Dynamics of drug prescriptions
IN a recent advancement the Drug Regulatory Authority of Pakistan wrote a letter addressing various health bodies of the country to ensure that doctors prescribe medicines by their generic names rather than the commercial names; provided by a vast array of pharmaceutical companies.
The most important point in this is that DRAP does not have any direct jurisdiction over doctors’ prescriptions.
The authority’s domain includes pharmaceutical companies, distributions, storage facilities, whole sale and retail medicine outlets and pharmacists.
Moreover it is their responsibility to maintain the quality and pricing of medicines, which the organization continuously fail to achieve.
A clear proof of this failure is the up to 260 percent increase in the prices of 94 life saving drugs approved by the parliament in 2020, during a global pandemic and despite the reduction in drug salt prices in the global market.
This seems to be a hasty decision, the dynamics of which have not been well examined. Before we move on to the minor details of this action, it is imperative to understand the context of the whole situation.
Pakistan has a mixed health system, where the out of pocket expenditure on health is mostly borne by the clients.
Most of the medicines are purchased by the public from privately owned pharmacies and medical stores, spread across the country in various forms.
These retail shops are always supposed to have qualified and registered pharmacists or pharmacy assistants employed at them, in order to ensure the distribution, storage and management of drugs and other sensitive substances.
However the reality is that a huge majority of these establishments do not have qualified individuals present at their premises at all times.
There is a huge market for sale and purchase of pharmacy qualifications, the price of which is paid to the qualified people in absentia.
We must also remember how the Pharmaceutical industry functions. According to the Pakistan Pharmaceutical Manufacturers Association; there are more than 750 pharmaceutical companies currently working in Pakistan, out of which at least 25 are multinational companies.
The market is in a perpetual state of cutthroat competition. The quality and prices of all kinds of drugs vary greatly.
Some companies spend less on quality and produce much cheaper drugs with high retail prices and huge profit margins; these companies spend little on marketing by offering the retailer a major profit on the actual price.
Other companies spend large sums of money on a variety of marketing strategies, which often involve incentives for various practitioners.
Another important factor to consider here is the existence of the unregulated and unqualified section of the healthcare system.
According to some estimates there are over a million people practicing healthcare in various forms, out of which only around 200,000 are registered with Pakistan Medical Commission. The rest of these practitioners are unqualified and unregistered.
They often start their careers by working for qualified people, develop partial knowledge and skill and start practicing medicine without supervision.
Pakistan has a huge population with a doctor to patient ratio of 1:1300. This leaves ample space for quackery.
The unauthorized practice of medicine would further thrive on this apparent prescription flexibility.
Many unregistered medicinal substances are sold through different methods, especially through social media these days.
Most of these products are used as sex boosters and address various other physical complexes of the society such as skin fairness, breast size, short height, obesity, infertility and even slimness.
Pakistan has one of most unsafe medicine prescription and use practices, internationally.
This has given rise to problems such as antimicrobial resistance, self medication, unwarranted injection use, over the counter sale of prohibited and addictive drugs.
Prescribing medication is an extremely sensitive task, requiring a broad knowledge base and the ability to customize each prescription according to the patient’s needs and circumstances.
The considerations in this regard include a proper diagnosis, affordability, co-morbids, drug interactions, allergies, safety and quality, compliance and even social constraints.
It is essential that we critically look into the prescription practices of doctors in Pakistan. Poly-pharmacy or the simultaneous prescription of multiple medicines is a serious issue which often goes unchecked with several drugs being prescribed without giving proper consideration to drug interactions and contraindications.
Often conditions are over treated, which gives rise to problems ranging from adverse drug reactions and antibiotic resistance to added financial pressures on the patients and failure of social and financial risk protection.
Doctors are often offered a diverse range of incentives by the pharmaceutical industry. This in turn gives rise to complex ethical issues.
Lastly we must address the health seeking behaviours of Pakistan’s population. Often physicians end up prescribing medicines to cure the impatience of patients rather than the actual diseases.
We need to understand that hospitals are actually meant to provide sick-care, whereas healthcare should be searched for in our kitchens and parks.
People continue to make poor life choices and then ask for immediate alleviation of their symptoms, through medication.
The future lies in the concept of lifestyle medicine, which tells people to use their food as medicine.
The consumerist nature of our society helps in selling anything, especially medicines.
We need to understand that only a small number of our problems can be solved by a pill, the rest need conscious efforts on other fronts.
—The writer is Assistant Professor Public Health, Islamabad Medical and Dental College.