Our high medicine prices are killing patients

Control astronomical prices of medicines now

Expenditure on medicines comprise a large share of total health expenditure. The Ministry of Health (MOH) expenditure on medicines has been steadily increasing from RM1.61 billion in 2010; to RM1.76 billion in 2011; RM1.98 billion in 2012 and RM2.2 billion in 2013. This was an increase of 36.5% in the span of 3 years.

Medicines expenditure will only increase in the future with an ageing population, the shift to chronic diseases, new patented medicines at monopoly prices, and the increased demand for health care.

Ensuring universal access to medicines and meeting the health needs of the population will be a major challenge.

Most of the medicines expenditure is paid out of pocket (OOP). One study (Babar 2003) revealed that 79% of patients obtained their medicines from private sources, implying that a large number of consumers pay for medicines out of their own pocket.

Astronomical drug prices are making expensive medicines inaccessible to patients and in the process may be killing them. There is a shortage of affordable HIV drugs and very expensive cancer treatments create financial catastrophe among cancer patients, making them quit treatments altogether. One study estimated that 19% of them stop treatments.

There is an immediate need to control drug prices as they are spiralling upwards, out of control. CAP looks at why drug prices are shooting up and what needs to be done.

Privatisation of Medicine Supplies Pushes Up Prices

In 1994, procurement of medicines and the MOH’s medical store was privatised to Remedi Pharmaceuticals, a subsidiary of United Engineers Malaysia, a construction company, which led to the cost of medicines doubling the following year.

A study in 1997 subsequently showed that prices increased by 3.3 times after privatisation. Remedi Pharmaceuticals was renamed Pharmaniaga. Pharmaniaga holds the exclusive concession which is renewable to distribute medical products to Government hospitals and clinics for 10 years expiring 30 November 2019.

Recent studies have confirmed the sustained increasing trends in the price of certain essential medicines (like anti-infective and cardiovascular agents) after privatisation in the public sector was disproportionate to the rate of inflation.

High Mark-Ups in the Private Sector

In a study by Babar et al (2007) the authors noted that the high costs of medicines were due to the high mark-ups in the private healthcare sector.

In private pharmacies patented products were on average priced 16 times higher than the recorded international reference prices (IRPs), while generics (medicines whose patents have expired) were priced about 6.6 times higher.

Dispensing doctors’ clinics also had higher prices, 15 times higher than recorded IRPs while generics were 7.5 times higher.

For retail pharmacies mark-ups were 25-38% for patented products and 100-140% for generics.

The huge differences between local and international prices in the different sectors and between patented medicines and generics suggest that prices can be brought down significantly.

The authors commented that a “price deregulation system” in which manufacturers, distributors, and retailers set medicine prices without Government control (or interference) have seen medicine prices escalating even faster than in the developed world, indicating high medical costs.

Very Low Usage of Generic Drugs

The 2007 study also found the availability of medicines in the public sector was very low, only 25% of generic medicines were available.

Interestingly a WHO-HAI study (2005) found many examples of off-patent medicines available only as patented brands in the public sector (e.g. beclometasone inhaler, phenytoin and prozosin).

This shows that there is a preference for costlier patented brands instead of cheaper generics in the procurement of medicines in the public sector. In 2015, less than half of the medicines used in MOH facilities were generics.

Shortage of Affordable HIV Drugs

Low availability of HIV medicines such as indinavir, nevirapine and zidovudine was found in public hospitals, private pharmacies and dispensing doctors’ clinics.

This should not be the case in public hospitals as the Malaysian government had issued a compulsory licence in 2003 for 2 years under “Government Use” and allowed a local company to import generic versions of didanosine, zidovudine and lamivudine fixed dosed combination HIV medicines from the Indian generic manufacturer Cipla for use by MOH.

Low availability of medicines at public hospitals  forces patients to buy these medicines from private pharmacies or dispensing doctor clinics. Private pharmacies carry fewer generic medicines and prefer to dispense more expensive patented brands which are less affordable.

Drugs Too Expensive for Public

In terms of affordability, the study also revealed that a large part of the population are unable to pay for their medications in the private sector.

Treatment for heart disorders, high blood pressure, and diabetes using patented brands were expensive and was equivalent to a few days wages.

This has direct impact on morbidity and mortality, bearing in mind that non-communicable diseases (NCDs) i.e. cancer, diabetes, obesity, stroke and heart diseases have seen an alarming increase in prevalence and is among the top 10 principal causes of death at Government hospitals. There is a need to increase the availability of these medicines in the public sector.

Cancer Patients Face “Financial Catastrophe”

According to an Asean study by the Australian George Institute for Global Health, about half (45%) of Malaysian cancer patients suffer from “financial catastrophe” a year after they were diagnosed.

Around 51% will be pushed into “economic hardship” with 49% of them already using up all their personal savings while 39% of all respondents could not pay for their medication.

Of the respondents, 35% could not pay for medical consultation fees, 22% could no longer pay for their rents and mortgages, while 19% of them quit treatments altogether.

The study found that patients become financially vulnerable from high OOP spending on loans, debts and depletion of assets; and high treatment and medical spending.

Cancer is the third biggest killer in Malaysia. About 100,000 Malaysians suffer from cancer yearly and 1 in 4 Malaysians get cancer by 75 years of age.

This illustrates the acute need for more affordable access to cancer treatment and care. High costs of essential medicines and the imperative to make them more accessible and affordable to the population challenges the Government to develop long term strategies and policy options to make it possible.

More Expensive Than International Prices

The study found that public sector procurement prices were high for patented original brands. For example, in procurement for the public sector, the median price ratio (MPR) of 14 patented medicines were 2.41 times the international prices, while for 26 most sold generic (MSG) and the lowest price generic (LPGs) products, median price ratios were 1.56 and 1.09 times the international price respectively.

The MPR of 4 patented medicines, fluoxetine, loratadine, amlodipine and simvastatin were more than 10 times the international price. The pattern of high prices in the public sector indicates that there are problems in procurement and distribution.

High prices in the private retail pharmacies and high prices in patented brands and high-priced generics in dispensing doctors’ sector show that the market sets the price to what the market can bear. The large price difference between patented medicines and generics reveal that competition is not resulting in lower patent brand prices.

Expensive Patented Medicines Dominate Market

In Malaysia, there is a supplier monopoly of patented medicines with importation and distribution of patent medicines controlled by multinational pharmaceutical companies.

Patented medicines dominate the market with the largest market share of some 70%. High medicine prices are linked to the monopoly position of foreign pharmaceutical companies and patent protection in Malaysia.

The authors noted that higher mark-ups on generics in the study suggests that the prices of patent medicines are used as a marker for generic pricing. Thus high-patented medicine prices are incentives for dispensing doctors to overcharge on generic medicines.

Lack of Price Controls

Clearly, the lack of price controls has resulted in increasing medicine costs which in turn has led to rising medicine expenditure in both the public and private sectors.

When all players in the pharmaceutical industry including the manufacturer, distributor, wholesaler and retailer are free to set their own prices, this leads to high medicine prices and super profits.

The “free market” is detrimental to the access to affordable medicines and consumers pay excessive prices due to excessive mark-ups. Leaving the financing and supply of medicines to the market may fail to achieve public health objectives.

The market works well for society when there is price competition, comprehensive and accurate information, adequate supply of medicines and consumers can make informed choices. Under the prevailing price situation this is not the case.

Recommendations

Astronomical prices of patented medicines are a threat to health care systems both in the high-income developed and developing countries. As such, pricing regulations can be found in most European and Middle Eastern countries, Australia, New Zealand, Canada and East Asia.  However, Malaysia has not implemented any price control and regulatory practices.

CAP was made to understand that price control is under the Ministry of Domestic Trade, Co-operatives and Consumerism and not the Ministry of Health. We suggest that special provisions in the law must be made to allow the Ministry of Health to control prices of medicines as it is a specialised field that is best handled by the MOH.

CAP calls on the Government to formulate a comprehensive medicine pricing policy. This should include monitoring and regulating medicine prices and access to medicines with price control mechanisms; set and regulate maximum wholesale and retail mark-ups; regulate the prices of patented medicines as these are the main contributor to the retail price; and regulate generic medicine prices.

It should also promote the use of safe and effective generics and ensure their use in the public sector by making generic substitution mandatory.

It must establish a comprehensive transparent procurement system in the public sector which includes open competitive tender with price transparency; and use of international reference prices or pharmaeconomics or guidelines.

The control of prices of medicines by the Government is essential to protect the poor, promote an equitable health system and achieve better health outcomes.

Letter to Editor, 18 May 2017

Impose Price Control On Pharmaceutical Drugs

The Consumer Association of Penang calls for the urgent implementation of price control on pharmaceutical drugs.  As stated by the Domestic Trade, Cooperatives and Consumerism Minister Datuk Seri Hamzah Zainuddin in a local daily, “Malaysians have been paying excessive prices for pharmaceutical drugs due to an absence of government control.”

CAP has been calling for pharmaceutical drugs price control for years but it has fallen on deaf ears. Pharmaceutical drugs are an essential item and health is a basic need. Escalating drug prices put a tremendous strain on the financial resources of the Government and the public. It is about time pharmaceutical drug price control is implemented.

A National Drug Pricing Control System can be introduced which will maintain the prices of drugs in the public and private sector at a level that is reasonable, stable and affordable. The effective use of an Essential Drugs List and the wide usage of more generic drugs as opposed to patent brands can also be encouraged and supported.

The absence of a price control has led to the present situation where drug prices vary from place to place. Prices are set based on volume purchases putting small operators at a disadvantage.  Consumers throughout the nation in rural and urban areas should be able to get the drugs they need at an affordable published price. 

The current economic climate is putting a strain on consumers and it is timely that price control on pharmaceutical drugs is instated.

Press Statement, 12 October 2016

Call on government to address over-prescribing at source – and not just the fallout

CAP views with apprehension the Ministry’s strategy to tackle the fallout created by over-prescription, rather than the underlying cause, by calling on the public to return unused or expired medications at selected government medical centres and hospitals.  The rationale for the move initiated last year is to protect the environment against indiscriminate disposal of expired medications, and save government cost from the reuse of unopened, good condition medications.

According to the Ministry, returned medicines to the Kuala Lumpur Hospital in the first half of the year was valued at RM128,818, while at Seberang Jaya Hospital last year was RM27,899. The most common medications returned were those used to treat cardiovascular diseases, diabetes, anti-hypertensive agents and anti-cholesterol drugs.

Patients often are prescribed medications they don’t need, unwarranted by the symptoms they exhibit, or in greater doses than what is required for their particular ailment. This has become a trend, the norm in government and private hospitals in Malaysia.

From media reports and oft-heard grievances, patients are given a host of medications, pushing up their medical bills per visit. In instances of medical costs being covered by employers, patients usually do not object to the huge bill since they do not fork out from their own pockets. They simply take the medications home, using some while discarding or keeping the rest in storage.

The over-prescribing malaise, both in public or private hospitals, or by the general practitioners, is rampant. We see patients without cough prescribed cough mixtures, those without fever getting paracetamol, and for a mix of lotions or creams thrown in as well.

A simplistic view is to apportion blame on the patients for being ignorant, seeking quick-fix medications, or for accepting piles of medicines along with an inflated price tag, especially if the patients’ costs are covered. The over-prescribing by the medical profession and their relationship with drug companies is however the real issue at hand.

Nobody, most of all the government, should be surprised with the ballooning of healthcare costs over the years and loads of medications unused, left to expire or discarded by patients. It is a huge wastage since quality, fully subsidised medicines dispensed by government hospitals and clinics are literally going down the drain. The Health Ministry spent RM1.6 billion last year on medicines for the 135 hospitals in the country, an increase of almost 15% from the previous year.

A complaint published recently in a newspaper highlighted a man prescribed several different types of medicines every time he visits the Penang General Hospital, thus accumulating a few bags of unused medicines. Another patient a few years ago once lodged a formal complaint against a private hospital in the Klang Valley for prescribing stacks of paracetamol for his slight cough and sore throat, and for being given a high dosage, potent cough mixture and antibiotics in excess, pushing up his medical bill.  

Though we owe much to the pharmaceutical industry, we must however object to the current over-prescribing trend that has taken root in society. A host of drugs in a ‘not-to-miss’ approach is not the correct panacea to compensate for the limited time doctors spend in diagnosing ailments. The interest of the patients are being compromised for expediency, convenience, and to facilitate the profit-push of drug companies.

CAP calls for an end to this deep-seated culture of over-prescribing so as to avoid serious health repercussions. The government must review the needless and dangerous prescribing habits of the medical profession:

1. Proper education of the medical profession
This is to get rid of the new and current generation of doctors who find the need to close every consultation with writing prescriptions, no matter how minor the illness. They should endeavour to spend time with the patient, to properly diagnose the sickness, and avoid prescribing too quickly for symptoms not exhibited. They should be trained to look at the patient as a whole, taking a careful history of lifestyle habits, as sometimes what is needed by the patient is rest, exercise, a good sleep, a change in diet, or physical therapy.

2. Break the unhealthy relationship between drug companies and the medical profession
The doctors’ covert support for the pharmaceutical industry is seen in the amount of medications over-prescribed, with doctors being inclined to write down higher dosages than required, and suggesting more expensive medications. The unhealthy influence of the drug companies must be exposed and handled by the authorities if this undue pressure is to be neutralised.

3. Following a proposed list of drugs
The government should work with the medical profession to improve further on the agreed list of drugs allowed in hospital practices to avoid wastage of the taxpayers’ money. For example, the French Agency for Health-Product Security published a list of 77 drugs it has placed under reinforced surveillance – because of undesirable side-effects – to alert the medical profession and society.

4. Avoid the harm from over-prescribing
Besides the side-effects, complications, and addiction from taking medications not needed or in high dosages without any associated benefits, patients may slowly develop resistance to useful drugs, or suffer adverse drug reactions. Deaths may result from preventable adverse reactions to drugs that should not have been prescribed in the first place.

We must kick the habit of over-prescribing for the sake of the health of society and the nation.

Letter to the Editor – 31st August 2011

Illegal sale of oral contraceptives and the health problems caused by their misuse

altA survey conducted by Consumers Association of Penang on oral contraceptive pills showed that they were easily and freely available at pharmacies. These drugs are controlled by the Poisons Act 1952, which requires the seller to record their sales in a register called Poisons Book kept by the pharmacy. The easy availability of these drugs over the counter without the registration of the buyer's details makes a mockery of the Poisons Act. The law is openly flouted by pharmacies in Penang and a grocery shop in Kulim, Kedah. An earlier survey also found such pills being sold in the Chow Kit area in KL and in grocery shops in other rural areas.

It is frightening that the health authorities are unaware of this situation as the easy availability of these pills shows their very inept enforcement. As a result, thousands of Malaysian women may be suffering in silence from adverse health effects due to ignorance of the dangers that these drugs pose and the ineffective laws.

altIn a survey of 15 outlets, oral contraceptives were sold over the counter (without registration of the buyer's details in the Poisons Book) in 14 pharmacies. Only in 1 pharmacy, the buyer was asked to register herself but the authenticity of the buyer's details was not verified. This means that fake details can be entered into the Poisons Book. Of the 14 outlets, only 5 of the pharmacies asked some questions, but ultimately sold the pills. A male buyer was also able to get the pills from some pharmacies. He could buy it for the use of others.

The pharmacies surveyed were located in Penang. They were near schools, near a university, in shopping complexes and in residential areas.

A number of contraceptives were sold in loose strips with no drug information on the use, contraindications or side-effects given to the buyer.

The prices of the pills were marked up in some cases. For a same brand of pills, the price ranged from RM4.80-RM6.50. We also purchased an emergency contraceptive (2 pills) for RM3.50. Across the different brands, the prices of the contraceptive pills surveyed ranged from RM4.80-RM23.00. Some pharmacies allowed the pills to be sold cheaper when the buyer bargained for a better price.

The easy availability of these pills allows the dangerous abuse and misuse of the pills by Malaysian women. These drugs need to be dispensed under a doctor's supervision due to its dangers and long-term effects.

The pills, besides being used a contraceptive, is used for other off-label uses like for postponing periods. According to the survey reports, Malaysian girls seek online consultation for postponing their periods to prepare for university exams, or to visit their hometowns during religious, social and family functions as they do not want to be left out. The pills are often used by women during Ramadhan and when they go to perform the Haj.

According to a drug insert, the pills should not be used in the presence of any of the following conditions, including pregnancy, cardiovascular disorders, cerebrovascular disorders, hypertension, diabetes, obesity, anaemia, cancer and many more.

Taking synthetic hormones as in contraceptive pills to control the ovulation process, is suppressing the natural process of ovulation. This can disrupt the natural process of reproduction in women, causing pain, discomfort, change in moods and depression, and further creating reproductive problems for the woman who may later want to bear children.

The adverse effects of these pills are many and they include depression, breast lumps, heavy vaginal bleeding between periods, hypertension, high cholesterol, blood clot in the leg, chest pains, signs of liver damage, signs of stroke and others. Many of these serious adverse effects can be attributed to the estrogen content of birth control pills.

The effects of these oral contraceptive pills on a woman's reproductive cycle is like binding a child who is naturally active and full of enthusiasm, which will lead to a dramatic counterproductive reaction. Similarly the normal ovulating egg which is inhibited, will in the process, change the normal bodily and reproductive functions, and alter the woman's moods and psychological state.

altIn a typical female monthly reproductive cycle of 27-29 days, there are 7 days of menstruation, 8-10 days of ovulation, and 10-11 days of premenstrual syndrome. With all these, she is left with only 5 good days without any stress of pain from her cycle. The pain and distress in the reproductive cycle is common among all women but are aggravated by the pills which are trying to control the ovulation process. The use and misuse of these pills can totally disturb a woman's reproductive cycle and leave her body altered.

The hazards associated with contraceptive pills and the reproductive cycle:

• PMS(PMT) – Premenstrual Syndrome also known as Premenstrual Tension
• Ovulatory pain – Pain during the ovulation period
• Dysmenorrhea – pain during menstruation
• Menorrhagia – Disturbed menstrual bleeding

PMS (PMT) – Premenstrual Syndrome/ remenstrual Tension
Premenstrual syndrome (PMS), also known as Premenstrual Tension, relates to the changes of physical or emotional symptoms like serious crimpy pain, associated with engorged vein of the lower limbs, congestion of breasts, vomiting, nausea, depression and the increased sensitivity to sound and smell. These symptoms occur before a woman starts her monthly menstrual cycle, which could be about 5-11 days prior to the release of menses. The symptoms usually stop when menstruation begins, or shortly thereafter.

Ovulatory pain – Pain during ovulation
This pain occurs between the 11th and 17th day of the menstrual cycle and is associated with white discharge and pain radiating towards the thighs and also towards the lower base of the pelvic region. This is caused by the suppression of ovulation by the drug LEVONORGESTREL along with ETHINYLESTRADIOL for contraception.

Dysmenorrhea – pain during menstruation
Pain during menstruation is often accompanied with vomiting, nausea and irritation. The pain radiates from the lower abdomen towards the back and moves down the thigh and causes stiff legs.

Menorrhagia – Disturbed menstrual bleeding
Increased menstrual bleeding, often bleeding with clots and also with severe pain.

NOTE: These conditions may occur in about 80% of women but taking contraceptive pills or misuse of these pills for off-label uses will make the conditions worse.

Recommendations:

– The existing law, the Poisons Act 1952, in relation to contraceptives is totally meaningless as it has failed to protect women's health, and in the process, puts their reproductive health in jeopardy. Over-the-counter sale of contraceptive pills has to be stopped and the use of these pills needs to put under a doctor's prescription and supervision. New laws are needed to replace the existing ones.

– A campaign should be launched to educate women on the dangers and misuse of contraceptive pills and how they affect women's health and their reproductive system. Young women should be educated on how their reproductive cycles wok in relation to their health.

– Women should be educated on other safer contraception methods which pose fewer dangers to their health.

– Men should play their part in contraception and the protection of women's health. Condoms, coitus interruptus and vasectomies should be used. In Thailand, vasectomies are encouraged by both the Government and private sector. In 1984, 164,511 vasectomies were carried out there. The onus of contraception should not be placed on women alone. The concern should be shared to ensure the good quality of life of women and to ensure healthy mothers and offsprings.

If you have any enquiries on women's health problems, please write to cap.womenhealth@gmail.com

Also visit www.saynotocontraceptives.wordpress.com

 

No more excuses: Ban Codeine now

altCAP has for more than 15 years now raised the issue of the dangers and harmful effects of codeine in medications and its easy availability over the counter. We trust the Ministry of Health understands this, and its pharmaceutical authorities are well aware of the situation locally.

So, why is it that they are not taking any action? This is despite the concerns raised by CAP as well as by consumers in letters to the newspapers over numerous media reports of seizures of codeine-based cough mixtures illegally brought into the country.

Our surveys continue to show that codeine cough mixtures are very easy to obtain and that this is the drug addicts turn to if they cannot get their fix.

The Ministry of Health owes the public an explanation: What has happened to its pledge, specifically the unit under it, Pihak Berkuasa Kawalan Dadah, to end the sale and manufacture of codeine cough mixtures from June 2003? The Ministry has not responded to our queries on this issue!

Codeine, or O-methylmorphine, is an alkaloid found in the opium poppy and comes under a group of drugs called narcotic pain medicines. It is generally used to treat mild to moderately severe pain. It can be habit-forming and in the developed countries, it is a prescribed, controlled medication.

Codeine is currently the most widely used opiate in the world, and probably the most commonly used drug overall, according to numerous reports from several organisations including the World Health Organisation.

Reports on the dangers of codeine are continuing to emerge and more countries are banning or restricting its use in medications. A recent news report said that experts in Britain are increasingly worried about the use of codeine in medications and are calling for its review.

Some 27 million packs of codeine-containing painkillers are sold over-the-counter in Britain alone each year and the British Government’s Medicines and Healthcare Products Regulatory Agency has ruled that the risks of codeine-based cough drops and syrups outweigh its benefits, particularly for those under 18 years.

The authority said there is little evidence that codeine in cough mixtures relieves coughs in children and doctors in Britain, where it is estimated that 30,000 people may be addicted to the drug, and those in Canada and Australia are pressuring their governments to impose a total ban on codeine.

What is the true situation for Malaysia? Besides over-the-counter medication, how do the authorities keep track of all the illegal sales of codeine-containing drugs?

Quite shocking to the average Malaysian consumer was a news report in June this year, stating that two primary school teachers were among four people who arrested for distributing codeine in Shah Alam.

The Shah Alam district police headquarters seized eight bottles containing 14.8 litres of cough mixture and 2,200 pills of various types from the four during a raid on a house in Section 5 and police believe the four could be part of a major syndicate.

We see absolutely no reason for the Ministry of Health to remain silent on this matter. We insist that the Ministry carries out public education on the dangers of this drug, systematically and effectively, so that the masses become aware of its dangers.

This must be done together with a total ban on the manufacture and sale of all drugs containing codeine, and improving enforcement to prevent the smuggling of codeine into the country. This is important, since today codeine can also be purchased through the Internet.

Legislation should also come into force to provide more severe punishment for those who bring codeine into the country, sell it or distribute it. Do not give us any more excuses!

Letter to Editor – 26 October 2010