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Continued from Previous…… This series is based on a report compiled by Jilian Clare Cohen1, Monique Mrazek2, and Loraine Hawkins3 for World Bank.

Six decision points were identified where corruption could infiltrate. The first was manufacturing, second was marketing authorization, third is discussed below.

Decision Point Three: Selection

Pakistan allocates a fair amount of budget every year for public healthcare. It covers procurement of medicines, medical disposables, medical equipment and running of public healthcare infrastructure. It is a huge structure with billions of rupees in funding.

Public procurement procedures have undergone several revisions as the new learning came in and new guidelines were available. Current set of rules knows as ‘Public Procurement Rules’ is a set of elaborate policies and procedures, the purpose of which is to select products on merit and guard against corruption in the process. However, it should be understood that where large sums of money are involved, the entire system conspires to make corruption possible (using Paulo Coelho expression). This is true for ‘drugs’ as contraband items and ‘drugs’ as life saving drugs. The concerned staff devises ingenuous ways to beat the system. Another factor that sustains corruption in countries like Pakistan under all circumstances, is the compulsion to do so. The entire chain from bottom to top lives beyond legitimate means thanks to illegitimate income. If they stop earning the wrong way, they will not be able to maintain their standard of living. So, the corruption goes on unabated, so that the life of rich and not-so-famous is maintained.

Drug manufacturers are to be blamed equally. They desire that their drugs be procured in bulk by the government, whether they qualify or not. They make cartels, they join hands with procurement staff, and they backstab their fellow drug makers to get a large piece of cake.

“A 2005 USAID study on corruption in the pharmaceutical system in Bulgaria found that the national drug formulary had instances of under-inclusion involving the selection of newer (usually more expensive) pharmaceutical agents and the exclusion of older agents that were cost-effective. The national drug formulary included the antibiotics clarithromycin and azithromycin but not erythromycin – a longstanding first-line treatment for pneumonia and pathogens that cause other respiratory and soft-tissue infections. The study identified cases of over-inclusion; the selection of compounds that had questionable efficacy. It also found that many alternative compounds within a given therapeutic drug category were included –five statins, seven ACE-inhibitors and eight brands of ibuprofen. In some cases in the Balkans dosing has been used as a way for a favored manufacturer to secure selection, where its presentation of a given product has been different to the standard dosing offered by other manufacturers enabling it to win the bid. In other cases, failure by the regulatory authority to carefully specify its selected products has opened up doors to some manufacturers to behave unethically, if not illegally”. This sounds familiar because we, in Pakistan, face similar situation prevailing throughout the system.

“Strategies to curb the risk of corruption in the selection process are as follows.

  • Explicit criteria must be defined ahead of time by an expert committee (whose identity and credentials and terms of reference for membership on the committee are posted publicly) and published publicly so that stakeholders have clear knowledge about what criteria are being applied in the drug selection process.
  • Selection criteria should be based on international standards as set out by WHO which include:
    • relevance to the pattern of prevalent diseases in a country
    • proven efficacy and safety according to sound data
    • evidence of performance in a number of different environments
    • good quality of drugs including bioavailability and stability
    •  favorable cost-benefit ratio (based on assessment of total treatment cost)
    • preference for drugs that are well known with good pharmacokinetic properties
    • public scrutiny including the regular reporting by the media of drug selection meetings.

These measures would contribute to transparency and limit unethical practices.

Equally important, the deletion of a drug from the national drug formulary should be based on sound evidence that the drug is inappropriate or not cost-effective for the health needs of the population. Open and formal consultations with the public should be institutionalized to ensure all stakeholder views are taken into account in the drug selection process and in its aftermath and that no one group has undue influence”.

Fair pricing is usually ensured through bidding process which is concealed till submission and then open to all bidders. Apparently, it is a foolproof process, but the system exploiters here also find ways to circumvent procedures.

To be Continued……

Disclaimer. Most pictures in these blogs are taken from Google Images which does not show anyone’s copyright claim. However, if any such claim is presented, we shall remove the image with suitable regrets.

  1. Jilian Clare Cohen – Toronto, Canada
  2. Monique Mrazek – Latin America
  3. Loraine Hawkins – London

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