‘rational drug policy needed to curb doctor-pharma nexus’
Experts want a drug policy that will enforce quality assessment, permanent licensing, availability of generic medicines and banning of irrational drugs.
Even after the Ministry of Health issued a directive that mandated doctors to prescribe generic medicines in place of costly branded medicines, many doctors in the national capital region are not adhering to the advisory.
This reporter’s visit to multiple chemist stores and leading pharmacies in Delhi and the national capital region revealed that doctors are openly violating the Centre’s advisory and are prescribing branded medicines to patients. The noncompliance of the doctors is impacting the availability and promotion of generic medicines in the market.
“After Prime Minister Narendra Modi directed doctors to prescribe generic medicines we stocked them. But people still come with prescription of branded drugs,” revealed a pharmacist in Malviya Nagar market in south Delhi.
Generic medicines are non-branded drugs that have the same single ingredient, which cures the disease, as the branded ones. The difference is in the pricing. Generic versions of branded drugs cost around 20-50% less. However, owing to the unethical nexus between doctors and pharma giants, branded drugs account for 90% of the total sales. Unbranded generic medicines are sold only in public health centres and government-owned pharmacies such as Jan Aushadhi Stores.
“We stock what sells. There are definitely cheaper versions of the similar medicine, but there is no demand for them. For instance, there are varieties of cetirizine in the market ranging between Rs 25 and Rs 50 for a strip of 10 tablets. But it goes without saying that the demand for the costlier brand is always higher,” the pharmacist noted.
A pharmacist in the bustling market of Sector 18 in Noida told this newspaper that doctors have now identified a loophole in the directive, which mandates them not to prescribe costly medicines. While these doctors adhere to the advisory and prescribe generic drugs, they write the preferred brand name in bracket. This indirectly influences the market.
“This is like doing the same thing differently. Moreover, even if they tell people that the same medicine is available at a much cheaper price, they insist on providing the ones recommended by the doctors,” he said.
Another retailer of medicinal drugs in Malviya Nagar inveighed against the “unique” form of drug promotion adopted by doctors, where they write a generic prescription but verbally advise the patients to demand a specific brand from the chemists.
“There’s huge confusion on whether or not to stock generic drugs. The prescription mentions the generic name, but patients demand specific brands as suggested by the doctors. Now if any health inspector pays a surprise visit to us, we will be held for not stocking generics. What do we do?” he complained.
Last month, PM Modi announced that the government would map out a “legal framework” to ensure that doctors prescribe generic drugs. Several doctors and big drug companies opposed the move. A recent survey conducted by Curofy, an online community of verified doctors, claims that 73% doctors are against the prescription of generic drugs.
Experts have welcomed Prime Minister Narendra Modi’s initiative to formulate a legislation obligating doctors to prescribe generic medicines, a step they believe would curb the “unethical prescription practice of doctors”. However, they have also called for a policy overhaul in order to crack down on the nexus between doctors and big drug companies that helps them to rake in huge cash mutually.
“I think it’s a welcome move, but we have a long way to go to crack down on this nexus effectively. Quality assessment, price control and availability of generic drugs hold the key to address unethical practices that hinder affordable healthcare,” said Dr Jayaprakash, additional professor and child psychiatrist unit chief in Trivandrum Medical College.
Acting on reports that the unholy relationship between pharmaceutical companies and doctors pushes over 32 million people below poverty line, owing to expenditure on medical care, Prime Minister Modi announced last month that the government would formulate a legislation to arrest the trend. He was speaking during the inaugural ceremony of a multispecialty hospital in Surat. According to reports, pharmaceutical companies pump in around 7% of their turnover, around Rs 4,200 crore, into marketing and promotional activities. Prohibited to advertise the drugs, this amount is used as bait for doctors to influence their prescription practice.
“By default the prescriptions by considerable number of doctors are of the costliest brand when the much cheaper alternative of the drug, which is of equal quality, are available in the market,” said Dr Mira Shiva of All India Drug Action Network (AIDAN).
Under the pretext of drug promotion, medical representatives allegedly use unethical methods to influence the doctors to prescribe their medicines.
Talking to this newspaper, a medical representative of a leading pharmaceutical company revealed that it starts in the form of modest flattery like offering pens, calendars and prescription pads and leads on to funding foreign trips and covering education expenses of doctors’ children.
“During our training we are taught three Cs—convince, confuse and corrupt. We are directed to convince the doctor to prescribe our drugs, even if it means offering them bribes or gifts,” alleged a Kanpur-based medical representative under the condition of anonymity.
“Medical ethics prohibit doctors from even accepting a prescription pad from the pharmaceutical companies. However, many doctors accept gifts from these companies,” said Dr Jayaprakash. He further noted that this nexus is not limited to drug companies but extends to diagnostic laboratories as well.
“For an MRI, which costs Rs 6,000-7,000, around 40%50% goes to the referring doctor. After striking a deal, the diagnostic laboratories open an account in the name of the doctor and for every referral the commission is directly deposited into their account,” he alleged. The hand- in- glove association of the doctors and pharma giants has resulted in unprecedented rise in the irrational prescriptions of drugs, such as cough syrups, digestives and cognitive drugs that do not have any scientifically proven therapeutic merit.
“In neuroscience, there is no proven drug which can boast of improving memory or intelligence effectively. However, doctors still prescribe costly cognitive drugs,” claimed Dr Jayaprakash.
Furthermore, irrational prescriptions by doctors, allegedly fed and bred by pharma companies, pushes costly medicines over the generic versions that are priced around 40%-50% less than the branded medicines.
“The manufacturing of Atorvastatil costs around Rs 3, which is more or less the same for branded and unbranded drugs. While the generic version is sold for Rs 6 in the market, a branded version sells for around Rs 60-65. This is because ceiling prices are determined on the basis of market-based mechanism,” said S. Srinivasan, who runs Low Cost Standard Therapeutics and is associated with AIDAN.
According to doctors, generic medicines are the ones that are sold under their International Non-proprietary Names ( INN) in the later stage of the drug cycle, which is after the patent of the pioneering drug expires. By default, all drugs come into the market as branded. For a stipulated period, the pioneering company sells the drug in the market at a high price to recover its expenditure on research and development of the formulation. Once the patent expires, other companies start selling the same formulation at a much cheaper price. However, even after the patent expires, the pioneering companies continue to sell the medicine at the same price.
“The ingredient that cures the disease remains the same. The notion of higher the cost, better the quality is a myth circulated by the big pharmas. In many cases the drugs are manufactured by one company and marketed by someone else. Our generic drugs are exported in huge quantities. The UNICEF and Doctors without Borders buy these generics in huge quantities,” claimed Dr Mira Shiva of AIDAN.
Pharmaceutical companies pump in around 7% of their turnover, around Rs 4,200 crore, into marketing and promotional activities, which is used as bait for doctors tO INfluENCE tHEIr PrEsCrIPtION PrACtICE, As they aren’t allowed to advertise the drugs.
Experts unanimously told The Sunday Guardian that the debate over generics and branded medicines is misplaced. They believe that the discussions should instead be about formulation of Rational Drug Policy that enforces proper quality assessment, permanent licensing, availability of generic medicines, robust “pharmaco-vigilance”, banning of irrational drugs and the use of cost-based pricing, instead of a market based pricing mechanism, to determine ceiling prices for medicines.
“There has to be a comparative drug therapeutic analysis on cost, quality and availability of generic drugs. A rational drug policy would ensure that a proper quality assessment of all the drugs entering the drug market is in place, that a ceiling price is determined on cost-based mechanism and that irrational drugs are banned, while the availability of essential drugs is increased,” Dr Shiva added.