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Passing the buck?


20170515ep02Prime Minister Modi’s announcement  that his government would ensure doctors prescribed generic medicines stirred a hornet’s nest. But his visit to his home state was part of the build up to state elections later this year, so the April 17 announcement should not have been a surprise. This pro-people, pro-poor move to reduce the cost of medicines is in line with the recent price caps on stents and reports indicated that more such moves, like a code of conduct governing marketing activities by pharmaceutical companies, could be part of the amendments to the Drugs and Cosmetics Act.

If WhatsApp humour is a mirror of our lives, then the two gems below, are representative of the reactions to the PM’s declaration. When asked by a patient to prescribe some vitamin tablets, this was what the doctor wrote: Tab Thiamine + Riboflavin + Niacin + Pantothenic acid + Pyridoxine + Biotin + Folic acid + Cobalamin and Ascorbic acid + Vit D + Vit E. With the instruction to take once a day after lunch. Leaving the hapless patient to wonder: what do I ask for at the chemist? What will I finally end up with?

Another message doing the rounds makes the point that if people insist on purchasing branded cars, branded clothes, etc, then why do they single out branded medicines (or medical devices) for abuse? Both messages highlight the influence of brands and branding strategies in our lives. For instance, we never photocopy documents, we xerox them even though Xerox is a brand. The government’s own initiative to brand its generic medicine outlets under the Jan Aushadhi label is validation enough that brands do matter.

Corporates invest time and resources over many years to build brands, just to gain the trust and loyalty (and wallet) of the consumer. The brand comes with a guarantee of delivering what they promise. In the case of medicines, that’s quick relief and no side effects. Which is why pharma companies have invested in creating brands around their generics, giving rise to the category of branded generics.

The government’s intention is noble, when  price/ cost becomes the first benchmark, quality tends to go out of the window. Questionable and inconsistent quality could potentially lead to life threatening situations. Representing the doctors’ point of view, the Indian Medical Association (IMA) appreciated the PM’s push for generics but pointed out that no new legislation is required to get doctors to prescribe generic drugs since the Indian Medical Council’s (MCI) code of ethics already requires them to write the name of the generic on the prescription. Has the IMA been able to ensure this among their members? Not really.

But pharma companies argue that if the aim of the move was to break the pharma company-doctor nexus by taking the choice away from the doctor, prescribing generics only transfers this power to the chemist/ pharmacist.

In response, IMA has clarified that the MCI guidelines in fact require  doctors to mention both the generic name of the drug as well as the name of the company whose generic the patient should buy and ensure that it was available freely. Another IMA suggestion is that the Central Government Health Scheme (CGHS), PSUs and insurance regulator Insurance Regulatory and Development Authority (IRDA) should mandate reimbursement of only National List of Essential Medicines (NLEM) drugs, unless there is a good reason why this cannot be done.

IMA also hits out at the perceived weak underbelly of the pharma industry in India – quality-  alleging that the regulator has been unable to rectify the situation. Hence, IMA has suggested that the Department of Pharmaceuticals be transferred to the Ministry of Health from the current Ministry of Chemicals and Petroleum. This tug of war has been in the works for quite some time.

Just as doctor associations pass the buck to the regulator and the pharma industry, commentators from the latter point to the cost of hospitalisation and consultation fees. Each segment vows to put the ‘patient at the centre’ but it doesn’t seem so.

Are we already seeing the fallout of some of these regulations? The move by pricing watchdog National Pharmaceutical Pricing Authority (NPPA) to cut prices of stents under the Drug Price Control Order (DPCO) in February this year definitely bought down the costs of such surgeries. Two months later, three MNCs, (Abbott, Medtronic India and Boston Scientific) applied to the NPPA to withdraw some of their high end stents from the market. Abbott’s statement indicated that the price cuts made it unviable to continue to supply these stents in India. However, one of these stents was anyway being withdrawn from markets after the  US FDA raised a safety alert. So are these moves  simply posturing?

Indian stent manufacturers have called this a levelling of the playing field and foresee a victory for the Make in India initiative, and we hope this will lead to equal emphasis on ‘Innovate in India.’ A trade off between  availability, accessibility, choice and affordability should not be acceptable. If so, the patient will be the loser … yet again.

Viveka Roychowdhury

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