SAO PAULO — Brazil’s new pharmacy rules give a whole new meaning to the term “over the counter medication.”
Citing the dangers of self-medication and the desire to bring more information to consumers, the federal National Health Surveillance Agency has released regulations that require virtually all medications, down to aspirin, to be sold over the counter. Literally.
So forget browsing the shelves and comparing the price of Tylenol to Advil. Brazilians will soon have to go to the counter and ask staff members for what they want. They hand it to you – with or without advice. If the regulations stand as published, the decongestants and laxatives and just about all other oral medications that now stock the shelves will be removed from customers' reach by next February.
The new rules also prohibit sales of items that are not health related, such as ice cream or calling cards. That will affect different states differently; Sao Paulo already has relatively strict regulations, allowing sugarless chewing gum (it’s for diabetics!) but not candy or soda; some states allow a wider variety of products.
“What we’ve constructed over time is a system that requires pharmacies to play the role of health care provider more than commercial service provider,” said Dirceu Barbano, the director of the agency, known here by the Portuguese abbrevation Anvisa. These regulations, he said, would further that goal. “Is it true that all products available without a prescription should be where anyone can pick them up with absolutely no guidance and bring them home? We arrived at a conclusion: no.” He noted that the 180-day waiting period between last week's announcement of the rules and their implementation would include discussions about expanding the list of medications approved for “self-service” purchase, now mostly restricted to dermatological treatments and herbal medicines.
Taking up the soapbox against the new regulations is Sergio Mena Barreto, president of the Brazilian Association of Pharmacy and Drugstore Networks. He promises something different for those 180 days: lawsuits. Abrafarma, as the organization is known, is planning a consumer survey first, but in about a month will begin legal proceedings arguing that the new regulations violate existing law.
Regardless of the legal issues, Mena Barreto said, the government’s concern about self-medication is wrong. Only a tiny percentage of poisonings in Brazil — 0.8 percent, according to him — occur from over-medication, and it is unclear whether requiring consumers to ask for medication rather than simply pick it up will change that, anyway. And then there’s the other aspect: “Pharmacies in Brazil are businesses,” he said. “[Barbano’s] definition of a pharmacy as a health center is ideological. He believes it cannot be a business, it has to be pure.”
In pharmacies around Sao Paulo, reaction to the new rules was varied — and sometimes muted. Managers of some large chains have advised workers not to speak to the press, though they haven’t always been successful. “I think people are going to buy less, and I’m going to work more,” said a pharmacy worker at Drogaria Sao Paulo in the residential Vila Mariana neighborhood. “They’re going to ask me for something, and I’m going to give it to them. It’s going to be self-medication, just like before.” Before she could give her name, a manager shot out from the back and shepherded her away.
Elio Oda, who runs a small, family-owned Droga Nossa pharmacy in the same neighborhood, said he is waiting to see the final rules, but said he is not against moving some non-prescription drugs behind the counter. “It depends on the type of medication,” he said. “Some medication should be kept behind the counter, for other types, there’s no problem.”
And Marcelo Marques, a drug company representative who was visiting his clients at Drogaria Marques de Itu near Santa Casa, a large public hospital, said he questioned whether purchasing decisions would be swayed by having to ask a pharmacist for items. “Sincerely, someone who comes in a pharmacy to buy a pack of gum is not going to make an impulse purchase of a $25 antibiotic,” he said. But Mena Barreto of Abrafarma sees another problem: a reduction of competition between the drug companies. “Now, a customer goes into the store, finds 20 kinds of antacid powder, and can choose his brand freely, either from his past experience, from advertising or by price,” he said. “If I put that product behind the counter, there will be fewer brands available. That has a serious collateral effect: the price goes up.”
Hiding Tylenol behind the counter may seem absurd from an American perspective, but to an outsider there is something charming about the old-fashioned drugstores of Sao Paulo, where the focus is on medication, not photo developing or greeting cards, and the staff is — or at least seems — knowledgeable about medications available.
Barbano, the director of the health agency, notes that it is not just about charm, but necessity. “We are talking about the level of people’s vulnerability to commercialization,” he said. “Certainly, you or I are not very vulnerable, but there is a sector of the Brazilian population that is immensely vulnerable. We’re talking about making pharmacies responsible for giving them guidance about the use of these products.”
And, he notes, even when self-medication is not dangerous to one’s health, it is harmful to one’s pocketbook. “The American model is not the best for us,” he said. “When it comes to consumption of health care, we admire their more liberal behavior, but it costs money. Good for them that they can foot the bill.”