A taste of our own medicine

In the ten years since Krishna Bahadur Magar opened his pharmaceutical store, Sabika Pharma, opposite the Teaching Hospital in Maharajgunj, his shelves have found increasing space for made-in-Nepal products.

Domestically manufactured medicines now contribute as much as half of the sales of pharmaceutical products in Nepal. But although this has made Nepal more self-reliant in medicines, there are problems with quality, aggressive commercialisation and over-prescription.

Says Magar: “When I first set up shop, the drugs I bought for retail used to entirely be imported ones, almost exclusively from India. Today, about a half come from factories in Nepal.”

There are now 128 companies licensed for drug manufacture in Nepal, compared to 87 a decade ago. Drugs like painkillers, liquid medicines, syrups, calcium supplements, and multivitamins are now largely produced within the country. These medications have become the mainstay of Nepali pharmaceuticals because they do not require research into new molecules and formulae.

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Called generic formulations, they have been around in the market long enough that they are no longer protected by patents, allowing virtually any company to manufacture them.

 “Say if the patent on an Indian company’s drug expires, a Nepali company can start producing it by retaining the same active ingredients, but altering other aspects like colour, and packaging,” explains Prayas Acharya of Deurali-Janta Pharmaceuticals. This ability to tweak and rebrand drugs has allowed Nepali companies to push a wide range of products.

Krishna Bahadur Magar has witnessed this market growth firsthand. Customers come to his store to purchase over-the-counter drugs. He says, “Nowadays they refer to most medications by their Nepali brand names. They don’t often ask for paracetamol, they ask for Niko.”

But even as Nepali brands are becoming household names, customers believe Nepali makes of medication are inferior in quality. Glancing at the doctor’s prescription a customer has just handed him, Nischal KC, who also owns a pharmacy, says none of them are Nepali brands.

“There are no laws to limit the import of drugs that can be readily manufactured inside Nepal”, explains Acharya, adding that this has allowed foreign companies to aggressively push drugs into Nepal and doctors to prescribe them even when cheaper Nepal-made alternatives are available.

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“Prescribers play a huge role in shaping the demand of specific drug brands because they are the ‘advertisers’ of medicines, so to speak, and the most persuasive ones at that,” says Mahesh Shahi, pharmacy chief at Bayalpata Hospital in Achham.

In a 2018 study, hospital pharmacies from across the country conceded that doctor prescriptions indeed influenced which medicines they bought for retail, as did established business relationships with wholesalers and pharmaceutical companies’ marketing strategies, creating undeclared conflicts of interest.

“When doctors prescribe brands instead of generic medication names, ethics are called into question,” reveals Shahi. “It may be that they are under monetary influence and are prescribing certain foreign brands over Nepali ones, and then blaming it on the fact that Nepali medications are poorly made. It is a false assumption that quality is necessarily affected by where a drug is made.”

The WHO has outlined detailed guidelines for good manufacturing practices (GMPs) to ensure quality is maintained in each step of the production process. As of 2023, 34 pharmaceutical manufacturers in Nepal are WHO GMP certified.

“Even though access to testing machinery still relies on imports, many Nepali factories today have the technology to carry out quality checks in a semi-automated manner,” says Prayas Acharya.

Before products are launched into the market, their chemical composition is tested at the National Medicines Laboratory. The Department of Drug Administration (DDA) under the Ministry of Health and Population evaluates the quality of medical products before licensing them.

But despite regulations, there are still cases of counterfeit drugs. While the DDA orders recalls of such medications, patient safety is at risk when pharmaceutical demands shoot up unexpectedly, as was seen during the pandemic.

In the past decade, 404 substandard, falsified or unregistered pharmaceutical products were recalled by the DDA. Interestingly, a higher proportion of these were imported medicines.

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“Counterfeit drugs are a global problem, not just a Nepal problem,” says Acharya.

Privately owned pharmacies sell prescription medications over the counter, and even operate without registration under the DDA. Acharya is worried that pharmaceuticals are rapidly turning into a push-market, allowing retailers to cash in on unsuspecting customers, which is why community pharmacy practices need to be incorporated into the health system.

“Here at Bayalpata, we have a Drug and Therapeutics Committee to oversee all pharmaceutical activities,” says Mahesh Shahi, who is the pharmacy chief at the Achham hospital.

The DDA’s National Essential Medicines List has 398 medicines deemed necessary to address the priority health needs of Nepalis. Sticking to these and minimising the number of medicines in the hospital formulary has helped the Bayalpata pharmacy to prevent over-commercialisation.

Having these essential medications available means that access is not compromised, and limiting brand options means prescribers are kept from being swayed in their decision and from favouring certain companies.

This strategy also reduces the possibility of antimicrobial resistance, which is when certain antibiotics no longer function against target pathogens because they are overused. Limiting the number of antibiotics sold keeps options open for patients if the commonly available medicines stop having their intended effects.

In urban areas like Kathmandu, unhindered access to medications has made drug misuse easier, leading to increasing cases of antimicrobial resistance, and hazards due to self-medication. With more Made in Nepal brands, commercialisation is a growing concern.

“It is a good thing that access to domestically produced medications is increasing,” says Shahi. “But we still need regulations to ensure that the drugs patients receive are correctly prescribed and properly functioning, and have response mechanisms in place if they are not.”

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