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Implications of Inaccessible Insulin in US Markets

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The  Recent Telephonic Survey report conducted by the Staff of two  U.S  Senators i.e Elizabeth  Warren and    Richard  Blumenthal in the Month of Decembers 2019, is an eye-opener since three Market Leaders of  Insulin manufacturers   –  Sanofi, Novo Nordisk and  Eli Lilly controlling the  80% market share has failed to provide  Insulin to market despite their promises to ensure supply of the discounted authorized generic version of Insulin in the market to avoid shortage.

The report spells a cursory glance missing other market players who are equally involved making the report useful since it underpins loopholes which were neglected by only blasting only player –Eli Lilli. The reported outcome might have been very fruitful had the researches included other market players who are equally responsible in the issue those include manufacturer, insurer, doctors and pharmacies.

It was disgusting to know that despite using resources, the staff worked hard to conduct the research over the chain and no chain suppliers through the telephonic  survey  but the results unsatisfactory as the report targeted the only market player and provided safe passage to others deliberately providing safe cover to escape responsibility.  What the authors of the report did in their findings without analyzing the supply chain process, equally shows that they failed to substantiate their argument and threw all the burden to a single actor in the market – Eli Lilly.

It is also surprising that the report did not mention anywhere that the Pharmacy  Benefit  Manager is also  responsible including the National body  -Food and Drug  Administration whose responsibility has also been skipped in the report. Even  Legislators skipped their responsibility to legislate against the profiteers and how to ensure accessibility in the market.

The research methodology used in the survey was inefficient that failed to give desired results rather dropped the burden on a single actor. The Manufacturer has a limited role in the supply chain –all it could do to ensure production but other factors such as pharmacies, doctors and suppliers etc are equally responsible.

The survey results were alarming since  85% of the respondents confirmed that the promised authorized generic version of the  Insulin was not available in the market raising concerns for the people with diabetes that the situation was critical and abysmal. But the truth is that whether the company informed the doctors or patients about the authorized Generic insulin, Had any doctor prescribed any such drug for the patients  -the report is mum over the issue. 

The PBM is a great player to govern prices  but in this case Insulin prices, it shows that regulator has become beneficiary leaving patients at the mercy of profiteer who are playing with the lives of the people.

It was high time the legislators, policymakers and Price regulators to be vigilant by taking initiatives against such criminal negligence that might cause serious consequences for diabetic patients in the US. The Report would have been comprehensive, had it discussed all the stakeholders without making any single player a scapegoat.

Despite pocketing millions of dollars by these  Pharmaceutical companies in the US,  the companies’  Up graph in the price increase, has not halted as these companies have market dominance, hence, they kept raising the prices making it impossible for Patients, Taxpayers to buy these Medicine at the relatively high price range.

The average prices were reported at $7 to $11 per patient per month.  There has been a significant price hike in overall drugs including the Insulin. Alarmingly, Over 30 million American living with Diabetes, Insulin is the essential medical treatment for Diabetes. Insulin helps the body to process the Glucose obtained from Food.

The Glucose is the essential part of the body to work properly but Diabetes disrupts the natural process, as a result, Insulin is used to control diabetes and process the glucose produced by food in the human body.

According to words of Diabetes Patient “They either use Insulin or they will die because of low or Excessive glucose present in the body.

The report  raised  the important concern  of  the  patients and caregivers in length   that  rising  prices  will affect the purchasing power parity of  people if the price  goes beyond the capacity of  Patients  risking their life  to death if  body glucose  is not processed  properly causing serious  health complications such as nephropathy( Kidney Disease Caused by Long Diabetes ), fainting   etc but failed  to make their argument defence by  sufficient evidence

The report heralds that given the growing public pressures, these Pharmacy companies promised to introduce the generic product Insulin to help decrease the out of pocket expenses of the Patients with Diabetes.

According to the report, Insulin Producer Eli Lilly had announced in March  2019 that it will introduce a generic version of its Rapid Action Insulin  Humalog –to “Insulin Lisper” promising to keep its price lower to almost 50% to facilitate the people with Diabetes. It had also clarified that the “Insulin Lispro” will be used diabetes unlike Humalog as both drugs are same.

While going through the report, one wonders that the report is only revolving around Eli Lilly the only manufacturer while other players are absolved or not held responsible for  Insulin prices hike or subsequent unavailability in the markets.

It is also debatable that authorized generic is the actual substitute of original product Humalog or not.

Furthermore, why researchers or staffers have not referred to other market players. Whether the other players have ensured the supply of Insulin to market or not just remains unanswered.

Whether the essential drug is available or not -a point that is supposed to be missing in the report.   Such exceptions or omissions have made the report questionable or targeting a single market player and shifting the responsibility seems to be unjustified since Telephonic Survey seems to have fallen apart as random physical verification of the medicine may have different results as compared to telephonic survey research.

The report makes the respondents as anonymous raising doubts that whether actual respondents were taken aboard while preparing the report or not, also remains ambiguous. The report does not follow the research methodology or specific tools that might have multiplied its credibility since it missed important details.  Though the report has drawn the attention of the legislators towards the key issue of availability and affordability of medicines including insulin.

By far, responsibility does not fall upon single insulin producer Eli Lily when there are three to four other Market players come under the domain of oligopoly. The excessively and expedient mention of  Eli Lilli several times giving the impression that it had monopolized the insulin market. As a  researcher, one must be aware that research does not allow any personal prejudice or obsession with any market player.

Drugs, especially of diabetes, often have elastic demand thus the manufacturer is under pressure to double the production to supply the elastic demanded products in Market.

Moreover, patients with cardio or diabetes are very particular to use the medicines of specific pharmacy or specific brand since they fear that if they changed the drug brand, they may have serious complications or its efficacy may be much lower as compared to the brand they have been using for a long time.

It was ironic that such negligence on the part of  Insulin manufacturers, Doctors, insurers and pharmaceuticals warrant a strong legislation against Pharmaceutical companies and strict laws to govern their operation and regulate their pricing and supply chain strategies so that situation may not get out of control given the serious and essential nature of Insulin for diabetic patients.

Moreover, It was unjust on the part of respectable senators i.e Elizabeth Warren and Richard Blumenthal to blast  Eli Lilly by holding it responsible for the failure to make the discounted version of authorized generic of Insulin availability and affordability issues, while absolving other market players. Since doctors advise multiple pharmacies not just stuck to singe manufacturer i.e Eli Lilly. Even the role of  PBM is not referred to in the report.

All the doctors having specialization in diabetes advise insulin manufactured by various manufacturers to discourage monopoly in the Pharmaceutical Industry because it will be too difficult for policymakers to regulate and restrict the prices at approved rates. The subsidies will also help lower drug prices.

The Legislators should empower the Food and Drug Administration  (FDA) to regulate prices so that  people may not bear the burden of  skyrocketing prices  which are slipping out of consumers reach especially the essential drug  “The Insulin”

FDA should bound the pharmaceutical companies to carry out mass awareness campaigns through  TV, Radio and Newspapers so that people may have updates regarding drug recalls, replacements, renaming or stock availability so the inconvenience caused to both the patients and caregivers may be averted.  Laws should apply to all not just apply to a single individual.

The survey indicators show the ratio of availability and unavailability as  15% and 85% which is alarming and calls for immediate measures to address the inaccessibility issues of an essential drug “The Insulin”  but at the same times, results of results are misleading and skipping some key market players.

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Development

The Development of microfinance industry depends upon the resilience and risk management: SECP Chairman Amir Khan

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Islamabad : SECP Chairman, Aamir Khan emphasized that in these challenging times the development of microfinance industry depends upon the resilience and risk management, achieved through quintessential pillars of liquidity-tapped through private capital and technology embracement. Khan was addressing the Non-Bank Microfinance Companies Stakeholders Forum organized by SECP to devise a way forward and collaborate strategic response to cope the challenges posed by COVID-19 pandemic and ensuing lockdowns.

The SECP Chairman Amir Khan, along with Commissioner Specialized Companies Division, Farrukh Sabzwari chaired the session. Representatives of Pakistan Microfinance Network (PMN), State Bank of Pakistan (SBP), National Bank of Pakistan (NBP), Pakistan Poverty Alleviation Fund (PPAF), Pakistan Microfinance Investment Company Limited (PMIC), Karandaaz Pakistan and multilateral donor agencies including the World Bank, International Finance Corporation (IFC) and Department for International Development (DFID) attended the session.

 The Chairman SECP advised NBMFCs to go far product diversification to insurance solutions and saving products and build capacity of their workforce to attain business development and operational efficiency. He endorsed formation of a working group consisting of nominees from SECP, PMN, PMIC and NBMFCs to further analyze the situation. The working group will also take up the matters with relevant forums including ministry of finance, SBP and multilateral donor agencies for possible solutions.

Khan expressed SECP’s firm commitment to providing all possible support to industry not only during the current pandemic times but also in developing the industry on a strong footing. SECP Commissioner, Sabzwari highlighted the measures taken by SECP to provide relief and flexibility to the NBMFCs and their wholesale lender in managing funding requirements. He also talked about SECP’s advice to NBMFCs to defer and reschedule borrower loans.

Participants acknowledged SECP’s timely intervention to provide regulatory relief to NBMFCs in managing their credit lines and funding requirements. However, industry representatives expressed their concerns on potential defaults by borrower and liquidity crunch that may lead to capital crisis in the industry.

They raised the need of new money injection into the industry through collaborative efforts of microfinance regulators and the government. Representatives of international donor agencies attending the Forum expressed their resolve to extend fullest possible support to Pakistan’s microfinance sector.    

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Development

Gov’t releases Rs 533.33 billion for various development projects so far

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Islamabad: The federal government has so far authorized release of Rs 533.33 billion for various ongoing and new social sector uplift projects under its Public Sector Development Programme (PSDP) 2019-20, as against the total allocation of Rs 701 billion.

Under its development programme, the government has released an amount of Rs 230.3 billion for federal ministries, Rs 175.65 billion for corporations and Rs 43.46 billion for special areas, according to a latest data released by Ministry of Planning, Development and Reform.

Out of these allocations, the government released Rs 38.5 billion for security enhancement in the country for which the government had allocated Rs 53 billion during the year 2019-20.

An amount of Rs 81.37 billion has also been released for the blocks managed by finance division under the government’s 10 years development programme.

Similarly, for Higher Education Commission, the government released an amount of Rs 27.07 billion out of its total allocation of Rs 29 billion while Rs 301.47 million were released for Pakistan Nuclear Energy Authority for which the government had allocated Rs 301.48 million in the development budget.

For National Highway Authority, the government released Rs154.94 billion. Under annual development agenda, the government also released Rs 10.7 billion for Railways Division out of total allocation of Rs16 billion, Rs 7.7 billion for Interior Division, and Rs 8.38 billion for National Health Services, Regulations, and Coordination Division.

Revenue Division received Rs 4.3 billion whereas the Cabinet Division also received Rs 30.18 billion for which an amount of Rs 39.986 billion has been allocated for the year 2019-20.

The government also released Rs 26.9 billion for Azad Jammu and Kashmir (AJK) block and other projects out of its allocations of Rs 27.26 billion and Rs 16.54 billion for Gilgit Baltistan (Block and other projects).

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Covid-19

Pakistan’s small businesses hit hard by COVID-19

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Small businesses in Pakistan have been adversely affected by the Covid-19 pandemic. The low demand at home, disruptions in supply chains, constraints in international trading, and expected prolonged lockdowns are now leading to severe cash flow problems, the inability to pay back debts and cancellation of orders from clients. 

This rising uncertainty is gradually leading them to lay off employees which will have welfare implications. In some sectors where recovery is difficult to predict, small businesses have started planning for the worst: complete shutdown. This crisis could also imply a much bleaker outcome for the startup ecosystem in Pakistan.  

The government has announced a SME relief package. The central bank has also come forward to relieve some of the funding and finance related concerns of private enterprises. Yet, many micro and small businesses do not understand how to apply or if they are eligible, to receive such assistance. There are others who argue that this one off relief may not be enough given that businesses are going to face depressed demand for a longer term. Pakistan’s past record of small businesses trying to access such fiscal packages is also not encouraging, partly because many such firms do not access formal banking channels for their needs or banks impose steep collateral requirements. Also, large segments of micro enterprises have the entire or some components of their businesses in the informal sector.

Federal and provincial governments have two issues to address now: how to ensure that small businesses are able to access and utilize existing government-provided assistance, and secondly, what more can be done to support private enterprise in these times.

A progressive fiscal policy and commitment to redistributive taxation is in line with the spirit of Riasat-e-Madinah to which Prime Minister Imran Khan often refers to. A sincere effort is required to reduce the burden of compliance costs faced by small firms- often filing returns several times during a year and to multiple tax bodies across the country. 

Dr. Vaqar Ahmed

On the former, it would be best to start by addressing information and outreach gaps. As the problems for businesses are evolving in real-time, hence there remains a need for structured and more frequent public-private dialogue which should be inclusive enough to also give representation to women, youth-led firms and social enterprises. Such a dialogue will also give a sense to the government about how these businesses will get affected in the forthcoming rounds of Covid-19.

On the latter, I believe the forthcoming budget for the fiscal year 2020-21 should be seen as an opportunity not only to provide support to collapsing businesses but also to put in place economic incentives that encourage enterprises to consider resilient business models. A large part of this has to do with reimagining a better taxation regime.

A progressive fiscal policy and commitment to redistributive taxation is in line with the spirit of Riasat-e-Madinah to which Prime Minister Imran Khan often refers to. A sincere effort is required to reduce the burden of compliance costs faced by small firms – often filing returns several times during a year and to multiple tax bodies across the country. It is an opportunity now to automate, rationalize or eliminate several filing and payment layers in taxation to ultimately help reduce the cost of doing business.

After a lot of persuasion from local think tanks and the International Monetary Fund (IMF), federal and provincial governments agreed to establish a National Tax Council (NTC) to harmonize the general sales tax (GST). 

Currently all provinces have a different structure of GST on services. There are also issues regarding definition of certain activities which the federal government may assume to be under its jurisdiction. Perhaps smaller firms have been the hardest hit due to the fragmented tax structure across the federation and it is time now to expedite NTC’s establishment and work in this direction. Even when the system is finally harmonized, the GST should not be collected by multiple windows at federal and provincial levels. A unified tax return and collection should be made possible through online mechanisms.

It will also be timely to think about which sectors should be motivated to scale up production and services in the face of this health-related emergency. Hospitals and private clinics operating at micro, small, and medium scale are primary candidates for cut in GST on services and even rationalization in direct tax rates. Firms producing personal protective equipment should also see a relief in taxes. The trade taxes faced by such producers or even hospitals importing from abroad need to be revisited. The agro-based and food processing enterprises will need similar help as their input supplies face price and supply volatilities.

Covid-19 also increased demand on several other sectors providing essential services. Our policy circles have rarely seen these sectors as important for the social and mental wellbeing of society until the pandemic struck. It will now be timely to recognize the services of firms (including schools) providing online services. The economic policy managers must think out of the box how best to leverage e-commerce in the battle against Covid-19. 

– Dr. Vaqar Ahmed is an economist and former civil servant. He is author of ‘Pakistan’s Agenda for Economic Reforms’ published by the Oxford University Press. Twitter: @vaqarahmed

Courtesy : ArabNews

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