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Continued from Previous…… This series is based on a report compiled by Jilian Clare Cohen1, Monique Mrazek2, and Loraine Hawkins3 for World Bank.
Six decision points were identified where corruption could infiltrate. The first was manufacturing, second was marketing authorization, third was selection, fourth was procurement, fifth was distribution, sixth is discussed below.
Decision Point Six: Drug Prescribing and Dispensing[Quote] Drug prescribing and dispensing involves the participation of physicians, pharmacists, nurses, and other health-care providers who diagnose patients and identify what drugs a patient should consume (if any) to treat a particular disease. This is the decision point at which patients should experience the benefits of the entire system, if it is functioning well. Patients should receive the right drug at the right time and with the appropriate information. [Unquote]
The patient may not always get the most appropriate drug for his/her condition because the decision may be influenced by factors other than the appropriateness.
The developed countries have adopted a system in which the prescribing function has been separated from dispensing function. The doctors do not get any financial benefit by prescribing a more costly drug or more quantities of a drug. The dispensing decision is taken by the dispensing pharmacist who may also offer cheaper generic version to a patient if he agrees. Exemptions may sometimes be permitted for rural doctors where they may be allowed to dispense also.[Quote] A problem area in many countries is the potential for corruption between physicians and drug companies in terms of undue influence on drug prescription practices. A 2000 study by Wazana (Ashley Wazana, ‘Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?’ JAMA Volume 283, No.3, 19 January 2000) found that physician interaction with the pharmaceutical industry was associated with increased requests for additional drugs on hospital formularies and changes in prescribing practice . The influence of industry on physician prescribing behaviour is a concern globally but it can be particularly influential in developing countries where physicians are typically not paid well and standards of legal or professional ethical behaviour are less well established or enforced. A WHO report on drug promotion noted that in the United States, almost US$21 billion was spent on promotion in 2002. The same report emphasizes that the pharmaceutical industry is often the only source of drug information for health care providers in developing countries.
Drug promotion in itself is not a corrupt act if fair marketing practices are adhered to. However, when physicians are provided with “incentives” from the pharmaceutical industry for prescribing particular products, this practice can more expressly lead to corruption. Oftentimes physicians are invited to “educational” seminars from the industry, which may involve travel to desirable venues and invitations for their family members. Corruption takes on many forms and even if a particular action is not blatantly in breach of the law, if it violates basic ethical norms, it should be a source of concern and a target for remedial action. [Unquote]
Several studies in various countries have raised concern about the nexus between physicians and the drug companies and how it is hurting the patients’ interest. In Pakistan, Dr. Rizwan Raheem wrote a thesis on the existing relationship between physicians and drug companies and its impact on prescribing patterns. I had used his study in my earlier blogs. Studies from Dr. Rizwan Ahmed et al of GC University Lahore and Ms. Tehmina Adnan et al of Hamdard University Karachi were also quoted in my blogs.
Situation in Pakistan is similar to other developing countries. The primary reasons are the inadequate legislation in this area, and the ineffective implementation of oversight procedures. Corruption in Pharma happens all over the world. Some of the worst kinds have been seen in the US. However, the difference is that the system ultimately detects it, investigates it, prosecutes it, and is able to get huge fines clamped on the culprits. Developing countries on the other hand, show weakness at all steps. The detection may not happen at all, the investigation will certainly be influenced to ensure a poor case going to court. Of course, prosecution would not happen due to this factor, and the culprits will keep roaming without any fear at all.
To be Continued……
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- Jilian Clare Cohen – Toronto, Canada
- Monique Mrazek – Latin America
- Loraine Hawkins – London