Doctors are the one who are made the scapegoat for the poor health care system
While inaugurating a charity hospital in Surat, Prime Minister Shri. Narendra Modi announced that the government intended to move a law to ensure that doctors prescribe medicines by their generic names only. The proposal has generated a heated conversation in the media and in the pharma industry.
The suggestion that doctors must write prescriptions in generic names is based on the idea that products sold as unbranded generic medicines are cheaper than others. With branded drugs making up 90% of the market, the move may end up missing the wood for the trees.
Who decides the MRP of branded whether it is doctor or the Government?
The National Pharmaceutical Pricing Authority (NPPA) is a government regulatory agency that controls the prices of pharmaceutical drugs in India. Doctor’s priority thus should be limited to treating their patients with the best quality medicine available.
Health care will become affordable in our country by pushing NNPA to regulate more drugs in to controlled category (Fixed Price) and not by asking doctors to prescribe the generic medicines.
Move over the suggestion that doctors must write prescriptions in generic names is based on the idea that products sold as unbranded generic medicines are cheaper than others. This premise itself is not true for all generic medicines all the time. Retail pharmacists, in turn, have little incentive in stocking and selling low-price generic medicines since they have lower profit margins. Retail pharmacies have also no interest in selling low-priced branded medicines unless they are fast moving too.
In 2008, the government launched a chain of pharmacies called Jan Aushadhi to supply inexpensive generic medicines. In the last nine years, only a few such stores have been operational and they often have had stockouts and other problems. None of the leading companies participated in the Jan Ausadhi tenders as sometime the manufacturing cost the the drug was more than the procurement cost of Jan Aushadhi. The major complaint thus was non-availability of all listed medicines, defeating the purpose of opening more stores. India has seven lakh retail pharmacy shops and still many rural areas are underserved. There are less than 10,000 Jan Aushadhis. Thus subsidized medicines under Jan Aushadhi turns a failure.
Also it is the duty of the regulatory authority to systematically ensure good quality of medicines over a sustained period of time and strict quality control, audits and deterrent punishment for companies violating regulatory standards. Neither prescribing doctors nor patients can, normally, second guess the quality of branded or generic medicines without actual testing.
Last month we witnessed series of attacks on the doctors in Maharashtra leading them to go for strike. In these times of Medico-Legal cases and lot of litigations, how can a doctor take chance of prescribing generic medicine wherein a Pharmacist only have the authority to push the brand. Field personnel will focus on the chemist retailers rather than the doctors, offer incentives to retailers to push their products.
At least 90% of the domestic Indian pharmaceutical market, therefore, consists of sale of branded products. If the government does institute a rule that doctors must prescribe only generic names, a patient will, in most cases, still end up buying a branded drug because as already pointed out generic medicines have low margins and therefore unlikely to be stocked by the retail pharmacist. This therefore does not ensure that the cost of his medication will come down by generic name prescriptions.
Doctors could end up writing an “official” prescription of only generic names and write an “unofficial” one recommending particular brands.
The market for fixed dose combinations is about 45% of the total market and worth about Rs 45,000 crores. To prescribe these medications under generic names, a doctor will have to write explicitly the generic constituents of the fixed dose combination in every prescription. For example, a doctor writing a prescription for Ascoril will have to write Bromhexine, Guaifenesin, Menthol, and Terbutaline maleate , or amoxicillin plus clavulanic acid instead of Clavum. These are simpler medications. Many fixed-dose combinations like multivitamin products have between three and 10 ingredients. So for at least for 45 % of the market, the move to get prescribing doctors to write prescriptions in generic names will be a non-starter.
Also the pharmacist cannot legally substitute a generic for a brand, or brand for a generic, or brand for another brand. This law needs to be changed and perception too.
The Way Forward….
To actually have better access to medicines, we need, at the minimum, the following:
- All formulations, representation and dosages of an enlarged list of essential and life-saving drugs to be put under price control.
- The market must be rid of all currently licensed irrational fixed dose combinations and useless and/or harmful medicines.
- The method of fixing price control in Drug Price Control Orders 2013 must be changed to a cost-based ceiling price determination. The current simple average formula legitimises high margins of up to 3000% over the cost of the product. So, methods of price control also need much more fine tuning.
- Laws for enabling substitution of generic and branded equivalents by pharmacists need to be introduced.
- A fully functioning public health system with free healthcare for all like in the United Kingdom, Canada and Scandinavian countries.
- Creative use of government compulsory licence provisions in the Patents Act to ensure competition in costly patented drugs and thereby make them less costly.
All the above initiatives are to be implemented by the government and not the doctors.
Picture Credit: LinkedIn
Author is Dr Sudip Lal Nagar. A Senior Executive In Leading Indian Pharmaceutical Company