Narendra Modi in London: PM's remarks on doctors rile medicos, but studies confirm high costs ail India's healthcare

Prime Minister Narendra Modi has faced flak from medicos for his recent remarks in London to the effect that doctors in India prescribe medications at the behest of pharmaceutical companies. The doctors have also received support from Delhi’s chief minister and Modi’s perennial critic Arvind Kejriwal. However, this criticism does not negate the fact that the prime minister, during his "Bharat ki baat, sab ke saath" talk, referred to a grim reality in India’s health sector, one in which only common people are made to suffer. Modi made the above controversial statement while discussing the Pradhan Mantri Bharatiya Janaushadhi Pariyojana scheme. Under it, the government sells cheap un-branded generic medicines, through nearly three thousand Janaushadhi stores. Explaining the rationale for the scheme, the prime minister referred to practices of doctors in India. He said, “You all know that medicines have good packaging. The people who prescribe them also get something. You also know that doctors go to attend conferences in Dubai and Singapore. They don’t go there to treat patients, but because (of the) pharmaceutical companies.” Modi hinted at a nexus between the medicos and pharmaceutical companies, one which is said to have an effect on prices of medicines. In his recent public address in London, the prime minister further said, “We have arranged for generic medicines through the Janaushadhi Pariyojana. Under this scheme, medicines which are priced at Rs 100 in the market are made available at Rs 15.” [caption id=“attachment_4446977” align=“alignleft” width=“380”]  Representational image. Reuters[/caption] This is not the first time that Modi has endorsed generic medicines. In 2017, he had said that the government would bring in a legal framework making it mandatory for doctors to prescribe generic medicines. A week after this statement, the Medical Council of India had issued a circular suggesting that doctors should prescribe generic medicines only. The Indian Medical Association issued a statement reacting to Modi’s remarks quoted above, saying that they show India’s health industry in poor light in a foreign country, that too in one ‘where 70 percent of the medical system is run by Indians’. However, the debate about generic and branded medicines is an old one. The basic contours of this debate are: Do the majority of doctors still prescribe branded medicines at the behest of pharmaceutical companies, even when cheaper generic variants are available? Is it is a legal and moral responsibility of doctors to prescribe generic drugs? Can doctors evade such responsibility and prescribe brands of their choice? Numerous studies show that medical bills in India mostly consist of expensive branded drugs. A study jointly conducted by Maulana Azad Medical College in Dehi and Delhi Society for Promotion of Rational Use of Drugs in the year 2011 said that up to 90 percent of medical bills of the poor in India consist of the cost of medicines. This was the situation nearly nine years after the Union government decided to push for generic medicines in its health policy in the year 2002 and after the Medical Council of India made it a part of the ethical code of conduct of doctors to prescribe generics. The 2011 study, referred to earlier, also suggested that prescribing of generic drugs should be made mandatory to control costs of medication. But experts say that making it mandatory for doctors to prescribe generics is not legally possible. “The Government of India is not a totalitarian body and hence, it cannot impose such rules for all kinds of medicines,” says Alok Mukhopadhyay, a health expert who has been associated with the formulation of National Health Policies since 2002. Keeping this in mind, prescribing generic medicines has not been made mandatory by the government. “The Medical Council of India’s circular issued last year telling doctors to prescribe generics is actually advisory in nature. It says that doctors ‘should’ prescribe generic medicine and is worded in the form of a moral obligation,” says Dr Girish Tyagi, Registrar of Delhi Medical Council, a quasi-judicial body under the Delhi Government that oversees ethical practices among the doctors. Since prescribing generic medicines is not compulsory for doctors, nothing much has changed in India on this front, says Mahendra Prasad, a qualified pharmacist who runs a drug store in Dwarka. He says, “Branded drugs are expensive and hence, their sale is more profitable. The profit is shared among pharmaceutical companies, doctors and drug stores. On the other hand, non-branded generic drugs yield less profit. Pharmaceutical companies lay relatively less emphasis on selling them.” However, Dr Bipin Mittal, a dental surgeon in Delhi said to Firspost that commercial considerations are not the only reason why many doctors prescribe branded medicines. “Many doctors believe that branded medicines are more effective than generic ones. So, they fear that if they prescribe generic medicines, these may prove ineffective,” he says. However, a source in the Bureau of Pharma PSUs of India (a Union government body which is the implementing agency of the Janaushadhi Pariyojana) said to Firstpost that it is a myth that generic medicines in India are not as effective as branded ones. “Generic medicines have to go through bio-equivalence tests to prove that they are equivalent to branded medicines, before they are allowed to be sold in the market,” the source said. Significantly, the Food and Drug Administration of the United States defines generics as “a medication created to be the same as an existing approved brand-name drug in dosage form, safety, strength, route of administration, quality, and performance characteristics." The BPPI source further said that generic medicines which are sold under the Janaushadhi Pariyojana are produced by companies certified by the World Health Organisation for Good Manufacturing Practice. The source also said that the medicines are tested by laboratories under the National Accreditation Board for Testing and Calibration of Laboratories. “The medicines sold under the scheme are of export quality. Hence, there is no question of them being sub-standard,” said Biplab Chatterjee, Chief Executive Officer of BPPI. This reporter spoke to Fateh Singh, an autorickshaw driver waiting for his turn at a Janaushadhi Kendra. Singh said, “Three of my children were afflicted with tuberculosis. Earlier, I was getting them treated at a private hospital. Not only were the medicines expensive, but they were also relatively ineffective. Later, I started getting medicines from Janaushadhi Kendras. Now, my children are recovering fast and I am managing the cost of the treatment smoothly.” The Indian Medical Association, while expressing displeasure over Narendra Modi’s statement, had questioned the quality of generic medicines. However, the Ranbaxy scam unearthed in the year 2004 showed that it was possible even for multi-national brands to obtain permission to release products in the market by submitting false test data. In such a situation, singling out generics as inferior in quality reeks of bias. The Delhi government’s health sector thrives on generic medicines, says Hemprakash, Additional Director, Delhi Health Department. “The Delhi health department has made it compulsory for every doctor in government hospitals to prescribe generics only,” he said. The mohalla clinics opened by the Delhi health department, which treat patients only with generic medicines, manage a maddening crowd of patients on a daily basis. On the other hand, the private health sector in Delhi hinges on branded medicines. “Since there is no rule to compel private players to prescribe generics, most doctors in private hospitals prescribe branded medicines,” says Ashok Agarwal, member of a monitoring committee formed by the Delhi High Court to ensure treatment for economically weaker sections in private hospitals. Even government hospitals outside Delhi prescribe branded medicines, says Raghav Chand, who came to Noida to get his newborn son treated at a government hospital. “Not only do doctors prescribe expensive medicines, but they also sometimes specify the shops where they need to be bought from,” he says Raghav Chand does not know about the Janaushadhi Pariyojana and he has also never heard of generic medicines. Dr Girish Tyagi of the DMC says that although it is legal to prescribe branded medicines, it is an offence for doctors to accept any gifts or hospitality from any pharmaceutical company. The penalty for the same can extend to cancellation of licence. Earlier, the council suspended the license of a doctor working in the government sector in Delhi for violating such rules. “However, very few people bring such illegal activities to our notice. So, it is very difficult to assess the magnitude of such transactions,” Tyagi said.