Pharma-physician dynamics in the Pakistan context

Pakistan is the fifth most populous country in the world with a population of approximately 216.6 million people. Out-of-pocket spending on healthcare has been declining since the early 2000s from around 78% to 56% by 2018 according to World Bank data, although studies suggest that between 57% and 80% of health service utilization still occurs in the private sector [27]. Meanwhile, the value of the pharmaceutical industry has doubled over the past decade and more than 620 pharmaceutical companies are registered with the Drug Regulatory Authority of Pakistan (DRAP). The majority of pharmaceutical sales companies are local, domestic companies as opposed to multinational companies [16]. The high-value and powerful pharmaceutical industry generates sales of over US$2 billion per annum, of which two-thirds are prescription drugs [16]. Studies show that almost 90% of medicines in Pakistan are prescribed by their brand names, demonstrating the influence of pharmaceutical companies, and that MSRs are the main information sources regarding medicines for most physicians [28].

Despite national policies to regulate the pharmaceutical industry and its marketing practices, the ‘well-established, symbiotic’ [7] relationship between pharmaceutical companies and physicians, coupled with weak policy implementation, may have turned inducement through MSR into an acceptable norm in Pakistan [16, 29]. An exploratory qualitative study by de Andrade et al. (2018), and a more recent survey conducted by Gul et al. in 2021 (albeit biased in participant selection), provide initial evidence of the pharma-physician relationship and the weak regulatory environment in creating the space for powerful market forces to prevail [16, 29]. Yet detailed empirical information of incentivisation dynamics is still lacking. Building upon initial research, our study systematically characterises the different types of incentives exchanged between physicians and MSRs, and compares incentivisation in practice to the stated key policies on ethical practice. We aim to provide empirical evidence to strengthen the current discourse on unethical exchanges between the pharmaceutical industry’s MSR and physicians in the Pakistan context, and to identify any weaknesses in the formulation or implementation of existing policy documents that contribute towards an enabling environment for these interactions to persist.

Study setting and participants

The mixed-methods study was conducted in Karachi, which has the largest population of medical doctors in the country. We focused on private primary care physicians (i.e., general practitioners) since the majority of healthcare in Pakistan [approximately 74%] is delivered by the for-profit private sector [30]. Further, unlike physicians only working in government facilities, physicians who work in private clinics have more freedom to meet with MSRs and agree to deals with them. There is thus more of a risk that conflicts of interest will occur and, owing to the widespread use of for-profit private providers, improving the quality of care they deliver is vital to overall health system performance. Physicians were considered eligible for the study if they ran a solo for-profit primary care clinic, with or without additional work in a government facility (dual practice). Eligible physicians were initially identified from the research team’s institutional and individual networks, and then purposively sampled to ensure representativeness across Karachi’s six administrative districts and a range of sociodemographic characteristics (Table 1). We additionally explored districts by-foot, asking [eligible] physicians directly if they would consider participating in the study. To identify MSRs, the research team, again, used their own networks and then applied a snowballing technique to widen the selection. Eligible MSRs were those in positions of managers or salespersons at multinational, national, or franchise-based companies.

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Table 1. Study participant characteristics.

https://doi.org/10.1371/journal.pgph.0001890.t001

Approach to conducting interviews and data analysis

We conducted semi-structured interviews with the physicians and MSRs from February to July 2021. The interview guide for physicians covered perceptions of the pharma-physician relationship, experience or observations of incentivisation and factors that drive physician-induced demand for medicines. The exploratory interview guide for MSRs covered the extent to which pharmaceutical companies offer incentives (and what types) to physicians, how MSRs build relationships with physicians, and their perceptions about the ethics of incentivising physicians. All bar one interview with a physician was audio-recorded and conducted in the Urdu language. Interview transcripts were translated into English by independent translators and checked for accuracy by bilingual members of the research team (Urdu and English), who read the English transcripts while listening to the Urdu audio to identify and correct any translating errors.

We conducted a thematic analysis of the transcripts. SS and ARS analysed the same ten transcripts inductively (and independently) to develop a codebook. The codebooks were compared and discussed among the wider research team, two of whom tested it independently on approximately five transcripts to reach consensus on the coding. The final codebook organised the data under three major themes: the MSR-physician relationship, types of incentives offered and accepted, and general perspectives on incentivisation. SS and ARS coded each of the remaining transcripts deductively in NVivo using the finalised codebook, such that each transcript was coded independently twice.

Policy document selection and analysis

We analysed ethical practice policies from the two regulatory bodies responsible for the pharmaceutical industry and medical providers in Pakistan, and the WHO’s Ethical Criteria for Medicinal Drug Promotion. Box 1 describes each policy in more detail. We extracted policy statements on incentivisation and broadly classified whether they were prohibitive or permissive; a statement was considered ‘prohibitive’ if it explicitly objected an incentive category and ‘permissive’ if it allowed an incentive category.

Until October 2019, the PM&DC was the formal statutory regulatory authority that oversaw medical and dental colleges in Pakistan. However, the PM&DC Ordinance 1962 was replaced by the Pakistan Medical Commission (PMC) Ordinance 2019, making PMC a successor of PM&DC. Although several rules and regulations have changed under the new ordinance, the Code of Ethics of Practice for Medical and Dental Practitioners, Regulations issued by PM&DC in 2011 has not yet been replaced [31]. The Regulations provide guidance on the practitioners’ code of conduct towards the medical profession and the patient, as well as guidance on interactions between practitioners and pharmaceutical industry including the exchange of gifts, inducements, or promotional aids; use of drug samples; attending meetings, conferences, and hospitality; endorsement of drug or medical equipment; and receiving direct payments from medical research initiatives. While there are no specific provisions for implementation and enforcement of the Regulations, complaints and violations can be brought to the PM&DC to adjudicate. The most severe penalty includes (public) disqualification of the practitioner’s medical license.

The WHO issued guidance on Ethical Criteria for Medicinal Drug Promotion in 1988 as a normative framework for the standards of interactions between the pharmaceutical industry and physicians [33]. The ethics criteria described by WHO include promotion in the form of financial or material incentives, advertising in line with scientific evidence and whom to advertise to, roles and responsibilities of MSRs, use and implications of free samples, incentivising medical professional through meetings and symposia. While these guidelines directly address national governments and oblige Member States to adopt the criteria, they are not legally binding. The document acknowledges what is considered ethical ‘varies in different parts of the world and in different societies’ [33] and that the criteria outlined constitute general principles, which governments may adapt to national circumstances. The onus is thus on governments to develop appropriate accountability and enforcement measures.

Ethics statement

The team received ethics approval the Aga Khan University Ethics Review Committee (reference 2020-4759-1129), the National Bioethics Committee of Pakistan (reference 4-87/NBC-582/21/1364), and the London School of Hygiene and Tropical Medicine Research Ethics Committee. Informed consent was obtained from all study participants in written form.

Incentivisation in practice versus policy

It was clear from the interviews that offering incentives to physicians by MSRs to influence clinical decision-making was the norm; this practice was mentioned in all 40 interviews included in the analysis:

“As you continue your interviews, you will keep getting different views and you will see that 99% of the doctors will be involved. I am talking about the doctors who are my colleagues; they do it with the pharmaceutical companies. They give air tickets for going abroad, give cars, and give gifts.” [Physician-05]

“It is 100% common. Every doctor has some kind of arrangement, whether it is me or a small doctor or a big doctor or a quack, the sale is counted towards him. I know this.” [Physician- 02]

We identified five broad categories of incentives, often referred to as ‘activities’ by MSR: financial, material, professional or educational, social or recreational, and familial. Table 2 summarises each incentive category, the number of interviews it was mentioned in, and relevant statements from the three organizations’ policies. While we were able to broadly categorise incentives, certain types of incentives fell under multiple categories depending on the context within which they were offered. For example, holidays and tourism activities could be offered as part of a professional opportunity, or as a purely recreational activity, or a familial activity. We also found incentives could be offered in combination, for example some form of financial incentive (e.g., cash) plus a variety of material and familial incentives, such as gifts and an all-expenses paid trip for the family. In fact, the majority of interviewees described ‘packages’ of incentives and elaborate incentives schemes, which served to increase physicians’ obligation toward the MSR or pharmaceutical company and more deeply entrench their arrangements with MSRs across a number of personal and professional needs. Indeed, data from one MSR highlighted how dynamic incentivisation schemes can be; over the course of the COVID-19 pandemic, he noted that in-person professional or educational opportunities weren’t possible, so the demands and offerings shifted to the provision of infection prevention measures, such as sanitizers, masks, and clinic fumigation.

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Table 2. Incentive categories and relevant policy statements from the three organizations.

https://doi.org/10.1371/journal.pgph.0001890.t002

Financial incentives were the most frequently mentioned category of incentives, mentioned by 36 interviewees (90%), and included a variety of direct and indirect means (Box 2). Some of these indirect routes are captured in the quotes given below:

‘What do most of the companies do if authorities come to check if there is an inflow and outflow of cash? Most of the companies give material items [instead]. There is a well-established arrangement of doctors in the electronics market; when a one or one and half ton AC comes [to the doctor] from the company, it will come here and go there [to the electronic market], and they will exchange it for cash from there.’ [MSR-05; edited for clarity]

‘When you get associated with a pharmaceutical company, the doctor also asks which drug store [the MSR] has kept the medicines in, so obviously he will send the patients only there … If the patient buys it from that store, then his [the MSR’s] income will also go up and so will the doctor’s commission.’ [Physician- 05]

When comparing practice to policy, all three policy documents that were analysed prohibited financial incentives, though no policy defined nor detailed what would constitute a financial incentive and used vague terms, such as ‘gifts’ in the DRAP policy, ‘economic advantage’ in the PM&DC policy, and ‘financial benefits’ in the WHO policy, which could refer to a variety of different direct and/or indirect financial incentive types.

Material incentives were the second most frequently mentioned category, mentioned by 35 (88%) interviewees. The types of incentives identified varied in size and value, as summarised in Box 2, and included numerous incentives to enhance clinics. As one physician, explained, the offerings are substantial but not without linked targets for prescribing:

‘In this one year, I have been offered a car also. But they have conditions… that within one month you have to achieve the target.’ [Physician-03]

Both the DRAP and PM&DC policies allow for some flexibility in providing or accepting material incentives, as long as, according to DRAP, they ‘serve a genuine educational function’, are ‘modest in cost’, and not ‘provided in excess’, or, according to PM&DC, are ‘primarily for the benefit of patients’ [31, 32]. Any number of incentives identified in our research could be justified by these policies and, indeed, this was a rationale used by a number of interviewees as illustrated below:

‘But to achieve the specific [sales] target, the company has not allowed offering cash, but the company has said this, that if you give the doctor an ECG machine then he can do a good diagnosis.’ [MSR-08]

‘They get the whole clinic renovated. Everything comes [with] it, from 0 to 100: it includes repainting it, there is work on the doors, or the furniture.. the needs of the patient in the waiting area [of the clinic] are fulfilled.’ [MSR-09; edited for clarity]

Professional or educational incentives were mentioned by 26 (65%) interviewees. When discussing this incentive category, interviewees frequently talked about the side-benefits commonly offered as part of or alongside the educational opportunity, such as travel fare, accommodation, meals, and various forms of entertainment or leisure activities. As one interviewee expressed, ‘70% [of doctors] go for entertainment, 30% gain some knowledge’ [Physician-01]. We found that educational events can be used to oblige physicians in different ways: providing access to the educational opportunity itself is used by pharmaceutical companies to induce prescriptions of their products, or the variety of side-benefits accompanying the educational opportunity (e.g., first-class airfare, five-star accommodation, luxury dining experiences, cultural tours and activities), can result in an obligation to prescribe the sponsoring company’s medicines. Here the policy documents are not comprehensive in covering the routes of incentivisation by pharmaceutical companies through educational events (Table 2). The WHO policy prohibits any support that is conditional upon the promotion of products, while the DRAP policy prohibits any support from ‘inappropriately benefiting’ individual physicians (including side-benefits) but falls short of addressing sales targets set by pharmaceutical companies in exchange for attending the educational event. Under the DRAP policy, companies are allowed to provide training and education to physicians along with ‘reasonably-priced’ travel, meals, and accommodation [32]. The PM&DC policy adopts a generally permissive statement, allowing physicians to accept support from pharmaceutical companies, even allowing pharma-issued cheques or bank transfers to ‘duly designated’, not personal, accounts [31].

‘There will be a lecture by the company for a couple of hours in those five days and the rest you do sightseeing, etc., as the company has to show that they are taking [doctors] for CME.’ [Physician- 01]

‘If my [company name redacted] product is sold a lot, like if my sale is two, three, five, eight lakhs per year, then [the MSR] will be able to give me a CME of one and a half lakh rupees. Like he will be able to send me to a conference in Italy or Cancun.’ [Physician- 02]

Social or recreational incentives and familial incentives were less frequently talked about in interviews, being mentioned by 20 (50%) and 15 (38%) of interviewees respectively. The PM&DC and WHO policies are generally permissive of social and recreational activities within the context of a professional or educational event, only introducing arbitrary limits such as a maximum time allocation, being ’secondary’ to the main purpose of the event, and kept to a ‘modest’ level [31, 33]. Furthermore, these policies do not call out the common practices we identified outside of professional or educational activities, such as paying for physicians’ meals or holidays. The DRAP policy begins by prohibiting this form of incentivisation but then allows MSRs to meet with physicians in non-professional settings and provide meals [32]. In the familial incentives category, we identified a number of highly-personalised examples (Box 2). There was limited coverage of these types of incentives in the policy documents, and those policies with statements (DRAP and WHO) only addressed familial incentives within the context of another incentive category, such as a business contract or a professional/educational event. They missed a number of intricate and unusual incentives in this category that we were able to identify, which further entrench the MSR into the physicians’ personal lives.

‘So [MSRs] say [to doctors] that we know your daughter is taking pre-medical [examination for] getting admission for an MBBS degree and we have heard she is quite good, but she couldn’t get admission in [a public college]. But if you want to get her into a [higher fee] private college, then we can support.’ [MSR-08]

‘But if you see today, a father’s 40 day of death [prayer ceremony] is being paid for by [a] pharmaceutical company, walima [wedding reception] is being paid for by the pharmaceutical company, and this is the state of our country.’ [Physician- 02]

How MSRs initiate, build, and sustain relationships with physicians

The interviews with the MSRs revealed a highly strategic process that MSRs follow to select which physicians to approach and which to initiate a relationship with. Some MSRs described a classification system used to rank physicians according to how many patients they routinely see, which determined their ‘business potential’ and priority for MSR. A number of physicians also noticed this trend, as one interviewee stated, ‘pharma people approach the ones [physicians] who have heavy practice’ [Physician-02]. The interaction between the MSR and the physician informed the frequency of the MSRs’ visits, how and when they would broach the topic of incentives, and the types of incentives they offered to the physician. According to some MSRs, a regular time investment, for example paying physicians frequent visits, was sufficient to convince them to prescribe their products while other physicians would not change their prescription practices until an incentive is offered. If physicians refused incentives or did not make their sales targets, both MSRs and physicians explained that they would not be approached again, and a relationship would not develop.

‘The way is that these pharmaceutical companies are also in touch with each other about doctors. Whoever comes to me now has understood my nature.’ [Physician-03]

‘What happens is that the “A class” doctors… they resist having any irrelevant discussions with them. If we look at “B class” doctors, they have a friendly nature…So, the “B class” doctor is not only friendly, but he is also not resisting this kind of discussion [about incentives].’ [MSR-05]

‘[Sometimes] we get our medicines prescribed on footwork meaning we go on daily routine and meet them. Doctors feel good that he has come, and I will write it because of him. Second one is, even though we are meeting, until we give cash, he is not going to write it.’ [MSR-09]

Physicians also appeared to have some criteria for evaluating whether an MSR was worth their time, for example a number of physicians said they would only accept incentives from MSRs from ‘good companies’. This was based on their perceptions of the pharmaceutical company’s reputation, the marketed drug’s efficacy [according to the MSR], and its price point. However, one MSR interviewee suggested that if a physician has a strong relationship with a MSR, they could be convinced to prescribe that MSR’s brand regardless of the drug’s perceived efficacy. Once MSRs had established a relationship with a physician, they identified their needs, either personal or professional (or both), to determine what types of incentives to offer them. The MSRs we interviewed indicated that they would often do this by asking the physicians directly what they desired. After learning what types of incentives were most attractive to the physician, MSRs communicated this to more senior company employees who would approve the incentive(s). Two MSR interviewees alluded to a level of confidentiality or a ‘contract’ [MSR-04], between the pharma company, the MSR, and the physician regarding the incentives or ‘activities’ offered. The legal nature and details of such a contract was not disclosed by the interviewees.

‘It depends upon the need. If the doctor needs cash, then 20% is in the form of cash. If their need is to get a tour, then it can be in the form of tour. If the need is for planning anniversary, then it will be in that form. So as per the need, the doctor is going to tell you.’ [MSR-04]

‘The doctors can ask anything… And whatever amount of money they give to the doctors, then to such ratio the doctor will give them business.’ [MSR-08]

Several MSR and physician interviewees reported that multinational companies (MNCs) had stricter limits on what could be offered compared to national companies; for example, MNCs prohibit any form of direct financial incentive. However, interviewees also stated that this did not preclude MSRs from MNCs offering financial incentives in indirect and covert ways, along with a variety of other incentive categories. An example of this described by interviewees was the ‘gifting’ of items, such as air-conditioning units or electro-cardiogram machines, with the tacit understanding that physicians would sell these items for the equivalent in cash. Or alternatively, they offer more attractive international professional and educational opportunities. Some MSRs, regardless of whether they worked for a MNC or a national company, were also reported to act somewhat independently of their companies’ policies, taking decisions regarding incentives at their own discretion from personal funds—often to advance their own agendas and meet more ambitious targets, which would result in greater bonuses at the end of the month.

Interviewees had mixed opinions on who—pharmaceutical companies/MSRs or physicians—were ultimately responsible for driving the relationship dynamics. On one hand, several physicians felt very strongly that they were the victims in this cycle and had been increasingly corrupted by the pharmaceutical industry, which held more power and resources. On the other, a minority of physicians and several MSR criticized the medical community for encouraging an incentives-based culture; both physician and MSR interviewees reported the active role that some physicians play in driving incentivisation by demanding any incentive(s) they want. These interviewees thought that physicians should take more responsibility for their part in sustaining the culture. Both physician and MSR interviewees widely described the relationship as ‘give and take’, based on a shared understanding of the stakes and the mutual benefits involved.