By Zubeida Mustafa
AT the inauguration of the Hanifa Suleman Dawood Centre of Oncology, the director of SIUT, Dr Adib Rizvi, promised to launch a movement against the spiralling prices of drugs. His concern at what can be described as the anti-social strategies of pharmaceutical manufacturers is quite valid.
The Sindh Institute of Urology and Transplantation in Karachi, prescribing to the maxim ‘health is the birthright of every man’, provides free medical treatment to every patient who enters its portal.
Since the bulk of SIUT’s budget comes from public donations and it is always looking around for funds, it has to be extra mindful of its spending. It is, therefore, worrying for it that 38 per cent of its budget goes towards financing the cost of medicines alone. This trend is nothing unusual. The Pakistan Association of Mental Health, which runs a free clinic for indigent patients and provides drugs free of charge to quite a substantial number of patients, spends 25 per cent of its budget on medicines. It may be noted that PAMH’s formulary includes only the lower-priced items.
This phenomenon of high drug prices, which amounts to the pharmaceutical industry capitalising on the distress of an ill person in desperate need of medicines, is nothing new for Pakistan. The country never went in for the manufacture of basic drugs and has always depended on the pharmaceutical multinationals importing their products at transfer prices. When combined with the corruption in the health sector, especially in the regulatory bodies that fix prices, give licences and inspect the quality of the drugs produced and marketed, the fortunes of the manufacturers have never flourished as much as they have today in Pakistan.
The Drug Regulatory Authority that has been on the cards for over two years has yet to see the light of day. The process might be expedited somewhat now that the prime minister has given his approval for the DRA Act which will be introduced in the National Assembly. But how the DRA will perform will be known only after it starts functioning.
Seen against the backdrop of the world pharmaceutical industry that had a hefty turnover of $550 billion in 2004 and has been growing at the rate of seven per cent per annum, the drug manufacturers — both indigenous and multinational — have fared well. Considering that this is a third world country with nearly a third of the population living below the poverty level and the public sector gradually disengaging from the health delivery system, can Pakistan afford to turn a blind eye to the waywardness of the drug manufacturers?
The pharmaceutical industry differs from other manufacturers in a basic way. The decision to use any of its products is not made primarily by the user. It is basically the health practitioner who makes the choice. That would explain why manufacturers cannot advertise their products in the media. Their advertising is directed only at the health professionals. In a way it has made the manufacturers’ job a tougher one. They have to employ an army of medical representatives to carry their samples to the physicians and persuade them to give their drugs a try. They cannot take the easier way out and place an advertisement in the newspaper or on television. The Drug Act 1976 does not allow it for sound reasons. How can a patient who is a layperson decide which medicine is best to treat his condition?
Hence the drugs manufacturers can only advertise in medical journals/papers that are read by doctors and surgeons. They have now found the easy way out. They try to buy over the health professionals in a bid to influence them into prescribing their brands of medicines to create a seller’s market for the pharmaceutical company. Many of the marketing tactics the manufacturers have employed have been unethical and unscrupulous.
A leading Pakistani psychiatrist, Dr Murad Moosa Khan, writes about a multinational pharmaceutical company that launched a drug for dementia in Pakistan and flew 70 Pakistani doctors to Bangkok for a three-night all-expenses-paid trip estimating to have cost the sponsor seven million rupees. Other promotional practices include sponsoring attendance at conferences, underwriting symposia, free drug samples and expensive gifts such as cars, air conditioners, laptops, etc. for writing 200 prescriptions for a medicine.
The manufacturers easily recover the cost of their marketing strategy by jacking up the price of their drugs. In Pakistan, since minimal basic manufacturing is done, multinationals import their own products and by employing the technique of transfer pricing keep the prices pitched high.
Another grave problem the country faces — and that too is linked to the price issue — is in respect of the quality of drugs. It is estimated that 50 to 70 per cent of the medicines in the market are spurious or fake. They are referred to as “dou number” (#2) and cost less. They do not cure a patient as effectively as the genuine ones are supposed to.
Given all these malpractices in which a number of physicians and manufacturers are involved, and the wrong policies adopted in the drug sector, it is not surprising that medicines are so expensive in this country. In neighbouring India the same drugs are much cheaper than what they are here. The following prices are eye-opening.
Ranitadine for acidity costs Rs2 per tablet in India as compared to Rs10 in Pakistan. Ciprofloxacin for pneumonia is Rs1.5 per tablet in India and is Rs20 in Pakistan. Alfazosin for hypertension is Rs10 per tablet in India and is Rs100 in Pakistan. Injection Amphotericin B, an antibiotic, costs Rs150 in India and is Rs300 in Pakistan. Bicalutamide, used for treating prostate cancer, is Rs35 per tablet in India compared to Rs450 per tablet in Pakistan. Lipitor, for lowering cholesterol, costs Rs8 in India and Rs60 in Pakistan.
In the absence of basic manufacturing, Pakistan is at the mercy of the drug multinationals. As a result, even after the patent of a drug has expired, not many companies other than the original manufacturers feasibly manufacture generic drugs at a lower price. India has done this successfully and thus brought down its drug prices. If the SIUT’s campaign is to succeed, Pakistan will have to promote the manufacture of generic drugs and at the same time defeat the ulterior motives of the multinationals who would not want the generic drugs to sell. It is here that the medical profession should refuse to be bought over by the drug manufacturers. Can one be hopeful? After all Z.A. Bhutto’s health policy that introduced the generic scheme failed to popularise it.
Under Trips (Agreement on Trade-Related Aspects of Intellectual Property Rights) of the WTO, a patented medicine cannot be manufactured by another company until the patent expires. But Trips contains a clause which allows their generic manufacture in case of an emergency. That is how South African manufacturers could get away without being penalised for making anti-retrovirals, used in the treatment of Aids. Why are Pakistani drug manufacturers not more inclined towards social justice? Why are profit motives allowed to determine their policies?