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Opening Note
February 2022 marks my completing 47 years of working in Pharma Industry. Allah be praised. I am still working. The first half of my working career was spent in Multinational companies, and the latter half in the Local Pharma, making me well-versed with both innovators and generics markets. I also had the opportunity to work in business as well as operations.
My journey of near half century is also the journey of Pharma Industry in Pakistan. Great changes have occurred in this time and a lot could be written about it. In my blogs, which were started about four and a half years ago, I have covered several topics related to Pakistan Pharma Industry. This multi-part series shall do and review the SWOT – Strengths, Weaknesses, Opportunities, Threats – of the Pharma Industry.
SWOT – OPPORTUNITIES……
As mentioned in the introduction of SWOT, Strengths and Weaknesses are internal while Opportunities and Threats are external.
Another point to mention is that my focus is mostly on Local Pharma which is dominating the Pharma Industry since many years.
- Acceptance of Generic Products by Doctors and Patients – The change took time, but it did happen finally. Doctors mattered more because whatever they prescribed would be accepted by the patients. In the beginning, the doctors were unsure about the efficacy of generic drugs; safety wss no one’s concern. They were reluctant to switch and did so only if they wanted to give economic relief to certain patients who were not able to afford the innovator drugs. They rationalized prescribing of generic drugs on this basis, and many considered it appropriate to inform the patient also. I remember taking a patient to a leading gastroenterologist in Lahore, who did not know me personally. The consultant wrote the prescription and then explained to me. “This here is the original drug, but it is expensive. Below is its cheaper version. The price may be 20-25% less, and efficacy may be 40-50% less”. This sentiment was quite telling. This is also true that initial generics of innovator drugs were given 15-20% less prices because the MoH was also unclear. Later, the prices of generic drugs kept going down and came down to even 10-15% of the innovator drug. Such low prices also caused concerns about efficacy in the beginning but settled later. Currently, the questions of efficacy and prices are settled. It is understood by doctors that generic versions may be similarly effective, but significantly less costly.
The prescriptions of generic products were further escalated due to the unprecedented, extraordinary services provided by the generic manufacturers. The patients became familiar with generic drugs through doctors’ prescriptions, and later developed their own confidence also. Some generic pharmaceuticals such as Dicloran are now household names, and public is greatly satisfied with their efficacy.
The last barrier to break was long term medications for chronic diseases such as heart disease, diabetes, metabolic disorders, and neuropsychiatry drugs. During late 1980 and 1990s, the MNCs made a great case against generic drugs in chronic care. Their major stances were two: the generic drugs did not ensure stated bioavailability, and the generic drugs would have batch to batch variations. Both factors would seriously impact the long-term control and outcome in patients. They might not have been entirely incorrect. However, the generic manufacturers improved quality control and the clinical experience did not endorse the fears raised by MNCs. Generic drugs are the mainstay of chronic diseases management.
Local Pharma has a great opportunity in this one fact. Pharma market is growing at a rapid pace in Pakistan. Among other factors, increase in doctors’ population and patient population are most significant. Local Pharma shall be the major beneficiary of these ongoing developments.
- Access to Healthcare – Several factors have contributed to the increase in access to healthcare.
- Number of Medical Colleges has increased manifold. For a long time, there were few medical colleges in each province. The government took years to establish a new medical college because it was expensive, with a large new building, an affiliated teaching hospital with tertiary care facilities, and all the related arrangements. On an average, one new medical college was established every ten years in the whole country. The general education was rapidly shifting from government to private sector, and some investors thought why not medical education be done in private sector? In a country which urges boys to become doctors to secure their economic future and urges girls to become doctors to get more attractive marriage proposals, it was akin to tapping a goldmine, and a goldmine it did prove to be. With some influential backing, and political wheeling-dealing, private medical colleges grew like mushrooms in monsoon. The number of doctors produced every year multiplied. Much later, the government also realized the opportunity and started establishing medical colleges with the Divisional Head Quarters Hospitals which had already been functioning and had a certain number of consultants also.
Presently, there are 117 medical colleges in Pakistan: 59 in public sector and 58 in private sector. The number of seats in various medical colleges ranges from 100 to 350. The number of doctors being produced every year is around 14,000 which is still less than what is required as per population. 70% of these are women, around 50% of whom do not work after marriage. This is a huge waste of public money and is affecting the health outcome further.
- Long time back, in the days of few medical colleges and few hundred doctors qualifying every year, the government had the policy that the newly qualified doctors would either serve for two years in a rural area BHU/RHC, or in army medical corps. MBBS doctors were taken in army directly at the rank of Captain, and they could continue working in army if they wished; many did so. Then the army established its own medical college and stopped recruiting qualified doctors. Rural area working rule is relaxed but additional marks are still added in merit for such work. Forced posting of doctors to rural area improved access to healthcare, though many doctors resisted it, and did not attend their posting places regularly.
- Newly graduating doctors and qualifying consultants found that it was hard work to establish private practice in major urban areas. Presence of their seniors, availability of many doctors and discerning patients made it difficult for young doctors to get accepted, or it took long, hard work. They discovered that when they moved to peripheral areas, the landscape changed. There was less competition, and they could set up their practice quickly. What could not be achieved through government compulsion for many years was done by economic motivation. More and more doctors opted for going further and deeper into peripheral areas thereby increasing the access to healthcare.
- When we study demographics, we find that medical college seats were more and more occupied by students from remote areas. They studied hard, got high marks, and got admission on merit. Some seats were allocated based on rural allocation also. When these students graduated, they preferred to return to their hometowns and work there privately, rather than toiling in the large cities. This led to further increase in the number of healthcare professionals in suburban and rural areas. The access to healthcare was further increased.
- Many years back, the provincial governments decided to post newly qualified postgraduates in major specialties like internal medicine, general surgery, orthopedic surgery, pediatrics, and gynecology to District Head Quarters – DHQ hospitals. The move was aimed to reduce pressure on the major tertiary care hospitals in major urban centers. The new postgraduates were initially dismayed at this decision because they had the dreams to make their name the big cities. When they arrived at DHQs finally and started working, they realized what a great opportunity there was to earn money. The private consultant practices established by the first batches of consultants posted at DHQs became the envy of everyone. Their economic fortune besides, the access to specialist healthcare became available in the peripheries. The patients did not have to run to major cities to get treated for some complex diseases at least.
To be Continued……
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