It is becoming clearer with each passing day that the decisions of the Aam Aadmi Party, or AAP, government in Delhi are not well thought through. Lost somewhere in the din over power tariffs, water entitlement, plebiscite in Kashmir, interface with the judiciary and foreign investment in retail was an order given by Delhi's health minister, Satyendra Jain (an architect by training and a former employee of the Central Public Works Department, he is also responsible for industries and gurudwaras), last week that doctors in government-run hospitals can only write generic medicine in their prescriptions, not brands. The idea is to bring down the cost of medication. Some AAP sympathisers would say this will also help break the unholy nexus that exists between drug makers and doctors.
It is an open secret that drug companies shower numerous inducements on doctors so that they prescribe their medicines. These "gifts" can range from stationery to overseas junkets to even picking up the bill for children's weddings. The higher the doctor in the pecking order, the bigger the gift. This frequently results in over-prescription and, at times, under-medication.
How much does Mr Jain's message to doctors help the situation? Actually, such a directive already exists in the statute books. In that sense, Mr Jain is simply reiterating the norm. Two things can happen after the doctor (in a government hospital) scribbles a generic medicine on the prescription sheet: the patient can get it free from the dispensary in the hospital or buy it from a chemist in the market. If he has to buy it from the market, it is the chemist who will decide which brand to supply. That decision will now move from the doctor to the chemist. In this situation, it is still quite possible that the patient may end up buying an expensive brand of the medicine.
If the doctor can be biased towards a particular brand, there is greater likelihood of the chemist being on the payroll of a drug maker. The chemist will sell that company's brand that offers him the highest profit margin. In the trade, this is normally done by companies that have quality issues - those who do not spend adequately on good manufacturing practices. Chemists, mind you, are fiercely protective of their margins. Last year, when some companies tried to cap retailer and wholesaler margins (at 16 per cent and eight per cent, respectively) on price-controlled medicine, the companies were boycotted and their business plummeted. Many fell in line and restored the old (higher) margins. Such is the clout the chemists wield.
There are similar concerns over quality if the patient gets medicine free from the hospital pharmacy. The government places orders for such medicine - this is truly unbranded - with the lowest bidders in auctions. There are genuine fears that lowest-cost suppliers may cut corners in order to preserve their profit margins on such orders. In Rajasthan, where Ashok Gehlot two years ago started a huge initiative to provide free medicine in government hospitals round the clock, many doctors were reluctant to prescribe generic medicine bought by the government because of the poor quality. If Mr Jain wants generic medicine to be freely prescribed by doctors in government-run hospitals, he should instill confidence in that medicine. And that can be done through proper procurement. This requires stringent quality standards and checks at regular intervals. At the moment, the government does not have the manpower to do that. Mr Jain's priority should be to put this infrastructure in place. Simply asking doctors in government hospitals to prescribe generic medicine won't help.
Also, free medicine in a distant hospital doesn't come without a price for poor patients. They need to travel long distances, sacrifice a day's wages, and stand in a queue for hours without end for the free medicine. It can be truly free only if it is dispensed not far from the patient's residence and quickly. For that, the network of government hospitals and primary health centres needs to be strengthened. One hasn't heard anything on that from Mr Jain. Nobody can challenge the need for free or inexpensive medicine, especially for the poor. But that can happen only through a comprehensive systemic change. Strange as it may sound, the public sector dispenses a lot more medicine in the developed markets than in India. In Europe, it is as high as 80 per cent. In India, it is as low as 25 per cent. In a city like Delhi, it would not be more than 10 per cent. So, Mr Jain's initiative addresses a small part of the problem.
The real challenge is to regulate the private trade in medicine. There are no quick-fix solutions to it. This is a problem the whole world is grappling with. (A bigger problem in the West is the growing unregulated medicine trade on the internet.) Self-regulation is the only hope. Some beginning has been made. GlaxoSmithKline recently said it will stop paying doctors for promoting its drugs and scrap prescription targets for its marketing staff. A few months before that, the company was accused by the Chinese authorities of bribing doctors, hospitals and government officers so that it could sell at higher prices. Last year, it pleaded guilty to criminal charges in the United States that it illegally promoted drugs and withheld drug safety data, and agreed to pay $3 billion in settlement.
It is a mess that will take Mr Jain more than a stern letter to clear.
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