Medical Science

Abdul Kader Mohiuddin

A Review of Pharmaceutical Science.

Support for Viva and Job Interviews

Academic Paper
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Abdul Kader Mohiuddin

A Review of Pharmaceutical Science. Support for Viva

and Job Interviews

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 PharmaTune Abdul Kader Mohiuddin
A Brief Review of Pharmaceutical Science for
Viva and Job Interview
Preface
The expanded role of pharmacists uplifts them to patient care, industrial marketing,
regulatory affairs from dispensing and manufacturing of drugs. The sector is
emerging in both developed and under-developed countries. Furthermore, pharmacy
teaching institutions need to revise and up-date their curricula to accommodate the
progressively increasing development in the pharmaceutical education and the
evolving new roles of practicing pharmacists in healthcare arena. The study aid
highlights the pharmacists’ roles and responsibilities along with basic pharmacy
education, with the most recent information obtained from publications in several
journals, books, bulletins, newsletters, magazines, etc. Also, many of the prospective
viva and interview questions are solved along with a few chapter outlines, covering
many of the pharmacy courses. However, it is very important to remember that no
study aid can help do well in a viva session or job interview unless a knowledge base
is kept sharpen. Therefore, authors of this study aid do not claim any superiority over
textbooks and current knowledge from quality pharmacy magazines and other similar
sources, as the world is changing every day. The sole of this book is to support a
pharmacy student or professional to give an accelerated mental support when books
are not feasible to carry before an interview and viva session.

1
 Index

Chapters Page
Chapter 1. Introduction to Pharmacy Practice 3-10
Chapter 2. Bangladesh Pharmaceutical Industry 11-19
Chapter 3. Bangladesh Health System Review 20-2
Chapter 4. Clinical Pharmacy Practice 28-36
Chapter 5. Pharmacists in Hospital Management 37-45
Chapter 6. Pharmacists in Community Care 46-55
Chapter 7. Prescription Pharmacy 56-70
Chapter 8. Rational Use of Drugs 71-79
Chapter 9. Patient Education and Compliance 80-92
Chapter 10. Pharmacoeconomics 93-100
Chapter 11. Pharmacovigilance and ADR Management 101-110
Chapter 12. Clinical Pharmacists in Chronic Care 111-121
Chapter 13. Managerial Role of a Pharmacist 122-136
Chapter 14. Basic Marketing Concept 137-150
Chapter 15. Professional Communication 151-161
Chapter 16. Pharmaceutical Regulatory Affairs 162-174
Chapter 17. Pharmaceutical Marketing Practice 175-180
Chapter 18. Tablet: Formulation & Manufacturing 181-190
Chapter 19. Pharmaceutical Pre-formulation 191-195
Chapter 20. Dispersed System 196-203
Chapter 21. Mixing & Separation Techniques 204-210
Chapter 22. Pharmaceutical Analysis 211-215
Chapter 23. QC and Method Validation 216-225
Chapter 24. Advanced Drug Delivery System 226-228
Chapter 25. Topical Inorganic Preparations 229-237
Chapter 26. Major Electrolytes 238-241
Chapter 27. Pharmaceutical Excipients 242-246
Chapter 28. Pharmacology Review 247-261
Chapter 29. Pharmaceutical Microbiology 262-266
Chapter 30. Medicinal Plants of Bangladesh 267-270
Annexure 1. Sample Questions on Pharmaceutical Technology 271-291
Annexure 2. Sample Question for the Post of Executive, 292-296
PMD/Training
Author Profile 297

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 Chapter 1. Introduction to Pharmacy Practice

Background
As a profession pharmacy was recognized in Bangladesh after the promulgation of
Bangladesh Pharmacy Ordinance-1976. Although, the pharmacy education started its
journey by the hand of the Department of Pharmacy, Dhaka University in 1964. Major
work field for pharmacist in hospital as hospital, clinical pharmacist and community
pharmacist in a specific community. In Bangladesh, pharmacy practice areas for
graduate pharmacist is limited in industry i.e., industrial pharmacy practices or in the
marketing sections. A few numbers of pharmacists are involved in administrative
positions. In the area of industry or marketing sections graduate pharmacists involved
in production, research & development, quality control, quality assurance and
product marketing, etc. But graduate from other disciplines like biochemistry,
microbiology, biotechnology, chemistry can also work in these sections. The
educational system of pharmacy is one of the major reasons for bounded pharmacy
practices because the courses included in bachelor degree principally emphasize on
industrial practices. The government and pharmacy regulatory authority should take
sufficient initiative to develop the pharmacy sector in Bangladesh.

Practice for Pharmacists' Care Imposed by American Pharmacists Association

(APhA)
1. Serves patients by preparing medications, giving pharmacological information
to multidisciplinary health care team, and monitoring patient drug therapies.
2. Prepares medications by reviewing and interpreting physician orders and
detecting therapeutic incompatibilities.
3. Dispenses medications by compounding, packaging, and labeling
pharmaceuticals.
4. Controls medications by monitoring drug therapies; advising interventions.
5. Completes pharmacy operational requirements by organizing and directing
the workflow of technologists, evaluating their pharmaceutical preparation
and labeling, and validating order entries, fees and safety checks.
6. Provides pharmacological information by answering questions and requests of
health care professionals and counseling patients on drug therapies.
7. Develops hospital staff’s pharmacological knowledge by participating in
clinical programs and training pharmacy staff, students, interns, externs,
residents, and health care professionals.
8. Complies with state and federal drug laws as regulated by the pharmacy board,
drug enforcement administration and FDA by checking of nursing units.
9. Maintains records for controlled substances and removes outdated and
damaged drugs from the pharmacy inventory.
10. Supervises the work results of support personnel.
11. Maintains current registration, studies existing and new legislation, anticipates
legislation, and advises management on needed actions.
12. Protects patients and technicians by adhering to infection-control protocols.
13. Maintains safe and clean working environment by complying with procedures,
rules, and regulations.

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 14. Contributes to team effort by accomplishing related results as needed [1].

Pharmacy Code of Ethics

1. A pharmacist respects the covenantal relationship between the patient and
pharmacist.
2. A pharmacist promotes the good of every patient in a caring, compassionate,
and confidential manner.
3. A pharmacist respects the autonomy and dignity of each patient.
4. A pharmacist acts with honesty and integrity in professional relationships.
5. A pharmacist maintains professional competence.
6. A pharmacist respects the values and abilities of colleagues and other health
professionals.
7. A pharmacist serves individual, community, and societal needs.
8. A pharmacist seeks justice in the distribution of health resources [2].

Scope of Pharmacists in Bangladesh

1. Pharmacy Education: Pharmacy is taught in about 100 public and private
universities in Bangladesh and about 8000 pharmacy students graduate every
year. Nearly a thousand of pharmacists are engaged in pharmacy education
and several other training projects.
2. Pharmaceutical Marketing: Medical Services Department (MSD), Product
Management Department (PMD), Clinical Services, Training field forces, Sales
Promotion/Medical Promotion and International Marketing (IM) departments.
3. Pharmaceutical industries (Finished medicines, Active Pharmaceutical
Ingredients/APIs, and Excipients Manufacturing industries): In Production,
Quality Control (QC), Quality Assurance (QA), Product Development (PD),
cGMP Training, Warehouse, Drug Research and Invention, and Technical
Services Department (TSD).
4. Hospital Pharmacy: Hospital pharmacy practice in Bangladesh is confined to
selling drugs till today. Nearly 75% of pharmacists around the world work in
patient care but an opposite scenario is found in Bangladesh. The practice has
just begun in some modern private hospitals in Bangladesh like Apollo
hospital, Square hospital, United hospital and Gastro liver hospital etc. and
showing a huge prospect in future.
5. Drug Testing Laboratories (Dhaka and Chittagong)
6. Research & Development in Pharma industries, educational and research
institutes (Research for new drug molecules, Novel Drug Delivery Systems,
Improved Healthcare, Clinical aspects, etc.)
7. Drug Regulation: To register pharmaceutical products in regulated markets it
requires highly standardized documents. Currently pharmacists are working
in BPS, PCB and DGDA (affiliated with Commonwealth Pharmaceutical
Association and International Pharmaceutical Federation), watching standard
of both pharmacy education and standard of manufacturing procedure of
pharmaceutical companies of the country [3,4].

4
Prospect of Pharmacists in Abroad
Pharmacists acquire medical and medicinal history, check medication errors including
prescription, dispensing and administration errors, identify drug interactions,
monitor ADR, suggest dosage regimen individualization, provide patient counseling,
etc. in many developed countries like:
1. In the USA: US National Center for Health Workforce Analysis projected that,
between 2012 and 2025 the pharmacist supply, would increase by 16%.
Pharmacy graduates are employed in hospitals, health systems and ambulatory
clinics at a greater rate than in the traditional community chain or independent
pharmacy settings. It is a good time to be a pharmacist in the US, but how good
it is will depend on the ability of the profession to foster and strengthen
autonomy in practice and to continue to expand their scope of practice and
impact on patient outcomes [5].
2. In UK: Around 30% of GP accomplices have declared not having the capacity
to fill a GP opening in their training. There are currently over 1000 Full Time
Equivalent clinical pharmacists working across the country through the NHS
England Clinical Pharmacists in General Practice Program since it started in
2015 [6].
3. In UAE: There is still a clear shortage of pharmacists in UAE and it is expected
to be even worse by the year 2020. Pharmacy education was first established in
the UAE in the year 1992 by Dubai Pharmacy College. However, majority of
students enrolled in UAE College of pharmacy were nonnational residents, and
a large number of graduates leave the country after graduation [7].
4. In Malaysia: Pharmacy practice in public health clinics and community
pharmacies are very different. Pharmacists in the public health clinics possess
complete control over the supply of medicines. A pharmacy practice reform
that integrates pharmacists into primary healthcare clinics can be a potential
initiative to deliver comprehensive primary healthcare services to the public
[8].
5. In Australia: The community pharmacies looking to recruit permanent
pharmacists have to wait for months. Government is trying to attract more
pharmacists to rural, regional and remote areas. Pharmacist salaries in rural
and remote areas are on the rise as the demand for professionals in community
and hospital roles increases [9].
6. In New Zealand: Demand for healthcare is increasing because the population
is ageing and because new technology means more health problems can now
be treated. As a result, employment prospects for hospital pharmacists,
industrial pharmacists and retail pharmacists are good [10].

Challenges of Pharmacy Profession in Bangladesh

1. Education System: The graduates who pass out do not get employment easily
due to their inadequate training, lack of thorough knowledge of fundamental
concepts and practical skills. Universities in Bangladesh should formulate
curricula based on market demand and real-life situation as 36% of employers
in the country are now facing the shortage of skilled manpower.
2. Job Environment: At present, industrial jobs are apparently saturated.

5
 Therefore, getting entrance of new Pharmacists to Pharmaceutical Industries
become quite tough or have narrow scope for new Pharmacists. On the
contrary, companies are seeking experienced pharmacists with higher skill,
professionalism and exposure for top management/new ventures.
3. Eligibility in Abroad: The present Pharmacy education system of Bangladesh
does not comply with the international requirements for jobs and higher
studies in many developed countries.
4. Underutilization of Hospital Pharmacists: Though hospital pharmacists are
recognized in many developed nations for their importance as a healthcare
professional, in Bangladesh it is still underutilized or underestimated.
5. Lack of R&D Activities and Backward Linkage: Due to lack of financial and
technological support as well as collaboration between local manufacturers and
researchers, research practice among pharmacy profession is very limited in
Bangladesh. Also, the country lacks a strong backward linkage industry
including the APIs and machinery. All these things narrowed down the job
scopes further [11-14].

Table 1. International Pharmacist Organizations [15]

Name Description
APhA American Pharmacists Association, represents pharmacy practitioners,
and pharmaceutical scientists and students. Membership in one of the
three academies of the APhA are APPM, APRS, ASP—offers members
specialized benefits and the opportunity to influence their practice areas.
ASHP American Society of Hospital Pharmacists. It endeavors to create an
environment in which pharmacists can focus the full potential of their
knowledge and expertise on patient care to provide high-quality
pharmaceutical services that foster the efficacy, safety, and cost-
effectiveness of drug use.
AACP American Association of College of Pharmacy. The association includes
institutional members - the 142 schools of pharmacy accredited by the
Accreditation Council for Pharmacy Education - and individual
members, including administrators, faculty and staff. It represents more
than 6,400 faculty, 62,500 students enrolled in professional programs and
5,100 individuals pursuing graduate study.
ACCP American College of Clinical Pharmacy will drive positive changes in
health care as the professional organization most influential in advancing
clinical pharmacist roles and responsibilities to optimize
pharmacotherapy in the prevention and treatment of disease.
ASCP Promotes the development and advancement of pharmaceutical care
activities directed at patients in long-term care institutions.
NCPA Membership in National Community Pharmacists Association,
dedicated to the continuing growth and prosperity of the independent
community pharmacy in the United States.
AAPS American Association of Pharmaceutical Scientists, the members are
eligible for membership in one of several disciplinary sections: Analysis

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 and Pharmaceutical Quality; Biotechnology; Clinical Sciences; Economic,
Marketing, and Management Sciences; Medicinal and Natural Products
Chemistry; Pharmaceutical Technology; Pharmaceutics and Drug
Delivery; Pharmacokinetics, Pharmacodynamics, and Drug Metabolism;
and Regulatory Affairs.
FIP The International Pharmaceutical Federation (FIP) is the global body
representing over 4 million pharmacists and pharmaceutical scientists.
We work to meet the world's health care needs. FIP is a non-
governmental organization that has been in official relations with the
World Health Organization since 1948.
RPS Royal Pharmaceutical Society promotes pharmacy in the media and
government, lead the way in medicines information, and support
pharmacists in their education and development.

List of Pharmacy Networks/Blogs (in brief)

The Pharmacist, Innovative community pharmacy services in the UK, FiercePharma,
PharmaTimes, Pharmaphorum, PharmaTutor, PharmTech Talk, Patent Docs,
PharmaVOICE, APhA DrugInfoLine, In-Pharma Technologist , Reddit - Pharma,
The Catalyst - A PhRMA Blog, Royal Pharmaceutical Society Blog, Eye For
Pharmacy, NY Times - Drugs (Pharmaceuticals), Science Magazine - In The Pipeline,
Certara Blog, Optymyze OutSourcing Pharma, European Pharmaceutical Review,
Pharma Focus Asia Blog/Ochre Media Pvt. Ltd., Pharmacy Checker Blog, Tosc
Pharma Blog, WellSpring Pharma, FDA Law Blog

List of Pharmacy Magazines (in brief)

Pharmacy Times, Monthly Prescribing Reference, Drug Topics, Pharmacy Today,
U.S. Pharmacist, The Medical Letter on Drugs & Therapeutics, Pharmaceutical
Representative, BioSupply Trends Quarterly, Pharma Mirror, Pharma world,
Pharmacy Practice News, American Journal of Health-System Pharmacy

List of Pharmacy journals (in brief)

Expert Opinion on Therapeutic Patents, Indian Journal of Pharmaceutical Sciences,
International Journal of Clinical Pharmacy, International Journal of Pharmaceutics,
Journal of Controlled Release, Journal of Pharmacy and Pharmaceutical Sciences,
Journal of Pharmacy Practice and Research, Molecular Pharmaceutics, The
Pharmaceutical Journal, European Journal of Pharmaceutics and Biopharmaceutics,
The Annals of pharmacotherapy, The Western journal of medicine, Health
Expectations, BioMed Central, American Journal of Pharmaceutical Education,
American Health & Drug Benefits, British Journal of Clinical Pharmacology

List of Pharmacy Recruiting Agencies (in Brief)

 UK: Spencer Clarke Group, Flow care services limited, Health Care Recruits,
HRSS Recruitment Specialists, Kaleidoscope Consultants Ltd, Team 24,
Pearls International etc.
 US: UnitedTM Pharmacy Staffing, Cameron and Company Inc., CareerStaf
Unlimited®, Empire Pharmacy Consultants, Rx relief (Fresno, California) etc.

7
 Canada: Kelly Services, MNM Medical Recruiters, TAL Group Inc., RPI
Consulting Group, Health Match BC, Grapevine Executive Recruiters Inc. etc.
 Australia: LocumCo, Raven's Recruitment, Wavelength International, Career
Medical Recruitment, Frontline Retail Recruitment etc.
 UAE: Robert Half, Adecco Middle East, TASC Outsourcing, Hays UAE
(Dubai), Mindfield FZ LLC, Parker Connect Consultants (Crowne Plaza
Dubai) etc.
 New Zealand: Medacs Healthcare (Auckland), Horizon, Alpha Recruitment,
Michael Page (Auckland), Life Plus etc.
 Denmark: Compass HR Group, UniqueConsult, Hartmanns, StepStone, CBP
Network, Stanton Chase, JKS Vikar & Recruitment etc.

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References
1. Mohiuddin AK. Pharmacists in Public Health: Scope in Home and Abroad. SOJ
Pharmacy & Pharmaceutical Sciences 6, no. 1 (March 25, 2019): 1–23.
https://doi.org/10.15226/2374-6866/6/1/00196.
2. “Code of Ethics for Pharmacists - ASHP.” Accessed July 9, 2020.
https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-
documents/code-of-ethics-for-pharmacists.ashx.
3. Mohiuddin AK. Prospect of Tele-Pharmacists in Pandemic Situations:
Bangladesh Perspective. Journal of Health Care and Research. 2020;1(2):72-77.
doi:10.36502/2020/hcr.6164.
4. Mazid MA, Rashid MA. Bangladesh Pharmaceutical Journal, Vol. 14, No. 1,
January. Pharmacy Education and Career Opportunities for Pharmacists in
Bangladesh. Bangladesh Pharmaceutical Journal. 2011;14(1):1-9.
5. Walton SM, Manasse HR Jr. Is It a Good Time to Be a Pharmacist in the US?.
Pharmacy (Basel). 2018;6(3):61. Published 2018 Jul 3.
doi:10.3390/pharmacy6030061
6. Mohiuddin AK. Pharmacists in Public Health: Scope in Home and Abroad. SOJ
Pharmacy & Pharmaceutical Sciences. 2019;6(1):1-23. doi: 10.15226/2374-
6866/6/1/00196
7. Dameh M. Pharmacy in the United arab emirates. South Med Rev. 2009;2(1):15-
18.
8. Saw PS, Nissen LM, Freeman C, Wong PS, Mak V. Health care consumers'
perspectives on pharmacist integration into private general practitioner clinics
in Malaysia: a qualitative study. Patient Prefer Adherence. 2015;9:467-477.
Published 2015 Mar 19. doi:10.2147/PPA.S73953.
9. Cooper R. Pharmacists’ demand highest in rural and remote areas. Australian
Pharmacy/Industry, November 13, 2019.
10. New Zealand Pharmacist Salaries. Available in:
https://www.enz.org/salary-pharmacist.html
11. The Daily Star. '36pc BD employers facing skilled manpower shortage'.
National, May 04, 2019.
12. Mohiuddin A. An A-Z Pharmaceutical Industry: Bangladesh Perspective.
Asian Journal of Research in Pharmaceutical Science. 2019;9(1):17.
doi:10.5958/2231-5659.2019.00004.3
13. Alam G, Shahjamal M, Al-Amin A, Azam M. State of Pharmacy Education in
Bangladesh. Tropical Journal of Pharmaceutical Research. 2014;12(6):1106.
doi:10.4314/tjpr.v12i6.36
14. Mohiuddin AK, Nasirullah M. Scope of Tele-Pharmacists in Pandemic
Situations of Bangladesh. Curr Tr Clin & Med Sci. 1(5): 2020.
CTCMS.MS.ID.000525.
15. Chapter 1. Pharmacy Practice at a Glance. In: Abdul kader Mohiuddin. The
Role of the Pharmacist in Patient Care, published by Universal Publishers,
2020. ISBN-13: 9781627343084, Page 14.

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Further Reading
1. Kenneth W. Schafermeyer. McCarthy's Introduction to Health Care Delivery:
A Primer for Pharmacists, published by Jones & Bartlett Publishers, 2016. ISBN
1284094103, 9781284094107
2. Bruce Lubotsky Levin, Ardis Hanson, Peter D. Hurd. Introduction to Public
Health in Pharmacy, published by Oxford University Press, 2018. ISBN
0190238305, 9780190238308
3. Summerlin C. Preparing the future generation of pharmacists through
postgraduate training: Lessons learned and advice for current student
pharmacists. Journal of the American Pharmacists Association. 2019;59(1):7-8.
doi:10.1016/j.japh.2018.11.010
4. Federal Pharmacists: Leading Through APhA. Journal of the American
Pharmacists Association. 2003;43(5). doi:10.1331/154434503322612302
5. Zweber A. Pharmacy: An Introduction to the Profession. Am J Pharm Educ.
2009;73(8):140.
6. Jommi C. An Introduction to Economic Evaluation of Health Care Programs.
Economic Evaluation of Pharmacy Services. 2017:1-9. doi:10.1016/b978-0-12-
803659-4.00001-1
7. Kahaleh AA. Chapter 3: Pharmacy Reborn: From Clinical Services to
Pharmacists’ Patient Care Services. Pharmacy: An Introduction to the
Profession, 3rd Edition. 2016. doi:10.21019/9781582122779.ch3
8. Burrows J. Becoming pharmacists: exploring professional development of
pharmacists following graduation. doi:10.14264/uql.2019.291

10
Chapter 2. Bangladesh Pharmaceutical Industry

Background
Pharma market is now a days one of the fastest growing sector of Bangladesh.
Considering 1950 to present, significant changes taken place. After liberation,
Bangladesh pharma industry was largely dominated by the import dependent MNCs.
On or before 1982 ordinance, 75% of the market was dominated by the MNCs and the
rest share was with the other 133 local companies [1]. After NDP formulation and the
Drug Control Ordinance, there was a dramatic change of reverse. By 1994, a few
pharma companies achieved a tremendous growth and they reinvest their profit for
faster return. In 2015, the WTO extended patent waivers for pharmaceuticals products
for its members in the least developed countries category to January 2033. In 2018, the
country's domestic pharmaceutical market size stood at BDT 205 billion with 15.6%
compound annual growth rate (CAGR) for the last five years. Over the last three
years, approximately $250 million was invested in the sector and market is expected
to be worth between BDT 400 billion and 500 billion by the year 2022-23 [2-4]. Reasons
behind its growth are economic development, population blast, investment scopes,
FDIs along with many other unexplained matters. The annual growth of the sector
was estimated to be more than 24% in 2018-2019, which is nearly 7% by now due to
Covid-19 pandemic [5].

Products of The Industry

The Directorate General of Drug Administration under the Ministry of Health &
Family Welfare, Govt. of Bangladesh, is the Drug Regulatory Authority of the country.
This Directorate supervises and implements all prevailing Drug Regulations in the
country and regulates all activities related to import and procurement of raw and
packing materials, production and import of finished drugs, export, sale, pricing, etc.
of all kinds of medicine including those of Ayurvedic, Unani, Homoeopathic and
Herbal systems [6]. Among complementary medicine arena, at present there are 295
Unani, 201 Ayurvedic, 15 Herbal, 79 Homeopathic and nearly 300 allopathic
companies operating in Bangladesh. The industry has 3,657 generics of allopathic
medicine, 2,400 registered Homeopathic drugs, 6,389 registered Unani Drugs and
4,025 registered Ayurvedic drug [3], [7].

Local Market Overview

It’s predominantly a branded generic marketplace. They can either sell to the private
sector pharmacies, to the government and its public health care establishments
(HCEs), or to international organizations like UNICEF. The top 20 companies Pharma
are having a combined market share of near 80% of the total pharmaceutical market
of the country [8]. Bangladesh Association of Pharmaceutical Industries (BAPI) was
instituted in 1972, since then BAPI playing a pivotal role in shape up of the industry.

Product Segmentation
1. The primary layer of R&D Activities. This is often a very costly and high-risk
business, and for many of global Pharmaceutical firms, represent the majority
of costs. However, to continue to develop export capacity, sector specialists
strongly emphasize the need for increased investment in R&D.

11
 2. The second layer is manufacture of ingredients for finished formulations.
These activities cover production of API, solvents and excipients used as raw
material for drug formulations. Historically, Bangladesh is an import
dependent country for API and others. The local manufacturers arrange raw
materials from China, India, Japan, Germany, France, Holland, Italy,
Switzerland, Austria, Hungary, Ireland etc.
3. The final layer concerns producing final products, finished formulations. In
this layer, there are both patented and generic products. However, in
Bangladesh, only generic products are produced. Formulations represent the
mainstream business in pharmaceuticals industry of Bangladesh. Presently, the
market consists of approximately 8000 generic products and 258 firms with
manufacturing capability, along with some imported patented products [9-12].

Business Nature
1. High-End Biotech Products (Anti-Cancer, Insulin, Vaccines etc.): These are
essentially products specific to market niches, i.e. Anti-cancer, Diabatic
products, Vaccines etc. these products are usually high priced and represent a
small portion of the market. Profit margin in such products is very high.
Recently, domestic firms have been entering into this field, and competition is
expected to drive prices and import dependency down.
2. Branded generics (Anti-Ulcer, Antibiotic etc.): This represents broadest
segment of the market, comprising products with relatively stable margin and
Brand orientation. This segment is dominated by local manufacturers, and due
to high brand loyalty observed in our market, market share of manufacturers
is usually moving rarely.
3. Low End generics: This segment is small, often for products with low branding
possibility, and price war is most evident here. The number of competitors is
very high, and market share of each competitor depends on success of
marketing strategy.
4. Contract manufacturing (Domestic and export): Locally, this segment is small
as almost every firm manufactures its own products. The business usually
comes from Health organizations like SMC (Social Marketing Company),
UNICEF etc. to provide products such as saline, contraceptives etc. Presently,
a number of top firms engage in contract manufacturing. Competition is very
low, as each firm engages based on foreign counterpart relations [1].

Export
A number of companies have already obtained or in the process of obtaining
UKMHRA, EU, TGA, Australia and GCC certifications. At the beginning it was
exporting pharmaceutical products to Vietnam, Singapore, Myanmar, Bhutan, Nepal,
Sri Lanka, Pakistan, Yemen, Oman, Thailand, and some countries of Central Asia and
Africa. The industry today exports, besides a large spectrum of generic drugs, high-
tech specialized products like HFA inhalers, suppositories, nasal sprays, IV infusions,
etc., to nearly 15 countries. It also has a large market in European countries. However,
it remains to be said that in view of the highly regulated markets of the advanced
countries, most of the exports are confined to the less regulated markets in the

12
developing world. Approximately 1,200 pharmaceutical products received
registration for export since 2018 [13,14].

Import
The import is mostly from nearby countries, especially from India and China. Almost
95% of the BDT 5,000 crore worth of raw materials required by the pharmaceutical
sector are imported [15]. Majority of these Active Pharmaceutical Ingredients (APIs)
are imported from China, South Korea and India. Approximately 75-80% of the
imported APIs are generic and 20-25% is patented [16]. Novo Nordisk and Medimpex
are importing maximum amount of these types of products. Other organizations are
engaging to import the pharmaceuticals products. They are- Sanofi, Aventis, GSK
(now closing operation), Sandoz, Novartis, Roche, UniMed UniHealth, Servier etc.
Certain vaccines, anticancer products, hematological products and other biotech
products are imported [17,18].

API Business
The industry had to import about 97% of API every year for pharmaceutical goods
production. Although banned in domestic market, Ranitidine tablet was exported to
dozens of countries but it had to stop due to API shortage. The government initiated
a high-tech park for API production in 2008 and expected to launch in early 2023.
However, The API park built at Gazaria in Munshiganj (a 38 million BDT project on
200 acres land) does have space to accommodate more than 40 API producers. This
delay has been a major hurdle for the pharmaceutical industry to gain better control
over the inputs and improve operational efficiencies. India, the major generic drug
player, has more than 3500 Drug Master File (DMF) approval for APIs whereas
Bangladesh has none. While the industry is achieving self-sufficiency, it yet procures
90% of raw materials from 98 indenters around the world as only one company
(Active Fine Chemicals) produces raw materials independently. Currently, the
company produces 25 active pharmaceutical ingredients and three types of laboratory
reagents. There are 3000 valid sources of raw materials including countries like China,
India, Taiwan, Italy, Germany, Spain, Switzerland, France, the UK and the US. API
consists a significant percent of total cost in medicine which can run up to 30-40%. At
present, only a few companies – Square, Beximco, Ganasastha Pharmaceuticals, Globe
and Active Fine – are manufacturing raw materials for drugs like paracetamol,
amoxicillin, flucloxacillin, ampicillin and metformin, on a limited scale [19-22].

Domestic Drug Distribution

Bangladesh’s drug market place is composed of small independent pharmacies.
Pharmaceutical firms can sell their products to private sector pharmacies, the
government and its public health care facilities, or to international organizations
operating in Bangladesh (e.g., UNICEF). About 70% of prescribed drugs is distributed
through wholesalers to hospitals, health maintenance organizations (HMOs), and
retail pharmacies. There are approximately 200,000 unregistered and around 150,000
of registered drug stores in Bangladesh. Consumers purchase one to ten tablets or
capsules at a time. The quantity of drugs purchased often depends more on the
consumer’s finances of than on the required dose. The unscrupulous drug sellers sell

13
almost 90% of the stocked drugs without prescription and also date expired drugs are
sold in more than 90% drug stores [23-25].

Access to Essential Drugs

Although officially 80% of population has access to affordable essential drugs, there
is plenty of evidence of a scarcity of essential drugs in government healthcare
facilities. A study conducted in four district hospitals and one medical college hospital
showed that less than 10% of patients received the prescribed medicines from these
facilities. In most such cases, government officials and health professionals are
responsible for the shortage as they often sell government-supplied drugs to local
drug stores instead of dispensing them to poor patients [26-28].

Quality of Available Drugs

According to the WHO, falsified medicines, including contaminated, or contain the
wrong or no active ingredient, or may be out-of-date, is worth more than $30bn in
LMICs. Only 20 to 25 top pharmaceutical companies among the 300 produce drugs of
standard quality. An estimated Tk 600 crore of counterfeit medicines are traded in the
Tk 18,000 crore medicine market in Bangladesh each year [29]. It is widely alleged that
adulteration flourishes in the country because of poor government vigilance and
supervision over drug manufacturers and sellers. Also, quality of alternative
medicines still lags behind due to various bottlenecks as well as lack of goodwill on
the part of the stakeholders. However, Bangladesh is capable of producing high-
quality products as the industry employs state-of-the-art manufacturing facilities,
sophisticated quality control equipment and skilled human resources. To achieve the
goals of marketing, especially in high-value overseas markets, it has to fulfil the
compliance norms which are often market-specific.

Drug Promotion
Medical representatives, who are given annual drug sales targets, offer various gifts,
from stationery items to sample drugs to air tickets for overseas trips, while using
persuasion. Acceptance of these gifts, especially the expensive ones, obliges the
physicians to return the favor by changing established prescription norms and
increasing drug sale. Pharmaceutical companies in Bangladesh spend more than Tk
6,000 crore on marketing a year, around 30% of their turnover in 2018. A study shows
that the companies employ 65% of the work force in marketing — medical
representatives 45% and sales representatives 20%. Accordingly, the costs of drugs
increase because of the huge expenditure on marketing [30,31].

Drug Pricing
On May 28, 1992, a policy guideline for fixation of prices of drugs has been framed,
which is still followed by the pharmaceuticals industries. But due to an amendment
brought to the drug policy in 1994, the onus of fixing medicine prices outside essential
drugs' list went back to the producers. The VAT rate applicable to production of
medicines is 15% and to sales of the products is 2.4% cent under the new VAT and
Supplementary Duty Act-2012 that came into effect from July 1, 2019. That means, for
a unit of medicine with trade price at production stage at Tk 100, VAT will be Tk 17.78.

14
And the price is fixed including 16% commission the manufacturers give to chemist
or pharmacy [32-34].

Drug Dumping
Import of innovator drugs without valid licenses was prohibited and punishable
under the Drugs & Cosmetics Act, 1940. Many of these spurious and unlicensed drugs
are imported by luggage parties in an extremely clandestine and surreptitious
manner. This surreptitious trade channel witnesses supply of these drugs without
maintaining cash memos, demanding prescriptions or issuing invoices, and only
against cash payments. Some of these imported medicines are sold in the country
market at a much higher price than Bangladeshi medicines. This creates the barrier to
capture the market share by Bangladeshi pharmaceutical industries. There are also
entities which are manufacturing spurious and unlicensed drugs with a fictitious
address and contact details to escape any possibility of being detected. Many spurious
and unlicensed drugs are also advertised and supplied through media or by a doctor
himself [35,36].

Foreign Competition
It is largely protected from external competition by the restriction regarding import of
similar drugs manufactured locally. But our industry is not afraid of this foreign
competition. There are many multinational pharmaceutical organizations which have
established their plants in Bangladesh and importing their raw materials from abroad.
Among these competitors, Roche, Novartis are leading. In export market, the Novartis
is playing the dominant role. GSK, Organon, ICI, Pfizer closed their operation at
different time periods [37,38].

MNCs facing a lot of problems:

In pharmaceutical sector, multinational corporations are more concerned about
research and development than locally owned companies. In Bangladesh, they are
facing a lot of difficulties as none of them are to market their products without their
own factory in Bangladesh. No foreign brands are allowed to be manufactured under
third party license. Imports are also prohibited if similar products are manufactured
locally. And if the International patented trade name of the brands is allowed if their
raw materials are brought from the patented companies, which make MNCs to price
their products higher than the national companies in this generic market. As NDP
1982 implemented, most multinational companies sold their business to local
pharmaceutical. This fueled to the evolution of the local pharmaceutical sectors.
MNCs were dissatisfied with this development, already. However, Under the 1982
Ordinance, the Government determines Maximum Retail Prices (MRP) of essential
drug chemical substances. This is applicable for the local companies and still now the
MNCs are determining their price by their own way [1].

Contract Manufacturing
Pharmaceutical companies are increasingly engaging in toll or contract
manufacturing, a development that allows them to utilize unused capacities and
reduce the need for fresh investment. Toll manufacturing, ushered in by the

15
government in the National Drug Policy 2005, is an arrangement in which a company
with specialized equipment processes raw materials or semi-finished goods for
another company. As potential hub for global contract manufacturing, key advantages
of Bangladesh were: Patent waiver up to 2032; reverse engineering of new molecules
for API synthesis (already stopped in India and China); and overhead cost
(manpower+ utility cost) per unit conversion cost of product is 30% less. Contract
manufacturing is mainly used for specialized or high-tech products, the facilities for
which require considerable capital investment. It is unfeasible for a firm to develop
facilities to make a single product. However, Bangladesh pharma companies can only
contract manufacture for domestic distribution with MNCs that already have a
manufacturing facility in Bangladesh. For example: Beximco contract manufactures
Ventolin, which is an inhaler for GSK. More than 30 local companies including Renata,
Beximco and Popular are currently engaged in toll manufacturing for their local
counterparts or MNCs [39].

Emerging Business of Herbal Medicines

According to the WHO, about 80% of the population in developing countries
including Bangladesh depends on traditional healing for their primary healthcare
needs. The market size for herbal medicines including Ayurvedic and Unani is
expected to be BDT 250 billion in Bangladesh, which was BDT 100 billion in 2010. The
government termed herbs and herbal medicine as one of the five priority sectors to
diversify the country's export basket. Industry people observed that Bangladesh has
prospect in making footsteps on the global market for medicinal plant and products
as nearly 650 medicinal plant species have been identified to be in use in Bangladesh
with around 25 plants having high value. Over 30 companies have lined up for
licenses from the drug administration to manufacture such medicines to exploit
business potentials in the sector, still almost untapped.

16
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doi:10.5958/2231-5659.2019.00004.3
2. Ovi IH, Mahmud N. Bangladesh pharmaceutical industry blooms bigger.
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9. Chowdhury MAA. TRIPS and Innovative Capacity of Bangladesh’s
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10. Karim R. Cut dependence on pharma raw materials' import. The Financial
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11. Nadin M. Growth Of Pharmaceutical Company In Bangladesh. Available in:
http://dspace.daffodilvarsity.edu.bd:8080/bitstream/handle/20.500.11948/1
866/P05743.pdf?sequence=2&isAllowed=y
12. Rahman MF. Window of opportunity for the pharma industry. The Daily Star/
25th anniversary special part-2, February 02, 2016.
13. UK Trade & Investment. Sector briefing: Pharmaceutical opportunities in
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https://s3.amazonaws.com/StagingContentBucket/pdf/20110926121243121.
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14. Sheel SK. Problems of Export of Pharmaceutical Products from Bangladesh :
An Analysis . Journal of Business Studies. 2015;36(3):23-37. https://www.fbs-
du.com/news_event/15053071512. Dr.pdf. Accessed July 9, 2020.
15. DataBD.CO. Pharmaceuticals. Available in:
https://databd.co/profiles/industries/profile-pharmaceuticals

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16. Pharmaceutical Processing World. Pharma in Bangladesh. April 29, 2015.
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bangladesh/
17. Rahman S. GSK shuts factory after six decades. The Daily Star/Back Page, July
27, 2018.
18. Mirdha RU. Sanofi to leave Bangladesh. The Daily Star/Business, September
15, 2019.
19. Khan S. Expediting completion of API industrial park. The Financial
Express/Opinion, August 28, 2019.
20. Haider S. A prescription for growth. DhakaTribune, February 12, 2015.
21. Uddin J. Government discourages API export amid China supply snag.
NEWAGE/Business, March 08,2020.
22. Noyon A. Pharma industry spending a fortune on importing raw materials.
The Business Standard/ Pharma, 02 November, 2019.
23. Moniruzzaman M. Supply Chain Management in Pharmaceutical Industries: A
Study on Eskayef Bangladesh Ltd. Available in:
https://core.ac.uk/reader/74352570
24. Ahmed SM, Naher N, Hossain T, Rawal LB. Exploring the status of retail
private drug shops in Bangladesh and action points for developing an
accredited drug shop model: a facility based cross-sectional study. Journal of
Pharmaceutical Policy and Practice. 2017;10(1). doi:10.1186/s40545-017-0108-8
25. Hossain MA, Amran MS. A Cross-Sectional Pilot Study on Pharmacovigilance
to Improve the Drug Safety in Bangladesh. Biomedical & Pharmacology
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26. Akter SF, Rashid MA, Mazumder SK, Jabbar SA, Sultana F, Rahman MH, et al.
Essential drugs in Bangladesh and role of different stake holders – A qualitative
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27. Haque M. Essential Medicine Utilization and Situation in Selected Ten
Developing Countries: A Compendious Audit. J Int Soc Prev Community Dent.
2017;7(4):147-160. doi:10.4103/jispcd.JISPCD_224_17
28. Mannan MA. Access to Public Health Facilities in Bangladesh: A Study on
Facility Utilisation and Burden of Treatment. Bangladesh Development
Studies. 2013;36(4):25-80.
https://bids.org.bd/uploads/publication/BDS/36/36-4/2_Mannan.pdf.
29. Mohiuddin AK. Patient Satisfaction: A Healthcare Services Scenario In
Bangladesh. The American Journal of Medical Sciences and Pharmaceutical
Research. 2020;02(05):15-37. doi:10.37547/tajmspr.v2i05.344
30. Maswood MH. Tk 6,000cr spent on drug marketing a year.
NEWAGE/Bangladesh, Dec 09, 2019.
31. Mohiuddin M, Rashid SF, Shuvro MI, Nahar N, Ahmed SM. Qualitative
insights into promotion of pharmaceutical products in Bangladesh: how ethical
are the practices?. BMC Med Ethics. 2015;16(1):80. Published 2015 Dec 1.
doi:10.1186/s12910-015-0075-z
32. Staff Correspondent. VAT on pharma items included in retail prices: NBR says.
NEWAGE/Business, July 24, 2019.

18
 33. Mala DA. Industry frets about possible drug price hike. The financial
Express/Trade, August 25, 2019.
34. Star Business Report. VAT on medicine sales unchanged at 2.4pc: NBR. The
daily Star/Business, July 24, 2019.
35. Khan SI, Reza MM, Crowe SM, et al. People who inject drugs in Bangladesh -
The untold burden!. Int J Infect Dis. 2019;83:109-115.
doi:10.1016/j.ijid.2019.03.009
36. Rabbi AR. Drugs, smuggled goods worth Tk14.94cr seized by BGB in April.
DhakaTribune/Bangladesh, May 1, 2020.
37. Bhuiyan MNU, Hakim MA, Alam MF. Competitiveness and Global Prospects
of Pharmaceutical Industry of Bangladesh : An Overview. The Cost And
Management, Volume-47, Number-05, September-October 2019. Available in:
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content/uploads/2019/12/2.Competitiveness.pdf
38. Islam S, Rahman A, Mahmood AKA. Bangladesh Pharmaceutical Industry:
Perspective and the Prospects. Bangladesh Journal of Medical Science.
2018;17(4):519-525. doi:10.3329/bjms.v17i4.38306
39. Sultana J. Future Prospects and Barriers of Pharmaceutical Industries in
Bangladesh. Bangladesh Pharmaceutical Journal. 2016;19(1):53-57.
doi:10.3329/bpj.v19i1.29239

Further Reading
1. Faruque AA. Problems of enforcements of regulations on pharmaceutical
industry in Bangladesh. Pharmaceutical Regulatory Affairs: Open Access.
2014;S1(01). doi:10.4172/2167-7689.s1.016
2. Hoque A. Impulse of Dividend Payment Decision: Evidence from
Pharmaceutical Industry in Bangladesh. International Journal of Financial
Research. 2017;9(1):219. doi:10.5430/ijfr.v9n1p219
3. Islam S, Rahman A, Mahmood AKA. Bangladesh Pharmaceutical Industry:
Perspective and the Prospects. Bangladesh Journal of Medical Science.
2018;17(4):519-525. doi:10.3329/bjms.v17i4.38306
4. Aktar S, Islam MS, Hossen SM. Human Resource Management Practices and
Firms Performance in Bangladesh: An Empirical Study on Pharmaceutical
Industry. Asian Business Review. 2015;1(2):121. doi:10.18034/abr.v1i2.323
5. Rahman ARA. Continous Professional Development And The Pharmaceutical
Industry- Education Or Marketing? Bangladesh Journal of Medical Science.
2013;12(1):5-9. doi:10.3329/bjms.v12i1.13347

19
Chapter 3. Bangladesh Health System Review

Background
Bangladesh is the seventh most populous country in the world and population of the
country is expected to be nearly double by 2050. According to the 2018 Country
Environmental Analysis (CEA) report of the World Bank, air pollution causes the
deaths of 46,000 people in Bangladesh per year [1]. Less than 10% hospitals of this
country follow the Medical Waste Management Policies. In 2017, 26 incidents of
disease outbreak were investigated by IEDCR [2]. The rising burden of communicable
diseases in Bangladesh can be related to rapid urbanization, and nearly 50% of the
country's slum dwellers live in Dhaka [3]. There is little assessment of the quality of
provider care, low levels of professional knowledge and poor application of skills.
Bangladesh does not have a formal body for arbitration of complaints against health
providers. Hospital or clinic authorities address complaints and disputes
independently, without involving the government or legal entities. Bangladesh's
post-disaster management is inadequate due to a lack of adequate compensation,
inadequate or inaccessible health care facilities and the slow rehabilitation process to
accommodate disaster survivors within the mainstream society.

Implication of Medical Law and Ethics

Unsurprisingly, death due to oversight of physicians or medical laxity and doctors'
incompetence have been reported in the media all the year-round. Laws such as the
Penal Code 1860, Code of Criminal Procedure 1898, Consumer Rights Protection Act,
2009 under which cases can be filed for legal remedies [4]. In the event of death due
to medical laxity, cases may be filed under the penal code, 1860, as death by laxity is
a criminal offence and is punishable under section 304A of the penal code [5]. There
are also provisions for imprisonment and fine which are equally applicable to both
the doctors and the complainants. Doctors usually give little time, often less than one
minute, to examine patients and mistreat them; fixated mind-set of hospital staff who
overestimate their own performance, care little about the patients’ experiences and
don’t know that patients’ satisfaction index is related to clinical outcome [6,7].

Present Healthcare Situation

According to WHO, the current doctor-patient ratio in Bangladesh is only 5.26 to
10,000, which places the country second from the bottom, among the countries of
South Asia [8]. According to the Bangladesh Medical and Dental Council, there were
25,739 registered male doctors in the country between 2006 and 2018 (47%) and 28,425
female doctors (53%) [9]. Average consultation length is used as an outcome indicator
in the primary care monitoring tool which was found was found a less than a minute
to an outdoor patient. An average 1.5 hours is to spend to see a doctor in Dhaka
Medical College and other public hospital outdoors, sometimes there are no doctors
due to post vacancy [10]. Patients’ struggle for essential services during any disease
outbreak in hospital indoor and outdoor is common. The country has just 127,000
hospital beds, 91,000 of them in government-run hospitals. Overall, 67% of the
healthcare cost is being paid by people, whereas global standard is below 32% [11,12].
Only one hospital bed is allocated per 1667 people, and 34% of total posts in health

20
sector are vacant due to scarcity of funds. Unnecessary diagnostic tests and caesarean
sections are also common and impose a substantial economic burden on the poor.
Bangladesh Health Facility Survey (BFHS), 2017 reveals that over 70% of rural health
facilities do not have all six basic supplies (thermometers, stethoscopes, blood
pressure gages, infant and adult weighing scales, and torch lights) [13]. Only about
half of doctors employed in district-to-union sub-center public hospitals are satisfied
with the availability of medicines in their facilities, suggesting a widespread lack of
stocks of medications in public amenities. In 2013/2014, the infant mortality rate,
which is 34 per 1000 live births in urban areas overall, and 40 in rural communities,
rises to nearly 70 in urban slum areas. More than 80% of the population seeks care
from untrained or poorly trained village doctors and drug shop retailers. ‘Oversight
of Physicians’ and ‘Inappropriate Treatment’ have become commonly-used phrases
in print and electronic media of Bangladesh. The 2019 Dengue outbreak in August
2019 alone caused more than 50,000 hospital admissions and around 100,000
hospitalizations and claimed 112 deaths from January to October 2019, where
hospitals had been unable to cope with the huge number of patients flooding the
hospitals [14]. The country is hosting 1.1 million Rohingya refugees, who are posing
serious threat of diphtheria, HIV and other STDs transmission along with Covid-19.

System Collision with Traditional Medicine

There are around 86,000 villages in the country and almost every village has one or
two traditional practitioners [15]. More than 65% of Bangladesh's population receive
first-line healthcare services primarily from village doctors. An estimated 75% of the
country's people use traditional medicine for their health care [16]. 70% of females
also used at least one herbal product during their last pregnancy, mostly without a
qualified medical care practitioner's consultation. Again, alternative/traditional
medicine are not included in the medical school curriculum except in Ayurvedic
Medical College of Bangladesh. Illiteracy, poor financial status, social context,
uncertain diagnosis and treatment costs, physician absenteeism in rural health
complexes, divergent medical opinions, unhealthy competition between healthcare
professionals and their tendency to linger on treatment, negative impression of
expensive medical tests and unnecessary food supplements, as well as easy
accessibility and accessibility of alternative medicine diverted the patients to seek
help from orthodox to alternative medicine [17].

Drug Cost Vs OOP Expenditures

Out-of-pocket (OOP) treatment cost raised nearly 70% in the last decade. About 2/3rd
of the total health expenditure is from OOP, and of this, 65% is spent at the private
drug retail shops [18,19]. Very often, medical representatives rush at peak hours and
aggressively pulls patient prescriptions in the name of survey. Prescribing antibiotics
in 44% consultations, prescribing of 3 or more drugs in 46% in urban centers and 33%
in local health centers clearly raise OOP expenditure and create strong repulsion
towards modern medicine where nearly 22% of the population is below poverty line
[20]. Moreover, doctors are more often accused to take 30% to 50% commission on a
test from hospitals/diagnostic centers. Neither the regulatory authority nor the
professional or consumer rights bodies has any role to control or rectify the process.

21
'Global Monitoring Report on Financial Protection in Health 2019' estimates that
around 7% households are pushed into poverty due to OOP outlays wherein chronic
non-communicable diseases are the principle contributor [21]. Middle class families
spend 11% of their total budget on healthcare, with 9% of households facing financial
disaster, with 16.5% of the lowest paid and 9.2% of the richest households facing
catastrophic health expenditure [22].

Prescription patterns of drugs

Despite legal prohibitions, numerous drugs with similar or no significant benefits are
available in the market. As a specific example, there are seven members of
the Angiotensin-Converting Enzyme (ACE) inhibitors available in the country [23].
The efficacies and chemical structures of these molecules are more or less similar, but
their prices vary. The drug policy clearly prohibits the production of multi-
ingredient preparations of vitamins and minerals with the exception of B-complex
vitamins, but a mixture of 32 vitamins and minerals including selenium,
vanadium, molybdenum, tin and many other unnecessary ingredients has been
marketed in the country for a few years, violating the principles of the NDP [24].
The need for these trace elements in Bangladesh is not established whereas
nutritional deficiencies are mainly related to vitamins A and B-complex, iron,
calcium, iodine and zinc. Irrational prescription and use of antibiotics are rampant
throughout the country, with an estimated half of all antibiotics being sold
without prescriptions [25].

Downgrading Image of Supplied Medicines

Fake drugs kill more than 250,000 children a year worldwide. Rural people, who are
believed to be unaware of the situation are generally the victims of the adulterated
medicines. "People are taking poison without knowing it," according to the Dean,
faculty of Pharmacy at the University of Dhaka, who noted sales of counterfeit or sub-
standard medication are most common in rural areas due to the lower levels of health
awareness and formal education there [26]. According to a survey by BSMMU, as
many as 2,700 children died due to renal failure after taking toxic syrup from 1982 to
1992 [27]. Recently, a lot of people are being cheated in buying adulterated insulin.
The government revoked licenses of 20 pharmaceutical companies for producing
adulterated and low-quality medicine back in 2016. Besides those, licenses of 14
companies to manufacture antibiotics (penicillin, non-penicillin and cephalosporin
groups) are revoked and permission of 22 companies to produce medicine of
penicillin and cephalosporin groups be suspended [28]. Around 370 cases of fake
medicines had been filed in the first 6 months of 2019, according to the DGDA [29].
Even hospitals like Apollo and United, were accused for keeping and selling of
substandard reagents and drugs. Drug Testing Laboratories in the country, are fully-
equipped with modern machines and other testing facilities but their performance is
much lower than (5% of the total produce) present demand where more than 25,000
brands that produce more than 100,000 batches of medicines by nearly 300
pharmaceutical companies.

22
Quality of Medical Education
In a parliamentary session June 2019, the Health Minister informed that close to 50%
teaching positions are vacant in public medical and dental colleges, where most of the
vacant posts are of the basic subjects. The disappointing poor performance of the
private medical colleges noted from the honorable prime minister in a seminar on
critical disease treatment in Bangladesh. A deficit in 65% teaching staffs in both public
and private medical colleges has also been reported. Generally, 80% of medical
education should be provided to students through practical classes—the rest is
theoretical knowledge. But in some private medical colleges, students do not get to
see patients even in their fourth year [30]. Doctors without adequate practical and
field-based applied knowledge are increasingly become risk factors to the patients
they happen to treat. If a degree-holding doctor fails to find the vein for just a saline
push-in and then takes the professional help of an experienced nurse it is a shame not
only for the doctor in question but also for the whole nation. Definitely all these facts
have deep connections to progression of medical studies and quality of future doctors
in Bangladesh.

Debasement of Health Providers’ Image

Surprisingly, more than 40% of private hospitals, clinics, blood banks and diagnostic
centers are not registered with the relevant government agency [31]. The number of
hospitals of international or regional standard is quite a few and located only in
Dhaka. Taking hostage of dead bodies for not clearing the hospitalization costs by
some of the hospitals is becoming quite common. Other allegations also include such
as: swapping of a deceased child with a new born baby, abducting or stealing
newborn baby, staff not attending to patients in coma, high ICU, keeping clinically
dead patients in ICU and raising hospital bill, wrong diagnosis and treatment,
absence of human touch and care from the hospital staff, not maintaining proper
medical history or lack of electronic health record (EHR) or illegible prescription
writing etc. [32-34]. Hospital acquired infection rates in Bangladesh may exceed 30%
in some hospitals. Also, rural practitioners routinely made errors in death certification
practices (more than 95%) and medical record quality was poor (more than 70%) [35].
The country has still not introduced the subject of Emergency and Critical care
medicine in the curriculum 1 for graduate medical students.

Present Trend of Medical Tourism

In a press briefing, former health minister of Bangladesh revealed four reasons of
Bangladeshi patients seeking medical treatment in abroad (economic solvency, love
for treatment abroad, health tourism, and in some cases, for the lack of suitable
treatment facilities in the country). However, public health experts, health
economists, agents of foreign specialized hospitals and patients reported that
Bangladeshis seeking treatment abroad is on an upward trend since patients are
unwilling to gamble with their life and health. A low confidence on local doctors and
flawed diagnosis are forcing a large number of Bangladeshis to travel abroad for
treatment of medical conditions such as cancer, cardiac ailment, autism, infertility, as
well as medical check-ups. In fiscal year 2015-16, 165,000 patients from Bangladesh
visited different hospitals of India but only around 58,000 medical visas were issued

23
to Bangladeshi nationals. Some 63,000-65,000 patients went to Thailand in 2015. On
an average 1,000 Bangladeshis go to India daily and some 10,000 in Malaysia (in a
year) to take treatment, as reported by 2 directors of Indian and Malaysian
consultancy firms [36-38]. India, Thailand, Singapore and Malaysia are the most
visited countries by Bangladeshis medical tourists. For Bangladesh’s economy,
increasing medical tourism means the country economy is losing the amount of
money Bangladeshis are spending abroad. About 700,000 people go to abroad every
year for treatment spending US$ 3.5-4.0 billion during the period 2018-2019 which
was $ 2.0 billion in 2012, due to lack of confidence on the local physicians and poor
diagnosis system [39,40]. To cash in on the growing demand from Bangladesh's rising
mid-income people, some hospitals of India, Thailand, Singapore and Malaysia have
either opened their liaison offices or hooked clients through their consultants in
Bangladesh. Doctors and nurses are also demotivated by poor working conditions,
unfair treatment, and lack of career progression; private and unqualified practitioners
sought to please patients instead of giving medically appropriate care.

24