Unethical medical products sales promotional practices in Bangladesh

In Bangladesh, the National Drug Policy (NDP 1982) was instrumental in the development of indigenous pharmaceutical industry in the country. In 1980, eight multinational companies manufactured 75% of all products (by value) while indigenous pharmaceuticals now claim a market share of more than 75%. Currently, there are 262 pharma companies (eight multinationals among the top 20) in the country totaling a market value of of 7,000+ crore taka. With the rise in number of pharma companies and the market, aggressive marketing of pharmaceutical products has increased, sometimes crossing the boundaries of ethical practices.

One of the most important strategies adopted by the pharma cos. to promote their products and boost sales is detailing of the medical products by the medical sales representatives (MRs) to doctors and other healthcare providers. There are now 20,000+ MRs employed by the pharma cos., mostly fresh science graduates with good academic records and trained in the business for two months. Once they are deployed in the field after the inception period, they are given a target based on local sales target of the company and no. of active doctors.  Fulfilling this ‘target’ then becomes their lifeline for surviving the trade as this is linked to extra incentives, benefits and career advancement  etc.

Recently, Bangladesh Health Watch carried out a study on the sales promotion of pharmaceutical products  in the country. Very interesting facts came out of the study. Researchers found that to fulfill this ‘magic’ target of sales, the representatives are trained and motivated to do things which crosses the boundary of ethical promotion and sales of drugs. They are assisted by the HQ who maintains an area-wise database of the doctors and intelligence on doctors about their likings and disliking, morality, prescription habits etc. to chalk out customized strategy of doctor-representative interaction (BHW Report 2009, find posted in this blog).

Their main approach is to give gifts to the doctors which are not necessarily for professional use, and may be anything depending upon the patient size and popularity of the particular doctor. As one doctor said,

“Pharmaceutical companies have been providing everything except grocery. During the last Eid (religious festival) they provided perfumed rice, sugar, vermicelli etc. So it’s not easy to say what they don’t offer to us.”

Sometimes, big companies will undergo contract with popular and/or specialist doctors in the form of paid cash or luxury items such as TV, fridge, laptop, air conditioners etc. against prescribing their products. According to one medical representative,

“I know a very potential doctor of my territory whose chamber rent is provided by one company while his driver’s salary and attendant’s salary are paid by two other companies.”

The study further found that Small companies with budget constraint and no field workforce for promotional activities make contracts with drug shops or informal sector providers (Palli Chikitsoks, RMPs) to sell their drugs against cash incentives. At the time of detailing, medical representatives make exaggerated claims of their products, and provide less information about side-effects and contraindications. Interestingly, to keep track of the doctors’ prescribing habits, the pharma cos. buy monthly prescription survey reports from a pharmaceutical market consultancy firm in Dhaka for about two lacs taka per report.

This aggressive promotion results in influencing the prescribing pattern of the doctors.The doctors become obliged to write particular drugs whether there is an indication or not, or whether a cheaper and equally effective alternative is available or not. This causes unnecessary cost and harms to the patient in the form of side-effects and complications. What is most interesting, in the study, neither doctors nor medical representatives were found to be aware about the existing code of pharmaceutical marketing (e.g., clause 19-2 which states that “no gift or financial inducement shall be offered or given to members of the medical profession for purposes of sales promotion”.)

The financial, health and time cost for these unethical sales promotion is borne by the society through rising costs of drugs, and long waiting time while visiting doctors for treatment etc.  So, what can be done to reverse the process?  First and foremost, educating the health professionals (including medical representatives) on ‘code of pharmaceutical marketing’ and building awareness on drug prescribing ethics is very important. Besides, regulatory activity (by professional and statutory bodies) to check unethical promotion of drugs, motivating doctors and other healthcare providers to refuse all forms of gifts, prioritise patients’ interest over pharma cos. Interest, and promote rational use of drugs are needed.