x Abu Dhabi, UAEMonday 22 January 2018

UAE pays bigger bills for its pills

The World Health Organisation survey finds that some medicines can cost up to 23 times the recommended international price.

Some pharmacies do not carry generics because clients prefer branded drugs due to a perception that the cheaper versions are inferior.
Some pharmacies do not carry generics because clients prefer branded drugs due to a perception that the cheaper versions are inferior.

ABU DHABI // Prescription drugs in the UAE are significantly more expensive than in other parts of the world, including much of the Middle East, recent studies show. In addition, some lifesaving drugs are not even available in government-run pharmacies, where prices are lower, and must be bought in retail outlets, says the research.

According to the World Health Organisation's World Health Statistics 2009 survey, the prices of selected generic medicines sold in pharmacies are 13.8 times the international reference price. This is the average procurement price at which the generic versions of drugs are offered to developing countries on a not-for-profit basis. The survey also shows that branded drugs in private UAE pharmacies, which include non-government hospitals, cost on average 23.52 times the reference price.

Of the Middle East countries included in the survey, only Kuwait has higher private generic-drug prices than the UAE, averaging 15.7 times the international reference. By contrast, Lebanon's prices are just 6.1 times the reference mark and Yemen's even lower, at 3.5 times. The highest-priced drug in the survey was Ciprofloxacin, which is used to treat severe and life-threatening bacterial infections. The branded version cost 121.90 times the international reference price in the private retail pharmacies.

It was not available in any of the public sector outlets, but it was stocked in all of the private pharmacies. Doctors say some of their patients have stopped taking prescribed drugs altogether or are buying cheaper and perhaps unreliable supplies abroad. Pharmacists also say their wholesale costs are so high that they can barely make a profit. Moreover, many generic drugs, which can be much cheaper than branded versions, are often unavailable in public clinics, forcing patients to buy them at expensive retail pharmacies.

Doctors, pharmacists and healthcare experts all agreed the situation was serious. "In the private sector, both the prices of original brands and generics were very high," said Margaret Ewen, one of the researchers behind the source material for the WHO report. "The question is how the country determines its medicine prices; it is different everywhere in the world." Since drug manufacturers do not set retail prices, the cost of drugs can vary from country to country.

In the UAE, the Ministry of Health is responsible for "reviewing technical specifications of all pharmaceutical products used in the UAE and their registration and pricing", according to its website. By doing so, it in effect licenses and registers all drug prices. Dr Amin al Amiri, the head of medical practice and licensing at the ministry, said a number of factors contributed to pricing, notably the volume of the product sold. "Suppose a country has a population of 60 million. They will buy maybe 20 times more than what we can buy in the UAE with a population of five million," he said.

Drug prices are set annually in contract negotiations with the ministry. The next review is in October. As well as agreeing on an import price, the ministry sets mark-up limits for private pharmacies and other drug distributors. It recently announced it had set lower prices for 71 medicines for illnesses including depression and asthma. These are expected to come into force in two months. The WHO figures come from a study by Health Action International (HAI), an organisation that works with the WHO to make drug pricing information more widely available.

"Overall, even for the lowest-priced generic drugs, the [UAE] prices were still very high," said Ms Ewen, the health co-ordinator of the WHO/HAI project. "You cannot expect it to be the same as the international reference price, but even if it was three times this price, that would be OK. But 13 is very high." In China, by comparison, consumers pay 1.1 times the reference price in the private sector for generic drugs, while in India they pay 1.8 times. Both have developed their own drug-manufacturing industries.

The HAI survey also found a discrepancy between what drugs were available in public and private outlets, and between branded drugs and cheaper generic versions. Dr Fatma Abdulla, a non-research fellow at the Dubai School of Government, said there needed to be a shift from believing the "myth" that branded drugs were better than their generic versions. "Fifty per cent of generic drug production is made by the brand-name companies," she said.

She also urged the MoH, as the sole legal importer, to do a better job of bargaining when buying branded drugs in the international market. "They need to negotiate more and lower the initial prices for the private sector," said Dr Abdulla, formerly chief strategy officer for Dubai Healthcare City. But Khaled Hamza, operations manager of the Dubai pharmaceutical distributor Medysinal, said the ministry did not have much room to negotiate in such a small market.

"The smaller the quantity, the higher the prices," he said. "Whenever the quantity is bigger, the price is lower; it is the same in any market." Essential medicines, for example, can be priced very high. Since these drugs are not made locally, the ministry has nowhere else to turn. "The Middle Eastern and North African market is only about one per cent of any international drug company's market," Mr Hamza said.

"This means the Ministry of Health has very little negotiating power. If a company says a product will be sold for Dh50, the ministry might ask for Dh49. They can barter for a dirham, maybe. In Saudi Arabia the market is five or six times larger than the UAE market, so prices are lower." Mr Hamza said he was aware of some private pharmacies struggling to stay open because of the high prices and small profits.

Dr Belal Hashim, a manager at the Lifeline Healthcare group in Dubai, agreed private pharmacies made little profit because of the pricing system determined by the MoH. "We are only allowed to add 15 per cent on to the price we buy the drugs for from the distributors," he explained. "I don't know why the drugs are so expensive when they come to us. But I do know it is very difficult for private pharmacies to make profit."

Dr Sahar Tawfik, of Al Safa Pharmacy in Abu Dhabi, said many of her customers chose brand names over generic types despite the higher price. Most requests for generics appeared on doctors' prescriptions, she said. Although the Health Authority-Abu Dhabi does not control drug pricing, it has tried to encourage people to buy generics. In February it ruled that doctors must write generic names on prescriptions; previously, many doctors wrote only the brand names. The Dubai Health Authority is expected to introduce similar rules next year.

"The providers know the generics and branded are the same," said Dr Tawfik. But doctors were reluctant to prescribe generics "because of the client, or because of some type of agreement with the pharmaceutical company". Elcy Koshy, of Al Ahood Pharmacy in Abu Dhabi, said most drugs in her store were branded versions because "that is what all customers want". The HAI survey measured the availability of both generic and branded versions of 25 types of medicines.

It found that in public facilities, only 16.7 per cent of all imported branded versions and 61.1 per cent of generics were available. Private outlets, however, stocked all the branded drugs and 73.9 per cent of the generics. Ms Ewen, of HAI, called for all lowest-priced generic drugs to be available in both public and private outlets. "If it is not available in the public sector you are forcing people to go to the private sector," she said.

One solution may be to produce more drugs locally; currently the UAE imports about 90 per cent of its pharmaceuticals. "Importing drugs from abroad is expensive," Dr Hashim said. "Prices would be much less if we had more factories in this country." The Ministry of Health has said it is "looking to build up the local industry", but did not elaborate. Dr John Craig, a primary care physician at the American Hospital Dubai, said a number of his patients had stopped taking drugs because they could not afford to pay for them.

"Exactly what the mechanism is that leads to the huge discrepancy in prices, I don't know," he said. Dr Craig has worked in several countries that have state-funded health services, including Britain. In these circumstances, doctors are encouraged to keep costs low and prescribe generic drugs. "I am not surprised by the WHO figures," he said. "It explains why many of my patients opt for cheaper alternatives or decide not to take treatment at all."

Dr Sabina Aidarous, a family practitioner at a private clinic in Dubai, said she had seen a number of patients who chose to buy medicines from abroad, often in India and Pakistan, to avoid paying UAE prices. "A lot of patients without health insurance are paying for medicines out of their own pocket," she said. "So they get them from abroad. They bring in the box to show me that it is cheaper and exactly the same. But we don't know where all the drugs have come from, so what health problems could we be opening ourselves up to?"

Dr Aidarous said she always tried to write the generic name on a prescription. She also said the discrepancies in the availability of drugs could be to do with the pharmaceutical companies' targeting the private sector more than the public. "In government facilities there is an ethical issue about drug representatives' pushing certain drugs," she said. "It is easier for them to target the private sector, so this may be why there is more availability there.

"But we don't really know why the prices are so high; it is a very interesting question." munderwood@thenational.ae