Doctors say that more than 60 percent of pharmaceutical spending is on imported drugs, but in terms of quantity, imported drugs account for only 30 percent. Many Thais believe that imported drugs are of a higher standard.



Dr Mongkol, director of GPO.

HEALTH: The co-dependents

By Kritsada Subpawanthanakun

25 July 2006

How patients and the medical industry are being duped into an addiction to expensive drugs

Following the release of The Truth About the Drug Companies: How They Deceive Us and What to Do About It, a book by Dr Marcia Angell that reveals how US drug companies are betraying consumer trust, the American public reacted with anger, feeling deceived by the government bodies they thought were in place to protect them.

A similar situation may be happening here. The book was recently translated into Thai by Dr Wichai Chokewiwat and had a ripple effect, prompting some medical personnel to reveal interesting insights about their country’s own pharmaceutical workings.

In The Truth, the former editor of the New England Journal of Medicine explains the many ways in which the pharmaceutical industry is a marketing machine that produces drugs of questionable benefit, having moved away from its original purpose of finding and producing useful new drugs. She says it is an industry that uses its wealth and power over such institutions as the US Congress, the Food and Drug Administration (FDA), academic medical centers and the medical profession.

Medical professionals here suggest Thailand’s problems are an extension of the US’s, not only related to small chemical tablets but reflective of the country’s politics, economy, society, educational system, beliefs and culture.

The blame game

Pharmaceutical spending is estimated to account for 60 to 80 billion baht of the country’s 200 billion baht healthcare budget. Doctors reveal that more than 60 percent of pharmaceutical spending is on imported drugs, even though in terms of quantity, imported drugs account for only 30 percent.

Simply put, imported drugs are incredibly expensive, which prompts an obvious question: why? “Because we don’t have a price-control mechanism for drugs. At the moment, the Commerce Ministry is responsible for the drug price but the organization that has pharmaceutical knowledge is the Food and Drug Administration [FDA] under the Health Ministry,” says Katha Bunditanukul, the Pharmacy Council’s spokesperson. “So when there are complaints about overly expensive drugs, the FDA brushes them away by saying it is the Commerce Ministry’s responsibility. And the Commerce Ministry would say ‘yes it is our responsibility but we know nothing about drugs.’”

Katha explains that drugs are on a control list, meaning approval from the Commerce Ministry is required when producers want to increase the price. “But ask if there is a price-control mechanism by the Commerce Ministry. The answer is no, there isn’t one. So it turned out that the ministry often allowed the price increases.”

Although there is a huge difference in price between locally-made and imported drugs, experts say the quality is pretty much the same.

The Government Pharmaceutical Organization (GPO) can produce 300 types of drugs, which sufficiently covers local demands. The organization has an income of about five billion baht a year, according to Dr Mongkol Jivasantikarn, GPO’s director.

“But it is considered small compared with the drugs’ market share in the country. We account for only 10 percent while the remaining 70 percent belongs to foreign pharmaceutical companies and 20 percent to local factories,” he says. “New drugs are indeed expensive. But we have to see whether or not they are over-priced. Some drugs have a monopoly so the pharmaceutical companies can mark them up to whatever they want, and we don’t know whether it is a reasonable price or not.”

Drug parties

Although imported drugs are expensive, they remain popular among Thais. Observers point out that the marketing strategies of pharmaceutical companies will often influence doctors to order these new imported drugs.

First, whenever a company launches a new drug, it frequently entertains doctors who have the power to order medicine for hospital use by giving gifts or organizing trips to foreign countries. Although observers believe such strategies affect doctors’ decisions when ordering drugs, there is no concrete evidence to confirm these allegations to date.

Second, pharmaceutical companies often give their new product to the doctors to conduct new research, with the drug company footing the bill for all research expenses. As a result, when the research is approved, doctors often order the drugs, says Katha.

“So that promotes the use of that drug. And there is no competition because the new drug is under patent which means local factories cannot produce it until the patent expires…so pharmaceutical companies can mark it up to any price they want,” says Katha.

Third, a number of doctors believe they will “fall behind” if they don’t offer the latest drug. So whenever there is a new drug launched, doctors often order it without considering that the old drugs are in many cases still effective.

Fourth, patients’ attitudes are a factor. Medical observers say patients still cling to the old belief that locally-made drugs are not as good as the imported ones, while heavy marketing campaigns by foreign pharmaceutical companies have been successful among Thais.

“Parts of Thai society believe the doctors while another part are influenced by marketing. This affected the patients under the 30-baht healthcare scheme who often asked why they got cheaper drugs than others despite such drugs working the same,” says Dr Kasem Tantiphlachiva, vice president of the Psychiatric Association of Thailand. He adds that in many cases the patients may not need the drugs.

“For example, if the patient’s blood pressure is a little higher than normal level, we should begin with diuretic drugs. Or if we know that it is caused by stress we should fix that problem, not just prescribe drugs for high blood pressure. Ordering such drugs for patients is unnecessary,” Dr Kasem says.

Tricks of the trade

There are a few popular tactics that pharmaceutical companies often use when they are producing new drugs. First is the “me, too” syndrome, a way to get around drug patents.

“For example, a company launches a new 10mg drug with a patent selling at 30 baht a tablet. After the patent expires, local companies can produce it and sell it for three baht a tablet. The pharmaceutical company then takes the old drug but increases it to 20mg and launches new research saying that the 20mg is better than the 10mg. Then they will register a new patent. The cycle goes further to 40mg, 80mg etc,” Katha says.

“Or they will use the old drug but add a few more substances. For example, they’ll mix two old drugs together such as pain relief drugs ‘A’ + ‘B’ and launch a new study with new patents.”

Another tactic is to create new sicknesses in order to produce new drugs to heal them, says Dr Kasem.

“For example, the women’s gloomy emotion felt after their periods. Actually, it is a very natural thing that does not need drugs. But pharmaceutical companies will say that their drugs can heal that. But such an emotion does not require drugs and the drug that patients are given is actually designed for depression, which is not good for their health if people continue to use it,” says Dr Kasem.

Drug dependency

Such problems are not limited to the tablets, experts say, but reflect a health system that is ailing from several problems. Today the country’s health system is somewhat dependant on drugs, whereas people feel that they are not being treated if they are not prescribed something.

“Thailand doesn’t have a doctor fee system. Suppose a doctor treats a patient with a common cold. If the doctor tells the patient to just go home, take a rest and drink a lot water and then charged a doctor fee of 100 baht, the patient could get angry and question why he or she has not been prescribed any drugs. So without the doctor fees, what can the doctor do? So the doctor then prescribes some drugs and charges 150 baht and the patient is happy,” Katha says.

“We must blame it on the healthcare system that has implanted the wrong attitude in people. They feel that they always need a doctor, even for small sicknesses. If you look back 40 to 50 years ago, family members looked after each other for small sicknesses. But later the authorities kept telling them not to buy drugs on their own as it could be a danger to their health. So things changed from people being self-dependent to hospital and drug dependent,” he says.

At the same time, patients’ rights are not sufficiently promoted and legally endorsed. Most people do not know that they have the right to know the doctor’s name, how the doctor treats them and what medicines they are given and why. Not many patients dare to ask the doctors such questions.

Also, patient participation does not often happen here, Katha says. Pharmacists normally give out the medicine without explaining or building attitudes and knowledge for the patients to decide on their own course of treatment, something Katha blames on the country’s pharmacology education system.

Also, Dr Kasem says that the government still cannot come up with effective drug polices that will cope with the free-market world.

“We are inevitably in a free market full of competition. But we do not have any protective measures to control drug prices. And if we change the price system, the US will pressure us. The government is hoping to sell other products to the US so they always give in with drugs issues. But sometimes it is not worth it,” Dr Kasem says.

Dr Mongkol hopes that people will use locally-made drugs more, according to His Majesty the King’s philosophy of a sufficiency economy and self-dependency: “Many big local factories here meet the international standard and have been producing drugs for a long time without any problems.”

Thai Day