Anal­y­sis Med­i­cal Emer­gency

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Qual­ity health­care is the ba­sic right of the cit­i­zens and it is the re­spon­si­bil­ity of the state to en­sure an en­vi­ron­ment where they get it with­out much has­sle. The state is also sup­posed to pro­vide af­ford­able health­care to its peo­ple and, in the case of pri­vate health­care sec­tor, set up a reg­u­la­tory frame­work that min­imises or puts an end to any chances of ex­ploita­tion and foul play. Another im­por­tant duty of the state is to en­sure sup­ply of af­ford­able and qual­ity medicines in the mar­ket, pro­mot­ing a cul­ture of ad­vanced re­search in the field of cu­ra­tive medicine.

Such episodes are a grow­ing in Pak­istan. The sit­u­a­tion is that the govern­ment-run hos­pi­tals and health­care fa­cil­i­ties like the Ba­sic Health Units (BHUs) are gen­er­ally not up to the mark and the pa­tients have to rely pri­mar­ily on the pri­vate sec­tor. The over­all cost of pri­vate med­i­cal treat­ment that may in­clude physi­cian’s fee, cost of lab­o­ra­tory tests, room charges at hos­pi­tals, surgery fee, medicine prices, etc., is quite high, es­pe­cially when com­pared with the av­er­age earn­ing ca­pac­ity of the peo­ple. There­fore, it is un­der­stand­able and of­ten ad­vised that the govern­ment must reg­u­late this sec­tor and make in­ter­ven­tions wher­ever re­quired.

How­ever, over the last many years a stand­off be­tween the govern­ment and the phar­ma­ceu­ti­cal com­pa­nies has cre­ated some prob­lems for the pa­tients, in­dus­try and the reg­u­la­tors. The is­sue at hand is the health min­istry that en­joys con­trol over the pric­ing of medicines and has not al­lowed any gen­eral in­crease in the prices since 2001.

Though there is an op­tion of de­mand­ing price in­crease up to a max­i­mum of 15 per cent in “hard­ship cases,” the ap­pli­cant com­pa­nies have to prove that it is eco­nom­i­cally non-fea­si­ble for them to pro­duce these medicines at ex­ist­ing prices. The Drug Reg­u­la­tory Au­thor­ity of Pak­istan (DRAP) can ei­ther re­ject the ap­pli­ca­tion al­to­gether or raise the price by a per­cent­age (equal to or less than 15 per cent) that it finds is suit­able.

Most of the cases de­cided re­cently in the favour of the com­pa­nies have seen price in­crease of around eight per cent.

No doubt, it is more than an ideal sit­u­a­tion for the peo­ple, but the ques­tion is are there any other com­modi­ties that have faced price cap for 15 years and can the phar­ma­ceu­ti­cal in­dus­try sur­vive in such a sce­nario, asks Khalid J Chaudhry, Chair­man, Medi­pak Group. The cost of petrol, diesel, elec­tric­ity, raw ma­te­rial, labour, land, con­struc­tion, main­te­nance, etc., has sky­rock­eted in the last 15 years, but the govern­ment still wants the in­dus­try to stick to the decades-old prices, he adds. Another neg­a­tive, he says, is that the cash-strapped and non­vi­able com­pa­nies due to this price cap can­not in­vest at all in re­search and de­vel­op­ment.

He com­plains that many medicines are out of pro­duc­tion due to their non­vi­a­bil­ity and in­stead smug­gled and sub­stan­dard medicines are fill­ing the de­mand and sup­ply gap. It is a pity, he says, that the govern­ment was not ready to raise the price of 100 tablet pack of thy­roxin from Rs50 to Rs100 but the pa­tients had to buy it for be­tween Rs500 and Rs800 from the black mar­ket. “It seems the govern­ment is con­vinced that this in­dus­try is not af­fected by in­fla­tion and the rise in the cost of do­ing busi­ness.”

The lat­est is­sue is that of the tu­ber­cu­lo­sis (TB) drugs that are ex­tremely short in the mar­ket and the main rea­son is that most of the com­pa­nies pro­duc­ing them in Pak­istan have sus­pended their pro­duc­tion. The only ones pro­duc­ing them at the mo­ment are also in prob­lems and if they quit there will be a cri­sis in Pak­istan that is cur­rently ranked as a coun­try hav­ing the eighth largest pop­u­la­tion of TB pa­tients.

The short­age of cer­tain medicines, in­clud­ing cough syrups and reme­dies for psy­chi­atric pa­tients, caused by de­lay in re­lease of nar­cotics quota by the govern­ment adds to the in­ten­sity of the prob­lem. Af­ter the no­to­ri­ous ephedrine quota scan­dal, it is the in­dus­try that has had to suf­fer due to strict con­trols on re­lease of nar­cotics that are used as raw ma­te­rial in their prod­ucts.

There are al­le­ga­tions as well that the govern­ment sim­ply wants to gain po­lit­i­cal mileage by twist­ing the arm of the phar­ma­ceu­ti­cal in­dus­try. The crit­ics claim it has failed mis­er­ably to con­trol the cost of med­i­cal con­sul­tancy and ser­vices as well as smug­gling and coun­ter­feit­ing of medicines. The prices of medicines were in­creased in Novem­ber 2013 by 15 per cent but re­versed by the Prime Min­is­ter Nawaz Sharif within 48 hours to avoid pub­lic back­lash. It was around one per cent raise per year if cal­cu­lated over a pe­riod of 15 years.

Any­how, the crit­ics of the phar­ma­ceu­ti­cal in­dus­try are also there who claim the profit mar­gins of the medicine com­pa­nies are quite high even in the cur­rent sce­nario. “They warn of bank­ruptcy on one hand and on the other take doc­tors and their fam­i­lies on in­ter­na­tional plea­sure trips. They also spend a lot on ren­o­va­tion of their pri­vate clin­ics and give them ex­pen­sive gifts. All they want in re­turn is that these doc­tors shall pre­scribe medicines of their com­pany to their pa­tients,” al­leges Ah­mad Raza, a so­cial worker liv­ing in north­ern La­hore.

Aye­sha Tammy Haq, Ex­ec­u­tive Di­rec­tor, Pharma Bu­reau Pak­istan -a body of multi­na­tional phar­ma­ceu­ti­cal com­pa­nies op­er­at­ing in the coun­try states that only those medicines go out of pro­duc­tion whose prices fixed by the govern­ment are far lower than their very cost of pro­duc­tion.

She says that with the es­ca­la­tion of in­put cost over the last one and a half decades the com­pa­nies have tried all they could to con­tinue pro­duc­tion of such medicines. “We com­pro­mised on the qual­ity of pack­ing, re­moved ac­ces­sories like plas­tic spoons and mea­sur­ing cups etc. to cost cuts, but now there is no op­tion left.”

Aye­sha says they were even ad­vised to de­crease the vol­ume of medicines in the pack­ing to cover the loss but this sug­ges­tion was ruled out as it was against busi­ness ethics and their head of­fices would also ob­ject to it. “The MNCs are ex­tremely touchy about their rep­u­ta­tion and can­not put it to stake by re­sort­ing to such tac­tics.”

On the short­age of TB drugs, she ex­plains that out of the 18 com­pa­nies that pro­duced these all but two have stopped their pro­duc­tion and the rea­son once again is “the un­jus­ti­fied price con­trol.” She says the prices of medicines were fixed at a time when a US dol­lar was equal to 60 Pak­istani ru­pees. To­day de­spite es­ca­la­tion of 80 per cent in this ex­change rate in favour of the dol­lar, there is no sup­port for the sec­tor, she adds. “Ex­change rate is vi­tal as most of the raw ma­te­rial is im­ported.”

Aye­sha in­sists that Pak­istan govern­ment must pre­pare a list of es­sen­tial medicines ap­proved by the World Health Or­gan­i­sa­tion (WHO) and en­sure their reg­u­lar sup­ply in the mar­ket at any cost. It can keep prices in con­trol by of­fer­ing sub­sidy or other in­cen­tives to the man­u­fac­tur­ers and trans­fer to the con­sumers.

But, on the other hand, she says, it must with­draw from the un­nec­es­sary price con­trol and let the mar­ket flour­ish. “When new com­pa­nies will en­ter there will be com­pe­ti­tion. Prices will come down and the qual­ity will im­prove. At the mo­ment in­vestors are wary due to the 15 years old price cap and the un­nec­es­sary state in­ter­fer­ence. “If there is no profit, who will be will­ing to in­vest?”

Aye­sha states that none of the com­pa­nies she rep­re­sents, lav­ishly spend money on doc­tors and their fam­i­lies or take them abroad on plea­sure trips. If some­body is found in­volved in such ac­tiv­i­ties, strict dis­ci­plinary ac­tion is taken against him and his com­pany, she clar­i­fies. How­ever, she says, se­lec­tive doc­tors are taken abroad to at­tend in­ter­na­tional con­fer­ences on new re­search, ther­a­pies, medicines, etc., so that they can up­date their knowl­edge and serve their pa­tients bet­ter than be­fore.

The facts stated by the phar­ma­ceu­ti­cal com­pa­nies have been cor­rob­o­rated by the Min­is­ter of State for Na­tional Health Ser­vices Saira Afzal Tarar. She in­formed the Se­nate on June 7, 2016 that the com­pa­nies were seek­ing an in­crease in prices of 612 medicines but DRAP had ap­proved a price in­crease (mostly around 8 per cent) for only 177 medicines.

All said, the point to stress is that the stake­hold­ers in­clud­ing the in­dus­try and the govern­ment shall reach an ar­range­ment where the in­ter­ests of cit­i­zens are not com­pro­mised and nei­ther does the in­dus­try be­come eco­nom­i­cally un­vi­able. Ex­am­ples of other coun­tries in the re­gion that have faced sim­i­lar chal­lenges and over­come these can also be fol­lowed. But the most im­por­tant point is that all this shall be done on a pri­or­ity ba­sis and with­out fur­ther dilly-dal­ly­ing as it is a mat­ter of health and life.

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