INTRODUCTION

The supply chain is a lifecycle practice in which substances or items move from the producer to the position of utilization and collection of money, such as retailer and wholesaler dealers (Chopra & Meindl, 2007; Tseng, 2010). The producers and distributors, medical service providers, medical clusters, indemnity companies, public sector organizations, corporations, government watchdogs, and customers of health care services are the main participants of the medicine supply chain (Mackey, Liang, York, & Kubic, 2015). Protecting the integrity and genuineness of the supply chain of drugs appears to be one of the leading and sophisticated issues in today’s world due to the comprehensiveness of health and care delivery (Mackey et al., 2015). Notorious criminal groups are engaged in selling hazardous forms of medicines, which are putting the safety of patients at stake. The illegitimate global trade of counterfeit medication is huge and deep-rooted, including health products of simple therapy use in life-saving drugs (Elmuti, Khoury, Omran, & Abou-Zaid, 2013; Mackey et al., 2015).

Blockchain technology or blockchain is a decentralized data storage system (data stored in multiple storage units instead of a single centralized unit or server) that can be spread across millions of small data storage units so, hacking blockchain would mean hacking millions of servers simultaneously, and that’s the real challenge for hackers (Ali, Jaradat, Kulakli, & Abuhalimeh, 2021). Blockchain technology provides a way to know exactly where a piece of knowledge originated. If evidence is put into an appropriately sustained blockchain, it is permanent, unalterable, and time-framed. This shows a definite validity for a particular piece of data created at that specific moment highlighted in the blockchain ( Brennan, 2017). Applicants who wish to store information on the blockchain are granted digital Identities and confidential keys; further, any evidence or documentation they keep on the blockchain is electronically signed ( Brennan, 2017). This technology bears no fee for the transaction. There is a likelihood of setup cost but no cost of the transaction. This blockchain technology is an uncomplicated but creative mode of transiting data from one point to another in a completely mechanized and secured style.

A block in the blockchain is created when a blockchain stakeholder starts a transaction, that particular block is then validated by hundreds or even thousands of workstations spread across the network (Khan, 2016), then the block, that was, validated is subsequently enlisted to a string which is piled throughout the network, resulting not only distinctive record but a distinctive chain of past events; this makes that block unique. Forging one record would result in developing the whole sequence comprising thousands of events, making it almost impractical. Bitcoin technology works on this methodology for transactions related to financial and economic markets, but it can be applied to many other areas, including health, privacy, and information sharing (Khan, 2016).

Blockchain technology became prominent through the swift growth of the Bitcoin currency, and the organizations giving financial services were quick to understand its significance. Still, Blockchain technology is advancing in different fields, including health services (Bhutta et al., 2021), manufacturing, legal services, financial services, and electronics (Bhardwaj & Kaushik, 2018). For Example, Wikipedia is one of many instances depicting Blockchain technology's working. Wikipedia is decentralized and can be accessed entirely by anyone. The only access to an internet connection and anyone can make traceable amendments to the Wikipedia page that are visible to the common person. The BT is extremely protected which makes it impossible to corrupt any transactions.Blockchain users have fully acknowledged the movement of their funds. Blockchain technology is a completely protected genuine instrument that can operate as a check and balance method for transactions; hence, documenting and specifying all transactions that have been performed (Zheng, Xie, & Dai, 2018).

LITERATURE REVIEW

There are different type of technologies for the blockchain. These different types of applications of Block Chain technology have been briefed in the appended literature. Generally, the applications of said technology are categorized into finance, the Internet of Things, public and social services, reputation system, and security and privacy. In Financial services, the crisis of blockchain technology, for example, Bitcoin (Nakamoto, 2014) has resulted in a vast effect on conventional financial and trade facilities (Parlikar, 2015). Peters and Panayi (2015) proposed that blockchain technology could potentially disturb the universe of banking services. Blockchain technology can be functional in numerous fields comprising trade of financial resources etc. Moreover, in enterprise transformation, the development of financial and trade facilities, blockchain technology can aid conventional corporations to accomplish venture conversion effortlessly (Javaid, Haleem, Singh, Khan, & Suman, 2021). In Risk management, the risk mitigation structure performs a significant job in FinTech, and currently, it may be merged with blockchain technology to work better. Pilkington (2016) offered a new risk-mitigation structure where the said technology is practised to scrutinize investment uncertainties in the Luxembourgish situation.

The most prominent technology Internet of things (IoT) which is Information and Communication Technology (ICT) is speeding up these days. The IoT technology combines the things commonly known as smart objects into networking and facilitates the subscribers with many facilities (Atzori, Iera, & Morabito, 2010; Miorandi, Sicari, Pellegrini, & Chlamtac, 2012). In Safety and privacy, Security and confidentiality maintenance is another essential apprehension for IoT businesses, and Blockchain technology can also assist in increasing confidentiality in IoT workflows. Hardjono and Smith (2016) suggested a confidentiality-saving process for onboarding an IoT machine into a cloud system. In land registration, one of the distinctive blockchains practiced in municipal services is the registration of property, i.e. land (Togawa, 2015), where the land data, including the bodily position and associated privileges, can be recorded and revealed on the blockchains. Also, any amendments made on the land, like the shifting of land or the development of a mortgage, can be registered and administered on the blockchain, as a result, enhancing the competence of local communal services. In Energy-saving, Apart from that, blockchain technology can be practised in pollution-free fuel resources.Gogerty and Zitoli (2011) suggested the solar coin to support the practice of reusable energies. The particular solar coin is an electronic currency facilitating sun energy creators. Blockchain technology is initially designed to enable currency trade to be worked out in an uncertain atmosphere. Though we remark on the knowledge and learning phase as the currency, blockchain technology can be functional in the web-based educational marketplace (Devine, 2015).

There is an increasing amount of instances of individual repute of document forgery, such as, in electronic trade, several facility providers register an enormous figure of bogus clients to attain a high reputation, blockchain technology may help resolve this dilemma. Status is essential to academia. Sharples and Domingue (2015) proposed a blockchain-affiliated scattered structure for educational documentation and repute. Initially, each organization and scholar member would be provided with a primary honour of academic reputation money. An academic institute could grant a membership by transmitting some status documentation to the members. Since these trades are recorded on blockchain technology, all the repute changes could be discovered comfortably.In Web community, the capacity to judge a worker's reputation in a web society is extremely significant. Carboni (2015) suggested a reputation-based model related to the blockchain. Since businesses are recorded on blockchain technology, reputation documentation is almost impossible to corrupt.

In security enhancement, blockchain technology can most likely assist in improving the safety of the dispersed system. Noyes (2016) suggested a new malware-free atmosphere called BitAV where subscribers may allocate the virus outline on the blockchain, and it in that way may improve the error patience. As it is exhibited byNoyes (2016) that BitAV may progress the scanning momentum and increase the error dependability, reducing vulnerability to besieged denial-of-service assaults. Blockchain technologies may also be practiced to improve the reliability of the safety system. In privacy protection, blockchain technology has the prospect to make the safety of security susceptible information. Zyskind and Nathan (2015) suggested a delegated system of individual data management that guarantees the client possession of its data. This structure is based on blockchain technology (Lim, Li, Wang, & Tseng, 2021).

The use of blockchain technology is becoming prominent in international organizations globally, where tracking is necessary to maintain records on the whereabouts and quality of products (Yiannas, 2018). Walmart, which operates globally and has a hypermarket chain, uses blockchain technology to ensure quality food products by tracking and recording the whole procedure of the supply chain from the farms to the final customer (Tan, Yan, Chen, & Liu, 2018). Using this approach, the customers can transparently investigate the origin of products (where and when it was manufactured) (Yiannas, 2018). Blockchain technology is also being used in America for global trade due to the purpose of export and import that is implemented and managed by the organization “Gliding Eagle”. It has reduced the complexity of the trade process and provides transparency to the customer like never before (Duan, 2018).

Blockchain technology is the time-bound sequence of indisputable informative documentation administered by a group of workstations not possessed by any particular corporation. All these chunks of information, which are blocks, are protected and restricted to one another, exercising cryptographic standards. Three attributes of the said technology may help interrupt the logistics management system i.e. first is decentralization, the second is immutable, and the last is transparency. Some logistical networks are already using the blockchain technology, and professionals propose that this technology may soon become a common operating system in the supply chain. This blockchain technology may help improve some procedures, which are documenting the amount and relocation of resources like pallets and containers as they travel between different points of the supply chain, tracking purchased orders, and other records related to trade. Conveying or validating documentation or different attributes of products such as deciding, if an edible good is a natural or reasonable deal, connecting material products to serial figures, electronic signatures such as RFID (Radio-frequency identification), allocating data related to production course, assembling, maintaining, and delivering to vendors and suppliers (Vorabutra, 2016).

Irrespective of the form, blockchain technology provides transporters different benefits such as improved clearness by recording a good’s voyage across the logistical network, disclosing its actual foundation and key points; hence, increasing reliance and assisting in the elimination of the prejudice witnessed in the supply chain networks these days. Producers may also lessen summon up by informing about history logs with Original Equipment Manufacturer (OEMs) and supervisory body, approaching from any amount of touch-nodes, is likely, enhanced safety by giving out ineradicable ledger with encrypted principles may potentially eradicate the examination mandatory by in house systems and procedures and better novelty offering prospects thrive to build innovative, dedicated usage for the said technology as a product of the decentralized structure (Vorabutra, 2016).

Blockchai n and Pharmaceutical Supply chain

The medicine business has a specifically sophisticated supply chain structure involving different parties in the production and supply of a particular medicine. Blockchain technology gives a prospect to shorten the supply chain procedures and facilitate the quality management across the same. Further, it also validates that the responsible people have pursued and performed the accurate production procedure, for example, ensuring that the product has not been done at an unauthorized or unregistered facility. Malfunctioning has been observed in China concerning food safety, as a result, Walmart is operating blockchain tech to make the tracking of food better (Tan et al., 2018). Many industries, following blockchain technology, can be benchmarked and replicated in the pharmaceutical industry (Blomfield & Ghhogra, 2019).

Countries worldwide are monitoring serialization (allocating a serial number to every package) to make follow-up better in the supply chain area due to fears of bogus drug markets. It has been advised to all the stakeholders in the field of the supply chain to facilitate electronic follow-up capability as proposed by the US Act on Drug Supply by the year 2023. The directives on counterfeit drugs, i.e. falsified medicine directives (FMD) in Europe, have required all medicine corporations to incorporate security attributes on their medicines and drugs and become part of the central data warehouse of the European Union. Blockchain technology drives away the obstacles of intrusion across suppliers and equipment and gives a supportable modification log maintained in a protected cyber atmosphere. Big players in the pharmaceutical industry like Pfizer and Genentech, are operating on a blockchain-framed design to accomplish their needs (Blomfield & Ghhogra, 2019).

The most important concern for the end-user in the drug industry is the quality of medicine, this concern can be addressed through BT in multiple ways (Bocek, Rodrigues, Strasser, & Stiller, 2017). An organization MODEM.IO is using BT to ensure that the quality of medicine is not compromised on the long routes by monitoring its temperature and securely recording exchange data between buyer and seller (Bocek et al., 2017). Because the information stored on BT is immune to hacking, it helps fight the problem of counterfeit medicine, this has been ensured with respect to more transparency of medicine whereabouts, better privacy protection, and extended information security (Choun & Nasr, 2018; Haq & Esuka, 2018). So it enables the end-user to know the exact source of origination. The interface of such a BT-based system is shown in Figure 1.

METHODOLOGY

We used a qualitative approach that involved interviewing pharmaceutical and health experts from all over the Pakistan using distinct organizational, professional, and disciplinary contexts. Interviews were conducted, face to face in Karachi city and via phone calls to the respondents in other cities of Pakistan. A qualitative method was considered most suited as we aimed to study the counterfeit medicine market in Pakistan’s context. About the philosophical underpinning, interpretive research philosophy is followed as it argues that studying social constructs is the only way to access reality; that also includes the interview approach. Using Purposive sampling, we constructed a sampling matrix of pharmaceutical professionals (sales/supply chain/operations), drug regularity authority of Pakistan (DRAP) officials, and doctors (general practitioners). Participants were voluntarily selected individuals and were sent an invitation for participation on leaflets, topic guides, and consent forms. None of the respondents were sent more than three reminders. Following interpretivism research philosophy, the final sample size was purely selected based on saturation point attainment. The final sample size for this purpose was 12.

The sampling framework was examined throughout the data collection and was implemented to make sure of the breadth and depth of coverage. Here, we kept on interviewing until data saturation was reached, as suggested by (Guest & Bunce, 2006). Interviews lasted for a median of 12.5 minutes. Interviews were conducted from February 1, 2019, to March 31, 2019. Interviews were undertaken in Urdu and English following respondents’ preferences. Some interviews were conducted in a mixture of both languages. Written or recorded verbal consent/permission was obtained before the conduct of all the interviews. A topic guide was used, although interviewees were given the liberty to speak freely and; hence, the topic guide itself evolved during the research period. Interviews were digitally recorded in audio along with the written field notes and then transcribed manually. An analysis was undertaken continuingly to allow emerging themes to inform the topic guide for successive interviews to ensure the robustness of the study by removing any possible deviants. During data collection, we took special care that our backgrounds do not impact the findings of this research.

Conclusion

Strong government intervention is needed to implement BT-based systems that may regulate the supply chain processes for pharma in Pakistan. Both federal and provisional governments would play an important role in implementing it. DRAP is currently working on developing newer SOPs’, BT may enable them to enhance their systems at a technological level. But this can’t be implemented just now, as the healthcare system in Pakistan faces disparity across different regions of Pakistan in terms of development. DRAP is currently focusing on implementing packaging technologies such as barcode systems, these technologies enable package authentication through imprinted information and barcode. The supply chain transparency remains an issue and the proposed BT software application may be the right solution for it, provided that DRAP enforces its implementation.

Strength and limitations

The primary strength of this study is the sampling strategy with maximum variation (respondents are from different domains of the industry of public and private sectors with different levels of significance and influence). A response rate of 60% was achieved. The iterative approach was exercised for data analysis following the theory of deductive and inductive reasoning. To ensure the validity of the data, interviews were conducted until the point of saturation was reached. At the end of each interview, respondents were welcomed to raise any other concern that was not raised in the interview questions.

Even with the sampling strategy that was considered and the high response rate, there is always the possibility of some point of view being missed during the interviews. To minimize this risk, we interviewed the respondents until saturation was reached, to ensure that any new piece of information that is relevant to the study is gathered. Due to the barriers of distances and availability, some of the interviews were conducted telephonically. Related literature reveals that face-to-face interviews are more effective in terms of information gathering (Irvine, Drew, & Drew, 2013). It’s hard to find the female participants in this industry so, equally-weighted gender opinion was hard to maintain. Many respondents were short on time due to availability issues, so time constraints may have prevented some information from being recorded. In the end, the concern of transferability of findings to other settings is another concern. However, we believe that these findings apply to the context of other low-middle-income countries (LMIC) too.

Our findings of this research are broadly in keeping with the existing literature on the pharmaceutical industry which demonstrates that the current issue of counterfeit medicine can only be suppressed through the proactive role of government intervention. Along with that, the market for counterfeit medicine primarily exists due to non-transparent supply chain systems for pharmaceutical medicines, starting from raw material to the end product (Bocek et al., 2017). BT has the potential to make the whole supply chain transparent which would allow the end consumer to be sure about the authenticity of the end product they use (Tan et al., 2018).

Implications for Policy, Practice, and Research

The role of government in implementing systems such as BT is even more important in low or middle-income countries (LMIC), as there is no systematic way to enforce such processes. To implement such a system, the analysis of the need of the people is essential to be understood, this would ensure that the intervention that we introduce are interlinked with the needs of the people. In the process of implementing such a system, partnership with international and local healthcare institutions would be needed to establish centers for training and spread awareness to the general public regarding the use of this system and its need. However, it might be difficult to forecast the learning curve and implementation rate in different regions of Pakistan due to the disparity in education and healthcare facilities.

We believe that many of the findings of this research apply to other LMICs’ as they face the same barriers compared to Pakistan (Lewis, Synowiec, Lagomarsino, & J, 2012). To some extent, the findings of this research are culturally influenced and future research in other LIMCs’ may prove to be beneficial in this context. For example, general practitioners tend to recommend the drugs to the patients based on their networking with the pharma industry, instead of judgment based on quality.

Conflict of interest statement

The authors declare no conflict of interests.