The deletion of the Concurrent List and consequential devolution of drugs and medicines to the provinces under the 18th Constitutional Amendment has aggravated an already untenable health situation. The range and intensity of health issues keeps growing because of long governmental neglect and institutional apathy. The only losers are the poor consumers, who, despite incurring expenses that they cannot afford, end up consuming expensive, substandard, and often not-required medicines. Failing to find a doctor or a health facility close to home they fall an easy prey to quacks, who are playing havoc with human health. The allocation in the health budget for the purchase of drugs and medicines is abysmally low. Most of the health budget is consumed for the payment of salaries, travelling and other expenses. With the population growing at 2.8 percent per annum, there should have been a significant and meaningful increase in both the federal and provincial budgets for the purchase of drugs and medicines, for maintenance of pathology labs and an addition of the state-of-the-art treatment facilities. Quite to the contrary, there has been a contraction in the allocations for the health sector. The growing menace of substandard and spurious drugs, highlighted in the media repeatedly, poses a major challenge to the health managers. After having downplayed the extent of the problem for years, it real extent came to light when Interior Minister Rehman Malik informed the country in January this year, that 45 to 50 percent of the drugs sold were fake. The Minister was speaking on a motion tabled in the National Assembly. We also have a Health Minister, who was either not present in the House, or preferred to maintain a discreet silence on the issue. Anyway, the Interior Minister said that no one would be allowed to play with the lives of the masses and not only would strict legislation be enacted, but also implemented at all costs. The disclosure made is frightening. He did not shed light on the reasons that had prevented the government so far from enacting strict legislation when the problem of fake drugs was at least 10 years old. He failed to lay down any timeframe for the passage of the legislation and the machinery that would ensure its implementation. Participating in the debate, members charged that the drug inspectors and the provincial and federal health departments had failed to take strict measures against quacks and sellers of fake medicines. Spurious medicines are being sold openly, they said, adding that licences of those involved in the selling of uncertified drugs should be cancelled. They also demanded that the government should prevent the smuggling of drugs from India and Bangladesh. Although there are 50 states in the US, there is only one central agency called Food and Drug Administration (FDA), which is responsible for protecting public health in America by assuring that foods or eatables are safe, wholesome, sanitary and properly labelled; human and veterinary drugs and vaccines, and other biological products and medical devices intended for human use, are safe and effective. FDA is also responsible for advancing public health by helping to speed product innovations and helping the public get accurate science-based information they need to use medicines, devices, and foods to improve their health. Even India has a centralised agency for drug approval, pricing and quality control. The production of fake drugs in Pakistan has become possible due to poor financing of regulatory institutions and weaknesses in the accountability mechanism. The drug inspectors and the staff provided to them are meant to ensure that fake drug manufacturing facilities do not go into business. They are specifically responsible for ensuring the quality of drugs at the retail level. However, the large-scale marketing of fake drugs is evidence that these drug inspectors and their subordinates have no incentives to perform. Their salary package is inadequate. There is no societal recognition of the important task that they have been assigned. As a result, institutionalised collusion and corruption has become a way of life. And harmful and fake drugs get manufactured and sold openly in drug stores whose number has shown a phenomenal increase in recent times. Many of these drug stores are unlicensed; they encourage the use of drugs that are not required by the patients. Reportedly, many of these drug stores are owned by doctors. Pharmaceutical companies are liberal in providing gifts and inducements to drug stores, especially those owned by doctors. The Drugs Act 1976, with a limited ground force of drug inspectors, has failed to make any dent in the volume of trade in fake drugs. In recent years, the addition of a fistful of drug inspectors has hardly matched the extent of this proliferating problem. The Drugs Act also does not cover other nutritional and herbal products, which have flooded the market without any regulatory mechanism. The global trade in counterfeit drugs is estimated to be around $20 billion and is one of the fastest growing grey economies - after prostitution, narcotics, terrorism and arms trade. Nearly 10 percent of the international trade in pharmaceuticals is attributed to fake drugs. Bulk of the fake drugs are produced and consumed in the developing countries. Devolution of drugs and medicines will only worsen an already alarming situation. n The writer is a member of the former Civil Service of Pakistan.