Pakistan’s healthcare sector faces a myriad of governance challenges. There is a weak regulatory enforcement mechanism allowing substandard medicines to be marketed.
There is also a proliferation of inadequately trained or unlicensed healthcare providers in the absence of a strong inspection or complaints system. And a general lack of awareness when it comes to patients simply knowing their rights and unethical practices, whereby healthcare is driven not by quality patient-care but the need to drive up profits.
In Pakistan, public trust in healthcare remains fragile. According to the National Corruption Perception Survey released by Transparency International Pakistan in December 2023, the health sector was ranked as the fourth most corrupt in the perception of citizens. From unsafe medical practices to the circulation of substandard and counterfeit drugs, this mistrust is fueled not only by widespread unethical practices but also by the absence of data on regulatory actions taken against violators.
It is no secret that regulators in Pakistan, both at the federal and provincial levels – including the Drug Regulatory Authority of Pakistan (DRAP), provincial healthcare commissions and quality control boards – publish little to no information about their enforcement actions.
For effective health governance, it is imperative that the regulatory bodies regularly disclose data on the disciplinary measures taken against doctors, dentists, pharmacists, laboratories and pharmaceutical companies who break rules on ethical and safe medical practices. Such data does not need to name and shame individuals and can be designed sensitively. Transparent disclosure of regulatory actions is crucial for building public trust in the healthcare system, deterring malpractice and ensuring that rules are not just on paper but are enforced in practice.
Pharmaceutical marketing is another area requiring urgent reform. Hidden marketing practices in the form of non-transparent promotional spending influence prescription patterns and compromise patient welfare. In 2021, DRAP promulgated the Ethical Marketing to Healthcare Professionals Rules to make the interaction between companies and healthcare professionals transparent, free from corrupt practices and to facilitate medical decision-making in the best interest of the patient.
However, in practice, pharmaceutical industry spending is weakly regulated. In many countries, listed pharmaceutical companies are required to display their ethical practice rules on their website, maintain a public complaint portal, and disclose their whistleblowing policy. Pakistan must follow suit. Strict enforcement of the rules requiring companies to report their marketing expenditures publicly would reveal how promotional funds are used, discourage unethical incentives and create a level playing field for companies that comply with ethical standards.
Equally concerning is the unchecked growth of the nutraceutical and alternative medicine market. Across Pakistan, an estimated more than 50,000 alternative medicine, nutraceutical, food supplement, Unani and homeopathic products are sold openly in pharmacies and retail outlets. Despite their widespread availability and aggressive marketing, most of these products carry safety, efficacy, or quality concerns.
The Drug Regulatory Authority of Pakistan (DRAP) Act, 2012 clearly mandates that all such goods must undergo a licensing and registration process to ensure their safety and effectiveness. Yet, alternative medicines continue to operate through the enlistment process. No one knows what safety methods, technical staff and laboratories the manufacturer of alternative medicines are using in line with good manufacturing practices (GMP). DRAP’s Quality Assurance Department must be empowered to conduct GMP inspections nationwide, and the authority should urgently enact the long-delayed licensing and registration rules for alternative medicines and nutraceuticals as required by the DRAP Act, 2012.
To perform these oversight functions effectively, regulatory bodies such as DRAP, Pakistan Medical and Dental Council (PMDC) and provincial healthcare commissions must also be provided with adequate funding, staffing and legal authority to proactively monitor compliance. This includes undertaking urgent merit-based appointments of essential technical human resources, such as Federal Inspectors of Drugs, a critical step for DRAP to aspire towards becoming a WHO Maturity Level 3 Regulatory Authority.
DRAP currently lacks sufficient human resources to conduct effective inspections and oversight. Despite the critical role of Federal Inspectors of Drugs (FIDs) in ensuring compliance and regulating the pharmaceutical industry, the appointment of FIDs has been pending with the federal government. Only eight FIDs have been notified recently. Without sufficient FIDs, the sector cannot be sufficiently regulated.
At the same time, we must also emphasise that the policy recommendations to address unethical practices in the healthcare sector in Pakistan must start with education and awareness raising. Pakistan’s system for healthcare professional education needs urgent reform and investment to build strong and lasting ethical foundations in those who are responsible for patient care. Ethics cannot be a peripheral subject relegated to a few lectures. This requires the establishment of a standardised national medical education curriculum for healthcare providers, including doctors, dentists and pharmacists, with dedicated topics on regulations, ethical practice and navigating conflicts of interest.
There must also be continuing medical education requirements for license renewal with the PMDC, with mandatory ethics refresher courses, ensuring this training is not a one-off event but a lifelong commitment. This must be complemented by mandatory annual training for pharmaceutical company sales representatives and managers on ethical marketing.
It is high time we ensured that ethical transgressions in our healthcare system are effectively regulated, putting patient welfare back at its heart.
Kashif Ali is the executive director at Transparency International Pakistan.
Saira Bano is the communications and partnerships manager at Transparency International Pakistan.
Note: The views expressed by the writers are independent and may not be associated with TI Pakistan.