Valeria Cruz has been selling black market medicines on the streets of Havana for three years. Friendships carefully maintained with several doctors means that she has no problems obtaining enough prescriptions to support her business.

She sells these medications at vastly inflated prices, but shortages in state-run pharmacies mean that many people have no choice but to turn to black market entrepreneurs like her.

“It’s true that the price of medicines is a little high but I have to pay two pesos for the prescriptions then buy the medicine at the pharmacy,” Cruz said. “I have to make money. If not, what will I live from? It works. The profits are obvious.”

Massive corruption throughout the Cuban health system means that this double-tier system is common across the country.

Although medicines are officially sold only through government pharmacies, prescriptions are routinely siphoned off to obtain remedies that are then resold on the streets for far higher prices.

As doctors are only paid up to 1,600 Cuban pesos (65 US dollars) each month  - barely a living wage - most need to find some way to subsidise their income.

“We’re talking about professionals who need to be creative to be able to take home some extra money,” Cruz said. “All Cubans know that doctors have thousands of needs and life challenges corrupt even the most honest.”

“We need to come up with something,” agreed retired paediatrician Alejandro Rodríguez. “If not, what do we live off? Snacks or presents from patients? No. It’s not enough.”

The best selling medicines on the street are salbutamol inhalers for treating asthma, the tranquiliser meprobamate, the painkiller ibuprofen and vitamin C in tablet form.

Topical treatments such as the anti-bacterial ointment gentamicin, skin cream triamcinolone and antifungal lotion clotrimazole are also in high demand.

Products such as these officially cost 0.65 Cuban pesos but are sold for ten pesos on the black market.

Teresita Rodríguez Cabrera is vice president of business operations BioCubaFarma, a state enterprise that produces medicine and high tech health equipment.

She told the official Granma newspaper that the beta-blocker atenolol and the anti-inflammatory analgesic dipyrone were in particularly high demand on the black market.

Cruz confirmed this, describing dipyrone as her bestseller. A strip of dipyrone is sold in a pharmacy for 0.70 Cuban pesos; on the street it costs five Cuban pesos.  

Eduardo Martínez Díaz, BioCubaFarma’s first vice president, also told Granma that supply shortages were making the situation worse.

Between January and July 2015, around 60 medicines were affected by problems with raw materials and the withdrawal of some suppliers. Other medicines are sourced from far away, leading to production delays.

“Of the 857 medicines that make up the state’s basic medicine supplies, 269 are imported from different countries, primarily from very distant markets like China, India and some European countries, and have a supply procurement cycle of between 60 and 90 days,” Martínez said.

Last November, the minister of public health announced new control measures to try and stamp out the illicit sales.

All doctors were limited to issuing 100 prescriptions a day, each identified by a numeric code.

“To prescribe a medicine I have to see the patient and give them a prescription,” said Adalberto Gutiérrez Mendoza, a family doctor. “Now no one can have blank prescriptions that haven’t been filled in which could be taken to a pharmacy falsifying the doctor’s name and the medicine.”

In addition, the doctor’s name and signature on the prescription must be legible and accompanied with instructions on how to take the medicine.

Without these details, the sales assistant can refuse to accept the prescription, explained Raquel Quezada, who has worked at La Palma Pharmacy for several years.

“If I can’t read what the prescription says, I won’t dispense it. My job is at risk if my boss finds a badly written prescription,” she said.

But the practice is proving hard to end, considering that the black market involves all levels of health care staff, from pharmacy workers up to doctors.

Worst affected are people who rely on these medicines, mostly of whom are elderly people.

Alejandra Gómez, 65, said, “Today I went to see the family doctor and he prescribed me cortisol cream. I went to buy it at the pharmacy and they told me that there wasn’t any.

“But on the corner of the pharmacy there was a man selling it for ten Cuban pesos,” she continued.  

“I don’t understand why the government doesn’t have enough for people´s needs but there are people selling it outside.”

María del Carmen Quintana Hechavarría is a Cuban journalist.