pharmaceuticals; interruption in the supply of finished products from abroad; issues with the quality of imported medicines; and medicines for which there is no locally available generic equivalent (a low-cost version of the original medicine).” The ministry noted also that “local pharmaceutical manufacturers are obliged to provide the necessary reserve stock of medicines according to Decree 02-263 of June 12, 2002, to manage periods of interrupted supply until the situation is resolved.”

The ministry says it has taken a number of steps to minimize the harmful consequences of drugs running out, or supplies being interrupted. These include “encouraging registration of new generic medicines to provide an alternative to patented medicines; and permanent, continuous monitoring of the monthly reserve stocks of medicines from industrial enterprises and materials held by the Directorate of Medicines and Pharmacy in order to prevent avoidable shortages.”

Although the Moroccan government has issued a number of statements and justifications regarding the interruption in supply of medicines, or their non availability in pharmacies, this reporter has found that the problem is continuing, amid persistent complaints from citizens. This has prompted a group of parliamentarians to act by raising the issue and tabling questions to members of the government.

Marwa El Ansari, a member of parliament (MP) for the Istiqlal Party, has pointed to recurrent interruption in supply of several medicines in pharmacies, especially those used to treat chronic diseases.

On the same problem, Saloua Berdhi, an MP for the Justice and Development Party, asked about what happens to children with attention deficit hyperactivity disorder (ADHD), a psychological disorder in which neurological development is delayed. Berdhi says: “Today, doctors in our country have begun to diagnose this condition, but the problem is that we do not manufacture or market the drug prescribed by the doctor, and this redoubles the suffering of the person affected and their family. If some families have recourse to buying it from European countries, this won’t be easy, nor will it be an option for all social groups and all Moroccan families.”

Regarding the selling of medicines through social networking sites, Fatima Zahra Bata, also an MP for the Justice and Development Party, says: “The purchasing of medicines and pharmaceutical products through social networking sites is something that is growing daily, and many digital forums have become virtual pharmacies for selling medicines… though this violates the legal controls in force in Morocco.”

On the question of the high prices charged for medicines in Morocco, in contrast to neighboring countries, Cherkaoui Znaydi, MP for the Socialist Union of Popular Forces party, asks: “There are many problems with the government’s pharmaceutical policy, including the high cost of the most commonly used medicines, especially those for treating chronic or incurable diseases. A 300mg dose of Ocrevus, a drug for patients with multiple sclerosis, costs over 50 thousand dirhams ($5,000). This adds to both the financial and physical suffering for patients, especially those in the poor and middle-income groups, while the same drug is available in some countries for less than a thousand dirhams ($100).”

This investigation contacted a number of MPs to see how the government had responded to questions they had posed to the Ministry of Health on medicine shortages in general, and those for treating mental illnesses in particular, and on the online trade in medicines. It concluded that a number of these questions remain pending, amid complete silence from the authorities. Among these are the questions posed by Fatima Zahra Bata and Saloua Berdhi.

“I submitted my question more than a month ago,” Bata says. “But unfortunately we are yet to receive an answer.” Berdhi told me the same thing had happened to her: “Sadly there has been no answer from the Ministry of Health, even though the question was submitted on January 3, 2023.”

Ruqaya and countless others who suffer from mental illness are constantly having to wait, to fight, and to compete for medicines that could help reduce the risk of their or their relative’s condition deteriorating further. Meanwhile they have to wait patiently for what the Competition Council called for in its 2020 report – an end to the infighting between government agencies which could perhaps bring a solution to this problem.

This investigation was completed with support from ARIJ