Essential Drugs-A story of corruption and betrayal of people


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Essential Drugs-A story of corruption

and betrayal of people

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

I have read with interest “Essential drugs” in your “Off the Record” column published in February 1, 2015 issue. . I would like to trace the history of “Essential drugs” in Pakistan as I have been involved with the origin/evolution of the “Essential Drugs” concept in Pakistan. My interest in this subject originated with the development of clinical pharmacology/clinical therapeutic as one of my subspecialties. In 1970s Lt. Gen. M. Ayub Khan D.G Armed Forces Medical Services established the department of clinical pharmacology /clinical therapeutics in the Armed Forces Medical College and the Military Hospital Rawalpindi. Lt Gen Ayub Khan was a pioneer of the development of medical specialties in the Armed Forces. I was already a senior medical specialist with Hepato-gastroenterology as a sub-specialty. I was sent for courses in clinical pharmacology / therapeutics abroad to UK, Europe and USA. The department was involved in up-dating the drug formularies for the Armed Forces Medical Services and making guidelines for the rational treatments. Cost effectiveness i.e. pharmaco-economics was given special emphasis. It was the practice before evolving cost-effective drugs treatments that the drug budget of the Armed Forces used to be consumed by the middle of the financial year. The low ranking patients, particularly retired, did not get enough medicines. By adopting the pharmaco-economic strategy, the budget not only full-filled the needs for the whole-fiscal year but also finances were saved to buy equipments for the patients care. Education and training of medical students and doctors in clinical pharmacology / clinical therapeutics was given special emphasis.

Lt. Gen. (R) Prof. Mahmud Ahmad Akhtar

Many articles pertaining to the sub-specialty were published in the Pak Armed Forces Medical Journal. A clinical trial on the use of the drug “Silymarin” in acute viral hepatitis on modern lines i.e. double-blind and placebo controlled for the first time in Pakistan was conducted, establishing the conclusion that the drug is no more effective than a placebo, therefore it had no role in treatment, in agreement with other drug trials i.e. at famous institutions abroad. Unfortunately the drug was registered and is misused /abused on a large scale in Pakistan.

WHO representatives visited Rawalpindi Armed Forces Medical Institutions in 1989 and discussed the concept of “Essential Drugs” list which was prepared by the WHO in 1988. I had discussion with Dr. I.H. Baloch; Director General of Health (ENT Surgeon) along with WHO representatives and a decision was made to prepare an “Essential Drug List” for Pakistan keeping the WHO “Essential Drug List” as the model. A meeting was held at the Ministry of Health. Sixty eight doctors representing Federal and Provincial Govts, all the organizations like the Armed Forces, Railways, WAPDA etc and representative of specialty organizations participated and Pakistan’s 1st “Essential Drug  List”  prepared in 1989 consisted of around 430 basic drugs and 2500 dosage form (Reference: Pakistan Drug Formulary 1989, Ministry of Health revised list 1990). Essential Drug was defined as a drug which is effective, efficacious, relatively safe, affordable, cost-effective and needed by the majority of the population. It is essentially meant to cater for the needs of the common people.

Most of the participants had no idea of the concept of “Essential Drugs”. Only Prof Khwaja Sadiq Hussain and Col Ashfaq Ahmad Khan (later Major Gen) a dermatologist made contributions in their fields. Drug packs for twenty common conditions were also prepared for use in the far-flung areas. However, the list was only utilized in the Armed Forces. Federal and provincial govt institutions kept on buying irrational, expensive drugs – based on corrupt practices- harming the poor patients. India, Bangladesh and other SAARC countries developed their “Essential Drug lists much later but implemented them immediately and vigorously.

In February 1994, the steering committee on health setup chaired by Begum Shahnaz Wazir Ali, the special Assistant to Prime Minister Benazir Bhutto recommended preparation of “National Essential Drugs List” although there was already an “Essential Drugs list” prepared in 1989 but never implemented.

A meeting was held on 11th April 1994 at the National Health Institute attended by representatives of WHO, Federal and provincial institutions, of medical organizations, the Armed Forces, Railways, WAPDA with much fanfare. Prof Nek Mohammad Sheikh Director General of Health had earlier approached me for the preparation of “Essential Drug List”. I told him that the list was there (1989) since long but never implemented. He assured me that the new list would be implemented all over the country.  Most of the participants of the meeting had no knowledge about the basic concept of “Essential Drugs’ with the exception of Prof Zaki Hassan (Psychiatrist), Brig Ashfaq Ahmad Khan (Dermatologist), Prof Mushtaq A Khan (Paediatrics) and Prof Siraj-ud-Din Ahmad who made contributions in their respective fields, other participants were involved in making a list on the basis of interests of the pharmaceutical industry. Under my chairmanship with much difficulty and hard work, a list was prepared for the primary, secondary and tertiary health care requirements of the country. In acknowledgment the D.G Health stated the most difficult role, I had to undergo in preparing the list. You also attended the conference and wrote in the “PULSE” about my largely singular contribution. A much larger list was made. D.G. Health announced that the list will be implemented vigorously and Lt Gen Mahmud Akhtar would be authorized and facilitated to check the implementation. However, soon I came to know that even the Federal medical institutions at Islamabad were not using essential drugs but expensive non-essential and even irrational drugs.

I drew the attention of the D.G. Health to this fact. He told me that the ruling politicians/bureaucrats had made commitments with the pharma – companies earlier and in future the “Essential Drugs” would be used. In June 1995 the Federal govt announced “National Drug Policy” of Pakistan of which the most prominent objective was to develop and promote the concept of essential drugs and to ensure regular availability of such drugs of acceptable quality, at reasonable prices. It was just a political rhetoric of empty words, devoid of any action and substance. During this era corruption reached dizzy heights – essential drugs even the life-saving ones disappeared from the market compelling the people to buy expensive irrational preparations and depriving poor people even of emergency life-saving drugs. Just to give an example, the iron deficiency anaemia which is very common in Pakistan particularly amongst the poor people, the essential drug Ferrous sulphate for its treatment costing a few paisas disappeared from the market, while expensive irrational preparations beyond the financial reach of majority of the people inundated the market. Likewise basic first-line anti-bacterials, penicillin V, furadantin, trimethoprim anti-staphylococcal penicillins, anti-hypertensive bendo-fluazide etc disappeared. The list is endless to mention.

It is pertinent to note that Pakistan is the only country in the World even amongst the SAARC countries where a large number of essential drugs are not available. Furadantin, the first line drug to treat urinary tract infection is not available while it is sold with impunity in the black market for 60 to 100 rupees a tablet. Due to the non availability of essential drugs, poor people cannot get treatment and that is the major reason for Pakistani population to have numerous ailments and highest maternal, neo-natal, infant, child mortality in the world, even highest among the SARRC countries. This is the country which is called the “Islamic Republic of Pakistan” which is neither Islamic nor republic nor Quaid-e-Azam’s Pakistan.

In 1995, the DG Health asked me to review the list which was revised, published in 1995 (Ref National Essential drugs list of Pakistan – Ministry of Health publication). After my retirement in 1992, an NGO titled “Network of Rational use of Medication” of which I was the first chairman was established to make people aware about the concept of essential drugs and to pressurize the Govt. to make the essential drugs available and introduce the use of essential drugs in the healthcare facilities. From the NGO’s platform a lot of articles were published in the press including the fortnightly “Doctor” which has now been renamed as “Pulse International” on this subject. I had authored the book “Rational Therapeutics in 1990 which earned a lot of appreciation from the WHO authorities and medical profession. Its second edition in 1995 earned the National Book Foundation award. In addition representations were made to the govts both PPP and Nawaz Sharif’s but without any effect. Later representations were made to President Musharaf and his govt but to no avail. You may recall that you wrote an article in  “PULSE International” in the “Off the Record” column imploring General Musharraf to at least listen on this issue to a medical General from the Army for the welfare of the common people of Pakistan.

In 2000 the NGO “Rational use of Medications” was converted to the new organization “Network of Consumers Protection”. Its executive officer, against all the laws of the country, joined General Musharraf campaign for referendum, and later in support of his party. The executive officer was awarded a place in the WHO organization.

Pakistani rulers consisting of dictators and their created leaders after the mysterious assassination of P.M Liaquat Ali Khan and removal of PM Khwaja Nazim-ud-Din by G.G. Ghulam Muhammad joined by Sikandar Mirza. Ayub Khan and Mr. Bhuto made policies for the benefits of elites – the elitist and anti-people polices. It is high time that there should be turnaround and Pakistan made a social democratic welfare state, as envisaged by the founding father of Pakistan.