The Ethics of Medicine

On 7th April 2014, the nation woke up to a surprising reality One of the
leading pharmaceutical company of India Sun Pharma
out rightly
purchased another pharma giant Ranbaxy for a whooping Rs.21,231.48
crores! The Indian Pharmaceutical segment had touched Rs.1,65,803 crores
that year!! Thanks to the foresight and perseverance, today, the Indian
Pharma companies are much more valued and respected in the international
scenario. As per the latest report of CCI, in 2020 the Indian pharma industry
is pegged to touch Rs.5,63,732 crores!!! Though the major share is of
domestic market, there is a sizeable turnover from international markets.
With low pricing and USFDA approved facility, the pharma industry has been
able to stand firmly in the international arena.
Generally the Indian pharma companies work in 4 different segments
branded formulations, branded generics, generics and API (active
pharmaceutical ingredients). India has less than 1 % medicines which
can be really claimed as branded as per the international definition. A
brand is defined as that which is researched, developed, clinically tried and
tested and patented. No other company can introduce such formulation till
the patent period is over. In India, most of the formulations are merely copycats of their western counterparts. To give an example Cetirizine is a
medicine that is used for treatment of allergy, running nose, etc. Cipla, a
reputed pharma company having operations in nearly 150 countries,
promotes its brand of Cetirizine under the brand name Alerid to Doctors who
prescribe the same to us. Cipla also markets Cetirizine under brand name
Okacet to medical stores. To redefine, Alerid is a branded formulation
whereas Okacet is a branded generic. In the international generic market,
Cetirizine is sold as Cetirizine and not by any other brand name. Generics, as
we know, are much more economical than any prescribed brand. Now a
surprising fact! In India, there is no difference in MRP prices of Alerid and
Okacet. the difference is in the discount or commission given to the next
door medical store! For selling Alerid, the medical store gets 16 %
commission on MRP, whereas for selling Okacet, the commission is in
multiples of 16!!! The same is true with nearly all pharmaceutical giants in
India. So, naturally, a question arises that being one of the largest suppliers
of generics and that too at a lowest cost to the world, why are the medicine
prices so expensive in India? The prescription that your Doctor writes comes
after huge amount of hard work promotion by the companys medical
representatives, their salaries, allowances, incentives; gifts in cash or kind to

your Doctor for remembering the brand names, schemes to medical stores
and stockists for stocking the product. Now since this costs money, it is quite
natural that the company should charge the patients with higher MRP which
no doctor has ever complained. Hence the branded formulations
(unknowingly called branded products) are expensive. The branded
generics do not require so much effort. All that is required is to offer a
lowest possible price to the medical stores. But as a part of marketing gameplan and to keep the medical retailer happy, the MRP of branded generics is
at par with the branded formulation!! Most of the times, especially in rural
areas, taking disadvantage of the patients knowledge, branded generics are
given in lieu of branded formulation by offering some discount to the
patients.
If the Doctors sincerely decide to help the patients, they can write only
generic form of medicine (eg. Cetirizine, instead of a brand name). This will
be of great help to the patients who would have to shell out less cash. The
Maharashtra FDA had issued an ideal prescription format and distributed
copies to various medical associations and doctors. Even if that is
implemented, many of the patients would be benefitted. Second, if the MRP
of branded generics is adjusted as per price parity index, the patients
would get medicines at a much cheaper cost. However this decision has to
be taken by a combined force of the MCI, NPPA, AIOCD and the Health
Ministry. When will that happen..is a big question. An objection would be
raised or is rather raised by the Doctors that generic medicines would not be
of quality standards. But then isnt it true that a same ingredient is marketed
by one company in both segments branded formulations and branded
generics?
As a matter of caution not all low cost branded generics or generics should
be an answer, since everyday newer companies are launched and all want to
make a profit, branded generics or generics become an easy option and
quality sometimes might be overlooked. Hence, renowned and quality
conscious pharma companies who are having proper set up can be a good
choice. The Health Ministry started a very good initiative of setting up
generic medicine stores by giving incentive to those who want to start a
medical store. But impractical rules have flopped this great initiative.
Irrespective of the time frame within which patient friendly decision might be
taken, from the humanity point of view, even if the medical stores start
giving up to 50 % discount on branded generics, the patients would be

benefitted. But then, this is all about moral consciousness and desire to
serve. Right?
The MCI, a governing body of Doctors association clearly states in their
ethics statements that Doctors should as far as possible prescribe the
generic name of the salt. Eg. Paracetamol, Rosuvastatin, etc. Many doctors
have also started either their own retail outlet or are partners to outside
retail stores. Hence a pharma company that offers maximum schemes or
commission becomes favored. The patients are also coaxed or rather
pressurized to purchase medicines from these favored medical stores. The
ethics guideline given to the Doctors does not prescribe to such things.
A good initiative is launched by Click On Pharmacy, a newly started FDA
licensed medical store in Nashik. They give 5 % discount on MRP of
prescription i.e. branded formulation and up to 50 % discount on MRP of
branded generics of international repute companies with no change in
formulation. For better convenience, the patient need not even visit the
store. The prescription can be uploaded through WhatsApp on the given nos.
and the patient is given a choice of quality branded generics wherever
possible. You also receive a stamped receipt for every purchase. Additionally
the medicines are delivered at your door step at no extra cost. This service is
available throughout the country.
One is reminded of the Hippocrates and Pharmacist Oath that the Doctors
and Pharmacists respectively take on completion of their course. Even if the
patients are served while remembering these Oaths, it will help to strengthen
the doctor pharmacist patient bond.