Medicines or drugs are perhaps the only commercially available set of products that consumers buy on someone else’s advice. The presence of a middleman between the producer and the consumer makes drugs a unique product category. While consumers or patients are end users of medicines, they have little role to play in the crucial product purchase decision. The prescriber or the middleman thus becomes a critical part of the drug marketing chain. The prescriber could be a doctor, a nurse, a paramedic or practitioner of any system of medicine. As far as drug companies are concerned, doctors or prescribers are their ‘consumers’ even though they don’t buy the medicine or consume it. Therefore, all drug marketing efforts are directed at doctors or prescribers. In the classical marketing narrative, this arrangement makes perfect sense. However, in reality this harmless sounding marketing chain has given rise to serious ethical concerns which put consumer or patient interests in peril.
It is in this context that the announcement made by drug major GSK that it will stop making direct or indirect payments to prescribers and also stop incentivising sales people only for prescriptions they are able to generate, becomes important. It is an open secret how drug companies try to influence doctors and health-care professionals and how sales representatives are given incentives based on how many prescribers they are able to influence. But it is rare for a leading drug maker to admit that it has been making direct payments to health-care professionals for speaking engagements and for attendance at medical conferences, and that it is now going to put an end to this practice. By saying it will end the practice, the company has admitted that it has been “paying health-care professionals to speak on its behalf, about its products or disease areas, to audiences who can prescribe or influence prescribing.” In fact, it is not just GSK; all major drug companies have been doing this.
Somehow drug companies have taken upon themselves the task of ‘medical education’ of practicing doctors and professional bodies of doctors have been too willing to become a partner in this. Even now, GSK is not ruling out its role in ‘educating’ doctors and health-care professionals. Instead of paying doctors directly to attend conferences, it says it will develop alternative means to “appropriately lead engagement with health-care professionals”. It is one thing to inform doctors about clinical data of their new products or provide information about safety of drugs and quite another to fly them to exotic locations like Goa, Pattaya or Mauritius for an all-expenses paid family trip in the name of medical education. Similarly, giving a pen, letter pad, calendar or a weighing machine to doctors for the purpose of ‘brand recall’ may be an acceptable courtesy, but what about giving gold chains, air conditioners, refrigerators, gift vouchers and even cars to prescribers? Isn’t it plain bribery?
It is not just the question of drug companies making payments to doctors or showering them with expensive gifts so that they prescribe costly — sometimes even irrational or unnecessary — drugs or tests. It is a vicious cycle in which a patient ends up paying both ways. When companies spend a huge amount on marketing (paying doctors, sales representatives) they add up these expenses to the price of a medicine, making it costly. And when doctors prescribe these costly medicines, patients have to pay in any case. This means patients are being made to pay more so that companies make enough money and can also keep prescribers happy. The parliamentary standing committee on health too deliberated on this issue and recommended steps to curb the practice in 2012, but both the government and professional medical bodies seem least interested in moving ahead to stop these unethical marketing practices of drug companies.
The Medical Council of India (MCI) — the regulatory body of the medical profession — washed its hands of by saying it has put in place a code of ethics for doctors but has no jurisdiction over bribe givers ie drug companies. The record of MCI itself in dealing with ethical violations has been pathetic, to say the least. The wing of the government that deals with the drug industry — Department of Pharmaceuticals — too seems reluctant to act in this regard. Instead of going in for a legal framework to deal with the problem, DoP has been pussyfooting with a so-called voluntary code of ‘Marketing Practices for Indian Pharmaceutical Industry’, which leaves the doors wide open for corrupt practices and has no teeth at all. The third player — the Indian Medical Association (IMA) and numerous professional bodies of doctors — are also turning a blind eye. In fact, these bodies are the biggest beneficiaries of the munificence of the drug industry. Holding medical conferences with ‘gold’ and ‘silver’ sponsors from the industry has itself become an industry for medical associations. The budget for a three-day cancer conference held in the national capital a couple of months ago was a whopping Rs15 crore. No prizes for guessing who footed the bill.
In such a situation, only a legally enforceable framework against companies bribing doctors can work. To begin with, it should be mandatory for all drug companies to declare details of their marketing expenses. It should be like income-tax returns — giving details of how much was spent on gifts, conferences, foreign trips and other ‘educational’ activities. At least, consumers will get a chance to know which company is paying how much to doctors. The MCI should mandate under the MCI Act that audits of all medical conferences with details of their sponsors be filed with it and subsequently made public. The DoP should convert the voluntary code into a law and set up an enforcing mechanism with adequate representation of consumer groups. Above all, the health ministry should root for the promotion of generic medicines on a massive scale, and not on a pilot scale as is being done now. It can potentially dismantle artificial competition in the market and bring prices down. All this will be possible if we make patients the focus of our drug policies. The current focus is not on patients but on the industry.
The writer is a science journalist and author