A bitter pill: The corrupt business of prescription

58% of the 395 fixed-dose combinations of antibiotics sold across the country were on WHO's 'not recommended' list

Conferences at exotic locales, a few hours of scientific discussions turning into a four-day family holiday package, expensive gadgets and gold coins as gifts and cash in bank accounts — the extent of medical corruption in India is there for everyone to see without anyone acknowledging it.

The menace continues to grow. The infamous 40 per cent commission — allegedly demanded by government contractors in Karnataka — seems to have entered the medical field as well.

“The commission given to doctors (to prescribe certain medicines) has increased, from 20 per cent earlier, to about 40 per cent now. Many top pharma companies make such offers and the money is deposited in the accounts of the doctors’ relatives,” said Sharan*, a medical and sales representative with 22 years of experience.

Not every doctor is corrupt and not every pharmaceutical firm resorts to unethical means to sell their products. However, there is no denying that a large number of doctors and medical companies adopt unfair means. Even the Supreme Court frowned at the expenses incurred on sales promotion of Dolo 650, a paracetamol brand that became popular during the pandemic.

Hearing a petition on medical corruption last month, a Supreme Court bench of Justice D Y Chandrachud and Justice A S Bopanna described it as a “serious matter” when it was brought to their notice that the manufacturers of Dolo-650 spent nearly Rs 1,000 crore on freebies to doctors, according to the Central Board of Direct Taxes. “This is not music to ears. Even I was asked to have the same medicine when I had Covid,” said Justice Chandrachud.

The bench was hearing a petition by the Federation of Medical and Sales Representatives Association of India (FMRAI), which demanded that the Uniform Code of Pharmaceutical Marketing Practices (UCPMP) be made statutory. They also called for a monitoring mechanism to increase transparency, accountability and ensure consequences for violations.

Till such regulations are made, the federation requested the top court to “lay down guidelines to control and regulate unethical marketing practices by pharmaceutical companies or in the alternative make the existing code binding with such modifications/additions as the apex court may find proper and reasonable.”

The FMRAI argued that in India, pharmaceutical companies spent large amounts of money on sales promotion to influence doctors to prescribe their products to increase drug sales.

“One study noted that the top seven companies together spent Rs 34,186.95 crores in marketing in eight years, making drugs expensive. Sales promotion expenses constitute 20 per cent of the cost of drugs, thereby taking them further away from the reach of the common man,” said the FMRAI petition to the Supreme Court.

Though termed as ‘sales promotion,’ these freebies include direct or indirect advantages offered to doctors as gifts and entertainment, sponsored foreign trips, hospitality and other benefits. "Medical representatives introduce products to doctors and the senior sales managers negotiate with them by offering cars, appliances, trips abroad, etc," says Sharan.

There are two broad categories in which such a nexus between medicine and marketing persists.

The first is overuse or over-prescription of drugs. This can happen in three ways — prescription of higher dosages of drugs than necessary, prescription of drugs for a longer period than necessary and prescription of a higher number of drugs than necessary.

The second category involves the prescription of irrational combinations of drugs. Such drug combinations, prescribed due to high-pressure promotional tactics, usually lack the backing of medical literature and are potentially injurious to health.

Hundreds of these combinations have been banned by the government on several occasions but drug firms have managed to continue flooding the market with them.

A study published in the World Health Organisation bulletin, has found that 229 (58 per cent) out of 395 fixed-dose combinations (FDCs) of antibiotics sold across the country were on the World Health Organisation's “not recommended” list. As many as 13 among India’s top-20 selling antibiotic cocktails have been classified by the WHO as neither evidence-based nor recommended.

Pressure on medical reps

On the other side, medical representatives are expected to meet skyrocketing targets. “We get fired if these targets are not met. Since the targets are high, area managers (who are in charge of multiple districts) work in each district intermittently and make offers to the doctors as well,” said Sharan.

A Coimbatore-based doctor said the pressure from medical representatives increased manifold in the past 20 years. “I personally know of doctors who have imposed a ban on meeting medical representatives. When I began practising, there used to be just one representative for a company. But today, there is one representative for each product,” she said.

She noted that the marketing had become increasingly aggressive over the years. “Most companies hold conferences and invite doctors with their families. The conference will be just for a few hours, but a tour will be planned for a couple of days.”

The intent of having pharmaceutical representatives meet doctors was initially to keep medical professionals updated about recent developments in drugs and treatments. Particularly for doctors in private clinics, meeting the sales personnel is important to know the prices of medicines so that they can prescribe affordable options to their patients.

The companies also argue that the conferences they organise aid professionals in continuing medical education.

Critics argue that the information doctors learn from these conferences is one-sided since it is dished out by the sponsoring pharmaceutical companies.

“More expensive drugs are getting sold instead of cheap ones because the patient is only an incidental buyer, and the product is marketed to doctors,” said public health researcher Prasanna Saligram, formerly associated with the Public Health Foundation of India.

Is the government not aware of such medical malpractice? What is it doing to tackle the problem? The Department of Pharmaceuticals, which comes under the Union Ministry of Chemicals and Fertilizers, repeatedly notified the Parliament that it had no plans to make the UCPMP mandatory.

Regulations

The code that came into effect in 2015, does not give any power to the department to deal with complaints on unethical practices. Any complaint received against a pharmaceutical company is to be handled by an Ethical Committee for Pharma Marketing Practices (ECPMP) that is to be constituted in each of the pharmaceutical associations. The ministry held a few meetings with the industry associations on implementation, but there has been no follow-up or action beyond that.

However, thanks to a somewhat increased level of awareness, some companies have changed their marketing strategies. "Earlier many companies used to offer foreign trips, or send appliances to doctor's houses. It was common. But the National Medical Commission (NMC) has been more strict in the last five to six years. Now, companies offer something that will help a doctor's practice or the clinic,” said a Bengaluru-based doctor.

A common practice is to sponsor scientific conferences that adhere to NMC guidelines. Pharmaceutical firms sponsor these events and put up stalls outside the halls where they display and give information about their products.

However, in specialisations like oncology and cardiology, new drugs are costly, and marketing is predatory. Big corporations invest in research and development and push their products aggressively.

Nowadays, firms sponsor panel discussions in which a doctor presents scientific information related to a new drug. While these presentations do not directly promote the drug, the doctor will talk about the formulation. Outside the hall, firms showcase these products. “The doctor who presents the information will get an incentive, which could vary between Rs 10,000 and Rs 1 lakh for a one-hour session, depending on the company and the doctor's profile,” the doctor said.

In February, the Supreme Court, in another ruling, categorically stated that the act of pharmaceutical companies doling out freebies to doctors was “clearly prohibited by the law”. A bench comprising Justices U U Lalit and S Ravindra Bhat, observed that medical practitioners were forbidden from accepting such gifts, or freebies.

"It is a matter of great public importance and concern, when it is demonstrated that a doctor’s prescription can be manipulated, and driven by the motive to avail the freebies offered to them by pharmaceutical companies, ranging from gifts such as gold coins, fridges and LCD TVs to funding international trips for vacations or to attend medical conferences,” the bench noted.

Despite such observations, the menace thrives on because there is no effective monitoring of doctors prescribing any particular brand of medicine, said a drug inspector in Thiruvananthapuram. There is also no provision for taking legal action against any doctor for prescribing any specific brand.

In 2017, the Union government proposed a new regulation, and a draft of the Drugs (Control Marketing) Order 2017 was sent to the Ministry of Law for clearance. "However, for reasons best known to the Ministry of Law, the same was not enacted. Thus, the UCPMP which exists today remains voluntary in nature, thereby making its implementation impossible,” the FMRAI summed up.

(With inputs from Mrityunjay Bose in Mumbai, E T B Sivapriyan in Chennai and Arjun Raghunath in Thiruvananthapuram)

(*Some names have been changed on request)