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UK, remember your settings and improve government services. We also use cookies set by other sites to help us deliver content from their services. You have accepted additional cookies. You can change your cookie settings at any time. You have rejected additional cookies. There is a high threat of terrorist attack globally affecting UK interests and British nationals, including from groups and individuals who view the UK and British nationals as targets. Stay aware of your surroundings at all times. UK Counter Terrorism Policing has information and advice on staying safe abroad and what to do in the event of a terrorist attack. Find out how to reduce your risk from terrorism while abroad. Protests can be unpredictable, occur at short notice and escalate quickly. You should avoid protests and demonstrations, monitor local media and follow advice from local authorities. You should avoid travelling around protest-affected areas at night. 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See advice for women travelling abroad. There have been incidents of targeted gang assassinations, some in tourist areas. Most of these crimes are between members of rival drug gangs. Limited exceptions apply. This is part of government efforts to tackle criminal groups and organised crime. On 4 September the curfew was introduced in San Miguelito and President Mulino has also announced a similar curfew will be introduced in Bocas del Toro but no specific date has been given. In Colon the curfew is from Sundays to Thursdays from 8pm to 5am and on Fridays to Saturdays from 9pm to 6am. The use of e-cigarettes is also banned in public places. Do not become involved with drugs of any kind. You can get a prison sentence for possessing even a small quantity of drugs. The judicial process is slow and sentencing may take up to 2 years. Conditions in prisons and other detention facilities in Panama are harsh. Most facilities are overcrowded with limited access to healthcare. There have been recent cases of riots ending in prisoner deaths. Same-sex civil unions are illegal, but same-sex relationships are legal in Panama. However, Panamanian law does not ban discrimination based on sexual orientation and gender identity. Showing affection in public can lead to unwanted attention. Take care when wading, swimming or taking part in water sports on Pacific and Caribbean beaches. Some beaches have strong currents and undertows and there are rarely warning signs. People drown every year. Do not swim in the Bay of Panama as it is highly polluted with untreated sewage and industrial waste. If hiking in the hills around Boquete and the Province of Chiriqui you should consider going with an experienced guide. Trails may not be well marked, and mobile phone coverage is unreliable. Tourists have gone missing and died hiking without a guide. Seek local advice before setting out. If you are planning on driving, see information on driving abroad. You can use a UK photocard driving licence to drive in Panama for up to 3 months. The Panamanian authorities will not accept a paper licence — you can update it to a photocard licence. Drivers and front-seat passengers must wear seatbelts. Children aged 4 and under must travel in the back in fitted child seats. Drink-driving is a serious offence in Panama. If you are tested and found to have any alcohol in your system, you may get a fine, have your licence revoked and your car impounded. Driving standards can be poor. Traffic accidents are common. Roads are often poorly lit and can have potholes and unfinished repairs. Darien Province and other remote rural areas may have very few surfaced roads. Avoid any type of confrontation with other drivers or passers-by. Unregistered taxis can be in poor condition. Many accidents are due to poor maintenance and driving standards. Picking up many passengers is common in Panama. Make sure your drivers do not do this. See extreme weather and natural hazards for information about how to prepare, and how to react if there is a warning. The Atlantic hurricane season runs from June to November. Hurricanes do not directly affect Panama but often cause heavy rain. There may be flash floods and landslides. October and November have the heaviest rainfall. Monitor local news, check World Meteorological Association weather reports for Panama and follow local advice. Earthquakes are a risk in Panama. The US Federal Emergency Management Agency website has advice about what to do before, during and after an earthquake or tsunami. To help us improve GOV. Please fill in this survey opens in a new tab. Cookies on GOV. UK We use some essential cookies to make this website work. Accept additional cookies Reject additional cookies View cookies. Hide this message. Home Passports, travel and living abroad Travel abroad Foreign travel advice. Foreign travel advice Panama. Safety and security Terrorism There is a high threat of terrorist attack globally affecting UK interests and British nationals, including from groups and individuals who view the UK and British nationals as targets. Terrorism in Panama Although there is no recent history of terrorism in Panama, attacks cannot be ruled out. Political situation Protests can be unpredictable, occur at short notice and escalate quickly. You can take steps to protect yourself and your belongings, including: not carrying large amounts of money or valuables around with you leaving valuables in a safe place such as a hotel safe People have been attacked after withdrawing cash from ATMs. Sexual assault There have been violent attacks, including sexual assault, in tourist destinations in Panama City and across the country. Gang-related crime There have been incidents of targeted gang assassinations, some in tourist areas. Illegal drugs and prison sentences Do not become involved with drugs of any kind. Outdoor activities and adventure tourism Swimming safety Take care when wading, swimming or taking part in water sports on Pacific and Caribbean beaches. Hiking and mountaineering If hiking in the hills around Boquete and the Province of Chiriqui you should consider going with an experienced guide. Transport risks Road travel If you are planning on driving, see information on driving abroad. Driving standards Driving standards can be poor. Traffic can be heavy in Panama City and other populated areas such as: Pacora Chorrera Capira Arraijan Repair work and construction sites are common in these areas. Taxis Unregistered taxis can be in poor condition. Extreme weather and natural disasters See extreme weather and natural hazards for information about how to prepare, and how to react if there is a warning. Hurricanes The Atlantic hurricane season runs from June to November. Earthquakes Earthquakes are a risk in Panama. Previous : Entry requirements. Next : Regional risks. 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Salvadorans Feel Pain of ‘Gringo’ Scourge: Crack

San Miguelito where can I buy cocaine

Abstract: We measured the perception of competition in the market for essential and orphan drugs. The inflation rate for original products was 0. The province of Panama, containing The Gini coefficients were 0. Keywords: Economic competition, generic drug policy, orphan drug, pharmacy, therapeutic equivalency. Los coeficientes de Gini fueron 0. Os coeficientes de Gini foram 0. The upward price increase in both generic and original products after the release of cap prices in , whereby the market was left to free supply and demand, has left reasonable doubts as to the effectiveness of this measure. So the importance of addressing this problem goes beyond the structural characteristics of the Panamanian market, making it necessary to investigate aspects related to the conduct of economic operators along the marketing channel, as well as how the perceived competition environment, in addition to the degree of independent pricing in the retail segment. Concerning orphan drugs sold in hospitals in general, there is no clear idea of whether there are policies regarding the management of lists in pharmacies, distributor companies, and manufacturers. These drugs are essential for the treatment of rare diseases. This aspect has been a great conflict between patients and the public health system in Panama, and even in other countries of the Americas, regarding their supply. Given these facts, it is necessary to carry out a comprehensive analysis of public policies, regarding the functioning of the drug market, in the context of social inefficiency. Panama is one of the countries of the Americas with one of the worst distributions, drug supply problems, and access to out-of-pocket spending in the private sector, which is a complex problem to consider in the forthcoming reform of the public health and social security system, under a model common to that of many countries in the Americas, such as Chile, which makes it necessary to open up the debate on national drug policy in the current circumstances. While there are publications on the drug market in different parts of the world, they do not generally address certain particular aspects of countries that, as in the case of Panama, are importers of medicines, and small economies such as those of Central America, which share common realities in the face of this problem. Since , Panama has had a policy of prices established for free supply and demand in the medicines market, in which it is expected that generic medicines will generate greater price competition than innovative medicines Gorgas, Furthermore, the current situation with orphan drugs is challeging; the low incidence of rare diseases results in very high prices in the private market, increasing the budget pressures on the public health systems. In general, orphan drugs are for hospital use, they acquire them directly from the distributors for their internal use, and few of these medications are sold directly to the public. Panama has not escaped from this reality, and in the last three decades, the country has followed a scheme that has shifted from regulated prices to, in , prices set for free supply and demand. In , a system of price regulation, by means of the Decree No. Law 1 of established the previous and subsequent control of medicines as well as the bioequivalence, surveillance, and safety of medicines Ley 1 de Medicamentos, Its article established a price ceiling system for two years, leaving only the obligation of communicating increases by distributors as well as manufacturers, this mechanism ended in , when Panama moved to a system of prices with free supply and demand. However, the main problem in the marketing of medicines to both the public and private sectors is exclusive distribution agreements between manufacturing laboratories and authorized distributors that do not allow the use of the parallel import mechanism established in Law 1, which would provide an alternative for import at lower prices. Meanwhile, the free trade agreements of medicines, especially those with developed countries, have been limited to the protection of intellectual property without technology transfer, which is an important issue to raise in most developing countries Gamba, In Panama, little is known about the functioning and organization of the medicine market and the competitive environment. Panama is characterized as an importer of most medications and currently has two complex public systems for purchase, the Ministry of Health and the Panamanian Social Security Institution, that act separately. Nevertheless, the private sector establishes the prices. At the time of the study, there were nine manufacturing plants in Panama producing generic medicines at a low scale. Overall, Panama imports most of its medicines and is dominated by the distribution segment. In accordance with the Panamanian guidelines for the analysis of vertical behaviours, a C4 index equal to or above 60 is considered a relevant collective market power, and, in this case, we can conceive it likely to capture an oligopoly structure in addition to allowing control of prices. There are drugs for hospital use and those sold in the community. Overall, the private market sales the drugs, and patients can purchase medicines in community pharmacies and hospital pharmacies. Distributors do not have pharmacies because vertical integration is prohibited in Panama. Nevertheless, there are pharmacy chains, some of which belong to the main supermarket chains in the country and have greater market control over independent pharmacies. The data were obtained from three surveys: the market for essential medicines and orphans to collect perceptions, of 8. The monthly price increase was calculated by linear regression. The competitive perception index was calculated using factor analysis, and the Gini coefficients were estimated for and The main findings of this research include that the average annual price increase for original products was 2. However, in the province of Panama, despite having These results make clear the problem of access to medicines and highlight the need to revise the pricing policy in addition to the rest of the regulations in this area. This analysis has been organised into four sections, namely: materials and methods that address sources of information and statistical analysis; the results, which describe the main findings; the discussion, in which the results are contrasted with the most recent scientific evidence, and, finally, the conclusions, which put the results in context against the current environment. We utilised data from three sources. Out of the private pharmacies existing in the country in , 59 private pharmacies were randomly chosen at the national level. A survey was performed in each establishment by direct interview. A total of distributors were registered in the country, and of those, 17 were chosen by simple random sampling selected in consensus with a panel of experts considering the principal distributors and to the widest medicines marketed variety. Regarding the laboratories, the existing nine were selected, of which five are national. The survey was sent to the laboratories via email. The same survey was administered to the pharmacies, the laboratories, and the distributors. The questionnaire was composed of 21 questions and included three variables: 1 the criteria to determine prices —for instance, does the price truly correspond to the product? Is the price established independently? Is the price suggested by the distributor, the manufacturer, or their headquarters? The second source of information is the survey of out-of-pocket expenditures performed in and Briefly, the aim of the survey was to measure access to and availability of medicines and their rational use. Cabamed was elaborated using 40 generic products and their corresponding originals. The survey was performed in the District of Panama and included a total of 50 private pharmacies. Three indicators were developed for the analysis. The time frame analysed was from October to October It is a weighted index considering August as the base month and calculated for both the original reference innovators products and generic products See equation 1. This indicator allows us to observe the recent price behaviour of the medicines and contextualize the perception of competition. The inflation rate was estimated with a semi-logarithmic function, as shown in equation 2. The second indicator is the index of perception of competition in private pharmacies. As the data obtained from the laboratories and distributors encompassed a small sample size, the indicator could not be estimated due to the small sample, particularly the Keyser-Meyer-Olkin. Therefore, to complement our statistical analysis, we performed a descriptive analysis. Because we have politomic variables, a polychoric correlation matrix was first constructed, and then a principal component analysis was performed with two factors at the maximum. The first principal component was utilized. We estimated the index for every pharmacy by means of linear regression models and obtained a national and per province average indicator. The analysis of the pcSIr will be supplemented with the results of the surveys of distributors and laboratories. The third indicator is the Gini coefficient, which is calculated based on the individual incomes of participants in the survey of out-of-pocket expenditures in and The beta coefficient for the original products was 0. For generic products, the beta coefficient was 0. Figure 1. A total of 16 of the distributors mentioned that the cause was the cost of the raw material. However, 6 of the 17 stated that they had received recommendations to increase the price from the laboratories, and 15 of 17 expressed that the laboratories required them to respect the suggested price. Finally, only 4 of the 17 distributors described having a policy for managing orphan medicinal products Ministerio de Salud, Similarly, eight stated that the reason for the increase was incremental cost increases in the raw material, and one explained that the increment was price inflation. Four of the nine laboratories mentioned that they instructed the distributors to raise prices, and only two described having the policy to manage orphan drugs Ministerio de Salud, It is obvious that the price increases are aligned throughout the marketing channel. The calculations for the index of perception of competitiveness in pharmacies are presented in table 1. In contrast, the index was constructed to measure the perception of the competitive environment and its possible relationship with the pricing decisions in the retail segment, in the sense of whether or not they truly have the freedom to establish prices, given that they represent the last link of the marketing chain and come into direct contact with the consumer. The variables with higher scores were perception of competition in the market 0. The coefficient of Keyser-Meyer-Olkin global of 0. Table 1. Score coefficients extracted by the regression method with varimax rotation. Figure 2 shows a graphical representation of the index estimates. The national average total was 2. Figure 2. As shown in figure 3 , the social gap has widened, as reflected in the Lorenz curves for and The Gini coefficient increased from 0. Notably, according to the World Bank, the Gini coefficient was 0. According to the results of both surveys, the annual average out-of-pocket expenditure was USD Figure 3. Social Gap in the Distribution of Income. Surveys of Out-of-Pocket Expenses in Medications and These results make it clear that the decisions regarding the retail prices are influenced by the laboratories, manufacturers, and distributors. Therefore, the perception that the market is very competitive is contradictory in light of these results. This finding raises questions about the expected effect of the current pricing policy based on free supply and demand. However, despite studies of interchangeability between innovative and generic products, some mechanisms of Law 1 have not been applied, such as parallel imports. This might be due to agreements regarding commercial exclusivity and the pricing policies of economic agents Caja de Seguro Social, We would expect that where there is a higher density of establishments, there will be a stronger perception of competition. This situation has had a negative impact on consumers, who have few options regarding prices. It also has generated access problems, particularly because Panama is among the countries in the Americas with the much unequal income distribution, as the Gini coefficient showed, which exacerbates the inequity with respect to out-of-pocket expenses. The results make clear the high social vulnerability with regard to the precarious nature of the labour market, which may lead many individuals to incur a social risk of catastrophic expenses, in addition to the distributive inequality demonstrated by the Gini coefficient. Our findings suggest that despite a system of free competition in prices, the upward trend in prices contradicts the perceptions that the market is very competitive in Panama. Moreover, our results suggest that there are limitations in access to the consumer segment and increases in prices in recent years, as reflected in the price index of medicines with CABAMED data. Although, the market works under free competition in price, generic and innovative products have shown a trend of increased prices. Regulation opposing competition policies sparks a controversial debate, particularly within the particularities of each country. Spain, for instance, has a much more strict regulatory policy compared to other European countries, and it proposes to encourage competition by lowering the prices of generic products, with funding and reimbursement schemes that require competitive bidding Puig-Junoy, Spain aims to remove barriers to entry once the patent rights are ended; in the case of developing countries, these barriers become real obstacles to competition. Less well known is the situation of orphan drugs, whose use is restricted primarily to hospitals and in many cases requires subsidy and risk-sharing policies that are cost-effective Drummond et al. However, in a study for Peru, it is concluded that instead of establishing price controls, what should be promoted is more competition between generic and brand name drugs, so that the gap between both types is closed more of products, given the fact that there were no clear trends between international and local prices Miranda, In Panama, law 28 of protects individuals with rare diseases, defined as those whose prevalence is fewer than one person per every One could argue that this type of medication should not follow the same general pricing schemes as other pharmaceuticals, especially in developing countries facing environments of imperfect competition Simoens, This situation highlights the relationship between access to medicines and health equity. Although our findings cannot demonstrate the performance of a practice that restricts competition, it is also not clear to what extent retailers are independent to establish their prices, especially in independent pharmacies. Competition in prices in the segment retail is challenging. The presence of pharmacies within large chains, directly or indirectly, has an impact on the determination of prices at independent pharmacies, which depend on distributor provisioning systems. Panama is mainly an import country that established its national drug policy in to promote generic drugs and essential quality medicines under the system of free competition; however, the results of this policy are still controversial A. In Panama, national laboratories do not play a role in fixing prices because they have a reduced market share and produce generic products only, while distributors control the market and have exclusive relationships with regard to foreign laboratories that hold the patents on innovative products. Although between December and July , the trend in the price index of generic drugs was decreasing, from August , there was a cyclic trend upward for the original reference drugs. The increase in the cost of raw material was mainly the explanation given by the economic agents. However, the findings regarding the interference in pricing decisions in the retail segment and other distortions of the market raise the question of whether other potential explanations are involved in this situation. Panama has a scarce national industry and is import-dependent, and thus, the conditions of competition are determined outside its borders. Moreover, the country is subject to price discrimination policies from the pharmaceutical industry, given that it is considered a medium-high income country World Bank, Similarly, there has been little or no transfer of technology to developed countries, making it difficult for Panama to manufacture costeffective generic products. Similarly, large multinational pharmaceutical firms establish different pricing strategies between countries and regions. Small and dependent countries that rely on imports, therefore, have few marketing mechanisms with regard to affordable prices, particularly for new products, such as those treating non-communicable diseases. The marketing of medicines based on the pharmaceutical industry strategies is complex and creates underlying inequalities at the social level and with access to drugs, which represents a challenge for the health sector in the face of important pricing policy. Our study has strengths and limitations. Out-of-pocket surveys cannot be extrapolated to the national level; however, the results are similar to those of other studies in the context of social inequalities. Further, the scarcity of information collected regarding the handling of orphan drugs leaves us with only partial conclusions regarding the objective of this research. To the best of our knowledge, this is the first comprehensive study in Panama that involves data from different sectors of the market of medicines. The findings provide a much broader picture of a slightly oligopolistic market structure that has been complemented by pricing mechanisms, and it also offers perceptions of the competition environment in terms of the prices of innovative and generic products in the three studied market segments. Our study shows that drug prices increased in an aligned manner in the marketing channel. Although it does not show the performance of a monopolistic practice, it does not make clear the independence of retail pharmacies to establish competitive prices. Similarly, the high percentage of people without social and private insurance and the increase in out-of-pocket expenses aggravates social inequality. This highlights the need to review the current pricing policy and consider other regulatory mechanisms. Our sincere thanks to all the staff of the Ministry of Health who participated in the infield surveys and to the Gorgas Memorial Institute for Health Studies. Abdel Rida, N. Medicines pricing policy and strategies in developing countries: A review. Ibrahim, Wertheimer, A. Academic Press. Banco Mundial. Caja de Seguro Social. Listado oficial de medicamentos. Costa-Font, J. Gaceta Sanitaria, 21 1 , Degtiar, I. A review of international coverage and pricing strategies for personalized medicine and orphan drugs. Health Policy, 12 , Drummond, M. Assessing the economic challenges posed by orphan drugs. Gamba, S. The effect of intellectual property rights on domestic innovation in the pharmaceutical sector. World Development, 99, World Bank. Current classification by income. Estudios Gerenciales, 31 , Gujarati, D. New York: McGraw Hill. Herrera-Ballesteros, V. Value in Health Regional Issues, 17, Lobo, F. Madrid: Civitas. Mangin, J. Barcelona: Pearson Education. Farmacia Hospitalaria, 35 Supplement 2 , Miranda, J. Lima: Instituto de Estudios Peruanos. Ley 1 de Medicamentos y otros Productos para la Salud Humana. Ley 94 Por la cual se crea el organismo especial denominado oficina de regulacion de precios y se derogan la ley 19 de 14 de febrero de y la ley 94 de 28 de diciembre de Ley 29 de por la cual se dictan normas sobre la defensa de la competencia y se adoptan otras medidas. Ley 45 Que dicta normas sobre proteccion al consumidor y defensa de la competencia y otra disposicion. Ley 28 Que garantiza la proteccion social a la poblacion que padece enfermedades raras, poco frecuentes y huerfanas Ministerio de Salud. Oliva, J. Gaceta Sanitaria, 29 4 , El impacto de los medicamentos en el bienestar. Informe sespas Gaceta Sanitaria, 22, Owen, A. A new model to evaluate the long-term cost effectiveness of orphan and highly specialised drugs following listing on the Australian Pharmaceutical Benefits Scheme: the Bosentan Patient Registry. Journal of Medical Economics, 11 2 , Petrecolla, D. Picavet, E. Drugs for rare diseases — orphan designation status influences price. Applied Health Economics and Health Policy, 9. Puig-Junoy, J. Gaceta Sanitaria, 24 3 , Resolucion por medio de la cual se adopta la politica nacional de medicamentos Sen, A. Shy, O. Industrial organization: Theory and applications. To quote this article:: Herrera Ballesteros, V. Herrera Ballesteros victor. Eric I. Cecilio N. Received: 28 October Accepted: 10 February Introduction The upward price increase in both generic and original products after the release of cap prices in , whereby the market was left to free supply and demand, has left reasonable doubts as to the effectiveness of this measure. Statistical Analysis Three indicators were developed for the analysis. Agradecimientos Our sincere thanks to all the staff of the Ministry of Health who participated in the infield surveys and to the Gorgas Memorial Institute for Health Studies. References Abdel Rida, N. This research was covered by the public research fund of the Gorgas Memorial Institute of Health Studies.

San Miguelito where can I buy cocaine