“Parallel importation could lower drug prices”

The Change Alliance’s election manifesto includes several measures for the pharmaceutical sector, including free medicines when they are not available in hospitals and parallel importation. Siddique Khodabocus believes that these proposals are promising but remains cautious. He would like to know the details of their implementation before making a decision.

In the election manifesto of the Alliance for Change, there is a measure concerning the establishment of a free system for prescribed medicines which are not available in hospitals. What do you think?

First of all, I would like to congratulate the new government on its victory. Now that the announcement effects have passed, it is time to work on implementing the measures. We hope that the minister will take into account all the players in the sector. Regarding free medicines, it is crucial to understand how this will be implemented. Four fundamental questions arise: which category of patients will benefit? What types of medications will be affected? Who will be responsible for prescribing these medications? And how will the distribution take place?

It is necessary to target this measure, because people have the means to obtain medicines, and it does not make sense to offer them this free. Others already have insurance. In addition, it is common knowledge that certain doctors have affinities with laboratories, and that some practice in both the public and private sectors. There is therefore a risk of prescription, among the public, of unavailable or expensive medicines, for the benefit of certain laboratories. Finally, it is essential to ensure that pharmacies close to power are not the only ones to obtain contracts to serve these prescriptions from the public system.

Before tackling the task of setting up a new system, shouldn’t we put the existing one in order?

We have to start with calls for tenders! Firstly, it is necessary to establish clear criteria regarding who can be a bidder, as not just anyone can be allowed to respond. We are talking about the health of the population. Calls must therefore be limited to bidders with experience in the field and a track record own. A list of prequalified suppliers with specific criteria must be defined. The selection criteria should also be reviewed, as some countries like Pakistan, Egypt and Bangladesh, which have very good laboratories, can currently only submit in a single category where the products are very minimal.

Regarding international tenders, it is essential to exclude bidders who are not represented by a local wholesaler, because if problems arise, it is difficult to know where to turn. Besides, did you know that this is the case in Madagascar? There, not just anyone can participate in tenders for medicines. Products must be registered with an organization, and this involves a whole procedure that includes submission of documents and quality analysis. In Madagascar, only registered products can be submitted, and to register, one must go through analyzes before being qualified. Another imperative is to make the process more transparent. Currently, we know who was awarded a contract, but we do not know which laboratory the products came from. It is therefore impossible to verify the track record and to know if this laboratory has ever encountered drug quality problems.

Finally, it is necessary to have functional departments with well-defined roles. We cannot have super civil servants who are responsible for product registration, inspection, import authorization, and who sit on the Pharmacy Board while managing everything themselves, bypassing the directors. We need to find a balance between professionals, health care workers and civil servants.

The manifesto also provides for a regulatory body to analyze drugs. Is this necessary?

This is essential. Evaluating medicines solely on the basis of documents does not make sense. It is essential to be able to test the active ingredient. Let me tell you what already happened when I was a community pharmacist. The story concerns atenolol, a drug used to treat hypertension. At one point, the hospital was prescribing 50 mg to patients, but when there was a stock shortage, patients turned to pharmacies. There were several complaints that the 50 mg we supplied, from another laboratory, was too strong. So we had to give them 25 mg, which suited them better. This means that, in the public sector, a medicine that was supposed to be purchased at a price of 50 mg was actually closer to 25 mg. This shows that sometimes, to keep prices low, manufacturers compromise on quality. If we systematically tested drugs to identify the concentration of the active ingredient, such situations would not arise. Of course, it is not possible to analyze everything, but samples could be tested from the start. In addition, a random analysis system should be put in place. When manufacturers know their products can be tested at any time, they will work harder to meet standards.

You have been asking for authorization for the parallel importation of medicines for more than a decade…

If this is really implemented, it will be a real revolution. Let me explain simply what this entails. When a laboratory develops a drug, it is the reference drug. This same laboratory can produce this drug in other countries, where production costs are lower, which makes it possible to offer it at a lower price. These costs can be reduced by up to 45% compared to baseline production. Thus, parallel importation will make it possible to lower prices, offering a concrete solution against the high cost of medicines. In addition, it will promote competition, which will lead to further lower prices.

Another problem this will help solve is the recurring shortage of certain medications. Take the example of paracetamol: during a stock shortage in France, the drug was still produced by the laboratory elsewhere. Parallel importation would have allowed Mauritius not to feel this lack. However, it is crucial to have a competent testing laboratory to ensure the quality of imported products. It is also imperative to think carefully about the implementation of this system. Allowing only the importer of the reference product to import from other countries without an appropriate framework would be ineffective. Competition is essential to protect consumers. As for the allocation of contracts, it is necessary to establish criteria beyond the lowest offer. For example, 70% of the contract could be awarded to the lowest bidder and 30% to the lowest bidder. “second best” offer. This would help avoid shortages, as manufacturers themselves sometimes face difficulties that delay the supply chain. With such a system, there would always be a backup stock for the population, even in the event of a delay by one of the contractors.

But to compensate for rising prices, there is already the “regressive mark-up”. Isn’t that enough?

It didn’t change anything. First of all, profit margins in Mauritius are already minimal. Let’s take the example of Madagascar: a wholesaler makes a profit margin of 25 to 35%, while a retailer oscillates between 30 and 35%. In Mauritius, margins are much lower: a wholesaler gets between 7 and 8%, and a retailer 17%. For certain products governed by the regressive mark-upthe margin can even be reduced by 5%. Removing these profit margins would therefore have only a limited impact, as prices continue to rise, due to the continued devaluation of the rupee, increased transport costs and high inflation in producing countries. . Once again, the solution lies in parallel import. It is also important to raise awareness about generic products, which cost between 50% and 60% less than standard drugs. Pharmacists have the possibility of substituting certain medications with generics when a prescription allows it, but this requires patient acceptance. Finally, it would be wise to consider a contributory reimbursement system for medicines in the private sector.

Another issue you have been very vocal on is the Mauritius Revenue Authority’s platform to control psychotropic drugs. Has there been any development?

No, the problem remains. It is still incomprehensible why only private pharmacies are affected, while psychotropic drugs are also prescribed in the public sector. It is crucial to protect patient confidentiality, and it is necessary that control begins with doctors. This would provide better visibility on convenience orders. Furthermore, this tracking platform should in no case be managed by the MRA. It would be preferable for it to be managed internally by the ministry, within a specific unit.