Mag.-Pharm. Dimitar Marinov: The Pharmacy Between the Market and the Patient – Guaranteed Access, Ethics, and Sustainability

Master Pharmacist Dimitar Marinov is the Chairman of the Board of the Bulgarian Pharmaceutical Union (BPU). His professional path includes over 10 years of experience in pharmacy practice, a significant part of which was as the manager of his own pharmacy. He has 5 years of experience as a responsible pharmacist, wholesaler, and manager in a marketing authorization holder company.

In parallel, he has been active in professional guild activities for more than 15 years, holding leadership positions in regional pharmaceutical structures and participating in working groups drafting key regulatory and contractual frameworks for the pharmaceutical sector.

Today, as Chairman of the BPU, Dimitar Marinov focuses his efforts on the modernization of the pharmaceutical profession and strengthening the role of pharmacists in the modern healthcare system.

I. ACCESS TO MEDICINES AND THE ROLE OF THE PHARMACY NETWORK

The Bulgarian pharmaceutical sector is in a period of regulatory and market transformations. In your opinion, what are the critical factors for sustainable patient access to medicines over the next 3–5 years?

Dimitar Marinov: Reform has been talked about in Bulgaria for years. Usually, there is more talk than action, especially in the medicine supply sector. In practice, the last major change occurred in 2006–2007, when the so-called model was abolished where only a pharmacist could own a pharmacy and could own only one pharmacy.

At that time, it was permitted for anyone to own a practically unlimited number of pharmacies, leaving a regulatory loophole for the same entities to be manufacturers, wholesalers, and own as many pharmacies as they wished. This marked the beginning of vertically and horizontally integrated structures. The prerequisites for the start of large chains were created. Today, years later, we see the result – impaired access to medicines, many pharmacies that are unevenly distributed, poorly stocked, and chronically suffering from staff shortages, despite the existence of six pharmaceutical faculties.

The challenges in the coming years will be equal access for pharmacies to medicines and the overall survival of pharmacies, given the extremely low markups on medicines for pharmacies, which are regulated by law and are increasingly insufficient against the backdrop of constantly rising operating costs.

One of the major systemic problems is the uneven access to pharmacies in smaller settlements.

What policies and European models can be adapted in our country so that the pharmacy remains close to the patient – not only in large cities?

Dimitar Marinov: In recent years, opportunities have been created for additional funding for pharmacies that are remote, located in hard-to-reach settlements, are the sole NHIF contractor in a municipality, or operate 24/7. The methodology for this funding is already yielding results – there are newly opened pharmacies in such places, and more pharmacies are performing more activities under the Health Insurance Fund, which significantly improves access to products and services. In Bulgaria, unlike many European practices, there are no geographical or demographic criteria for opening a pharmacy.

There is no requirement for the distance between pharmacies, and there is no regulation on the number of pharmacies for a specific population or need. Adding to this the removal of the restriction that only a pharmacist can own up to one pharmacy, we have reached a point where pharmacy activity has been reduced to pure trade – discounts, promotions, pseudo-economies of scale, and all sorts of unfair commercial practices that have led to senseless overconsumption of medicines with all the negative consequences thereof. The patient and their health problems are no longer important, nor is the professionalism of the pharmacist. What matters is the speed and volume of turnover, as well as the patient, but now in terms of solvency, and the public fund as a budget to be utilized. The 24-hour pharmaceutical service is critical for the system but often economically unsustainable.

What is the sustainable model for 24/7 access to medicines? Municipal participation, state support, or other mechanisms?

Dimitar Marinov: Any mechanisms that would provide additional funding for the extremely unprofitable 24-hour service are acceptable, but it must be clear that this cannot come at the expense of service quality and patient safety. Unacceptable options that imitate solutions include medicine vending machines outside the pharmacy, mobile pharmacies, online delivery of prescription medicines, and unqualified persons selling – because they cannot dispense – medicines.

During this period of medication shortages in the EU, what are we doing as a state and a professional guild to guarantee availability and protection for Bulgarian patients, given that we are a small market?

Dimitar Marinov: There must be incentives or at least conditions for marketing authorization holders to register and maintain stocks of medicines on our market. We should probably also discuss a requirement for the mandatory maintenance of essential products that we cannot do without.

II. THE ROLE OF THE PHARMACIST, DIGITALIZATION, AND PROFESSIONAL STANDARDS

You note that digitalization has changed the way work is done in the pharmacy. What needs to be improved in the electronic system so that it serves as a tool for quality and safety, rather than an administrative burden?

Dimitar Marinov: The introduction of an innovation never goes smoothly and is always associated with change. There is no doubt about the benefits of digitalization, and it is definitely not an administrative burden. Anyone claiming the opposite should recall the tons of paper that were filled out and stored in hospitals and pharmacies. Control is only a small part of the possibilities of digitalization. A huge amount of information is being accumulated, which I hope someone will eventually begin to analyze to make objective policy decisions.

Software maintenance and increasing requirements are raising costs for pharmacies. What are the most acute technological and organizational challenges today?

Dimitar Marinov: Definitely, the planned mandatory introduction of SUPTO (Software for Management of Sales in Retail Outlets) is the number one challenge. This is unnecessary because pharmacies are perhaps the most transparent part of the economy; thus, there will be no fiscal effect, but it will make the work of pharmacies very difficult. First, financially, because contrary to the Ministry of Finance’s claims, this will cost a lot of money, and pharmacies cannot calculate their costs into the final price of medicines and increase them because prices are regulated. Second, organizationally, because SUPTO changes the work processes in a pharmacy, which can no longer be assessed as anything but a burden.

What new competencies and professional roles do you see as a natural development for the Master Pharmacist in the context of personalized medicine and new therapies?

Dimitar Marinov: The resources of pharmacies are not being fully utilized by the state. We have over 3,000 pharmacies that are healthcare facilities. In addition to dispensing medicines and other products, the provision of many other services can be regulated to support the activities of other medical specialists – screening, therapy monitoring, vaccination for certain vaccines and patient groups, and many other activities related to health promotion and rational drug use.

Ethics remains a foundation in healthcare. How is a balance achieved between the economic sustainability of the pharmacy and professional responsibility toward the patient – especially during shortages or inflationary pressure?

Dimitar Marinov: It is easy for people with morals and difficult for those lacking them, who feel the need to fill that void with material acquisitions and the creation of expensive but false emotions.

III. PHARMACY ECONOMICS AND CHALLENGES BEFORE THE ADOPTION OF THE EURO

The economics of the pharmacy is under pressure – costs, personnel, regulations. What is the sustainable business model for the Bulgarian pharmacy after 2025?

Dimitar Marinov: The only sustainable model for a pharmacy is always the one based on professionalism, ethics, and a humane attitude toward the patient. For such pharmacies to develop, fair and meaningful rules (regulatory framework) are necessary, which must apply to everyone; that is, control must be comprehensive, inevitable, preventive, and objective.

The possibility for someone to ignore the rules, and for control to be a weapon against some and a shield for others, kills even the idea of the pharmacy as a healthcare facility.

Why is it strategically important to separate the payment for professional pharmaceutical activity from the value of the medicinal product?

Dimitar Marinov: Because then payment will be linked to the activity performed and will not depend on turnover. In other words, the goal will be for the patient to be treated with the least expense – meaning they pay the least for the same quality, efficacy, and safety.

Under this funding model, the patient will seek the quality of service in the pharmacy rather than the price of the product.

Before the introduction of the euro, sensitivity to prices and transparency increases. What should patients know – and how is it guaranteed that the process will be transparent and protected?

Dimitar Marinov: There is no healthcare facility or economic entity more controlled than the pharmacy, especially regarding prices. In real-time, every dispensing and sale is checked and reported to various systems external to the pharmacy, where the information cannot be changed. Maximum and ceiling prices in pharmacies are not determined by the pharmacy, but by the state.