It is not easy to be a pharmacist in Egypt, especially nowadays.
People regularly ask pharmacists to suggest medication for a fever, cold or some joint pain.
In a country where millions suffer from heart disease, diabetes and Hepatitis C and where 40 percent of the population live under the poverty line without a decent national healthcare system, it is sometimes difficult for the ill to afford a visit to a doctor, and therefore patients treat local pharmacist as their primary physician.
However, according to pharmacist Nabil El-Degheidi, a drug shortage has made his job helping patients find an appropriate or much needed drug more complicated.
El-Degheidi is now finding himself forced to provide his clients with alternatives for necessary medicines amid what many say is an acute shortage of major drugs in the Egyptian market.
Officials downplay these claims and insist drugs and adequate non-brand names are in supply.
However, a rough list of more than 130 kinds of medicines missing from pharmacies all around in Egypt was provided to Ahram Online by Mohey Ebeid, the head of the Pharmacists Syndicate.
"I never succeed in convincing the patients to take a drug other than the one they are looking for, even though [the substitute] might contain the same active ingredients," says El-Degheidi.
The 65-year-old, who has been working in the field for the past 30 years, says that the drug shortage problem has been increasing. He believes that there are about 1,000 kinds of medicines missing from the Egyptian market.
Real shortage or confusion over efficacy of substitutes?
While interviewing El-Degheidi in his pharmacy which is located in an affluent district, he received a phone call from the Egyptian Pharmaceutical Trading Company, which is one of the largest distributing companies of local and imported drugs.
El-Degheidi asked the company, "do you have Otrivin for adults? For Kids? Do you have any of the drugs that I have been requesting for the past two days?"
The answer which came from the other side in the call to all of his questions was a "No."
He ended the phone call saying, "it seems the issue is not ending anytime soon."
Journalist Mohamed El-Garhy, the founder of the social media campaign #Medicine_isaRight, says, "when I caught a cold I looked for the subscribed medicine in more than three pharmacies in different districts, but I couldn’t find it."
The social media initiative, which quickly caught the attention of both pharmacists and patients, aims to help citizens locate any missing drug subscribed for chronic or temporary diseases, and to connect them with officials from the health ministry and the Pharmacists Syndicate to solve the issue.
"It is unlikely that a medicine sold for LE1 or 2 would still be manufactured in Egypt, companies still want to make money," says Pharmacists Syndicate head Ebeid.
Ebeid did stress, however, that every drug in shortage has 12 equivalents with the same active ingredient on the Egyptian pharmaceutical market.
The Egyptian Drug Shortage Organisation, which is part of the health ministry, announced that there are 200 missing medicines that have equivalents in the Egyptian market.
However, the organisation says there are almost 45 other drugs that are not available and have no equivalents or alternatives.
Some of the missing drugs reportedly include cancer treatments and medications for controlling heart rate.
Meanwhile, Mohamed El-Bahi, board member at the Egyptian Chamber for Pharmaceutical Manufacturing, told Ahram Online that there is no shortage in medicines.
"The problem is that patients go to pharmacies asking for the commercial name of the drug, and when they do not find it, they believe there is a shortage and that the equivalent suggested by the pharmacist is different than the drug they need," said El-Bahi.
El-Bahi insisted that medicines for all diseases, including chronic illnesses, are available.
Where could the problem lie?
Pharmaceutical companies are subject to the price ceiling for medicines set by the Egyptian government.
According to the Central Administration for Pharmaceutical Affairs (CAPA), registered medicines are grouped in categories based on their price range.
The categorisation list shows that 35 percent of drugs are priced at less than LE5 ($0.64), and that 75 percent of all medicines in the market are priced at less than LE20 ($2.55).
However, these figures do not include some higher-priced medicines used to treat various chronic diseases.
This has been an ongoing friction between investors, companies in the pharmaceutical sector and the Egyptian government.
The Chamber of Pharmaceutical Industries filed a case in 2012 against the Egyptian government calling for a "balance of rights" between the rights of pharmaceutical companies and the rights of consumers.
The health ministry says its priority is to provide drugs at low prices so that they are affordable for all citizens.
On that basis the minstry rejected the complaint, prompting some observers to deduce that say companies might stop manufacturing certain medicines.
"The price of some medicines has remained the same for 25 years," former undersecretary at the Pharmacists Syndicate Mohamed Seoudi told Ahram Online.
"The government says this is to protect citizens, but at the end of the day, it is an investment for companies, who will not continue to operate at a loss," Seoudi said.
Syndicate head Ebeid also points to another problem faced by the industry in Egypt, namely the need to import raw materials for the manufacturing of drugs, which is impacted by a foreign exchange crisis limiting importers' access to dollars.
The value of the Egyptian pound has also weakened against the US dollar, Ebeid says, thus raising the cost of imports.
This has resulted in a shortage of certain drugs best known by their commercial or brand names.
However, El-Bahi says this problem is being addressed through ensuring the availability of foreign currency specifically for the purchase of raw materials for the pharmaceutical sector.
"The new Central Bank governor, Tarek Amer – appointed late October – has taken immediate decisions concerning issues related to medicines," says El-Bahi.
Drug sales this year reached LE36 billion, according to the head of the Pharmacists Syndicate.
Pharmacists have put forward several recommendations for government measures to address the problems facing the sector.
One such recommendation by the Pharmacists Syndicate involves the building of a factory in Egypt to produce raw materials instead of relying solely on imports.
"The project would cost LE500 million and is currently being reviewed by the presidency," Ebeid told Ahram Online.
Other pharmacists are demanding the sector to be regulated by an independent body instead of remaining under the auspices of the health ministry.
The Pharmacists Syndicate also recommends that medicines be referred to and prescribed by their generic names instead of using commercial brand names marketed to doctors and distributors.
"There is a problem in drug distribution, and this issue should be tackled in order to prevent the black market sale of medicines in Egypt," former syndicate undersecretary Seoudi told Ahram Online.
In 2013, Egypt ranked 149th out of 188 countries in public healthcare expenditure as a percentage of GDP, according to World Bank data.
In 2014, governmental spending on the health sector was LE 42.4 billion (5.4 percent of the total budget).
The 2014 constitution requires the state to increase spending on the health and education sectors.