Greed over care: Decoding the unholy doctor-pharma alliance

At 55, Naseem* was in good health. Her joints ached occasionally, but everything else looked good, and she exercised regularly. Then, one day, she had a scare. During a brisk walk on a cool winter evening, she felt a shooting pain in her knees, the kind that forced her to stop and rest on a footpath for some minutes. Some time later, the pain subsided as swiftly as it had come.

That night, she thought more about it, and, despite her fear of hospitals, went to a nearby clinic. The doctor ruled out a fracture or sprain but prescribed her ibandronic acid, a medicinal drug used for the treatment of bone diseases, along with some Vitamin D and Calcium supplements. Naseem was told that she could only purchase the medicines, carrying a hefty price, from the pharmacy adjoining the clinic.

Relieved that it was nothing serious, she would continue to take the tablets for several months. But the fleeting pangs of pain in her knees never fully subsided. Five years later, at a family function, Naseem was suggested a different doctor. After an x-ray and some tests, the orthopedist concluded that there was nothing wrong with her bones. Instead, it was her shoes. The mauve pumps she wore to work every day were putting pressure on her joints, resulting in knee pain.

The medicines Naseem had been taking for nearly half a decade were unnecessary; she never needed them.

Haniyah* has a similar story. One afternoon, at the tender age of 15, she fell unconscious on her school ground. Days later, she was diagnosed with epilepsy. After switching through various doctors, she believed she had found the perfect match.

A few years later, however, he claimed to have detected her with Wilson’s disease, a genetic disorder that prevents the body from removing extra copper, causing copper to build up in the liver, brain, eyes, and other organs. No tests were conducted, and the diagnosis, Haniyah told Dawn.com, was solely based on a physical exam.

With the detection came additions to her long prescription, including a zinc tablet, which shot her medicine count for the day to eight tablets. “He was the best in the business, so we never went for a second opinion,” Haniyah said.

A teenager back then, who’s now in her mid-twenties, she continued to take the medicines until her doctor died and the family had to switch to another neurologist. It was then that she found out that she never needed any zinc tablets. Since then, Haniyah has been taking two tablets a day.

What both Naseem and Haniyah had in common was that neither needed the medicines they were prescribed. When you visit a doctor, you assume that the treatment you receive is backed by experience and medical research. Surely, why would you be recommended a drug if it wasn’t needed right?

However, research has shown that it is distressingly common for patients to get treatments that they don’t necessarily require. While there may be instances of innocent errors, at other times doctors are well aware of the state of play but continue to prescribe these treatments simply because it’s profitable.

In the medical world, this is referred to as incentive-linked prescribing or ILP — when healthcare providers accept incentives, such as cash or funded trips, from pharmaceutical companies for prescribing promoted medicines.

Understanding the doctor-pharma nexus

ILP is a global issue, one that exists in middle- and low-income countries in exploitative forms as opposed to developed nations where it is more sophisticated. In Pakistan, this malpractice is not just widespread but also strikingly common, according to recent research published in the British Medical Journal Global Health.

The study, conducted in Karachi, enrolled 419 participants, all of whom were private doctors working in for-profit and primary healthcare clinics across six districts of the city. They were enrolled into either an intervention or a control group. Participants of the former, about 210 doctors, attended a seminar on ethical prescribing followed by reinforcement messages.

Those in the focus group, meanwhile, attended a ‘placebo’ professional development seminar focusing on sharing guidelines and best practices for managing blood disorders in primary care, without any mention of ethical prescribing.

Three months after this activity, data collectors were engaged by the researchers and sent to the participants of the study as representatives of a fictitious pharmaceutical franchise company. They provided information to the doctors about incentives being offered to those who agreed to prescribe their promoted medicines.

The results were very concerning; over 40 per cent of doctors who were not exposed to the intervention agreed to incentives in exchange for prescribing medicines. Even those who did attend the seminars on ethical prescribing agreed to indulge in dealmaking with pharmaceutical representatives, that too without any evidence of the quality of medicines being promoted.

“Of those doctors who refused to accept incentives, the majority indicated an interest in discussing incentive-linked prescribing deals with other pharmaceutical companies known to them, indicating that the refusal was not related to a stance against incentivisation,” the research found.

It further highlighted that doctors played an active role in making deals with pharmaceutical sales representatives and their practices were difficult to change.

In fact, Sadia Shakoor, one of the authors of the research, told Dawn.com that ILP had become a standard practice in Pakistan, its prevalence and existence reaching a level where doctors not involved in it were regarded as an exception. “This is a covert practice that everyone cannot easily see,” she said.

Its repercussions, however, are far-reaching, particularly for patients.

‘A real public health issue’

As pointed out by the study, deals between healthcare providers and pharmaceutical companies create a conflict of interest because the former’s professional judgment concerning a primary interest, which in this case is the patient’s welfare, is at risk of being unduly influenced by financial gain.

Incentive-linked prescribing is known to drive the prescription of unnecessary or overly expensive medicines; this results in higher costs for patients, with a differential impact on the poorest, increases patients’ risk from adverse effects and undermines trust in the healthcare system, it noted.

Take Muhammad Naveed for example, a resident of Lyari and father of three. Whenever his children fall sick, he is handed a long prescription that costs him thousands of rupees, and most of the time, the money to purchase all the medicines comes from the children’s education fund.

“Every time we go to the doctor, he gives us an antibiotic,” he said, “so we have now switched to home remedies. They take some time but work fine.”

Antibiotics are one of the medicinal drugs that are irrationally and unnecessarily prescribed across the world, said former health minister Dr Zafar Mirza. This has rendered them ineffective and given rise to anti-microbial resistance — when microbes like bacteria, viruses, fungi and parasites, evolve to no longer respond to antimicrobials, making infections harder to treat and increasing the risk of spreading disease.

“In simple words, it means that antibiotics that were used to treat our common infections are no longer effective and the reason is their excessive use which happens due to incentives provided to doctors prescribing them and the culture that everything is available over the counter,” he explained.

He added that these antibiotics have become resistant to bacteria and infections partly because of unethical promotion and unethical use, culminating in a “real public health issue” because new antibiotics were not being developed and the old ones were becoming ineffective.

Dr Mirza gave an example: if a medicine for lowering blood pressure is unnecessarily prescribed to a person who does not have high blood pressure, their normal blood pressure would further go down due to the use of that medication.

“Medicines are double-edged swords — if they are prescribed for the right indications, they are solutions. But if they are used improperly, they can harm you,” he stressed. “Every medicine has a potentially harmful chemical. Thus, they need to be used very very carefully.

“But their prescribers, because of the incentives given to them, unnecessarily dole out those medicines to patients and charge them heavily so they are on the receiving end.”

This malpractice is ubiquitous even outside the prescription of antibiotics.

Zulfiqar*, who has an MBBS degree but is not a practising doctor, told Dawn.com of instances where physicians were found prescribing Hepatitis C injections of a certain brand to patients. In return, they were given free international trips among other gifts. There are also examples where patients are told by doctors to get CT scans, MRIs or X-rays from a certain lab when it is not needed.

He recalled another incident where his niece was prescribed medicines worth Rs15,000 by a dermatologist for acne. “Two days later, we found out that she had measles.”

The formula milk industry is also one big example, where a misconception is created that mother’s milk is not enough, which is then also propagated by doctors, nurses, midwives and paediatricians. Sponsorship, training activities and gifts are used — including offers of cash or commissions in some cases — to influence health workers’ practices and recommendations, according to the World Health Organisation.

Unfortunately, in Pakistan, where poverty is rampant and illiteracy is high, innocent patients and their families continue to consider doctors’ prescriptions as holy, believing they will cure them.

But why do doctors make deals?

“We must realise that doctors are as much a part of the society as are other people; a society that suffers from the epidemic of corruption,” said Dr Qaiser Sajjad, former secretary-general of the Pakistan Medical Association.

“Secondly, there is a perception among people that a doctor who owns a motorcycle or uses public transport is less qualified than a health practitioner who owns a flashy vehicle and has two assistants loitering around him,” he reckoned. This economic pressure forces doctors to indulge in bribes.

He added that general practitioners were most susceptible to incentive-linked prescribing because they deal with a vast number of patients each day and, hence, are targeted by pharmaceutical companies. Similar is the case with medical products linked to the fields of dermatology and dentistry because the cost of these treatments is higher.

“It is okay to take a pen or pad from pharmaceutical companies but anything beyond that questions the transparency and integrity of the doctor,” Sajjad noted, adding that medical practitioners who indulged in dealmaking were not just making big money but also enjoying international trips and other benefits.

His sentiments were echoed by Shakoor. Doctors, she said, have to make more of an income because they have a place within the society. “[Incentive-linked prescribing] is just a symptom or so to say of a failing economy where the doctor is not able to make enough and has to do with unethical practices.”

She highlighted that this was the reason given by several doctors during her interactions with them during the course of the study. But at the same time, Shakoor continued, many doctors didn’t see taking incentives as unethical because they rationalised it.

“Doctors rationalise that ‘oh we are just accepting an incentive from a pharmaceutical company and we are still prescribing the right medicine, it is just the medicine that the company is paying us for’. But it gets out of hand because they keep rationalising and eventually patients get excessive medication.”

“We do have doctors who engage in practices that uphold the rights of patients but we also have doctors who would rationalise prescribing an extra antibiotic or multivitamin to a patient or write up a medication that costs a little more. What is wrong is the dealmaking aspect, which has become a social force of its own,” she remarked.

Shakoor added that the practice was so prevalent that pharmaceutical companies said they could not even offer an honest drug, one supported by scientific literature, without actually offering something in exchange.

Bribery and extortion

Delving into the depth of the problem, Dr Ahson Naqvi, chief executive officer of the Sindh Healthcare Commission, explained that it was true to some extent that pharmaceutical companies indulged in bribing doctors for higher profits.

“Historically, only multinational companies worked in Pakistan’s pharmaceutical industry. They had no competition and began marketing practices by providing academic support to doctors, who did not have as many opportunities then, following all the ethical guidelines,” he told Dawn.com.

At the time, doctors did not have a choice in prescribing medicines because of the lack of competition in the market. With time, generic companies and local manufacturers entered the market. Presently, there are about 700+ such registered pharmaceutical firms.

According to Patients Not Profits, a network supporting ethical healthcare, the pharmaceutical industry in Pakistan generates sales of over $2 billion, with a majority coming from local and domestic companies rather than multinational corporations. Prescription drugs account for two-thirds of the sales, with almost 90pc medicines being prescribed by their brand names.

“With the emergence of this market, incentivisation of health practitioners increased,” Dr Naqvi said. He elaborated that because the pharmaceutical market in Pakistan was price-controlled then, there was not much difference in the prices of medicines, and to market themselves, these companies incentivised doctors.

“Henceforth began a transformation of doctors … initially the pharmaceutical industry was called a bribing industry but today, I refer to the medical community as extortion because they are extorting money from the former,” he claimed.

The majority of these local firms, Naqvi claimed, rarely followed ethical marketing guidelines established by the International Federation of Pharmaceutical Manufacturers and Associations, a body that advocates for policies and practices that improve global health.

Per Clause 19-1 of the code, “no gift or financial inducement shall be offered or given to members of the medical profession for purposes of sales promotion”. It added that gifts in the form of articles designed as promotional aids, whether related to a particular product or of general utility, may be distributed to healthcare providers but only if the gift is not unreasonably expensive and relevant to the practice of medicine or pharmacy.

The SHCC chief further explained that there was also a third aspect to the medicinal market in the country, which had to do with pharmaceutical franchises — a business model where a pharmaceutical manufacturing company offers exclusive marketing and selling rights to a business owner.

“These franchises purely function on the concept of taking money and prescribing medicines,” he said, adding that these franchises particularly targeted general physicians and private clinics.

Naqvi held doctors accountable for the mushroom growth of franchises and local pharmaceutical companies. “Those who take bribes are more to blame than the one who gives them. A doctor is an entity that carries the discretionary power to say no. But they don’t because of their greed,” he alleged.

The recent deregulation of non-essential medicines, done by the caretaker government last February, has further raised fears. The move enabled companies to set prices for drugs not listed on the National Essential Medicines List.

According to Dr Mirza, this has led to a surge in the prices of medicines across the country. This also means that marketing budgets will further go up and competition to sell will become ferocious. And with it, new lows in unethical marketing practices by pharmaceutical companies will be witnessed.

Finding a remedy

While the problem of incentive-linked prescribing exists worldwide, in Pakistan, one of the major reasons behind the vast scale of the problem is the lack of regulation — or where there is regulation, the lack of its implementation. “There is a general sense among practitioners that if their clinic is shut down in one place, they can easily open another in some other area,” said Shakoor.

There are some codes and ethics outlined by the Drug Regulatory Authority of Pakistan and the Pakistan Medical and Dental Council. Drap’s Ethical Marketing to Healthcare Professionals Rules prohibits practices like offering direct incentives to doctors for prescriptions and requires transparent interactions between pharmaceutical companies and healthcare providers among others.

In 2021, Drap also directed all provincial governments to ensure that doctors in public and private healthcare facilities prescribe medicines only with their generic names. The development came after citizens raised concerns over company-influenced brand-based prescriptions of medicines by doctors in government and private sectors. However, Dr Sajjad said that the move failed to bring about any change as the practice of prescribing medications with brand names still prevails.

“Let’s say I prescribe a paracetamol to my patients, when they go to the medical store, they would be sold a particular brand because pharmacies too are driven by commission,” he said. And then, he continued, there are also instances where medical stores sell medicines other than those prescribed, claiming that they have a “similar formula”. Patients usually fall for it because they don’t have the time to go back to the doctor.

Like Drap, the PMDC also has a code of ethics for medical and dental practitioners that bars them from taking incentives from pharmaceutical companies. The body also holds the power to penalise a doctor involved in such practices. Its implementation, however, is weak, experts said.

A code of conduct was also developed by the WHO — ‘Ethical criteria for medicinal drug promotion’. Dr Zafar Mirza told Dawn.com that the organisation wanted it to become a standard but could not take it beyond just being an ethical criterion, which means that it’s good if it is followed but there is no compulsion.

Despite these rules and ethics, an important question remains: how can even regulatory bodies monitor the practice of incentive-linked prescribing?

“People easily get away with it because how will you prove that a doctor has written a prescription out of an incentive and not objectively?” questioned Dr Zafar Mirza. “Secondly, there are no accountability mechanisms that are creative enough to catch such practices.”

He added that a multi-pronged approach was needed to address the issue.

Naqvi agreed, saying that it was impossible even for these regulatory bodies to visit every clinic and check if healthcare practitioners were following the code of ethics. He, however, mentioned that Pakistan could learn some lessons from other countries such as the US on tackling the problem through the legal route.

The SHCC head cited the Physician Payments Sunshine Act, which requires payments and transfers of value made by life science manufacturers to physicians and teaching hospitals to be reported.

“But at the end of the day, it all comes down to doctors and their values and ethics,” he highlighted. “Unless all the stakeholders — government, doctors, hospitals, patients, families and those involved in marketing on behalf of pharmaceutical companies — show some sense of responsibility in terms of their role and exercising some ethical values, this issue is going nowhere.”

There is another problem that is usually overlooked in the blame game attached to the malpractice — lack of education and basic civic sense.

Dr Shakoor told Dawn.com that during her interactions with doctors, they said that no one had taught them any ethics of practice. And as the results of the study she conducted showed, education over the same now doesn’t make much of a difference.

“It has to be done earlier, there has to be earlier intervention in a physician’s life while they are in medical college or maybe even in school; teaching them ethics and civic sense,” she said. “A basic change is needed in the way the society functions; we as a society need to have better ethics and then ask the same from physicians.”

She added that the PMDC, Drap and healthcare commissions need to sit together and come up with an interagency policy, one that includes looking into the behaviour of a doctor. “And then, we need to realise that this cannot be looked at as an individual issue; rather it needs to be seen with a bird’s eye view.”

Pharmaceutical companies and representatives are a reality, doctors not making enough is a reality and patients being poor are a reality, Shakoor added.

*Names changed to protect identity

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