Cost of health

Drug pricing has been a long-standing and contentious issue between the pharmaceutical industry and the government. Drug manufacturers argue that strict price controls by the regulator do not account for rising inflation, cost of raw materials and production, making it unviable to manufacture certain drugs.

The flip side of this argument is that price has to be controlled and kept low in order to ensure affordability. A feasibility assessment that focuses only on market economics and regulatory controls misses out an important factor in the equation: the consumer. When the manufacture of certain drugs is discontinued due to cost, it naturally impacts the availability of these drugs for consumers. And this has a direct bearing on public health.

Among consumers, there are different segments with specific health needs. And from among this base, some are prioritized over others. According to the 2017 census, Pakistan’s female population was estimated at 101,331,000. However, this segment’s health needs get little priority. Case in point: folic acid.

Folic acid is a Vitamin B supplement taken to meet the body’s required amount which otherwise is not met due to dietary and lifestyle habits. A large part of Pakistan’s female population is impoverished and unable to fulfill food and dietary needs due to lack of resources. Neither are they able to gain access to proper healthcare. Prevailing socio-cultural and gender norms place the girl child and women on the bottom rung of the food chain and yet also commoditize them as child-producing and rearing machines. Young girls, barely into their teen years, are known to produce children.

Women are especially susceptible to anemia during childbearing years due to menstruation and during pregnancy when the hemoglobin need by the body increases. Folic acid is taken to prevent or treat anemia, to help regulate the level of red blood cells in the body especially before and during pregnancy, as well as neural tube defects in newborns. Folic acid is therefore integral to maternal mortality and neonatal care.

A 2014 study titled ‘Perceptions of antenatal iron-folic acid supplements in urban and rural Pakistan’ stated: “51 percent of women are anaemic in pregnancy yet only 44 percent of women use antenatal iron-folic acid (IFA) supplements.” This was attributed to lack of awareness, perceptions and myths about supplements but also ease of access – both in terms of supply and cost. Speaking at a workshop on health reporting in 2017, Dr Asma Badar, the national campaign manager for the White Ribbon Alliance Pakistan, remarked, “Pakistan is placed at number 180 out of 185 countries for anemic prevalence in women”.

Quoting findings from the National Nutrition Survey 2011 for Sindh, she said: the “prevalence of maternal anaemia for non-pregnant women has gone up from 28.1 percent [2001] to 50.4 percent [2001] and for pregnant women it increased from 28.3 percent [2001] to 48.9 percent [2011]. The NNS 2011 further reported that in Sindh, 62 percent of non-pregnant mothers and 59 percent of pregnant mothers are anaemic. Maternal anaemia leads to poor pregnancy outcomes for the mother and newborn.”

The National Nutrition Survey Report 2018 published by Unicef Pakistan states: “more than half (53.7 percent) of Pakistani children are anaemic and 5.7 percent are severely anaemic.” In children under five, the report finds that the incidence of anemia in boys is marginally higher than in girls: 54.2 percent vs 53.1 percent. Since 2011, anemia has been exceptionally high in Pakistan: 50.9 percent in 2001, 60.9 percent in 2011 and 53.7 percent in 2018, affecting the rural population more than the urban.

A 2016 article on the shortage of medicines due to a price freeze listed names of medicines unavailable at chemist shops. Folic acid was on the list. Citing industry sources, an article published in April 2019 reported: “a pack of 1000 folic acid tablets was being sold for only Rs220 in the market, ie 22 paisa per tablet. Companies had stopped manufacturing them for not being able to even meet their production cost through sale of these drugs. The government increased its price to Rs550 per pack, ie 55 paisa per tablet.” Through SRO577(1) 2019, the price of folic acid, as of May 24, 2019, is now fixed at Rs192.50 for a 1000 tablet pack – approximately 19 paisas a tablet.

Provision of folic acid, whether free of cost or at a cost, will require a policy and priority shift to recognize the health needs of a significant segment of the population. If not for their well-being then to reduce the overall health costs and spending, by ensuring disease prevention and making folic acid available abundantly.

The writer is a Karachi-based APNS award-winning journalist and co-founder of Bolo Bhi.

Twitter: @FariehaAziz