Incentivisation practices and their influence on physicians’ prescriptions: A qualitative analysis of practice and policy in Pakistan

Abstract

Focus on profit-generating enterprise in healthcare can create conflicts of interest that adversely impact prescribing and pricing of medicines. Although a global challenge, addressing the impacts on quality of care is particularly difficult in countries where the pharmaceutical industry and physician lobby is strong relative to regulatory institutions. Our study characterises the range of incentives exchanged between the pharmaceutical industry and physicians, and investigates the differences between incentivisation practices and policies in Pakistan. In this mixed methods study, we first thematically analysed semi-structured interviews with 28 purposively selected for-profit primary-care physicians and 13 medical sales representatives from pharmaceutical companies working across Pakistan’s largest city, Karachi. We then conducted a content analysis of policies on ethical practice issued by two regulatory bodies responsible in Pakistan, and the World Health Organization. This enabled a systematic comparison of incentivisation practices with what is considered ‘prohibitive’ or ‘permissive’ in policy. Our findings demonstrate that incentivisation of physicians to meet pharmaceutical sales targets is the norm, and that both parties play in the symbiotic physician-pharma incentivisation dynamics. Further, we were able to categorise the types of incentive exchanged into one of five categories: financial, material, professional or educational, social or recreational, and familial. Our comparison of incentivisation practices with policies revealed three reasons for such widespread incentivisation linked to sales targets: first, some clear policies were being ignored by physicians; second, there are ambiguous or contradictory policies with respect to specific incentive types; and third, numerous incentive types are unaddressed by existing policies, such as pharmaceutical companies paying for private clinic renovations. There is a need for policies to be clarified and updated, and to build buy-in for policy enforcement from pharmaceutical companies and physicians, such that transgressions on target-driven prescribing are seen to be unethical.

"Caught In Each Other’s Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry

“…Characteristics of study participants are presented in Table and available in recent publications. 21 , 41 We found that 90% of PDs met with SRs at least once a week, with 15% of PDs meeting more than 25 SRs per week.…”

“…This may manifest in the issue being insufficiently prioritised at the agenda setting stage, or policy formulation and implementation of regulations being weak. 21 Strong stakeholder interests in maintaining the status quo may explain why the relationship between pharmaceutical companies and PDs has been a contentious and insufficiently managed policy issue for over 60 years globally, 10 despite studies highlighting the need for policy and education interventions. 23 , 47 …”

“… 17 , 19 , 20 Factors that support inappropriate relationships between pharmaceutical companies and doctors include weak implementation of regulations as well as doctor and pharmaceutical industry support for continuing incentivisation. 20 , 21 Being a powerful stakeholder group, doctors’ perceptions and attitudes towards relationships with the pharmaceutical industry and incentive-linked prescribing can influence the success of policies to reduce the impact of the pharmaceutical industry on prescribing practices 22 ; doctors’ awareness, attitudes, and reasons for engaging in incentive-linked prescribing are therefore important to understand. 23 However, because for-profit healthcare providers are often poorly monitored and documented in LMICs, large quantitative and mixed methods studies of their attitudes and practices are rare.…”

“…In spite of this, several studies have evidenced how common incentive-linked prescribing is in Pakistan. 19 , 21 , 27 The extent to which these practices occur has been described as “an acceptable norm,” one that is challenging to undo. 19 , 35…”

Healthcare consumers’ perceptions of incentive-linked prescribing: A scoping review

“…This has implications for not only developing clear-cut guidelines on the ethics of dealing with pharmaceutical companies but also ensuring that physicians can fully understand and follow them. In many LMICs, such as Pakistan, no clear guidelines on professional medical ethics exist, and physicians often find it difficult to determine ethical boundaries when they interact with pharmaceutical sales representatives who visit them to promote drugs [ 7 ]. Therefore, the development of guidelines on ethics should be the prime responsibility of states to help physicians recognise potential conflicts of interest while dealing with physicians.…”