Daily Times

Pakistan is a country with a population of over 200 million and more than 24.3 percent are living below poverty level. The total revised budget for year 2017-2018 is 4,774,567 million, out of which Health Affairs and services receives 12,944 million. The percentage of budget allocated to Health Affairs and Services is approximately 0.3% which clearly indicates the state of affairs and  priority given by the Government to the healthcare sector.

Basic Health services are available to only handful of population, magnitude of out of pocket expenditure on health per family is almost 76%.This very factor is sometimes a major barrier in seeking appropriate healthcare. This complex situation affects the health care seeking behaviour of the patients as they avoid medical care  to save money. In extreme  circumstances as a last resort  they do visit a physician , who after charging a hefty fee prescribes brand medications and insists that the patient should only get that specific brand. As a result the patient who could have spent Rs.100 or less is now spending Rs.1000 or more so that the physician can get his commission.

The Drug Regulatory Authority of Pakistan DRAP has fixed the Maximum retail price MRP of the drug and the medicine can not be sold above that price. The MRP is approved at the time of registration of the drug and it is printed on the label, the actual cost is different from MRP and trade cost, it includes all expenses incurred in the research and manufacturing of the drug. The pharmaceutical companies offers the physicians share in the percentage of profit in lieu of prescription generation based on the difference in  actual cost and MRP. This motivates the physicians to prescribe only specific brands and they insist that patient can only use those brands. Sometimes these brands are 10-20 times more expensive than the equally potent generic drugs available in the market, so unfortunately the patients who don’t have health insurance are paying for 10 times more expensive medication so that the prescribers can get their commissions. The ultimate loser is the patient.

With 880 registered pharmaceutical companies manufacturing drugs in Pakistan, the minimum type of brands a pharmacy needs to carry for one single medication is up to 50 which results in huge inventory for a small neighbourhood pharmacy amounting to almost 10 million. The failure to carry all the brands will result in the loss of customer, decrease in prescription count and ultimately closure of business. Again the cost of doing business for a common person is much higher because the prescriber wants to prescribe their own favourite brands and the pharmacist has no authority to dispense generic medication. Unlike in United States where Pharmacy carries only few brand medications and rest of the medicine are generic. Once the patent of a brand medication is expired and the medication is available in generic form all the patients are switched from brand to generic automatically, no new prescription is required and insurance companies pay for only generic medication resulting in a saving money for insurance company and lower copay for the patient .

This is also beneficial to the local businesses , pharmacy can run on a smaller inventory as the pharmacist has the authority to switch the brand medication to generic. The patient who don’t have health insurance for any odd reason can shop around and get the medication at cheapest price. There is long list of generic medications that are advertised for $4 per 30 days supply by different chain pharmacies. The ultimate beneficiary of this competition for lower pricing is again the patient.

A country like United States where elections are decided on health care reforms, where people who cannot afford insurance gets Medicaid and medicare, the role of physician is to diagnose the patient and prescribe medication based on the diagnosis. It is the pharmacist job to check the prescription, make sure the medication prescribed is according to the diagnosis, dosage is accurate, check any drug interaction and then dispense available generic medication and finally counsel the patient.

Same kind of system can be implemented in Pakistan, where the physician job will be to diagnose patient and prescribe the medication. The physician can not have a choice to direct the patient to buy a specific brand, The pharmacist should be able to dispense equivalent generic so that the patient can get some kind of relief in the absence of health insurance .

Drug Act of 1976 clearly states that generic medications should be prescribed when available but somehow this was never practiced by the physicians

The close collaboration between physician and pharmaceutical companies has not only harmed  the patient but has also proved lethal to the pharmacy profession in Pakistan. It is time to reform the system for better and a competitive health care system.

The author is Consultant Pharmacist Medicine Shoppe International, USA, Senior Pharmacist University of Pittsburgh Medical center, USA and has served in Pakistan as a civil servant.

Published in Daily Times, January 14^th 2019.