I have often wondered how the average Ghanaian in a country where 63 per cent of the population is not covered by any form of health insurance pays for medicine. My concern has not simply been on the basis of ability to pay but has also been driven by the concept of value for money. There are times I have checked the prices of generic medicines in the United Kingdom and compared them to their counterparts in Ghana and wondered why the products were more expensive in Ghana than they were in the UK. I have also known through pharmacist colleagues in Ghana that many patients preferred generic medicines manufactured for the UK and European market than those obtained from other sources especially the Indian sub-continent. Thus, it makes economic sense that such products will be sold at a premium price.
However, in the area of health, should the main driver of drug price be economics? On October 17, 2018 a report by the Centre for Global Development (CGD) indicated that lower-middle-income countries could be paying up to thirty times more for pharmaceutical products. The extent of the disparity shocked me to the core and made me wonder what the world was coming to. Reading the report further, I came to the realisation that this phenomenon is not going to be curtailed anytime soon.
Anyone who has insight into Ghana’s pharmaceutical supply chain will know that in the late 1990s, the market was flooded with many products, especially from India. Around that same time, anecdotal reports of treatment failure using these products began to emerge. The result was that many prescribers started advising patients with the ability to pay to purchase specific brands of medicines they prescribed as their efficacy could be guaranteed. With this knowledge, importers of generic pharmaceuticals started to get their products branded so as to give them some form of efficacious authenticity. The fact is the additional branding added no special value to these medicines.
How can it be right that “purchasers in low- and middle-income countries pay as much as 20 to 30 times the minimum international reference price for basic generic medicines like omeprazole, used to treat heartburn, or paracetamol, a common pain reliever” simply because someone put a fanciful name on the box?
In the field of drug discovery and research, a company that innovates to bring out medicine after taking it through all stages of clinical trials obtains a market authorisation that gives it exclusive rights to the manufacture and sale for a number of years. This period is referred to as the patent duration. The minute a product goes out of patent, any company that can produce or obtain the active ingredient and has the capability can produce generic versions of the original product. However, they are ineligible to sell their version under the original brand name.
For example, there is only one product known as Viagra (Sildenafil). However, there are many generic versions of Sildenafil available worldwide. Whilst a box of four tablets of Viagra (25mg strength) will retail at £20.00 in the UK, a similar pack of generic Sildenafil will retail between £4.99 and £9.00. In essence, one can pay up to £15.00 (GH¢103) less for the generic than they would have paid for the brand. In reality, if the quality assurance of the supply chain is guaranteed, both products would produce the same pleasures desired. The disparity is acceptable in this case because the difference accounts for the intellectual property commitments Pfizer would have made through the research and development stages of Viagra. On the contrary, branded generics have no intellectual property commitments and are only exploiting a loophole to fleece off many in lower-middle-income countries. In reality, their products can be best described as generics with a fanciful name.
How can it be right that “purchasers in low- and middle-income countries pay as much as 20 to 30 times the minimum international reference price for basic generic medicines like omeprazole, used to treat heartburn, or paracetamol, a common pain reliever” simply because someone put a fanciful name on the box? How can it be that through the years our governments and people have looked on whilst this fraud is carried out in the name of pharmaceutical economics?
Can anyone justify why in the poorest countries, branded generics which command a price premium make up about 66 per cent of the market by volume and value whilst unbranded generics, usually the least expensive option, are only 5 per cent of the market by volume and 3 per cent by value? Now, this is where the numbers get interesting. “In contrast, in the United States and the United Kingdom, unbranded quality-assured generics account for 85 per cent of the pharmaceutical market by volume, but only about 33 per cent by cost.” What this means is, for many of the chronic diseases that are becoming the mainstay of our countries disease burden we would end up paying more to stay alive locally than we should if we lived in a Western democracy.
What is happening in the name of pharmaceutical chain economics has no defined boundaries. It is not a branch of human biology or chemistry, the two science from which pharmacy draws inspiration, it is, therefore, no science. It is the anthropological art of greed and economic politics.
Considering that donors are actively withdrawing from our country, the outlook of our health spend has also changed significantly. According to data obtained from the Financing Global Health Database 2018, the annual average expense per person on health in Ghana is $75 (GH¢406.88). Of this $30 (GH¢162.75) is paid for by individuals from their own funds with the government paying a similar amount. Thus, these huge markups in the pharmaceutical supply chain affect us all directly and cut down on our meagre finances. It also has a significant effect on our approach to staying healthy, rather than seeking treatment when we are unwell. It may also be a major underlying factor in the reason why on average every Ghanaian attends a primary health care outpatient appointment less than once a year.
This is why I believe we need to start a conversation on how to ensure that the quality of unbranded generic medicines in Ghana can be guaranteed. Ensuring this should not be left to state players and regulators like the Food and Drugs Authority and the Pharmacy Council only. It would require the active involvement of citizens and health professionals in the policing of the pharmaceutical supply chain. As the end users of these products, we have more to gain if we do so. Having said that, I will concede that with our porous borders and a high proportion of medicines on our markets claimed to be counterfeits, the citizenry would require a lot more than just talk and education to ensure they can be vigilant enough to help police the pharmaceutical supply chain. Truth is, research has shown that even with the best will, the most experienced pharmacist is incapable of identifying over 90 per cent of sophisticated counterfeits unless aided technologically. This is why the European Union brought in the Falsified Medicines Directive (FMD) and why I believe technology holds the key to effective policing of our pharmaceutical supply chain.
What is happening in the name of pharmaceutical chain economics has no defined boundaries. It is not a branch of human biology or chemistry, the two science from which pharmacy draws inspiration, it is, therefore, no science. It is the anthropological art of greed and economic politics. The exploitation capitalist has found a gap through which they are holding us all by the testicles. Until we decide to rid ourselves of this excruciating strangulation and act to ensure that price and brand name are not the ultimate determinants of medicinal efficacy in our part of the world, they will continue to extort from our pain. I will end by warning that until we can guarantee the sanctity of the cheapest medicines on our market and educate people that as the data from the United States and Europe indicate; in healthcare quality of medicines in a majority of instances is not underpinned by price, the unruly pharmaceutical economic plunderers will continue to exploit this branded generics loophole and we would continue to pay through our noses. Whilst at it we would continue to receive little value for money in our medicines purchase and suffer the consequences especially when chronic diseases come to stay.
By Kwame Sarpong Asiedu