Patient Perceptions of Incentive-Linked Prescribing in Pakistan

doi:10.21203/rs.3.rs-3587011/v1

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Patient Perceptions of Incentive-Linked Prescribing in Pakistan

https://doi.org/10.21203/rs.3.rs-3587011/v1

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Background: Incentive-linked prescribing (ILP) – doctors’ accrual of incentives from pharmaceutical companies through prescribing promoted drugs – is a well-documented issue. However, little is known about patients’ perceptions of ILP and the extent to which it can affect their trust in doctors in Pakistan.

Methods: A qualitative approach was adopted to collect data from 25 conveniently selected patients visiting pharmacies with prescriptions from their doctors, in Karachi, Pakistan. A thematic analysis technique was used to analyse patients’ perceptions of ILP.

Results: Our analysis revealed that a majority of patients were aware of the profit-oriented relationship between doctors and pharmaceutical companies. Patients thought both doctors and pharmaceutical companies were highly motivated to maximise profits through ILP, which they believed was an unethical practice with negative consequences for patients. In addition to commissions linked with prescribing and dispensing medications, patients named several other incentives and benefits that pharmaceutical companies provided doctors with. Many patients also spoke about how pharmacists perform a catalytic role to enable ILP by selling specific pharmaceutical products to patients, for which they received commissions.

Conclusion: There is growing awareness of unethical relationships between doctors and pharmaceutical companies, which significantly contributes to patients’ mistrust of doctors; this not only harms doctors’ reputations in society but also affects their compliance with doctors’ advice, which is likely to have negative implications for healthcare delivery.

Patients

Doctors

Pharmaceutical Industry

Healthcare

Prescribing

Patient information asymmetry is a key feature of any healthcare system, as doctors have medical knowledge that patients do not possess. With this imbalance in mind, doctors need to act in the patient’s best interest. When a conflict of interests arises for doctors, this can impact patient wellbeing, trust, and utilisation of the healthcare services. In this paper, we focus on incentive-linked prescribing (ILP), a practice where healthcare providers accept incentives from pharmaceutical companies for prescribing promoted medications. [1, 2]

ILP is more likely to take place in settings where the private sector is responsible for the majority of health care provision and a lack of regulatory control. In Pakistan, a country where over 75% of the healthcare utilisation is sought from the private healthcare sector, ILP is a pressing issue. [3] While national and international codes of ethics are in place in Pakistan [4], implementation of these rules and monitoring and regulation of doctors and pharmaceutical companies has remained a challenge – creating a fertile environment for profit-driven partnerships to take place. Within this context, intense competition on the pharmaceutical industry’s side means companies will allocate specific budgets for incentivisation. [4]

Our previous research suggests doctors are likely to accept incentives as they can provide opportunities to fulfill socially desired standards of living [2]. Other studies in Pakistan have also been highlighting the mechanisms through which ILP happens, how ILP can lead doctors to prescribe unnecessary medications, and how this distorted prescribing behaviour can lead to negative health and financial outcomes for patients. [4, 5] When doctors engage in ILP, they may prescribe patients unnecessary medications or costlier alternatives, resulting in a higher financial burden for patients in settings like Pakistan where more than 50% of health expenditure is out-of-pocket. [6]

While deals made between doctors and industry may often be hidden, some studies point towards a high level of patient awareness of these interactions. [7] When patients believe their doctors and their prescribing behaviour are biased, it undermines the credibility of doctors and generates mistrust. [8, 9] Mistrust can further lead to the underutilisation of care and may delay patient care-seeking, placing a greater financial burden on the health system overall due to higher treatment costs. [10, 11]

Patients are a crucial part of the health system and an important indicator of health care quality. While interactions between doctors and the pharmaceutical industry are relatively frequently recorded in academic literature, there is a dearth of research that includes patients and their perceptions of doctors’ interactions with the pharmaceutical industry. In this study, we aim to investigate patient awareness and perceptions of ILP. To our knowledge, this is the first qualitative exploration of patients’ perceptions of doctor-pharmaceutical industry interactions in Pakistan.

Study objectives

The overarching objective of the study is to explore patient perceptions of the relationship between doctors and pharmaceutical companies in Pakistan. We specifically aim to:

Explore patient perceptions of the mechanism through which ILP happens.

Understand their level of awareness regarding the incentives the doctors may receive from pharmaceutical companies in return for prescribing.

Examine whether ILP can reduce patients’ trust in doctors.

Study design and setting

We conducted this study in Karachi, which is the largest city with respect to area and population size in Pakistan. [12] We adopted a qualitative approach to gather information about patients’ perceptions of ILP through in-depth interviews. This approach was well-suited to allow an open exploration of patients’ perceptions about the relationship between doctors and pharmaceutical companies. It enabled patients to draw on their observations and lived experiences of healthcare seeking, in rationalising their claims about doctors taking incentives from pharmaceutical companies and how this might affect them and other patients.

Study patients

Adopting a convenience sampling technique, [13] we recruited 25 patients visiting 6 pharmacies with prescriptions from their doctors in 6 different districts of Karachi, Pakistan. Convenience sampling, also known as haphazard sampling is a technique to select individuals based on their easy accessibility to researchers. [14]. Convenience sampling is commonly used in studies with patients because healthcare settings are often busy, and it can be problematic for healthcare providers and staff to facilitate patient recruitment in research. This technique allows researchers to come in direct contact with patients and upon patients’ willingness, enable their participation in research. [15]. We approached patients attending pharmacies in all six districts (East, West, South, Central, Korangi, and Malir) of Karachi, for representation from all areas. Two qualitative research specialists (ZA and HSA) of our team reached out to potential patients as soon as they came out of pharmacies, Those who were willing to participate were asked to provide written consent and interviewed.

Data Collection

We completed data collection in two phases. Phase 1 involved three pilot interviews which were analysed to identify areas of further exploration through the main interviews. Based on our preliminary analysis of the pilot interviews, more questions were added to the interview guide which comprised four major sections: demographic characteristics, perceptions about the relationship between doctors and pharmaceutical companies, polypharmacy, and the impact of ILP on patients. In phase 2, we conducted 25 interviews which were recorded and transcribed. Our ongoing analysis of the interviews guided us to determine data saturation.

Data analysis

All the interview transcripts were imported into NVivo (version 12) and three team members (ZA, HSA and NVM) were assigned to identify themes and subthemes within the qualitative data. The team lead (MNN) reviewed the codebook and reclassified the data as (1) doctor-patient interaction, (2) perceptions about ILP, (3) perceptions about polypharmacy, and (4) perceived impact of ILP on patients, and this reclassification aligned with the main study objectives. This revised codebook acted as a guiding document to reorganise data in NVivo.

Characteristics of patients

The sample consisted of 20 male and 05 female primary care patients. In the study sample, 6 patients received education up to grade 10, 5 patients received education up to grade 12, 11 patients held university degrees, and 3 patients had no education. A majority of patients had low incomes, as 4 patients were manual workers, 6 patients had low-salaried jobs, 7 patients were self-employed, 4 patients were students, and 4 patients did not have jobs.

The analysis of the interviews suggests that a majority of patients had some information about the financial relationship between private doctors and pharmaceutical companies. We organised their perceptions of ILP into four subsections concerning doctors’ desire to accumulate more resources, pharmaceutical incentivisation, the mediating role of pharmacies, and the effect of ILP on patients’ trust in doctors. Our analysis of patients' perceptions of ILP is summed up in Fig. 1.

Figure 1

The illustration of patients’ perceptions of the mechanisms through which incentive-linked prescribing occurs

Perceptions of profit-making mindset

Most of the patients believed that there was often a profit-oriented relationship between doctors and pharmaceutical companies, which they deemed against doctor’s professional ethics in medical practice. The suggestion of doctors for patients to buy medications from specific companies available at specific pharmacies led patients to assume doctors’ financial relationship with particular pharmaceutical companies:

When doctors prescribe medications by specific companies, it tells the nature of their relationship with those companies. Pharmacies owned by doctors close to their clinics are another sign of their business with pharmaceutical companies because it is difficult to find the prescribed medications from somewhere else (P12).

Many patients also believed that doctors who generate large prescriptions were more likely to be in a financial engagement with pharmaceutical companies:

There is some benefit for doctors when they prescribe a large quantity of medications. This is a way to get commissions from pharmaceutical companies, and this practice usually happens in private clinics (P01).

When asked about their perceptions of the reasons behind doctors’ establishment of financial partnerships with pharmaceutical companies, most of the patients pointed to greed/a desire to generate extra income, whereas a few pointed to corruption as an ingrained societal norm:

People want to get financially strong by any means; doctors may also try to get financially stronger by doing so. Although they earn money from patients by taking fees, to make more, they rely on pharmaceutical companies (P22).

They do so because they receive gifts and benefits. Corruption is prevalent here. Although doctors are supposed to serve people, not all of them do so. Some good doctors help keep the system running. Greed is everywhere, and honesty is lacking (P14).

Understanding of doctors’ partnerships with pharmaceutical companies

Many patients pointed to how the profit-making mindsets of doctors and the pharmaceutical industry converged, a byproduct of which they believed was ILP. Indeed, they spoke about how pharmaceutical marketing through pharmaceutical sales representatives (PSRs) was a tool to establish financial partnerships with doctors. Patients believed on behalf of pharmaceutical companies, PSRs could offer doctors a certain percentage of commission for prescribing their products:

The presence of several pharmaceutical company representatives in private clinics raises questions. They are obviously there to make deals with doctors. Doctors are often offered incentives or packages by them for prescriptions. I have personally noticed on several occasions how companies leave no stone unturned to entertain doctors (p14).

Once relationships with given pharmaceutical companies were established, doctors might ask patients to consume medications from those companies:

Doctors instruct patients to purchase medications of a particular brand because they receive commissions or other benefits from certain companies (P10).

Many patients also pointed to the types of incentives that doctors typically receive from pharmaceutical companies for prescribing their medications:

I have heard, seen and know, that doctors have trips abroad, companies pay school fees of their children, renovation of their clinics etcetera (P01)

These representatives often pay for dinners and give them many other benefits. In return, they expect doctors to prescribe their products to help achieve their sales targets (P20).

I have personally witnessed doctors receiving numerous gifts and boxes of sweets. These incidents have happened right in front of me (P13)

Pharmaceutical companies also pay for doctors’ flight tickets and make travelling easier for them. It allows doctors to see various destinations frequently (P14).

Views on the catalytic role of pharmacies

Patients viewed pharmacies as critical spaces catalysing the process of ILP. While pharmaceutical companies invested money and doctors prescribed for maximising profits, pharmacies, patients believed, also took their share by selling products of specific companies and keeping track of the sales enabled by doctors. Therefore, doctors ask patients to obtain their medications from specific pharmacies, patients said:

Pharmacists are also a beneficiary because they partner with doctors and there is mutual understanding between them (P04).

Sometimes doctors name the pharmacies from where their prescribed medications can be obtained, and they may not be available at other pharmacies. Even if you try, you will not get it from somewhere else; it happened to me (P05).

Many patients said it was common to see pharmacies within or close to private clinics. While it was convenient for patients to get medications from those pharmacies, it was a way for doctors to generate extra income by selling medications at a higher price:

I have seen many clinics having a pharmacy within or close to them and I often purchase medications from them for convenience, but I have noticed that the same medication is available at lower prices in other stores, while it tends to be more expensive at the clinic's store (P19).

Some patients also identified how doctors use sign language to communicate with pharmacists about their commissions when their patients visit partner pharmacies to buy medications:

Doctors put special marks on the prescriptions to get their commission from each referred patient from pharmacies. They do it to get their share of profit from the sales of specific products. Ultimately, it is all about the money (P07).

A few patients noticed that sometimes doctors’ prescriptions are not legible, and they did this intentionally, so pharmacists other than the ones who were their partners could not understand the prescriptions:

Once a doctor prescribed medications which was not possible for other pharmacists to understand. I went back to the doctor to discuss this, and he asked me to go to a pharmacy outside his clinic and said that the pharmacist would understand what I had written (P11).

Trust-deficit

Patients believed doctors deviated from their professional ethics by engaging in ILP, and this practice had several negative effects on patients as well as on doctors. Many patients, for instance, assumed ILP could influence the prescribing behaviour of doctors in a way that could compel them to produce large prescriptions for meeting pharmaceutical sales targets:

This is a very common practice, and many medications are prescribed with brand names, especially multivitamins and antibiotics. They make money by prescribing extra medications because they have contracts with companies. They need to refer medications from two or three companies for promotion which leads to unnecessary prescribing of medications and poor patients sometimes don’t even know about what is happening to them (P11).

Although some patients mentioned a lack of awareness about unnecessary medicines being prescribed, others gave examples of when they questioned doctors if they suspected they were given medications unnecessarily due to their partnerships with pharmaceutical companies, indicating their agential side:

I know a doctor who usually prescribes injectables to his patients. I am saying this because it happened to many of my family members. Another thing, it is difficult to find medications he prescribes except for his pharmacy within the clinic. I asked his compounder what that injection was for, and he directed me to the doctor, who could not provide a satisfactory answer. Then I convinced my parents to stop seeing him (P24).

Unfortunately, this mistrust in doctors due to suspected ILP affected a few patients to the extent that they preferred to either see alternative doctors or informal providers:

Whom should we see then? I would choose to go to hakim¹ or a homoeopathic practitioner instead of such doctors, or I would simply go to another doctor, in case it is highly necessary to see a doctor (P23).

To our knowledge, this study is the first qualitative exploration of patients’ perceptions of ILP and how it can lead to their mistrust of doctors in Pakistan. The analysis gives several important messages that doctors and policymakers must know about. First, it was clear that patients were reasonably aware of the magnitude of the unethical profit-driven relationship between doctors and pharmaceutical companies. This finding is consistent with Gillani, et al’s survey in five Pakistani cities, in which 66.7% of the sampled primary care patients reported being aware of the presence of PSRs in doctors’ clinics, and 60.8% of the patients believed receiving gifts from pharmaceutical companies was unethical. [16] Our study also corroborates with other qualitative studies in Pakistan, in which doctors, PSRs, and policy actors also admitted that ILP became a norm in the country, although it was considered an unethical practice. [5, 17] Second, ILP was seen to be embedded in the broader system of corruption where financial gains took primacy over patients’ best interests. This finding strongly supports the view that corrupt behaviours may be widely prevalent in societies where regulatory controls are weak because they allow individuals to act in self-interest. Consequently, even though people may condemn corrupt behaviours, they still engage in corrupt practices due to a larger doubt and mistrust in society. [18] Third, patients had good knowledge of the range of incentives that doctors might receive from pharmaceutical companies in exchange for prescriptions. Again, this finding is consistent with our research with doctors and PSRs who reported how commissions and travel sponsorships were highly valued resources exchanged for prescribing. [5, 19] Fourth, patients also knew about how pharmacies partnered with pharmaceutical companies and doctors and mediate ILP. Finally, ILP was seen to be decreasing patients’ trust in doctors and other healthcare professionals/entities including pharmaceutical companies and pharmacists. There is evidence that patients’ trust in doctors is maintained when they believe that doctors do not have financial ties with pharmaceutical companies. [9] Even in settings where doctors are required to publicly disclose their financial terms with pharmaceutical companies, patients are seen to have a low level of trust in doctors. [20, 21]

Our study had certain limitations in terms of its limited geographic focus and the types of patients. Pakistan is a diverse country geographically, socio-culturally, and economically. A nationwide study would have brought more insights into patients’ perceptions of doctors’ engagement in ILP. Similarly, a study with patients’ experiences and perceptions of secondary and tertiary care health facilities and doctors within them would have enriched data. However, despite these limitations, it was clear that patients doubted doctors’ prescribing behaviour and this finding is alarming in terms of doctors’ reputations in society. This also signals the need for a nationwide survey of patients’ awareness of ILP and their level of trust in doctors and other healthcare professionals. Doing so will not only stimulate thought in the medical community but will also make patients’ voices heard in policy domains.

Our study has several implications for policy and practice. There is a dire need to create awareness among doctors regarding the extent to which patients are aware of the financial relationship between doctors and pharmaceutical companies, how this affects prescribing behaviour, and finally, how this contributes to mistrust in doctors in society. Doing so has the potential for doctors to self-regulate their behaviour linked to their interactions with pharmaceutical companies. Electronic and print media can be an effective tool to create awareness among doctors. Doing so can be the first step toward sensitising doctors to self-regulate their medical practice. In 2021, the DRAP published rules for ethical pharmaceutical marketing, although there is no evidence of whether the rules were implemented. [22] It is critical to implement DRAP rules to ensure pharmaceutical companies work ethically, so the chances for doctors to obtain benefits and resources in exchange for prescribing are limited. Doctors should also be made aware of DRAP rules, so they refrain from expecting resources and benefits from pharmaceutical companies in return for prescribing promoted medications. Finally, healthcare commissions that are responsible for regulating healthcare facilities in provinces and the federal capital need to invest more resources in devising and implementing ways to monitor doctors’ ties with pharmaceutical companies.

Our study suggests that doctors’ engagement in ILP is widely known in the patient population, and this can significantly reduce patients’ trust in doctors. In a country where a majority of patients seek healthcare from private doctors, patients’ reduction of trust in doctors can be catastrophic for the healthcare system. Our study has clear evidence that if patients discovered doctors’ engagement in ILP by some means, they could not comply with doctors’ advice, and might choose to see alternative doctors, or even seek healthcare from informal providers, or adopt home remedies. To protect doctors’ reputations in society, ensure fair treatment of patients, and maintain the credibility of the health system including regulatory bodies, actions must be taken to address ILP with urgency.

Acknowledgements

We thank patients who participated in this study and provided us with insights into their perceptions about ILP and how this can affect them in many ways.

Ethics approval and consent to participate

The study was approved by the Pakistan National Bioethics Committee (4-87/NBC-582/23/1845), the human research ethics committees of the Aga Khan University, Pakistan (2023-6781-25983), and the London School of Hygiene and Tropical Medicine (88840/RR/31771). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all the study participants. Other ethical considerations such confidentiality and data security were also observed throughout the study.

Consent for publication

Not applicable.

Availability of data and materials

The qualitative data used in this study are available from the corresponding author upon a reasonable request.

Competing interests

The authors have no competing interests to declare.

Funding

This work is supported by the UK Research and Innovation (UKRI) under grant number MR/T02349X/1.

Authors’ contributions

MNN, SS, RH, and MK conceived the study idea. All authors contributed equally to the study design. NVM designed the interview guide. ZA and HSA conducted and transcribed the interviews. MNN, NVM, HSA, and ZA coded the qualitative data using NVivo. MNN led the research process and performed major writing. NVM and MNN developed Figure 1. All authors critically reviewed the manuscript.

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^[1] A local term used to refer to informal providers

No competing interests reported.

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Version 1

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You are reading this latest preprint version

Patient Perceptions of Incentive-Linked Prescribing in Pakistan

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Version 1

Abstract

Figures

Introduction

Study objectives

Methods

Study design and setting

Study patients

Data Collection

Data analysis

Results

Characteristics of patients

Perceptions of profit-making mindset

Understanding of doctors’ partnerships with pharmaceutical companies

Views on the catalytic role of pharmacies

Trust-deficit

Discussion

Conclusion

Declarations

References

Footnote

Additional Declarations

Status:

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