In the financial year 2024, the pharmaceutical industry achieved sales of 916 billion rupees, a 22% year-on-year increase according to brokerage house Topline Securities, citing data from IQVIA, a leading healthcare data company. Yet behind these impressive figures lies a troubling reality. The pharmaceutical industry’s influence on prescribing medicines remains unmatched with several investigations revealing pharmaceutical companies using a range of approaches, including bribery, to incentivise medical prescriptions. These approaches include financial, professional, and other materialistic gains thus creating a conflict of interest since the judgment of the medical professional concerning their primary interest i.e. the patient’s welfare, becomes compromised due to the presence of undue influence and secondary interests.
This unethical & rampant practice, known as Incentive-Linked Prescription (ILP), is a form of pharmaceutical bribery that compromises patient care. Research Published by the Journal of Pakistan Medical Association in 2023 (“Conflicts of Interests Driven by Pharmaceutical Incentivisation”, Volume 73, No. 11, November 2023), determined the widespread nature of ILP and discovered five broad categories of incentives which were monetary, material such as gifts or medical equipment, professional or educational, social or recreational i.e. paid holidays and leisure trips, and familiar such as paid children education. This was corroborated in another research published in the International Journal of Health and Policy (“Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry”, Volume 13, Issue 1, 2024) which not only presented the types of incentives, such as cash, car, air-conditioning units, and paid meals but discovered that often Pharmaceutical Sales Representatives would themselves ask the doctors what they wanted and the doctors would inform them of their needs leading to this practice becoming normalised to such an extent that it is no longer considered as an ethical transgression.
Yet the impact it has on patients cannot be understated with higher medical cost for the patient being only a single factor. ILP encourages the over-prescription of unnecessary medication, especially antibiotics. In 2018, A situation analysis report on antimicrobial resistance in Pakistan by the Global Antibiotic Resistance Partnership and Center for Disease Dynamics Economics & Policy revealed that this rampant practice has led to Pakistan having one of the highest antimicrobial resistance (AMR) in the world with Pakistan ranking 176th out of 204 nations in AMR-related mortality. It further showed that due to ILP, 70% of Pakistani physicians prescribe antibiotics, with general practitioners often prescribing more than three drugs to a patient. This has significantly contributed to Pakistan’s growing antibiotic crisis. Furthermore, when patients realise that their doctor’s prescriptions might be influenced by financial gain rather than their well-being then their trust in healthcare institutions erodes, discouraging people from seeking medical help and looking for alternative treatments leading to severe health consequences.
Pakistan lacks a proper legal framework to challenge ILP, and there is an urgent need for reform to immediately legislate a comprehensive anti-ILP law which should contain provisions that prohibit financial incentives following prescription decisions
While ILP is globally condemned due to its ethical, medical, and legal implications, the deficiencies in Pakistan’s legal system allow for the pharmaceutical industry to incentivise medical professionals absent care for the cost, cause, and nature of the drugs. Pakistan’s Pharmaceutical Law is governed through the foundational framework of The Drugs Act 1976 (DRA) along with The Drug Regulatory Authority of Pakistan Act 2012 (DRAP) and both these laws are home to multiple subsidiary rules and by-laws. Due to growing cases concerning ILP, the government passed The Ethical Marketing to Healthcare Professional Rules 2021 which provided guidelines on how pharmaceutical companies should approach medical professionals but remained absent of any proper punishment nor did the rules or the parent law mention the proper framework to adjudicate the matter. Both parent laws DRA and DRAP are largely concerned with drug quality, pricing, and licensing and offer little in regulating commercial relationships between Medical professionals and pharmaceutical companies.
On the other hand, the Pakistan Medical & Dental Commission (PMDC) Code of Ethics contains provisions that prohibit doctors from receiving such benefits but these guidelines are not penal. They are also rarely enforced. The provinces of Pakistan did pass their respective Health Care Commission Act (HCC), a legislation that acknowledges medical malpractice and offers a platform to litigate the matter. Yet the legislation is self-destructive and could not be properly implemented. It offers inherent immunity (Section 29) to medical professionals from the institution of suit against them in any other platform under any other law which is often used as a defence by medical practitioners litigated in other platforms. The law also imposes a heavy penalty of Rs. 200,000 (Section 28) against the aggrieved plaintiff if they are unable to prove their case discouraging complaints. The legislation is also focused on medical malpractice rather than ILP which is impossible to prove through the HCC and the immunity clause creates an impediment if any other platform is involved.
Apart from these frameworks, no other law is applicable as the bribery sections of the Pakistan Penal Code Sections 161-165 deal with bribes relating to public servants. The National Accountability Bureau 1999 does deal with corrupt practices but their target is public officeholders and high-value corruption cases. The Punjab Consumer Protection Act 2005 Section 2K concerning defective service and Section 2h misrepresentation has no jurisdiction concerning medical malpractice with the passing of the HCC Act 2010 as held by Justice Farrukh Irfan in PLD 2019 Lahore 429.
Pakistan also lacks clear regulations on medical corruption and pharmaceutical bribery. In addition to these framework limitations, there is also an absence of Anti-Kickback Laws such as the 42 U.S.C 1320a-7b which criminalises ILP, or the Stark Law which restricts financial referrals. Pakistan also does not have proper legislation concerning Medical malpractice that can allow the injured party to file for damages. The fiduciary duty principles of medical professionals having an obligation to prioritise patient welfare are non-existent in contrast to common law countries where a breach of fiduciary duty in medical practice can lead to severe legal action and compensation which are also hollow. In addition to weak compensation laws, the Judicature is also extremely reluctant to award heavy damages, be it punitive, cost, or compensatory.
Pakistan’s current legal framework is simply too outdated, fragmented, and inadequate to tackle this growing disease. Comprehensive legal reforms and government awareness programs are imperative with an announced state policy against the disease of ILP
There is no doubt that Pakistan lacks a proper legal framework to challenge ILP, and there is an urgent need for reform to immediately legislate a comprehensive anti-ILP law which should contain provisions that prohibit financial incentives following prescription decisions and establish penalties for violations which shall be awarded through a proper court of law. The act should also extend this liability to pharmaceutical companies and their sales representatives. There is also a further need to strengthen the provisions of DRAP which should have the power to audit and investigate pharmaceutical companies and medical practitioners as well as require hospitals and clinics to implement proper compliance with powers to take strict action against violators.
Pakistan can also take inspiration from the United States Physician Payments Sunshine Act 2010 or the European Union’s directive 2001/83/EC which governs transparency between doctors and pharmaceutical companies. Such transparency law can contain provisions such as annual disclosures of financial transactions between pharmaceutical companies and doctors which should be publicly available along with legal consequences for non-compliance such as fines and disciplinary actions. The PMDC should also be reformed for stricter implementation of the code of ethics. Provisions of the code such as Part XI which concerns the relationship between doctors and pharmaceutical companies should be given the status of legally enforceable regulation rather than ethical advisory. The immunity clause and penalising the complainant found in the HCC needs to be amended and a proper procedure concerning ILP must be added to the Law. These reforms can go a long way in combatting ILP.
With the horrifying commonality of ILP, it is clear that Pakistan has failed to effectively regulate this practice and this presents a significant challenge that it can no longer ignore. Pakistan’s current legal framework is simply too outdated, fragmented, and inadequate to tackle this growing disease. Comprehensive legal reforms and government awareness programs are imperative with an announced state policy against the disease of ILP. Without these critical interventions, Pakistan’s stagnating health care will continue to be compromised by corporate-driven medical malpractice which can have dire consequences for public health.