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Abstract
The cost of medicines in Bangladesh is among the lowest in the world. Over the last forty years, Bangladesh, a Least Developed Country (LDC), has nurtured a local industry based on strong industrial policy and a pharmaceutical patent-free system. Of the 46 LDCs in the world, it is the only one to have a thriving industry of this kind. In this paper, we explore how a relatively poor LDC managed to take on the dominance of MNCs in the global production of pharmaceuticals. We focus on the 1982 National Drug Policy (NDP) which transformed the pharmaceutical sector in Bangladesh from one in which three-quarters of drugs were supplied by just eight MNCs to one where almost all domestic demand is met by local industry. The thriving local pharmaceutical industry also exports generic medicines to 147 different countries. In 2026, Bangladesh is due to graduate to ‘Developing Country’ status, at which time, as a member of the WTO, Bangladesh will have to abide by the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement. Under TRIPS it will have to change its patent regime to allow for the registration of pharmaceutical patents by 2029. Using interview data with key Bangladeshi experts, we argue that TRIPS compliance could potentially wipe out this flourishing local pharmaceutical industry, leading to steep increases in the cost of essential medicines, with dire implications for the right to health. We explore policy options open to the Bangladesh government to protect affordable drugs in the country, in particular protection for the production of domestic generics in a post-TRIPS environment. We also argue that there are ways in which Bangladesh and India could co-operate to protect the affordability of high-quality medicines for domestic and international markets.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes
1. As of 2021, 46 countries are designated as LDCs by the United Nations: see ‘List of Least Developed Countries (as of 11 February 2021)’, Committee for Development Policy (CDP), United Nations (2021) [https://www.un.org/development/desa/dpad/wp-content/uploads/sites/45/publication/ldc_list.pdf, accessed 31 May 2021].
2. S. Kathuria and M.M. Malouche (eds), Attracting Investment in Bangladesh—Sectoral Analyses: A Diagnostic Trade Integration Study (Washington, DC: The World Bank, 2016), p. 197.
3. M. Azam, Intellectual Property and Public Health in the Developing World (Cambridge: Open Book Publishers, 2016), p. 82 [https://www.openbookpublishers.com/product/476, accessed 10 Sept. 2021].
4. S. Chaudhuri, ‘Evolution of the Pharmaceutical Industry in Bangladesh, 1982 to 2020’, Working Paper, Centre for Development Studies, Thiruvananthapuram, 2020 [Sudip-CDS-WP-Bangladesh-Pharma-Evolution-July-2020.pdf, accessed 19 Nov. 2020], p. 6.
5. Ibid., p. 8.
6. G. Sandhu, ‘Delhi-Dhaka Cooperation in Pharma Is Win-Win for Both’, The Pioneer (7 April 2021) [https://www.dailypioneer.com/2021/columnists/delhi-dhaka-cooperation-in-pharma-is-win-win-for-both.html, accessed 11 July 2021].
7. This includes corporate as well as individual income taxes: see Azam, Intellectual Property and Public Health in the Developing World, p. 60.
8. M. Munni, ‘A Handful of Companies Dominate Pharma Market’, The Financial Express (6 Feb. 2019). [https://www.thefinancialexpress.com.bd/trade/a-handful-of-companies-dominate-pharma-mkt-1549424895, accessed 10 Sept. 2021].
9. M.A. Razzaque et al., ‘Bangladesh’s Pharmaceutical Exports: Trends, Market Prospects, and Policies’, in M.A. Razzaque (ed.), Navigating New Waters: Unleashing Bangladesh’s Export Potential for Smooth LDC Graduation (Dhaka: Bangladesh Enterprise Institute, 2020), p. 377.
10. Ibid.
11. S.K. Sell, Private Power, Public Law: The Globalization of Intellectual Property Rights (Cambridge: Cambridge University Press, 2003), p. 12.
12. The World Bank, ‘The World Bank in Bangladesh’ (30 Mar. 2021) [https://www.worldbank.org/en/country/bangladesh/overview, accessed 19 July 2021].
13. Azam, Intellectual Property and Public Health in the Developing World, p. 5; and Kathuria and Malouche (eds), Attracting Investment in Bangladesh—Sectoral Analyses, p. 197.
14. When we say ‘post-TRIPS environment’, we refer to 2033 (and 2029 in the case of LDC graduation), when Bangladesh is obliged to change its patent regime to conform with the TRIPS Agreement.
15. APIs are the key raw materials needed for drug production.
16. India has over 3,000 firms with an aggregate annual turnover of US$20 billion and over 60,000 registered generic brands in comparison to Bangladesh’s 273 firms generating a total turnover of US$2.6 billion from 5300 generic brands—i.e. Bangladesh’s pharmaceutical industry is about one-tenth the size of India’s: see G. Sandhu, ‘Delhi–Dhaka Cooperation in Pharma Is Win-Win for Both’, p. 1.
17. M.R. Reich, ‘Bangladesh Pharmaceutical Policy and Politics’, in Health Policy and Planning, Vol. 9, no. 2 (1994), pp. 130–43 [130].
18. M.T. Islam, TRIPS Agreement of the WTO: Implications and Challenges for Bangladesh (Newcastle upon Tyne: Cambridge Scholars Publishing, 2013), p. 139; and Reich, ‘Bangladesh Pharmaceutical Policy and Politics’, p. 132.
19. Z. Chowdhury, The Politics of Essential Drugs: The Makings of a Successful Health Strategy—Lessons from Bangladesh (London: Zed Books, 1995), p. 46.
20. Azam, Intellectual Property and Public Health in the Developing World, p. 5; and Kathuria and Malouche (eds), Attracting Investment in Bangladesh—Sectoral Analyses, p. 197.
21. This is when APIs are processed into finished pharmaceutical products such as tablets or injections: see Chaudhuri, ‘Evolution of the Pharmaceutical Industry in Bangladesh, 1982 to 2020’, p. 6.
22. In the early 1980s, vitamins and antacids accounted for nearly 16 percent of the whole pharmaceutical industry in terms of sales revenue: see M. Nurul Amin and T. Sonobe, ‘Success of the Industrial Development Policy in the Pharmaceutical Industry’, GRIPS Discussion Paper 13-07, National Graduate Institute for Policy Studies, Tokyo, May 2013, p. 207 [https://core.ac.uk/download/pdf/51221415.pdf, accessed 10 Sept. 2021].
23. Ibid.
24. T. Sonobe et al., ‘The Miraculous Development of the Garment and Pharmaceutical Industries in Bangladesh’, in Economic and Social Development of Bangladesh (Cham: Palgrave Macmillan, 2018), p. 37.
25. Amin and Sonobe, ‘Success of the Industrial Development Policy in the Pharmaceutical Industry’, p. 208.
26. Transfer pricing refers to the prices of the goods or services (including intangible property such as IPRs) that are traded between commonly controlled legal entities within an enterprise.
27. Z. Chowdhury, ‘Bangladesh: A Tough Battle for a National Drug Policy’, in S. Hamrel and O. Nordberg (eds), Making National Drug Policies a Development Priority: A Strategy Paper and Six Country Stories (Sweden: Motala Grafiska AB Motala, 1995), pp. 96–147 [109].
28. Ibid., p. 104.
29. A. Chetley, Bangladesh: Finding the Right Prescription (London: War on Want, 1982), quoted in Chowdhury, ‘Bangladesh: A Tough Battle for a National Drug Policy’, p. 105.
30. Reich, ‘Bangladesh Pharmaceutical Policy and Politics’, p. 134.
31. Azam, Intellectual Property and Public Health in the Developing World, p. 50.
32. Chaudhuri, ‘Evolution of the Pharmaceutical Industry in Bangladesh, 1982 to 2020’, p. 10.
33. Reich, ‘Bangladesh Pharmaceutical Policy and Politics’, p. 134.
34. Amin and Sonobe, ‘The Success of the Industrial Development Policy in the Pharmaceutical Industry’, p. 198.
35. Chowdhury, ‘Bangladesh: A Tough Battle for a National Drug Policy’, p. 97.
36. Islam, TRIPS Agreement of the WTO, p. 140.
37. Amin and Sonobe, ‘The Success of the Industrial Development Policy in the Pharmaceutical Industry’, p. 198.
38. On 27 April 1982, an eight-person expert committee comprising renowned academics, regulatory personnel and health activists was formed to develop the 1982 NDP.
39. Chaudhuri, ‘Evolution of the Pharmaceutical Industry in Bangladesh, 1982 to 2020’, p. 12.
40. Ibid.
41. Ibid., p. 14.
42. Ibid., p. 18
43. Ibid., p. 14.
44. Intercontinental Medical Statistics (IMS) Health Data, Bangladesh, 2019 [https://login.customerportal.iqvia.com/EB2/User/CustomerLogin.aspx?, accessed 1 Oct. 2020].
45. H.U. Ahmed, ‘Pharmaceutical Sector Flourishing’, The Financial Express (27 Nov. 2019). [https://www.thefinancialexpress.com.bd/views/pharmaceutical-sector-flourishing-1574867109, accessed 10 Sept. 2021].
46. Bangladesh Association of Pharmaceutical Industries, ‘Overview Bangladesh Offers More for’ (Dhaka: BAPI, 2020) [http://www.bapi-bd.com/bangladesh-pharma-industry/overview, accessed 1 Oct. 2020].
47. Ibid.
48. According to the Directorate General of Drug Administration, as of 2020, there were 273 registered pharmaceutical companies in Bangladesh of which only 150 are involved in manufacturing. Most of these firms are involved in the production of generics.
49. Razzaque et al., ‘Bangladesh’s Pharmaceutical Exports’, p. 377.
50. Munni, ‘A Handful of Companies Dominate Pharma Market’.
51. D. Gay, ‘Pharmaceutical Dreams: TRIPs and Drugs Policy in Bangladesh’, Working Paper, UN Department of Economic and Social Affairs (2018), p. 3.
52. Sudip Chaudhuri, ‘Making Medicines for Pandemics: Can Bangladesh Do for Covid-19 What India Did for HIV/AIDS?’, The India Forum (14 Aug. 2020) [https://www.theindiaforum.in/article/making-medicines-pandemics, accessed 12 Oct. 2021].
53. K. Gokhale and M. Kitamura, ‘$10 Copy of Gilead Blockbuster Sovaldi Appears in Bangladesh’, Bloomberg (9 Mar. 2015) [https://www.bloomberg.com/news/articles/2015-03-08/-10-copy-of-gilead-s-blockbuster-sovaldi-appears-in-bangladesh, accessed 20 Nov. 2020].
54. A voluntary licence allows the production of a generic version of a patented drug (by a generic firm) after the patent holder authorises such production. The patent holder sets the required production and quality standards. Under a voluntary licensing agreement, the generic firm is required to pay a royalty to the patent holder, but sometimes generic firms are allowed to produce generic drugs without paying royalties.
55. M. Taibbi, ‘Big Pharma’s Covid-19 Profiteers’, Rolling Stone (13 Aug. 2020) [https://www.rollingstone.com/politics/politics-features/big-pharma-covid-19-profits-1041185/, accessed 20 Nov. 2020].
56. Gokhale and Kitamura, ‘$10 Copy of Gilead Blockbuster Sovaldi Appears in Bangladesh’, p. 1.
57. Interview with KI-4, 8 Aug. 2021. All interviews took place in Dhaka.
58. See, in this special section, Jagjit Kaur Plahe and Don McArthur, ‘After TRIPS: Can India Remain “the Pharmacy of the Developing World”?’, in South Asia: Journal of South Asian Studies, Vol. 44, no. 6 (Dec. 2021), DOI: 10.1080/00856401.2021.1980839.
59. Chaudhuri, ‘Making Medicines for Pandemics’, p. 4.
60. J. Chakma, ‘What Others Can Learn from Bangladesh on Making Cancer Drugs Available’, The Daily Star (29 July 2020) [https://www.thedailystar.net/business/news/what-others-can-learn-bangladesh-making-cancer-drugs-available-1937969, accessed 20 Nov. 2020].
61. See I.H. Ovi and N. Mahmud, ‘Bangladesh Pharmaceutical Industry Blooms Bigger’, Dhaka Tribune (22 Aug. 2019) [https://www.dhaikatribune.com/business/2019/08/22/bangladesh-pharmaceutical-industry-blooms-bigger, accessed 12 Sept. 2020].
62. EBL Securities, ‘Pharmaceutical Industry of Bangladesh’ [https://www.arx.cfa/∼/media/2A85F9B2CEAB43CFAF325AB54F3EF404.ashx, accessed 24 Nov. 2020].
63. Chaudhuri, ‘Evolution of the Pharmaceutical Industry in Bangladesh, 1982 to 2020’, p. 7.
64. Chaudhuri, ‘Making Medicines for Pandemics’, p. 4.
65. J. Chakma, ‘Govt Looks to Ramp Up API Production for Burgeoning Pharma Sector’, The Daily Star (15 Nov. 2020) [https://www.thedailystar.net/business/news/govt-looks-ramp-api-production-burgeoning-pharma-sector-1995145, accessed 25 Nov. 2020].
66. J. Uddin, ‘Government Discourages API Export Amid China Supply Snag’, NewAge Business (8 Mar. 2020) [https://www.newagebd.net/article/101546/government-discourages-api-export-amid-china-supply-snag, accessed 17 Nov. 2020].
67. Chaudhuri, ‘Evolution of the Pharmaceutical Industry in Bangladesh, 1982 to 2020’, p. 22.
68. R. Karim, ‘Govt to Study Prospects of Producing APIs Locally’, The Financial Express (1 June 2019) [https://www.thefinancialexpress.com.bd/trade/govt-to-study-prospects-of-producing-apis-locally-1559364205, accessed 17 Nov. 2020].
69. J. Bumpas et al., ‘Public and Private Sector Approaches to Improving Pharmaceutical Quality in Bangladesh’, Discussion Paper, The World Bank, Aug. 2007 [https://documents1.worldbank.org/curated/en/892611467998809882/pdf/683570WP0P10250IC00Discussion0paper.pdf, accessed 19 Oct. 2021], p. 4.
70. Interviews with KI-1, 12 Nov. 2020; KI-4, 29 Jan. 2019; and KI-5, 9 Nov. 2020.
71. See Gilead, ‘An Open Letter from Daniel O’Day, Chairman & CEO, Gilead Sciences’ (29 June 2020) [https://www.gilead.com/news-and-press/press-room/press-releases/2020/6/an-open-letter-from-daniel-oday-chairman–ceo-gilead-sciences, accessed 26 Nov. 2020].
72. See Plahe and McArthur, ‘After TRIPS’.
73. Chaudhuri, ‘Making Medicines for Pandemics’, p. 6.
74. Compulsory licensing refers to a regulatory mechanism that allows governments to make use of a patented invention by third parties without the consent of the patent holder.
75. See Plahe and McArthur, ‘After TRIPS’.
76. A. Devnath, ‘Bangladesh Becomes First in the World to Sell Generic Version of Remdesivir to Treat Covid’, The Print (21 May 2020) [https://theprint.in/world/bangladesh-becomes-first-in-the-world-to-sell-generic-version-of-remdesivir-to-treat-covid/426367/, accessed 5 Aug. 2021].
77. J. Chakma, ‘Remdesivir Proves Pharma Strength’, The Daily Star (8 Mar. 2021) [https://www.thedailystar.net/business/news/remdesivir-proves-pharma-strength-2056769, accessed 5 Aug. 2021].
78. Ibid.; and Interview with KI-10, 8 Aug. 2021.
79. Ibid.
80. Ibid.
81. Chakma, ‘Remdesivir Proves Pharma Strength’, p. 1.
82. Interview with KI-4, 29 Jan. 2019.
83. D. Gay and K. Gallagher, ‘The Need to Extend the WTO TRIPS Pharmaceuticals Transition Period for LDCs in the COVID-19 Era: Evidence from Bangladesh’, CDP Policy Review no. 10, UN DESA, 27 Aug. 2020, pp. 1–11 [4] [https://www.un.org/development/desa/dpad/wp-content/uploads/sites/45/publication/CDP-review-2020-1.pdf, accessed 10 Sept. 2021].
84. Interviews with KI-2, 27 April 2021; KI-4, 26 April 2021; and KI-6, 27 April 2021.
85. Second interview with KI-9, 26 Aug. 2019.
86. See Plahe and McArthur, ‘After TRIPS’.
87. S. Chaudhuri, ‘Multinationals and Monopolies’, in Economic & Political Weekly, Vol. 47, no. 12 (2012), pp. 46–54 [47].
88. Revenues ‘fall off a cliff’ once a lucrative drug’s patent expires. The pharmaceutical industry experienced the first ‘patent cliff’ during 2011–16: see Michael Bailey Associates, ‘What Do Patent Expirations Mean for the Pharma Industry?’ (8 Aug. 2014) [https://www.michaelbaileyassociates.com/news/pharmaceutical/what-do-patent-expirations-mean-for-the-pharma-industry, accessed 1 Oct. 2020].
89. These include the world’s largest publicly traded pharmaceutical companies such as Pfizer, Roche, Sanofi, Novartis, Johnson & Johnson and Merck & Co.
90. Michael Bailey Associates, ‘What Do Patent Expirations Mean for the Pharma Industry?’.
91. V. Pilla, ‘Top Selling Drugs Face Patent Expiration Between 2018 and 2024, Sales Worth $251 bn at Stake: Report’, Moneycontrol (18 June 2018) [https://www.moneycontrol.com/news/business/companies/top-selling-drugs-face-patent-expiration-between-2018-and-2024-sales-worth-251-bn-at-stake-report-2604401.html, accessed 8 Dec. 2020].
92. See Plahe and McArthur, ‘After TRIPS’.
93. Chaudhuri, ‘Multinationals and Monopolies’, p. 47.
94. Azam, Intellectual Property and Public Health in the Developing World, p. 130.
95. Branded generics are drugs that have been given a proprietary market name. Non-branded generic drugs are usually known by their chemical name. Branded generics, however, are given names to drive recognition and promote consumer loyalty (for example, Panadol, which is a branded generic as opposed to the non-branded paracetamol).
96. First interview with KI-6, 23 Jan. 2019; and interview with KI-4, 29 Jan. 2019.
97. M. Stilwell and E. Tuerk, ‘Towards a Full Review of the WTO’s TRIPs Agreement Under Article 71.1’ (Washington, DC: Center for International Environment Law, 2001), p. 6 [http://www.ciel.org/Publications/Assessment_Trips_article711.pdf, accessed 1 Oct. 2020].
98. First interview with KI-9, 29 Jan. 2019.
99. Chaudhuri, ‘Multinationals and Monopolies’, p. 48.
100. D. Alam et al., ‘Health Systems Preparedness for Responding to the Growing Burden of Non-Communicable Disease—A Case Study of Bangladesh’, in Health Policy & Health Finance Knowledge Hub (Melbourne: The University of Melbourne, 2013), p. 4.
101. According to the WHO, health expenditure is ‘catastrophic’ whenever out-of-pocket spending for medical treatment is equal to or greater than 40 percent of a household’s non-subsistence income, i.e. income available after basic needs have been met.
102. E. Van Doorslaer et al., ‘Catastrophic Payments for Health Care in Asia’, in Health Economics, Vol. 16, no. 11 (2007), pp. 1159–84.
103. Out-of-pocket (OoP) payments, as defined by the WHO, refer to direct payments made by individuals from their own cash reserves to health-care providers at the time of service use. Reliance on OoP payments for health care increases the financial burden on households.
104. Ministry of Health and Family (Bangladesh), ‘Bangladesh National Health Accounts, 1997–2015’ (Dhaka: Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh, 2017), p. 20 [https://www.researchgate.net/publication/327545331_Bangladesh_National_Health_Accounts_1997-2015_BNHA-V, accessed 22 Oct. 2019].
105. R.A. Mahumud et al., ‘Distribution and Determinants of Out-of-Pocket Healthcare Expenditures in Bangladesh’, in Journal of Preventive Medicine and Public Health, Vol. 50, no. 2 (2017), p. 91.
106. Government expenditure for health is about US$3 per person per year, yet an estimated US$12 is required to provide a minimum level of health care.
107. S.J. Nass et al. (eds), Making Medicines Affordable: A National Imperative (Washington, DC: National Academies Press, 2018), p. 17.
108. Azam, Intellectual Property and Public Health in the Developing World, p. 5.
109. A.K. Mohiuddin, ‘Diabetes Fact: Bangladesh Perspective’, in International Journal of Diabetes Research, Vol. 2, no. 1 (2019), p. 14.
110. Second interview with KI-2, 27 April 2021; and interview with KI-9, 29 April 2021.
111. Second interview with KI-2, 27 April 2021.
112. Interviews with KI-1, 12 Nov. 2020; KI-2, 27 April 2021; and KI-4, 26 April 2021
113. Interview with KI-3, 23 Jan. 2019.
114. J. Aspin, ‘Universal Health Coverage for Inclusive and Sustainable Development: Country Summary Report for Bangladesh’ (Washington, DC: World Bank, 2014), p. 1.
115. Interviews with KI-1, 12 Nov. 2020; and KI-2, 27 April 2021.
116. See Aspin, ‘Universal Health Coverage for Inclusive and Sustainable Development’, p. 3. The informal sector is typically characterised by small enterprises which do not pay taxes and are outside the framework of a country’s laws. The formal sector consists of registered enterprises: see M.K. Mujeri, ‘Informal Economy and Economic Inclusion’, The Daily Star (18 Feb. 2020) [https://www.thedailystar.net/supplements/29th-anniversary-supplements/digitisation-and-inclusivity-taking-everyone-along/news/informal-economy-and-economic-inclusion-1869601, accessed 21 July 2021].
117. Interviews with KI-2, 27 April 2021; KI-6, 27 April 2021; and KI-8, 29 April 2021.
118. Ibid.
119. Interview with KI-2, 27 April 2021.
120. N. Naher et al., ‘Irregularities, Informal Practices, and the Motivation of Frontline Healthcare Providers in Bangladesh: Current Scenario and Future Perspectives towards Achieving Universal Health Coverage by 2030’, ACE SOAS Consortium Working Paper 4, 2018 [https://ace.soas.ac.uk/wp-content/uploads/2018/07/ACE-WorkingPaper004-BD-Irregularities-180720.pdf, accessed 9 Aug. 2021].
121. A SEZ is defined as a duty-free zone and is considered foreign territory in terms of duties and tariffs.
122. Interviews with KI-1, 12 Nov. 2020; KI-4, 29 Jan. 2019; and KI-5, 09 Nov. 2020; see also S. Khan, ‘API Park to Boost Export of Medicines’, The Financial Express (11 July 2020) [https://www.thefinancialexpress.com.bd/views/api-park-to-boost-export-of-medicines-1594485666, accessed 27 Nov. 2020).
123. Statistica Research Department, ‘Area of Operational Pharma SEZs India 2019’, Statistica (28 Oct. 2020) [https://www.statista.com/statistics/1137248/india-operational-pharma-sezs-area/, accessed 29 Nov. 2020].
124. Second interview with KI-1, 12 Nov. 2020; interviews with KI-4, 29 Jan. 2019; and KI-5, 09 Nov. 2020.
125. First interview with KI-9, 29 Jan. 2019.
126. Interviews with KI-1, 12 Nov. 2020; KI-4, 29 Jan. 2019; and KI-5, 9 Nov. 2020.
127. Razzaque et al., ‘Bangladesh’s Pharmaceutical Exports’, p. 394.
128. For a full discussion on compulsory licensing, see Plahe and McArthur, ‘After TRIPS’.
129. Interviews with KI-1, 12 Nov. 2020; KI-2, 27 April 2021; KI-4, 26 April 2021; and KI-6, 27 April 2021.
130. Interviews with KI-2, 27 April 2021; KI-4, 26 April 2021; and KI-6, 27 April 2021.
131. Azam, Intellectual Property and Public Health in the Developing World, p. 127.
132. Interviews with KI-2, 27 April 2021; and KI-6, 27 April 2021.
133. A DMF is a confidential document which provides detailed information on the drug, including drug chemistry, the raw material components, and their stability and purity. It also provides information on how a drug is manufactured, processed, packaged and stored. The equivalent of DMFs is known as ‘The Active Substance Master Files’ in Europe. Master files are submitted by API manufacturers to drug administrations in developed countries to support marketing approval applications for generic medicines: see Akron Biotech, ‘What Is a Drug Master File (DMF)’, (2020) [https://www.akronbiotech.com/support/drug-master-files/, accessed 27. Nov. 2020].
134. Razzaque et al., ‘Bangladesh’s Pharmaceutical Exports’, p. 391.
135. Interviews with KI-1, 12 Nov. 2020; KI-4, 29 Jan. 2019; and KI-5, 9 Nov. 2020.
136. Interview with KI-1, 12 Nov. 2020.
137. Ibid.
138. Azam, Intellectual Property and Public Health in the Developing World, p. 50.