Pakistan Pharmaceutical Industry Pakistan has a very vibrant and forward looking Pharma Industry.

At the time of independence in 1947, there was hardly any pharma industry in the country. Today Pakistan has about 400 pharmaceutical manufacturing units including those operated by 25 multinationals present in the country. The Pakistan Pharmaceutical Industry meets around 70% of the country's demand of Finished Medicine. The domestic pharma market, in term of share market is almost evenly divided between the Nationals and the Multinationals. The National pharma industry has shown a progressive growth over the years, particularly over the last one decade. The industry has invested substantially to upgrade itself in the last few years and today the majority industry is following Good Manufacturing Practices (GMP), in accordance with the domestic as well as international Guidance. Currently the industry has the capacity to manufacture a variety of product ranging from simple pills to sophisticated Biotech, Oncology and Value Added Generic compounds. Although Pakistan 's pharmaceutical and healthcare sectors are expanding and evolving rapidly, about half the population has no access to modern medicines. Clearly this presents an opportunity, but much more work needs to be done by the government and industry's stakeholders. The value of pharmaceuticals sold in 2007 exceeded US$1.4bn, which equates to per capita consumption of less than US$ 10 per year and value of medicines sold is expected to exceed US$2.3 B by 2012. Pakistan is a developing pharmaceutical market, with a large population and economic progress evident, but per capita drug spending was rather low at around US$9.30 in 2007. Private spending accounts for 65% of total healthcare expenditure sourced through out-of pocket payments, international aid and religious or charitable institutions. Pharmaceutical spending accounts for less than 1% of the country's GDP, comparable to levels in some neighboring countries but above that in some of the South Asian countries. The forecast period is likely to witness the marginal strengthening of the generics sector, albeit more in terms of volumes than values. The share of generics is also likely to increase further as major drugs come off-patent in the near term, to the likely benefit of the generics-dominated local industry. The Pakistan pharma industry is relatively young in the international markets with an export turnover of over US$ 100 Million as of 2007. Pakistan Pharma Industry boasts of quality producers and many units are approved by regulatory authorities all over the world. Like domestic market the sales in international market have gone almost double during last five years. The pharma industry is focusing to an Export Vision of USD 500 Million by 2013. In the meantime, exports are also likely to be boosted by new regional and global opportunities. The Pakistan Pharmaceutical Industry is a success story, providing high quality essential drugs at affordable prices to Millions. Technologically, strong and self reliant National Pharmaceutical Industry is not only playing a key role in promoting and sustaining development in the vital field of medicine within the country, but is also well set to take on the international markets.

High expenditure and increasing health care costs are prime concerning factors in the health care system globally. In some of the developing countries WHO reported out-of-pocket payments as high as 80% of health care spending.1 At present Pakistan is spending only 1.2% of GDP on pharmaceuticals and despite more than 40000 registered brands in the country2 essential and life-saving drugs are missing from the market. Due to inaccessibility of drugs in the public hospitals, 77% of medicine expenditures are out of pocket and thus, access and affordability of medicines is a vital issue to tackle in Pakistan.3 In an attempt to struggle with the escalating drug cost in Pakistan generic prescribing and dispensing could be a solution to approximately one third of the population living below the poverty line. Although there is no ordinance or authoritative rule for generic prescribing or substitution in the public and private sector in Pakistan, recently the Government of Pakistan highlighted the use of generic medicines in order to check the prices of medicines. In Pakistan there is a need to sensitize patients, prescribers and pharmacists to improve the quality use of generic medicines.3 However, to gain a wider health professionals' support, it is vital to understand the issues surrounding generic medicines.4 Current study is aimed to explore the knowledge, perception and attitude of dispensing doctors towards generic medicines as well as to document the factors hindering and favouring generic medicine use by dispensing doctors of Karachi, Pakistan.

Methods and Results This exploratory study aimed to generate new dimensions for further studies on larger scale and therefore, rather than quantifying, understanding the issue was the target and for this purpose a qualitative methodology was adopted.5 A semi-structured interview guide developed after extensive literature search was used as an instrument to interview a purposively selected sample of eleven dispensing doctors. In the current study respondents were identified by snowball technique and the interviews were carried on till the point of saturation.5 Snowball sampling is considered the best way to locate respondents with certain attributes or characteristics as well as instrumental in difficult to reach population.5 All the interviews were conducted at the respective practice settings of the respondents from March 2008-May 2008. The interviews were audio-taped and transcribed verbatim. After verification from the respondents the principal author evaluated the transcripts using thematic content analysis which was further subjected to verification by other authors' analyses. Out of eleven dispensing doctors eight of them were males and three were females practicing in the peri-urban and slum areas of Karachi, Pakistan. The major themes identified were knowledge of generic medicines, perceptions regarding generic medicines, attitude towards generic medicines, and perception towards marketing strategies of pharmaceutical industry for brands and generics as well as recommendations to further enhance generic utilization.

Prescribing and dispensing, although knitted well, are two different domains harnessed by doctor and pharmacist respectively. In developing countries generally no consultation fee is paid to the doctor without getting medicine and thus doctors generate income by dispensing.6 In Pakistan there is no law regarding dispensing by doctors. Thus being taken as general presumption of permissibility to dispense, 80% of the doctors dispense in Pakistan.6 In a nutshell doctors in Pakistan exercised strong grip on both prescribing and dispensing. This study demonstrated gaps in understanding of the availability of generic medicines in Karachi, Pakistan. The current study also identified mixed views and attitudes of dispensing doctors towards generic medicines. The knowledge of dispensing doctors about generic medicines was sparse. On probing it was revealed that they miscorrelate the term 'generics' with International Nonproprietary Name (INN), which made them unaware of the presence of generic medicines in Pakistan. Although studies done in Slovene and West Indies showed respondents' confidence in knowledge about generic medicines and generic bioequivalence,7,8 however, this study failed to highlight any understanding of bioequivalence criteria for generic medicines. In this study low cost of generics and negative feedback from the patient made few doctors unsure of the quality and efficacy of generic medicines. This showed concordance with a Malaysian study in which generic drugs are viewed as cheap, lacking and questionable.9 In Pakistan the failure of Generic Medicine Act, due to logistical constraints in demonstrating drug quality, contributed to negative perception about generic medicines.10 In this study some of the respondents considered generic medicines, if being derived from high quality national companies, as safe and effective as any multinational product. Dispensing doctors admitted to be influenced by pharmaceutical industry and commercial sources of information. Interestingly, this qualitative study failed to highlight any incentives and gifts offered by multinational pharmaceutical companies to dispensing doctors. On the contrary mammoth incentives in the form of extra discounts to doctors, international trips to attend conferences and seminars, and compensable gifts such as cars and promotional gifts like penholder were admitted by the prescribers as 'driving forces' to write their products. This is in accordance with the work done by Hassali and his associates11 which highlighted the use of promotional gifts as factors influencing prescribing patterns. Quality assurance is questionable in Pakistan as effective bioequivalence studies are not required for generics at the time of registration of new molecules.2 Doctors who favoured generic medicine proposed some measures like generic prescribing and generic substitution with financial incentives both to the prescriber (doctor) and the dispenser (pharmacist). Registration of new generic entities with stringent guidelines and submission of bioequivalence testing for some therapeutic categories were other recommended measures by study participants.

G.M.P. Laws in Pakistan included requirements regulating the specific criteria for building, equipment, personnel, marketing documentation to be followed for Manufacturing, Quality Control, Record for Production, Quality Assurance Procedures, Packaging, Labelling, Distributing Records, Stability Testing Record, Customer complaints etc.

There is no doubt that GMP enactment has resulted to scientific improvements and development in the delivery of standard Life Saving Drugs of highest quality in Pakistan. Both Drug Control Administration and Pakistan Pharmaceutical industry, deserve the compliments of its whole hearted implementation in Pakistan. In order to have a clear prospective of the GMP enactment contribution in development of Pharmaceutical Industry in Pakistan, one should view the status of Pharma Industry in Pakistan at the time of its creation in 1947. At the time of independence, in Pakistan, there was no Pharmaceutical unit worth mentioning manufacturing pharma products in this part of the world. Most of the established Pharmaceutical manufacturing units remained in parts of India as in Calcutta, Bombay, Delhi etc. Almost all pharmaceutical requirements were met by imports from India and other foreign countries. However, in a span of a few years a good number of National and Multinational Pharmaceutical units were established. Today, Pharmaceutical Industry of Pakistan has more than 300 units including 29 Multinationals, catering 80 per cent of Pharma requirements of the country, 20 per cent requirements are supplemented by imports.

Now our Pharma Industry has grown to the extent of having a market of Rs.48 billion approx. in the year 199697. Our industry is fully catering the requirement of standard formulated drugs, but still depends largely on imported raw materials from various multinational sources. At present a few Pharma raw materials as Aspirin, Paracetamol, Ibuprofen, Ampicillin, Amoxacillin, Trimethoprim, Ephedrine and few other materials are being manufactured in Pakistan but there still is a big gap in requirements and supply of materials being manufactured in our country. A good number of active raw materials are still required to be manufactured in Pakistan. Realizing the economical importance of Basic Manufacturing for our country our Government very sensibly have offered good incentives. In order to attract further investment in raw material manufacturing, Government of Pakistan has recently offered very attractive terms and concessions as Protective duties, duty free import of plant and equipment, import of duty free intermediates, Tax holiday for raw material manufactured in Pakistan. Our formulated manufactured drugs after achieving self-sufficiency of country requirements, are also being exported to other developing countries of Africa, Middle East, Central Asia, Bangladesh, Nepal, Sri Lanka, Afghanistan, Iran etc. Our exported products international, are competing with multinational products in foreign countries in respect of their quality, efficacy, presentation and are being preferred in competition to Indian products. Our Pharmaceutical products are strictly manufactured under rigid Good Manufacturing Practices and controls and Pharma plants are inspected by Federal, Provincial Drug Inspectors 2-3 times in a year, conforming GMP being followed by the manufacturer in manufacturing and Quality Control as laid down by World Health Organization.

The licensed Pharma plants are also subjected to detailed inspection by Federal Inspection team once in two years at the time of renewal of Manufacturing Licence and any Manufacturing Plant not complying with GMP requirement, their licence is suspended or cancelled. During last month 15 Manufacturing Licence have been suspended or cancelled due to non compliance of GMP result to some substandard manufacturing of products. The fantastic growth of Pharmaceutical Industry in Pakistan is the result of coordinated efforts and proper legislation by Drug Control Administration, Ministry of Health, and Pakistan Pharmaceutical Industry. The major expansion of Pakistan Pharma industry has been recorded after the enactment of Drug Act of Pakistan 1976 where GMP was made mandatory as a law. GMP enactment in Pakistan has completely changed basic outlook of the pharmaceutical industry as compared to pre-era of GMP enactment and has brought Pakistan Pharma Industry at par with International Standards. Under the present conditions one feels proud of our Pharmaceutical Industry working on International, Standard scientific pattern conforming the requirement of GMP. Thus assuring implementations of proper methods of production quality assurance, compounding, packaging and distribution of drugs of highest standards. The strict observance of GMP prevents the rejection of batches, resulting control of losses, increased production and profitability. GMP provides specific guide-lines which also checks the critical operations within the organization following the concept of Total Quality Control System. GMP is a tool in building the quality in manufacturing of Pharmaceuticals the concept of Total Quality Management. Quality as per ISO is defined as totality of features and characteristic of a product or procedure resulting to satisfaction of the set objectives and requirements of the consumer. Quality is the requirement of the consumer and lack of quality leads to consumer dis-satisfaction, loss of public health, and ultimately the loss of business. Quality is the outcome of a quality culture in a business organization and GMP is a tool for providing such Total Quality Management Concept. The philosophy of Quality Assurance is an enlarged activity beyond Manufacturing Operations, covering all operations of the organization, described as "TOTAL QUALITY CONTROL", which starts even before start of any operation. The functions of TQC are to plan control, improve and audit of each activity in a manufacturing organization. TQC is extended to link the Suppliers, Manufacturers, Distributors and Customers in the chain of Quality, as such is called Total Quality Management. Primarily a customer's oriented continuous Quality improvement system involving each member of the team, lowest or highest in the rank. Each member of the team needs to recognize the requirement of the customer, to the fullest satisfaction. TQM is an approach continuous improvement of quality of Goods and Services delivered by co-ordinated efforts of all team members of the organization. TQM is based on the following fundamental concepts: 1. Commitment: It starts with the chief executive of the organization his commitment to TQM and active involvement in promotion and practice of TQM all employees at all levels to make it a success.

2. Customer Satisfaction: To know customer requirement and to coordinate to achieve satisfaction of the consumer. 3. Implication of loss of quality is loss of customer satisfaction, confidence, loss of future business and reputation of organization. Participation by all. 5. Problem, identification and solution of the problem. 6. Personnel accountability and development. Benefit of TQM 1. Customer Confidence 2. Improvement in reputation and business of organization. 3. Increase in profits - positive organization culture. The fundamental concept of TQM is fully covered in Good Manufacturing Practice. GMP is a good quality control practice, for the good of customer and is good product liability control for the manufacturer. Both the law enforcing agencies and industry agree that the customer's protection is in the interest of all, for the better product, customer's acceptance and objective of the manufacturer. If we go through the details laid down in GMP, elements considered in TQM are mostly included in GMP, hence GMP compliance also ensures the TQM compliance resulting to standard effective, quality product. Counterfeit drugs are emerging as a worldwide dilemma and in Pakistan. The Pakistan Manual of Drug Laws, defines a counterfeit drug as "a drug, the label or outer packing of which is an imitation of, resembles or so resembles as to be calculated to deceive the label or outer packing of a drug manufacturer." According to the World Health Organization, a counterfeit medicine is one, which is deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeit drugs may contain wrong active ingredients, wrong amounts of the ingredients or no active ingredients at all. Counterfeit drugs result in death or disability and are becoming leading causes of therapeutic failure and disease resistance Diplomatic niceties meant that the main manufacturers, China and India, were not named. Counterfeit drugs constitute 40 to 50 percent of all medicines available in Pakistan and according to the World Health Organization (WHO) Pakistanis spend 77 percent of their household health budgets on medicines half of which may be fake or unfit for human consumption The Pakistan Pharmaceutical Manufactures Association (PPMA) states that the rate of production of counterfeit drugs in the country is only 0.4 percent. What a Great joke with poor Nation? Pakistan is

considered one of the 13 countries of the world where the manufacturing of counterfeit medicines is on the rise. The situation is alarming, as the country is also alleged as being a counterfeit hub- exporting counterfeit drugs to North America, Europe and Africa . U.N. health and crime agencies say counterfeit drugs are killing people from China to Canada and they "promote the development of new strains of viruses, parasites and bacteria ... for example in the case of malaria or HIV.'' And in many countries their manufacture and distribution is not even illegal. British House of Commons, a member of the British parliament Charles Walker identified Pakistan as a country where counterfeit medicines were produced About 40 to 50 per cent of medicines being sold in the country were counterfeit, which might cause prolonged illness or even death of patients, According to The Centre for research and Security Studies of Pakistan in 2008. PMA Secretary General Dr Qaiser Sajjad that the government needs to seriously work to control the production and sale of counterfeit medicines in Pakistan, which is currently ranked 13th in the world for the practice. Nine Drugs Courts has been established by the Federal Governement in pursuance of Section 31 of the Drugs Act 1976. Counterfeiting is a reaction to the high drug prices imposed by pharmaceutical companies. This view holds that the solution would be to subsidize the pharmaceutical industry and impose strict price controls according to Noam Chomsky According to World Health Organisation estimates; fake medicines represent 10 per cent of the global pharmaceutical industry at some 45 billion euros and have started to penetrate drug markets in the developed world. Without such reforms, the counterfeiters will continue to kill hundreds and thousands of people every year." How duties push up the price of legal drugs Combined duties and taxes Sierra Leone 40% Nigeria 34% Pakistan 33% Bangladesh 29% Jamaica 27% Morocco 25% Mexico 24% according to European Union The problem of counterfeit medicine is an acute and burning problem in Pakistan. It has even become a cause of serious concern for both the government as well as for physicians, medical experts and patients. According to some polls, about 60 percent of PAKISTANI citizens fear that they are taking either counterfeit medicine or medicine of poor quality. According to the estimate of experts, the share of counterfeit medicine on the Pakistan market is a staggering 42-60% percent of the total production. The lack of government public health financing (Pakistan is spending on an average a mere 0.5-0.8 per cent of the GNP on health) and the absence of a national health insurance programme. In spite of buying medicines from their own pockets, consumers are still victims of irrational drug use and fake medicines. This also illustrates that

Pakistan's national medicine policy has failed to achieve its public health objectives. In Pakistan, both multinational and national pharmaceutical companies are heavily involved in the unethical marketing of medicines indirectly exploiting the consumers. Marketing incentives are so lucrative that many physicians are prescribing patients drugs which they really don't need. These medicines are posing an unnecessary risk to the health of the people. properly-qualified doctors in the public system often illegally moonlight in private practices. Under-thecounter payments are also common, sometimes just to get care. In Pakistan, a survey of 149 doctors, 100 medical information officers (sales representatives) and 99 medical store personnel, found that gifts may include included air conditioners, cars, cash, home appliances and domestic cattle. Murad M. Khan, professor & chairman of the department of psychiatry at Aga Khan University, describes the latest practice: For writing 200 prescriptions of a company s highpriced drug, a doctor is rewarded with the down payment on a brand new car It also states that in Pakistan, 32 per cent of drugs sold by German pharmaceutical companies are irrational and 61 per cent of drugs were not even present on the WHO essential drug list. Some of the drugs that were sold in the country were harmful and have been banned in developed western nations or have no added therapeutic value. A European Union study states that 50 per cent of medicines available in Pakistan are counterfeit. "It is not just a Pakistan problem. It should be considered not only in the light of the infliction of moral and economic damage. The question is about the security of the Pakistan population, our nation as a whole." A recent study in the Journal of Tropical Medicine and International Health estimated that 86 percent of under-strength fakes analyzed in Kenya and Congo came from India and China About 70 percent of counterfeit medicine comes from abroad, while 30 percent of it is produced and sold on the territory of the Pakistan. There has been much coverage by Western media over the last two years about the health risks posed by "Made in China" Vietnam, India, Combodia, Thailand, products, including Chinese export of counterfeit medicines. Chinese Vietnam, Indian, counterfeit medicines may have already caused hundreds if not thousands of deaths outside of their countries. Less is known, however, harm of contaminated goods to the Chinese people Nigeria and Africa is paying every day. Vietnam, India, China steps being taken to regulate the industries. China s foremost combatant against counterfeit medicine, Gao Jingde says that he has discovered through his investigations that two-thirds of China's drug stores sell counterfeit medicine. China is, aside from criminality within the pharmaceutical industry, that the State Food and Drug Administration has shirked its responsibility of properly regulating the industry.Indeed, according to

Gao, the government s usual response when he reported a counterfeit was paltry. A fine of 100 to 4,000 yuan ($15 to $580) would be levied against the responsible companies. For even a moderately sized pharmaceutical company, such a fine would amount to less than a slap on the wrist.. Some products in China have a counterfeit constituent of 50% to 85% * Some 37% of antibiotics and anti-malarials on the WHO essential drugs list in Nigeria and Thailand are substandard * A recent survey by the WHO of seven African countries found that between 20% and 90% of all antimalarials failed quality testing There was a programme called bad medicine on BBC channel, where in the drugs controller for Nigeria proved that 95% of drugs in nigeria are fake & 80% of them are being exported from india. These indian fake medicines are killing hundreds of innocents in nigeria & she is crusading to control to control it. pharma drugs mafia linked to india. She came over to india along with BBC correspondent & undercover they went to greedy industrialists. The said industrialists- FAKE SPECIALISTS boasted how they fake the holograms , labels of big MNCs , how they add chalk powder , paracetamol to all tablets Counterfeit medicines are on the rise worldwide, as criminals capitalize on the growing use of the Internet by consumers searching for inexpensive drugs.Seizures of bogus prescription medicines jumped 24% to 1,513 incidents in 2007, and illicit versions of 403 different prescription drugs were confiscated in 99 countries, according to the Pharmaceutical Security Institute, a Vienna, Virginia-group funded by 26 drug makers. The $3 billion (Rs12,870 crore) in counterfeit drugs seized include generic copies that violate patent laws and products that lack active chemical ingredients or contain improper dosages. In the decade since Internet sites began selling illegal copies of Pfizer Inc. s erectile dysfunction drug Viagra, counterfeiters have diversified, marketing pills to treat heart disease, arthritis, asthma, AIDS and cancer, according to the institute, which has been monitoring product seizures since the group was formed in 2002. Copies of 19 of the world s 25 best-selling drugs were among those seized by industry security, customs agents and police last year at ports of entry, in free-trade zones or at illicit manufacturing and distribution sites, according to data compiled by Bloomberg. It s a big issue, it s a global issue, it s an insidious issue, said John Lechleiter, Eli Lilly and Co. s president and chief executive officer, in an interview at his Indianapolis headquarters. New York-based Pfizer, the world s largest drug maker, estimates it may be losing sales of $2 billion a year in Viagra alone, given how much of the drug s active ingredient is produced in India and shipped abroad, says Rubie Mages, a company director of global anti-counterfeiting. Sales of the impotence drug in 2007 totalled $1.8 billion. Oftentimes, the drugs that are being sold emanate from China, from Russia and from India, says Steven Rucker, an executive managing director of Kroll Inc., a New York security firm used by

pharmaceutical companies to track down counterfeiters. Fake versions of Pfizer s Viagra and its impotence pill competitors Levitra from Leverkusen, Germanbased Bayer AG and Schering-Plough Corp. of Kenilworth, New Jersey, and Cialis from Eli Lilly have been traced to manufacturers in China and India According to Interpol data, Vietnam ranks second in Southeast Asia in the quantity of counterfeit medicine in circulation, said an inspector of the HCM City Department of Health. Largest quantity of counterfeit drugs in circulation, followed by Vietnam, Cambodia and Thailand. According to the World Health Organization (WHO), fake drugs account for 7-15% of the total quantity of medicines circulated in the market in developed countries and the percentage is 25% in developing ones. In Vietnam an investigation shows that 64% of anti malarial tablets contained no active ingredient, which eventually led to the death of patients. In India 7% of medicines were found counterfeit and Indian companies were accused of exporting counterfeits to African markets. In the first half of 2008, the HCM City Department of Health licenced more than 5,800 medicine-related businesses, including: 388 drug trading companies, 84 drug wholesale units, 3,356 drugstores, 460 drug agents of pharmaceutical companies, over 300 oriental medicine stores, and 105 pharmaceutical material trading firms. Meanwhile, the Department s Inspectorate has only four university-level pharmacists and only 12 of 24 districts in the city have pharmaceutical inspectors who are pharmacists of university level. It goes without saying that decisive measures are urgently required and needed to tackle this problem. "The protection of the health of citizens is the main task of the state,".. These are interrelated and mutually dependent tasks. Those who create underground illegal enterprises and who circulate such counterfeit medicine have to be strictly prosecuted. But so far in our budget we have lack of expenditures on the criminal and administrative expertise related to a circulation of counterfeit medicine in Pakistan. Punjab government Announced prosecution for the circulation of counterfeit medicine on a large scale.from last year December 2008 .Till now no big racket have been discovered yet. "But GOP need to prosecute the representatives of those wholesale organizations who circulate such medicine as well as the producers of such medicine who are engaged in a criminal activity on a large scale. "Punjab Government increases the punishment of such activities up to 10 years of imprisonment. And fine too" The U.S. based Center for Medicines in the Public Interest predicts that counterfeit drug sales will reach $75 billion globally in 2010, an increase of more than 90 percent from 2005. Most industrialized countries with effective regulatory systems and market control (e.g. U.S., most of

the EU, Australia, Canada, Japan, New Zealand) have a low proportion, i.e. less than 1 percent of market value. drug inspectors are fully aware of the locations where the manufacture of undesired medicines takes place and the medical stores where they are sold. The problem of fake drugs has plagued our community for many years. Few crimes can be more horrendous than this one. Indirectly, this is murder in cold blood. The agony of suffering from the administration of fake drugs can only be understood by those who have been affected. Fake drugs not only take away precious lives, but also lead to the emergence of drug resistance. Unfortunately, our legal system is painfully tardy. As in other spheres, our socio-political environment has allowed the culprits to carry on with their nefarious activities with utter disregard for the law of the land. Hang a few and this menace will come to an end. Despite being a serious health hazard, there has never been any concerted effort from all the stakeholders involved to counter this hazard. And that has continuously encouraged the culprits to profit from it. Lack of infrastructure and manpower for the regulator, coupled with major inadequacies in the existing laws, make the problem a very complex one,see the role of pakistan drugs inspectors and drugs compaines is really ashmed full. References 1.WHO. The World Medicines Situation. WHO/EDM/PAR/20045. Geneva: World Health Organization. (Online) (Cited 2010 Feb). Available from URL: http://www.searo.who.int/LinkFiles/Reports_World_Medicines_Situation.pdf. 2.Pakistan Pharmaceutical and Healthcare Report Q2 2010. BMI Industry Report and Forecast Series Business Monitor International 2010. 3.Babar Z U, Jamshed S. Social pharmacy strengthening clinical pharmacy: Why pharmaceutical policy research is needed in Pakistan. Pharm World Sci 2008; 30: 617-9. 4.Jamshed S, Babar Z U D, Ibrahim M I M, Hassali M A A. Generic medicines as away to improve access and affordability: a proposed framework for Pakistan. Journal of Clinical and Diagnostic Research. (Online) 2009 June (Cited 2009 June 1). 3: 1596-1600. Available from URL: http://www.jcdr.net/back_issues.asp?issn=0973709x&year=2009&month=June&volume=3&issue=3&page=1596-1600&id=431. 5.Gray, D E. Doing Research in the Real World. 2nd ed. Thousand Oaks, California: Sage, 2009. 6.Trap B. Practices of Dispensing Doctors - Drug Use and Health Economics. International Conference on Improving Use of Medicines; 1997 April 1-4; Chang Mai, Thailand: ICIUM, Group 4b: National Regulatory Issues. (Online) (Cited 2010 May 6). Available from URL: http://archives.who.int/icium/icium1997/posters/4b4_fin.html. 7.Kersnik J, Peklar J. Attitudes of Slovene general practitioners towards generic drug prescribing and comparison with international studies. J Clin Pharm Ther 2006; 31: 577-83. 8.Gossell-Williams M. Generic substitutions: a 2005 survey of the acceptance and perceptions of

physicians in Jamaica. West Indian Med J 2007; 56: 458-63. 9.de Run E C, Mee-Kon N F. Patented and generic pharmaceutical drugs: perception and prescription. Int J Business and Society 2006; 7: 55. 10.Quraeshi Z A, Luqmani M, Malhotra N. Brands or generics: the dilemma of pharmaceutical marketing in a developing country. J Health Care Mark 1983; 3: 27-37. 11.Hassali MA, Kong D, Stewart K. Generic medicines: Perceptions of general practitioners in Melbourne, Australia. J Generic Med 2006; 3: 214-25.