Pakistan’s Drug Policy and Pricing

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 Pakistan’s Drug Policy and Pricing

Lt Gen Prof Emeritus Mahmud Ahmad Akhtar\
Former Surgeon General/DGMS (IS), Pakistan Army

Pakistan’s drug policy is anti-people and pro-elite, like other policies of the government. To illustrate the drug situation in the country and drug pricing, vitamin B12 is taken as an example. Vit B12 deficiency is extremely rare in Pakistan. Its daily requirement for adults is only one microgram a day which is abundantly available in an average Pakistani diet. Vitamin literally means vit in minimum quantities (min). Human liver has a reserve of two to three years of daily requirement of Vit B12, therefore chances of deficiency occurring is extremely rare. 


Prof. Mahmud Ahmad Akhtar

Pernicious anaemia a disease of Vit B12 mal-absorption does not occur in Pakistan. It can be seen in Western countries. Deficiency can occur in gastro-intestinal mal-absorption disorders which too are uncommon.

Vitamin B12 is available as natural cyanocobalamin and its analogue hydroxycobalamin injections. Hydroxycobalamin is preferred due to its prolonged retention in the body; thereby lesser amount of vit is required for treatment. For treatment of uncommon deficiency disorders, one thousand microgram injections of hydroxycobalamin are given three times a week for 02 weeks and then one injection every 03 months. Cyanocobalamin injections are not recommended due to its shorter serum half life and shorter retention in the body – If used maintenance dose is one thousand microgram injection once every two months. Therefore the requirement of vit B12 as a drug is very meager. One thousand microgram injection of cyanocobalamin and hydroxycobalamin costs only Rupees two and the cost of one year treatment is less than Rupees twenty. Oral preparation are not used – if used the cost of oral cyanocobalamin is also very little. Injection hydroxycobalamin is included in the WHO list of ‘Essential Drugs’ (a gold standard) and is also recommended for treatment by the authentic medical scientific therapeutic guide-lines of the world, books of medicine, pharmacology, British National Formulary (BNF), American, European and other drug regulatory authorities.

In 1990s a new analogue methylcobalamin, having a shorter serum half-life and not recommended by any ‘Drug Regulatory Authority’, authentic scientific publications and not included in the WHO essential drug list, was registered by the Pakistan Ministry of Health. This preparation was earlier rejected by the ‘Drug Registration Board’ In 1980s. Furthermore it one thousand microgram injection of methylcobalamin was awarded a fantastic price of over Rupees one hundred sixty – more than eighty times of world-wide approved hydroxycobalamin. Furthermore that chosen company was granted unethical and illegal approval of advertisements – for use in every disorder – like fatigue, weakness, psycho-somatic/psychiatric disorders and all orthopedic, neurological disorders etc – for use in much higher doses for prolonged periods. Though the British National Formulary (BNF) the Bible of medicines only lists four rare disorders of deficiency as an indication for its use while it gives many side-effects which were not included in the advertising literature. This is unethical and a gross violation of the 1976 Drug Act. Incredibly over one hundred fifty pharmaceutical companies were given registration for this irrational drug. Even the oral preparations were registered – granting much higher prices.

Since then billions of rupees of methylcobalmin in foreign exchange have been imported, robbing patients of their meager financial resources and of the country already heavily debt-ridden – even unable to service the debt – dependent on IMF bail outs - a country who’s 40 percent of the population lives below the poverty line and another thirty percent touching the poverty line. Note the tremendous loss of the nation for the personal gains of the corrupt elite, many of whom became billionaires due to high prevalence of such scams.

It is worth noting that injection B complex preparation i.e. injection Trividox of the multi-national company Abbot containing Vit B1 100 mg, B6 30 mg and Vit B12 one thousand micro-gram costs Rs. twelve only and even less by other companies – huge contrast in the pricing, is it not incredible? It is to be further noted that these preparations contain one thousand micrograms of Vit B12. Methylcobalamin tablets are sold at Rupees five to ten per tablet while multivit tablet containing A to Z vits plus minerals cost Rs. three to five per tablet. Again  an astronomical contrast in pricing.

This is the so called ‘Drug Policy’ and the ‘Drug Pricing Policy’ of Pakistan. There are so many drugs in the National Formulary with the same dosage given 10 to 15 times more price of the same-molecule. In other countries the difference in price is hardly ten to fifteen percent. Due to Methylcobalamin, ephedrine and many other scams many people became billionaires while the country became poorer. The scams are repeated again and again without any accountability.

On these scams a series of representations and protests to all the ruling juntas, were lodged also by publications in the national press, fortnightly medical publication ‘PULSE’, from the platform of the NGOs, “Network of rational use of Medications” and “Network of Consumers Association” but to no avail. Recently reference was made to two members of the so called ‘Drug Regulatory Authority’ functioning without the services of a specialist in clinical therapeutics / clinical pharmacology a key specialty of drug treatment – but to no avail either.

About some life – saving essential drugs

Anti-bacterials: are life-saving drugs Penicillin V an essential first-line drug used for treating common infections is not available leading compulsively to use of 2nd line anti-bacterials which are expensive and also promotes the lethal problem of bacterial resistance.

Furadantin, the first line anti-bacterial used against urinary tract infections, costing less than Rs. two per tablet is not available officially while it is sold in the black market at a price of Rs. 60 to 100 with impunity.

Anti-staphylococcal Penicillins (cloxacillin and flucloxacillin) are not available with the result that for staphylococcal infections, extremely expensive antibiotics are needed resultantly the poor people are deprived of treatment and life. The country also looses foreign exchange by excessive spending on expensive antibiotics

Iron preparations

Pakistan’s poor people suffer enormously from iron-deficiency anaemia due to poor nutrition. The rational, cost-effective iron preparation ferrous sulphate is generally not available or scarcely available depriving people of treatment while the market is flooded with irrational expensive preparations. Due to anaemia, there is high maternal, new born, infant and child mortality.

High blood pressure

Hypertension is a very common condition in Pakistan. Bendrofluazide and hydrochlorathiozide WHO recommended cost-effective preparations are not available while an expensive analogue indipamide is freely available. This deprives many patients of affordable treatment.

Sulpha-salazine

These days sulphasalazine is out of market – the poor people suffering from rheumatoid arthritis are living in agony. The list of the unavailable essential drugs is endless. The question arises what is the solution?

The solution is simple as being done everywhere including in the SAARC countries like Bangladesh etc. The answer is to make WHO ‘Essential Drugs List’ available all over the country and at all times. For the poor people, the essential drugs should be free of cost as is the practice in other countries.

Drug Act 1976 empowers the Government to force the companies to produce Essential Drugs or loose licenses. De-register the irrational drugs which are not registered in the scientifically advanced countries of the world like UK, USA, Canada, Australia, New-Zealand, Scandinavia, European Union etc. Promote cost-effective essential drugs by including these in national and provincial formularies, issuing therapeutic guidelines, holding prescription audits, establishing the department of clinical pharmacology and clinical therapeutics a specialty like cardiology pulmonology, gastro-enterology etc., teaching rational therapeutic in the medical institutions. All these measures have been successfully adopted in other counties including Bangladesh. The “Drug Regulatory Authority” should be manned by competent professionals; the clinical pharmacologist is the most important.  

It is pathetic to note that most of the medical professional organizations are least interested in health issues affecting the common man but rather are involved in non-issues or are collaborating with the pharmaceutical industry in creating a pathetic drugs situation in Pakistan. Pakistan should be a social democratic welfare state as envisaged by the Quaid. Unfortunately it has become an elite state of the elite for the elite, by the elite. While the people of this country are denied basic rights – are one of the poorest in the world but its rulers are one of the richest in the world. The Prime Minister having a high ranking personal physician and a military secretary and ADCs, while nowhere in the world any Prime Minister has luxuries of such kind.