Generic
Medicine Prescription: Treat the Cause and not the Symptom
Prime Minister
Narendra Modi’s recent call for generic medicine prescription mandatorily by
the physicians with a view to reducing the cost of healthcare, and the likely
law surrounding it, is the culmination of three decades of effort to provide
affordable healthcare to the poor. Doctors in government hospitals are mandated
to prescribe only generic drugs. Moving from branded generics to generics, with
most pharmacies and medical stores manned by unqualified or semi-qualified
persons, would be well-nigh impossible, because 50% of drugs are combination
drugs.
A number of
studies conducted elsewhere in the world point out the factors influencing the
generics’ prescribing behavior. While the patient’s financial status, welfare,
compliance, and fear of punishment are positive factors, quality concerns, lack
of regulation by Food and Drug Administration (FDA), poor recall of generic
names, patient’s preference and personal experience are negative factors
influencing the generics prescribing behavior.
A qualified
physician checks the causes of an illness and treats the patient after a few
diagnostic tests, while quacks treat on the basis of symptoms. Insights into
the ecosystem of pharma health care in India will help understanding the burden
of our arguments:
1. Too Many
Brands, Loan licensing and Pharma-Physician Nexus
There are
about 92,000 branded generic formulations today. Loan licensing allows
manufacturing of fast moving drugs (largely prescribed molecules or fixed dose
combinations) yielding higher margins for the investors. A pharmaceutical
representative, manager or a physician or a group of physicians with sizable
clinical practice can start a pharma company easily. Such pseudo manufacturers
colluding with willing physicians, under mutually agreeable terms of contract,
share the gains, leaving the pain to the poor patient. Competitors with deeper
pockets can easily persuade them to prescribe their products by increasing the
transactional sum. This leads to a continuous escalation of marketing costs at
the expense of patients.
2.
Regulatory Standards
India’s current
drug regulatory mechanism has inherent inefficiencies and inadequate
infrastructure. There is a vast difference in the quality of generics in India
and elsewhere in the world. In the US and other well regulated markets,
stringent quality control measures ensure effectiveness of generics
administered on patients, through bioequivalence tests at the USFDA approved
laboratory. Mere comparisons with innovator drug of chemical equivalence does
not make it therapeutically equivalent. All this costs a lot and puts an entry
barrier on fly-by-night operators. The technical infrastructure in India is
grossly inadequate for quality testing and certainly not comparable with the
West.
Most of the
generic formulations are not tested by comparing them with the leader of the
branded generic formulation or the brand-name drug for bio-equivalence, and yet
they are approved. Many of the reported close to 10,000 drug companies do
not have a manufacturing facility that conforms to and approved by the World
Health Organization’s Good Manufacturing Practices (WHO GMP).
The loan
licensing system enables start-ups having a million rupees to enter the market
with their own generic, creating competing spaces at national, regional and
local levels. How will the Drug Controller General of India (DCGI) ensure that
the patients get the same quality of generic drug as the branded drug? A
branded drug manufacturer has his reputation at stake while the generic
manufacturer has little to lose.
3.
Continuous Cost Escalation of Medical Education
The
pharma-physician nexus is deepening by the day and along with it are the
irrational prescriptions of expensive branded drugs. The ever increasing cost
of medical education, both at the graduation and specialty level, are driving
the new entrants into medical practice to recover their education expenditure
through unholy contracts with pharma companies. Neither the government nor the
Medical Council of India is able to do anything to curtail the capitation fee
system in private medical colleges, the root cause for corruption among dotors.
4. Shortage
of Qualified and Trained Pharmacists in Retail Pharmacies
It is pathetic
that most of the 7.5 lakh retail pharma outlets do not have qualified
pharmacists at the shop floor. Even the compromising solution suggested by the
government, to train the sales persons of these shops, is yet to see the light
of day. What is more, the curriculum at the graduate level in our pharmacy
courses does not include many of the new drugs that are recently developed.
Empowering the not-so-qualified pharmacist to dispense generic drugs can do
more harm than good to the patient.
5. Breaking
the Pharma-Physician Nexus or Creating a New Pharma-Pharmacist Nexus?
The other root
cause of the problem lies in the hierarchy of pharmaceutical products –
innovator-branded medicines, value added drugs – those that carry the same
molecules with a perceptible premium and branded generics and generics, in that
pecking order. Go to any corporate hospital: medicines prescribed there with
the highest premium are available only in the attached pharmacy.
The
contemplated legislation on compulsive generic drug prescription would have the
distinct possibility of therapeutic prescription carrying the best price that
would make the manufacturer-retailer nexus coexist with the
physician-pharmacist nexus, making it a win-win situation for everyone –
barring the patients. The solution lies not so much in law as in cleaning up
the entire supply chain that includes the drug controllers.
6. Absence
of Good Governance
That there is
clearly a lack of good governance is evident from the fact that the government
has been unable to ensure compliance from all the stakeholders despite the
presence of well-defined rules governing the manufacturing and selling
pharmaceutical products in India such as the Drugs & Cosmetics Act,
Voluntary UCPMP (Universal Code of Pharmaceutical Marketing Practices), MCI
(Medical Council of India) etc. Yet another law makes no big difference.
Evolution
or De-evolution?
The modern
pharmaceutical industry as we know it today has evolved over many years and
contributed significantly to the discovery and development of important drugs.
The same industry has to develop future cures too. Therefore, it has to
continuously evolve around investments in research and innovation. Let the
industry be encouraged to continue in the evolution process.
The Way
Forward: A Prescription
- To change this negative perception
of generic drugs, all we have to do is approve every generic formulation
based on a bio-equivalence test, comparing it with the reference drug
(either the brand name drug or leader brand of the branded-generic drug).
If this is made mandatory the quality of the generic drugs would improve
significantly.
- Ensure that a qualified and trained
pharmacist, who has adequate knowledge about drugs and diseases and can
improve health awareness among patients, mans all retail pharmacies.
- In order to bring a sustainable and
lasting change in behavior, introduce recognition and reward systems among
physicians who prescribe more generic drugs and make the names public to
accelerate the rate of generic drug prescription.
- Strengthen the Drug Administration
Department with adequate manpower to ensure compliance and establish good
manufacturing practices (GMP) among all manufacturing units.
- It must be mandatory for a loan
licensee currently leveraging on outside manufacturers to manufacture in
its own manufacturing unit within a specified time, failing which the
unit’s license will be cancelled after the notice time. This will
rationalise the number of drug manufacturing units, improve their
productivity and the overall quality of generic drugs. It would also help
in stopping the pharma - physician nexus.
Currently,
there are an estimated 92,000 pharmaceutical products in India, of which about
60 per cent are different versions of branded-generic or generic versions of
single ingredient drugs. It is necessary to impose a cap on the number of
generic formulations for each single-ingredient drug. This is by no means
exhaustive. It is only to start the process of thinking holistically with a
singular purpose of treating the cause(s) and not merely the symptom(s).
(Ch SVR
Subbarao is former Director for Marketing at Sun Pharmaceuticals Ltd and Dr B
Yerram Raju is an economist and risk management specialist.)
