Khan Mishal, Rahman-Shepherd Afifah, Noor Muhammad Naveed, Sharif Sabeen, Hamid Meherunissa, Aftab Wafa, Isani Afshan Khurshid, Khan Robyna Irshad, Hasan Rumina, Shakoor Sadia, Siddiqi Sameen
Department of Global Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan.
PLOS Glob Public Health. 2023 Jun 29;3(6):e0001890. doi: 10.1371/journal.pgph.0001890. eCollection 2023.
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.
医疗保健领域专注于盈利性企业可能会产生利益冲突，对药品的处方和定价产生不利影响。尽管这是一个全球性挑战，但在制药行业和医生游说团体相对于监管机构势力较强的国家，应对对医疗质量的影响尤其困难。我们的研究描述了制药行业与医生之间交换的激励措施范围，并调查了巴基斯坦激励措施实践与政策之间的差异。在这项混合方法研究中，我们首先对28名有目的地挑选的营利性初级保健医生和13名来自在巴基斯坦最大城市卡拉奇开展业务的制药公司的医药销售代表进行了半结构化访谈，并进行了主题分析。然后，我们对巴基斯坦两个负责监管的机构以及世界卫生组织发布的道德实践政策进行了内容分析。这使得我们能够将激励措施实践与政策中被视为“禁止”或“允许”的内容进行系统比较。我们的研究结果表明，激励医生实现药品销售目标是常态，而且双方都参与了医生与制药行业的共生激励动态。此外，我们能够将交换的激励措施类型分为五类之一：财务、物质、专业或教育、社会或娱乐以及家庭。我们将激励措施实践与政策进行比较后发现，与销售目标相关的这种广泛激励存在三个原因：第一，一些明确的政策被医生忽视；第二，对于特定激励类型存在模糊或矛盾的政策；第三，现有政策未涉及众多激励类型，例如制药公司为私人诊所装修付费。有必要澄清和更新政策，并促使制药公司和医生接受政策执行，以使违背目标驱动处方的行为被视为不道德。
