ETHICAL AND NON-ETHICAL PHARMACEUTICAL MARKETING PRACTICES: CASE STUDY OF KARACHI CITY

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MARCH 2012 VOL 3, NO 11

ETHICAL AND NON-ETHICAL PHARMACEUTICAL MARKETING

PRACTICES: CASE STUDY OF KARACHI CITY

Rizwan Rahim Ahmed,

Research Scholar (PH.D)

Hamdard Institute of Education and Social Sciences (HIESS)

Hamdard University, Karachi - Pakistan

DR. AHMED SAEED

Research Supervisor

Abstract Unethical marketing practices has become an essential part of the pharmaceutical industry in Pakistan and it roots is so strong that it may not be possible to reverse the same. However previous study has a limitation and was a case study on pharmaceutical industry only in Hyderabad. In view of the findings of previous study there was a need to carry out the same on Pakistan basis. Thus this research has been undertaken with this objective in mind. The focus of the subject study was to identify the intensity and trends of unethical drug promotion practices in Pakistan. Ascertaining the contribution of the doctors, health related institutions and the pharmaceutical industry in promoting such practices.

Keywords: Ethical pharmaceutical marketing practices, non-ethical pharmaceutical

marketing practices, marketing practices

1. Introduction Unethical marketing practices has become an essential part of the pharmaceutical industry in Pakistan and it roots is so strong that it may not be possible to reverse the same (Parmar & Jalees, 2004). However this previous study has a limitation. It was a case study on pharmaceutical industry in Hyderabad. In view of the findings of this study there was a need to carry out the same on Pakistan basis. Thus this research has been undertaken with this objective in mind. The phenomenon of the unethical drug practices is common worldwide but its severity is more deep rooted in developing countries. Unethical drug practices have two dimensions. One is drug related, and other is drug promotion related. Extensive research on drug related unethical practices has been carried out internationally. However, the author was not able to find any empirical study on unethical drug promotion practices except the one that was carried out by (Parmar, Jalees, 2004). Parmar and Jalees (2004) in their study observed that pharmaceutical industry spends a substantial portion of its budget on market research but do not carry out the research on unethical drug promotion practices. One of the reasons is that the industry itself is indulged in this practice therefore it does not find any need to carry out the research on this issue.




Lack of research on the subject does not mean that unethical drug promotion practices do not exist. The pre-survey and focus groups discussions indicate that unethical pharmaceutical marketing practices have become an acceptable norm of the pharmaceutical industry, and almost all the pharmaceutical companies patronized these unethical practices in collaboration with doctors, government and private hospitals, health related agencies and pharmacies at the cost of patients’ well being. All the entities as discussed above appears to be corrupted, therefore, it may not be fair to blame any one of them, including pharmaceutical industry.

Doctors and other entities as discussed above have become greedy, therefore, are vulnerable to Pharmaceutical industry unethical drug promotion practices. Most of the conferences and academic activities of doctors are sponsored by the Pharmaceutical Industry; therefore, the industry uses the forum to pursue its goals which at times may not be the same as the purpose and objective of the conferences. Pakistan Medical Journalists Association (PMJA) has published a few articles on this issue. But this has not affected the prevailing unethical drug promotion practices (Zaidi et.al, 1995).

The focus of the subject study was to identify the intensity and trends of unethical drug promotion practices in Pakistan. Ascertaining the contribution of the doctors, health related institutions and the pharmaceutical industry in promoting such practices. Unethical marketing practices have now an integral part of drug promotion. Unethical practices could be classified into two segments. One is related to the medical side of the drug i.e. the trial of the drug both on animals and the human, and registration of indications and patent period in different countries. According to the prominent scholar and eminent physician of the country, Dr Sania Nishtar (2007), the anecdotal reports of corruption in the pharmaceutical sector must receive careful and objective analysis. Corruption in this domain has a direct bearing on the performance of the health system. This practice can involve both the regulators and the private sector and may involve any step along the drug supply chain, starting from registration, licensing and accreditation to the setting of prices, marketing of drugs and sale and procurements. Corruption in this sector has its roots in the commercial interests of the non-bonafide pharmaceutical companies, who find compliance with regulations costly and try to bypass procedures to get their product registered, speed up the approval process, and get favorable prices or to have their drugs included on the essential drug list in order to increase their market share. The contracting process for the purchase of drugs offers a lucrative source of returns for corrupt officials and suppliers through kickbacks, over-invoicing, and outright graft. There is anecdotal evidence for the same in Pakistan from several public hospitals; however this needs to be assessed carefully and its magnitude quantified. In a nutshell therefore, healthcare provision depends on a system which efficiently combines financial and human resources and supplies to deliver services; good governance and transparency are critical factors in making such a system function. However on the other hand, both poor governance and corruption in the health system are manifestations of a broader systems phenomenon in a country. Addressing these issues requires mandates and prerogatives both within but also outside of the health sector, which is why ideally, an anticorruption drive in health must ride a much larger wave (Sania, 2007).




2. Previous Research There are about 650 leading Nationals and Multinational pharmaceutical companies operating in Pakistan. Of this total 23 are multinationals and rests of companies are local companies. The local companies could be classified into three categories which are (1) Manufacturing units (2) Importers that imports drugs in finished form, and (3) Franchisers (not to be mixed up by the franchisors in the FMCG). These are companies that have all the marketing setup and facilities. These companies obtain the rights of marketing of the drugs of other companies on profit sharing basis. Total prevailing market size (March 2010) of the industry is of Rs.137.7 billion. [IMS, Q3, 2010]

GRAPH - 1 Pakistan Pharmaceutical Market (PKR in Billion)

Source: IMS – PKPI Q2 2010 (MAT)

In the year 2009 the industry realized a high degree of fluctuation in the growth rate. One of the major reasons for such a trend was merger and acquisition, and glutting the market by local pharmaceutical industry. However on an average the growth rate in the year 2009-10 was about 15.4% per annum. Comparatively the growth rate in the year was 2008-09 was about 12%. (IMS, Q2 & Q3, 2010) A tough competition exists between the multinationals and nationals, day by day nationals are taking up the share and in the last six years they have taken around 7% share in value. The gap between multinationals and nationals narrows further during 2009-10 with multinationals losing another 1.7% share to nationals. At present multinationals hold 46.9% share of the market while the nationals have captured 53.1% of the pharmaceutical business. From around 80% share in the pharma retail market, the MNCs have lost around 29% during the last twenty years as the national continue to improve their performance in the market place. Almost an identical trend is observed in units as well, nationals having 54.05% as compared to multinationals 45.95%. (IMS, Q1 & Q2, 2010)




GRAPH - 2 Top 10 Pharmaceutical Companies (PKR in Millions)


The overall market dynamics are tilted in favour of national companies as they are continuously launching new products at a much faster rate than MNCs, a trend which is becoming increasingly evident. In terms of new product market in value, the sales contribution gap between multinational and national companies has also increased over the last five years. The products launched before 1991 are dominated by the multinationals while after 1991 it is shifting towards the national. However, the leading 20 products of the industry are still those products which are launched by the MNCs between 1970 and 1990. (IMS, Q2 & Q3, 2010) Of the total markets size of 137.7 billion, the top 20 corporations contribute around 60% of total business, 34% of market concentrated among the top 5 corporations. The rest 40% of the market is distributed amongst 630 corporations in Pakistan. For the purpose of calculation in terms of value, the top 15 corporations make up 54%, top 35 corporations make up 75.09%, and top 75 corporations make up 90.91%, while the remaining corporations are competing for approximately 9% market share. (IMS, Q1 & Q2, 2007) The drugs prices of the national pharmaceutical companies are cheaper, as they have choice of procuring the raw material from those countries where it is available at a cheaper rate. The other reason for the price differential is that the national pharmaceutical industry does not invest in research and development compare to multinationals. Multinational companies invest a huge amount of their net profit in R & D, therefore, when they introduce a new molecule into the market they have already invested billions of dollars for a new product, therefore, the price of the new product keeps high in order to meet the total cost of the drug in a certain time period because after patent period any company can make its Me too or imitation at cheaper rate. So, the national companies have twice leverage to set their prices at the lower lever i.e. first they did not invest a single penny on Research & Development and secondly they are having cheaper raw material resources (Parmar & Jalees, 2004). Another, important point in price difference is that national companies are not bound to pay certain amount of profit to any other body, whereas, multinational companies are paying certain percentage of profit to their parent companies. Moreover, national companies do not have huge overhead expenses; in contrast, multinational companies allocate huge overhead expenses in different fields at the beginning of every fiscal year for every product in a certain ratio, therefore, the cost of goods (COG) are different in national and multinational




companies. In order to maintain all these costs they are bound to set a high price, otherwise bottom line will be very low and business would not be feasible any more. One of the reasons why the sector is vulnerable to corruption is that it is heavily regulated. Heavily regulation is essential to safeguard the population against sub-standard drugs and unfairly priced goods. But there is a second central reason why governments regulate the pharmaceutical market: to ensure that industrial policies strengthen economic competitiveness of the pharmaceutical sector and improve innovation and efficiency. These two objectives can sometimes lie at cross-purposes. If regulators are subject to pressure from commercial groups, health objectives can be compromised. Generous political campaign donations and lobbying expenditures by pharmaceutical companies are examples of such pressures. The relationship between drugs companies and physicians is also vulnerable to corruption. Doctors may be offered commissions for prescribing a particular drug or a drug from a particular company. Because this practice is illegal in most countries, companies may employ underhand methods to disguise such kickbacks. The aggressive promotion of medicines, the sheer volume of information that is received in its many forms by prescribers and the use of patient groups through which to generate demand for prescription drugs, all contribute to the inappropriate prescription of medicines. In the United States some US$ 16 billion is spent annually by pharmaceutical, device and biotechnology industries on marketing to physicians. The issue of unethical pharmaceutical marketing practice has received a great deal of attention in recent years, prompting many doctors associations, pharmaceutical industry associations and individual corporations to engage with the issue. Many have passed codes of conduct and ethical guidelines for the marketing of pharmaceuticals; but if not monitored and enforced, their impact will be limited. Another form of corruption threatening the pharmaceutical industry occurs during clinical trials. Doctors are often paid by pharmaceutical companies to recruit patients for clinical trials or sit on clinical trial boards while simultaneously on the pay role of the manufacturing company in question. Many research institutions and universities have institutional review boards or research ethics committees responsible for reporting procedures and policies regarding conflicts of interest. Problems arise as to who will monitor the conflicts of interest and what, if any, sanction doctors will receive for failing to disclose conflicts of interest. On a national level, oversight becomes even more problematic. Moreover, there is debate over whether disclosure is sufficient: should researchers be allowed to conduct research for companies in which they have a financial interest? Pakistani pharmaceutical industry also growing at rapid pace over last many years and reached to Rs. 137.7 Billion in 2010 (IMS Q2 2010) in this growth major chunk came from generic drugs manufacturer or generic drugs in Pakistan.




GRAPH - 3 Generic (Copy) Drugs (% Share of Total Market)


Above graph shows that market share of generic drugs in Pakistan in continuously increases over the years reach to 53.1% market share and likely to cross 55% market by the end of this year. This can also validated by the number of generic drugs making company in top ten pharmaceutical in Pakistan Getz Pharma, Hilton Pharma, Sami Pharma & Searle are top four generic drugs making companies listed in top 10 pharmaceutical companies in Pakistan.

GRAPH - 4

Research (Branded) Drugs (% Share of Total Market)


While looking at the research drugs market share in Pakistan continuously decreasing compare to the local / generic drugs making companies in Pakistan more than 53% market share in Year 2010 (IMS Q2 2010).




3. Hypotheses For studying the superiority of comprehensive income to net income for firm performance, we test the following hypotheses: H1o: The level of unethical drug promotion practices in pharmaceutical industry is high (at least 4) on the scale of (5 to 1) H1A: The level of unethical drug promotion practices in pharmaceutical industry is less than 4 on the scale of (5 to 1) H20: The levels of unethical drug promotion practices are high in rural areas. H2A: The levels of unethical drug promotion practices are not high in rural areas. H30: There is no significant difference on the opinions of doctor, pharmaceutics companies, hospitals and pharmacies on who initiated unethical drug promotion practices in Pakistan. H3A: There is significant difference on the opinions of doctor, pharmaceutics companies, hospitals and pharmacies on who initiated unethical drug promotion practices in Pakistan. H40: The contribution of the pharmaceutical industry in continuation of unethical drug promotion practices is higher than the doctors. H4A: The contribution of the pharmaceutical industry in continuation of unethical drug promotion practices is higher than the doctors.

4. Research Method The total population, and targeted population has been given as under and on the basis of targeted population we have selected our sample size which has also been elaborated as under, moreover, following research methodology will be adopted in order to conduct our research study. The total population of undertaken study consist of all Sales & Marketing Personnel of all Pharmaceutical Companies which are operating in Pakistan including Multinational & National Companies, all the doctor community whether they are General practitioner in rural or urban area or Medical Officers & Resident Medical Officers of Government & Private hospitals or the Consultants of all specialties whether they are working in Government or Private Hospitals, all the Retail Pharmacies' of the Country, all the whole sales pharmacies of the Country, all the Public & Private Hospitals of the Country, all the indoor & outdoor patients & their attendants' during the data collection time period and Government Offices & Officials which are directly or indirectly involved in order to implement & ensure the law enforcement which are related to the subject matter of undertaken study. Whereas the targeted population of undertaken study are Sales & Marketing Personnel of top 10 (according to IMS) Pharmaceutical Companies which are operating in Pakistan including Multinational & National Companies. These top 10 players have more than 80% share of total pharmaceutical volume, which include GSK, Abbott, Sanofi-Avantis, Novartis, Pfizer, Merck-Serrano, Buyer-Schering, Getz, Hilton, and Bosch Pharmaceuticals, peripheral and urban areas of Karachi City, general practitioner in rural (peripheral) and urban areas, medical officers & Resident Medical Officers of Government & Private hospitals or the Consultants of all specialties whether they are working in Government or Private Hospitals have been taken for this study. Probability sampling technique will be used because the research study based on quantitative analysis. For the sampling purpose the Cluster sampling technique will be used, another reason to use this sampling technique is, the overall population is very much scattered and spread in a larger geographical area of the city, moreover, the overall population is heterogeneous. Therefore, for sampling purpose different clusters will be collected from different areas of Karachi city. Researcher has used following six variables in order to




conduct the undertaken study and to draw statistical analysis & conclusions. The total sample of 300 has been extracted from following six different variables. - Multinational / national pharmaceutical's personnel - General practitioners (both rural & urban) - Medical officers & resident medical officers of public & private hospitals. - Consultants of all the specialties of public & private hospitals - Private and public hospitals including provincial & federal hospitals - Retail and whole sales pharmacies - Federal / provincial government officials - Indoor and outdoor patients & their attendants'

Both descriptive and inferential statistical techniques will be used through SPSS. The data will be presented in tables and charts. The statistical hypothesis will be tested with the help of z-test (involving two groups) and f-test (involving more than two groups) of significance. The graphical analysis will also be presented wherever it is needed. 4.1 HYPOTHESIS TESTING

4.1.1 HYPOTHESIS NO. I

H1o: The level of unethical drug promotion practices in pharmaceutical industry is high (at least 4) on the scale of (5 to 1) H1A: The level of unethical drug promotion practices in pharmaceutical industry is less than 4 on the scale of (5 to 1) The statistical representation of the above hypothesis is presented below: H10 : µ ≥ 4 H1A : µ � 4

The above hypothesis was tested through Z-test and the summarized result is presented below:

TABLE 01 LEVEL OF UNETHICAL DRUG PROMOTION PRACTICES

Mean 4.220 Standard Deviation 0.887 Hypothesized mean 4.00 Confidence level 0.95 Critical value one tail 1.645 Critical value two tail 1.96 Z-Calculated value 4.29 N 300 confidence interval 95.% lower 4.120 confidence interval 95.% upper 4.320 p-value (two-tailed) 1.76E-05 std. error 0.051 half-width 0.100

The hypothesis relating to high level of unethical drug promotion practices (at least 4 on the scale of 5-1) was substantiated. At 95% confident level, Z critical value is -1.645, and Z-calculated value is 4.29 that falls in the non-critical region.




So, it is concluded that the null hypothesis is accepted because 4.29 lies in non critical region and it is further concluded that the level of unethical pharmaceutical marketing practices is high (at least 4) on the scale of (5 to 1). 4.1.2 HYPOTHESIS NO. II Focus group discussions indicate that the level of unethical drug promotion practices is high in rural areas. Therefore the hypothesis developed in this context is presented below: H20: The levels of unethical drug promotion practices are equally higher in rural areas as compared to the urban areas. H2A: The levels of unethical drug promotion practices are not equally higher in rural areas as compared to the urban areas. The statistical representation of the above hypothesis is presented below: H20 : µ1 ≥ µ2 H2A : µ1 � µ2 Above test was carried out through by Z-two samples variables analysis, and the summarized result is presented below:

TABLE 02 LEVEL OF UNETHICAL DRUG PROMOTION PRACTICES IN RURAL AREA

Rural Urban Mean 4.03 3.50 Standard Deviation 1.01 1.21 Observations 300 300 Hypothesized Mean Difference 0 Z 5.81 p-value (one-tailed, lower) 1.0000 z Critical one-tail 1.645 P(Z<=z) two-tail 0 z Critical two-tail 1.95 difference (Rural - Urban) 0.527 standard error of difference 0.091

The hypothesis relating to higher level of unethical drug promotion practices in rural areas was substantiated. At 95% confidence level the Z-critical value taken from table is -1.645 and Z-calculated value is 5.81 that fall in the non-critical region. Therefore, it is further concluded that the levels of unethical drug promotion practices are higher in rural areas as compared to the urban areas.

TABLE 03

Unethical Practices (5 to 1) Common in Karachi Higher in Rural areas Equally higher in Urban areas

4.22 4.03 3.5

4.1.3 HYPOTHESIS NO. III

An important aspect is who was responsible for initiating the unethical drug promotion practices in Pakistan. Doctor, pharmaceutics companies, hospitals, pharmacies, Govt. Officials and Patients all have different opinions. In view of this disparity the developed hypothesis is presented below:




H30: There is no significant difference on the opinions of doctor, pharmaceutics companies, hospitals, pharmacies, Govt. Officials and Patients on who initiated unethical drug promotion practices in Pakistan. H3A: There is significant difference on the opinions of doctor, pharmaceutics companies, hospitals, pharmacies, Govt. Officials and Patients on who initiated unethical drug promotion practices in Pakistan. The statistical representation of the above hypothesis is presented below: H30 : µ1 = µ2 = µ3 = µ4 = µ5 = µ6 H3A : µ1 ≠ µ2 ≠ µ3 ≠ µ4 ≠ µ5 ≠ µ6 The above hypothesis was tested through simple ANOVA, and the summarized results are

presented below: TABLE 04

OPINION ON WHO INITIATED THE UNETHICAL DRUG PROMOTION PRACTICES

Groups Count Sum Average Variance Pharmaceutical company 300.00 439.00 3.59 2.62 Doctors 300.00 294.00 2.39 3.16 Hospitals 300.00 148.00 1.19 0.49 Pharmacy 300.00 140.00 1.11 0.19 Govt. Officials 300.00 140.00 2.11 1.29 Patients 300.00 140.00 2.29 2.31

Source of Variation SS df MS F P-value F crit

Bt. Groups 521.56 5.00 178.95 106.24 0.00 2.62 Within Groups 747.93 476.00 1.67

Total 1,269.48 479.00

The hypothesis relating to no significant difference of opinions on who initiated unethical drug promotion practices in Pakistan was rejected. At 95% confidence level and (5, 476) df the calculated F value of 106.24 is greater than F- critical values of 2.62.

TABLE 05

Unethical Practices (5 to 1) Groups Average Variance

Pharmaceutical companies 3.59 2.62 Doctors 2.39 3.16 Hospitals 1.19 0.49 Pharmacies 1.11 0.19 Govt. Officials 2.11 1.29 Patients 2.29 2.31

The above analysis also indicates that the pharmaceutical industry were found to be the entity that has initiated unethical drug promotion practices in Karachi with a mean of 3.59, followed by doctors with a mean of 2.39.




4.1.4 HYPOTHESIS NO. IV In the previous hypothesis, it was found out that the pharmaceutical industry initiated unethical drug promotion practices, in Pakistan. However, an important issue is that who is more responsible for the continuation of this practice. Based on the previous hypothesis the following hypothesis was developed. H40: The contribution of the pharmaceutical industry in continuation of unethical drug promotion practices is equal or higher than the doctors. H4A: The contribution of the pharmaceutical industry in continuation of unethical drug promotion practices is not equal or higher than the doctors. The statistical representation of the above hypothesis is presented below H40 : µ1 ≥ µ2 H4A : µ1 � µ2 Above test was carried out through by Z-two samples variables analysis, and the summarized result is presented below:

TABLE 06 OPINION ON WHO CONTINUED THE UNETHICAL DRUG PROMOTION

PRACTICES

Pharmaceutical

company Doctors Mean 2.94 3.81 Known Variance 3.52 2.61 Observations 300.00 300.00 Hypothesized Mean Difference 0 Z (4.39) P(Z<=z) one-tail 0.00 Z Critical one-tail 1.645 P(Z<=z) two-tail 0.00 Z Critical two-tail 1.96

The hypothesis relating to a higher contribution of pharmaceutical industry in unethical drug promotion practices was rejected. At 95% confidence level, the Z critical value is -1.645 and Z-calculated value is -4.39 that falls in the critical region. So, it is further concluded that the doctor community is more responsible for the continuation of unethical pharmaceutical practices.

TABLE 07 Pharmaceutical companies Doctors

Mean 2.94 3.81 Known Variance 3.52 2.61

Therefore, it is further concluded that the pharmaceutical companies do not have more contribution than the doctors in order to continue the unethical pharmaceutical marketing practices. In other words doctors’ community is more responsible for the continuation of unethical marketing practices in the industry.




5. Summary and Concluding Remarks

We have concluded the overall results and found that both doctors and pharmaceutical companies are equally responsible for unethical drug promotion practices in Pakistan. But most important and interesting findings are, basically pharmaceutical companies are responsible for initiating these unethical drug practices in Pakistan but now in continuation of these practices the doctor’s community is actually responsible for these unethical drug promotion practices in Pakistan. Now the doctors have become demanding and pharmaceutical companies are responsible to fulfill their ethical and unethical demands. Now, this has become an acceptable norm of the pharmaceutical industry and doctor’s community for the promotion of drugs in unethical ways. The monetary rewards, local and foreign visits in the name of scientific activities offered by the pharmaceutical companies for unethical promotion of the drugs are extensively used as a tool of promotion of their drugs. The entire above conclusion is evident from the four hypotheses that were tested through Simple ANOVA, F-tests and Z-tests.

The results of tested hypothesis are presented below:

1) The hypothesis relating to high level of unethical drug promotion practices (at least 4 on the scale of 5-1) was substantiated. At 95% confident level, Z critical value is -1.645, and Z-calculated value is 4.29 that falls in the non-critical region.

So, it is concluded that the null hypothesis is accepted because 4.29 lies in non critical region and it is further concluded that the level of unethical pharmaceutical marketing practices is high (at least 4) on the scale of (5 to 1).

It may be pointed that the level of unethical drug promotion practices as was ascertained by (Parmar and Jalees, 2004) in their research was 3.56. The reason could be that the study of (Parmar and Jalees) was case study of Hyderabad, where as this study is Karachi based, and the sample drawn was a more representative sample.

2) The hypothesis relating to higher level of unethical drug promotion practices in rural areas was substantiated. At 95% confidence level the Z-critical value taken from table is -1.645 and Z-calculated value is 5.81 that fall in the non-critical region. Therefore, it is further concluded that the levels of unethical drug promotion practices are higher in rural areas as compared to the urban areas.

An important aspect is who was responsible for initiating the unethical drug promotion practices in Pakistan. Doctor, pharmaceutics companies, hospitals and pharmacies all have different opinions. In view of this disparity the developed hypothesis is presented below:

3) The hypothesis relating to no significant difference of opinions on who initiated unethical drug promotion practices in Pakistan was rejected. At 95% confidence level and (5, 476) df the calculated F value of 106.24 is greater than F- critical values of 2.62.

The above analysis also indicates that the pharmaceutical industry were found to be the entity that has initiated unethical drug promotion practices in Pakistan with a mean of 3.59, followed by doctors with a mean of 2.39.




In the previous hypothesis, it was found out that the pharmaceutical industry initiated unethical drug promotion practices, in Pakistan. However, an important issue is that who is more responsible for the continuation of this practice.

4) The hypothesis relating to a higher contribution of pharmaceutical industry in unethical drug promotion practices was rejected. At 95% confidence level, the Z critical value is -1.645 and Z-calculated value is -4.39 that falls in the critical region.

Therefore, it is further concluded that the pharmaceutical companies do not have more contribution than the doctors in order to continue the unethical pharmaceutical marketing practices. In other words doctors’ community is more responsible for the continuation unethical marketing practices in the industry.

The qualitative analyses of determinants such as (a) tools of unethical drug promotion practices (b) drug promotion to the non-qualified doctors (c) Legislation for unethical drug promotion (d) eradication of unethical drug promotion is given as below:

a) As was discussed in the literature survey that the commonly used tools for unethical drug practices were, monetary rewards, local visits, and foreign visits etc. The summarized results are presented below:

It was discussed in earlier section that the doctors are the ones that are responsible for the continuation of unethical drug promotion practices. The Qualitative analysis shows that foreign visits with a mean of 4.59 are more in demand and local visits being the second. The reasons for high preferences for local visits and foreign visits are that pharmaceutical industry could justify these expenses by linking it with the conference.

b) Opinions on drug promotion to non qualified doctors were obtained. Ethically, the firms should not promote their drugs through them. The respondents’ opinions are presented below:

The Qualitative analysis shows that the majority of respondents’ of all the segments such as doctors, Pharmaceutical companies, hospitals, pharmacies, govt. officials or Patients were strongly against drug promotion to the non-qualified doctors. However, despite their opinions it is a fact that the drugs are being promoted through non-qualified doctors.

c) Respondents’ opinions were obtained on the prospects of strong legislation against unethical drug promotion practices. The respondents’ opinions are presented below:

Inference could be drawn from the Qualitative analysis that the majority of respondents are strongly in the favor of making some strong legislation against the unethical drug promotional practices in Pakistan. Although some legislation is already available but this research showed there is no implementation of that legislation, therefore, majority of respondent demanded that there must be strong legislation to stop this unethical drug promotion in Pakistan.

d) Opinions on eradication of drug promotion in Pakistan were obtained from the respondents’. The respondents’ opinions are presented below:




The Qualitative analysis shows that the majority of the respondents’ i.e. doctors, pharmaceutical personnel, hospitals, pharmacies, govt. officials and Patients strongly disagree about the opinion that the unethical drug promotion practices cannot be stopped now. Majority of respondents’ agreed upon that these unethical practices can still be stopped.

5.1 Recommendations

The focus groups discussions and survey findings suggest that strong legislation must be developed, implemented and enforced by the government. However, the regulations and legislation actually works when they are supported by the norms and values of the society.

In this particular case, these unethical practices are considered as the norms of the pharmaceutical industry and the doctor’s community; therefore, it could only be addressed by educating both the segments for realizing their social responsibilities with the focus on the patients’ well being.

Furthermore, there must be strong check and monitoring by the Ministry of Health and other monitoring agencies both on pharmaceutical industry and the doctors.

It is also strongly recommended that there should be strong legislation by the healthcare authorities and government agencies to stop or at least minimize these unethical pharmaceutical marketing practices both by the doctor community and the pharmaceutical industry.

There must be strong enforcement of existing rules and regulations by the relevant government departments and autonomous bodies who responsible to implement and ensure these rules and regulations both on pharmaceutical industry and the doctors’ community.

We also recommend to the doctors’ community that this is also their prime and ethical responsibility to avoid getting unethical benefits from pharmaceutical companies while they are prescribing their products.

The pharmaceutical industry should also restrict itself up to ethical marketing offers and discourage healthcare professionals if they would ask any thing which is unethical according to the ethical pharmaceutical practices guidelines.

Since the under taken study was a case study of Karachi City only, therefore, it could not be concluded that the result of the study if which would be conducted on country-wide would be the same as, therefore, further research can be conducted on Pan-Pakistan basis for more representative sample. Another dimension is to segregate the specialties and then could be conducted the study in order to analyze whether the results of different specialties are same or different. Since in this study only promotional or the marketing aspect of pharmaceutical industry is been covered, other areas of pharmaceutical industry like medical, production and procurement could also be covered. In this study few variables have been incorporated whereas, in further research more variables can be incorporated in order to have more clear and accurate results.




References A. Berenson & A. Pollack, Doctors Reap Millions for Anemia Drugs, N.Y. TIMES (May 9, 2007);

A. Catlin et al., National Health Spending in 2005, 26 HEALTH AFFAIRS 142 (2007).

Aaker, J. L., Williams, P. (1998). Empathy versus pride: The influence of emotional appeals across cultures. Journal of Consumer Research. 25(3), 241-261.

Aday, L. A. (1996). Designing and conducting health surveys (2nd ed.). San Francisco: Jossey-Bass. American College of Physicians. (1990). Physicians and the pharmaceutical industry. Annals of Internal Medicine, 112, 392-394.

Ahmed R.R & Jalees T, (2008), "Pharmaceutical Industry in Pakistan: Unethical Pharmaceutical Marketing Practices" (Eds) Market Forces, Karachi, Pakistan.

American Medical Association. (1991). Council on Ethical and Judicial Affairs. Gifts to physicians from the industry. JAMA, 265, 501.

American Medical Association. (1995-2002). Council on Ethical and Judicial Affairs. Ethical guidelines for gifts to physicians from the industry. Retrieved February 13, 2002 from: http://www.ama-assn.org/ama/pub/printcat/5689.html

Ashley Wazana, M.D., Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?, 283 JAMA 373 (Jan. 19, 2000).

Avorn, J., Chen, M., & Hartley, R. (1982). Scientific versus commercial sources of influence on prescribing behaviors of physicians. American Journal of Medicine, 73(1), 4-8.

Bar-On, R., Parker, J. D. (Ed.). (2000). The handbook of emotional intelligence. San Francisco: Jossey-Bass.

Bishnu P. Ravi S. (2005), “An educational initiative looks critically at the drug industry's promotional tactics” (Eds), 10.1371/journal.pmed.0020256, August 30.

Bodenheimer T. Uneasy alliance: clinical investigators and the pharmaceutical industry. N Engl J Med 2000; 342: 1539-1544.

Boseley, S. (2006) Drug firms a danger to health – report. The Guardian, 26th June

Bowman, M. A., & Pearle, D. L. (1988). Changes in drug prescribing patterns related to commercial company funding of continuing medical education. Journal of Continuing Education Health Professions, 8(1), 13-20.

Brennan, TA, Rothman, DJ, Blank, L, Blumenthal, Chimonas, S, Cohen, J.J., Goldman,J, Kassirer, JP, Kimball, H, Naughton, J, Smelser, N (2006). Health industry practices that create conflicts of interest, Journal of the American Medical Association, 295 (4); 429-433.




Campbell, E., Gruen, R., Mountford, J., Miller, L., Cleary, P., & Blumentahl, M., A National Survey of Physician –Industry Relationships, N. ENGL. J. MED. 356:17 (Apr. 26, 2007).

Chew, L. D., O’Young, T.S., Hazlet, T. K., Bradley, K. A., Maynard, C., & Lessler, D. S. (2000). A Physician Survey of the Effect of Drug Sample availability on Physicians' Behavior. Journal of General Internal Medicine, 15, 478-483.

Coleman, J., Katz, E., Menzel, H. (1968). Doctors and new drugs. New York: The Free Press of Glencoe.

Coyle, S. L. (2002a). Ethics and Human Rights Committee, American College of Physicians-American Society of Internal Medicine. Position Paper: Physician-industry relations. Part 1: Individual physicians. Annals of Internal Medicine, 136 (5), 396-402.

Coyle, S. L. (2002b). Ethics and Human Rights Committee, American College of Physicians-American Society of Internal Medicine. Position Paper: Physician-industry relations. Part 2: Organizational issues. Annals of Internal Medicine, 136 (5), 403-406.

Curcura, P. J. (1999). Stop saying “dinner meetings” it’s peer selling and it’s a science. Medical Marketing and Media, 34(12), 92-100.

Daniella. A and Michael. A (2005), “Interactions between Pharmaceutical Representatives and Doctors in Training”, J Gen Intern Med. August; 20(8): 777–786.

E. Hemminki, Review of Literature on the Factors Affecting Drug Prescribing, 9 SOC. SCI. & MED. 111 (1975).

Fisher S, Bryant SG, Kent TA (1993), “Post marketing surveillance by patient self-monitoring: trazodone versus fluoxetine”, J Clin Psychopharmacology; 13:235-242.

Frederick Sierles et al., Medical Students’ Exposure to and Attitudes About Drug Company Interactions, 294 JAMA 1034 (Sept. 7, 2005).

Gibbons, R. V., Landry, F. J., Blouch, D. L., Jones, D. L., Williams, F. K., Lucey, C. R. et al. (1998). A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts. J Gen Intern Medicine, 13, 151-154.

Gonul, F. F., Carter, F., Petrova, E., & Srinivasan, K. (2001). Promotion of prescription drugs and its impact on physician’s choice behaviors. Journal of Marketing, 65, 79-90.

Greene, J. (1999). Concern raised over increasing role of nonphysicians. American Medical News (December 6). Retrieved January 21, 2002 from: http://www.ama-assn.org .

Greene, J. (2000). Drug reps targeting non physicians. American Medical News (March 27). Retrieved January 21, 2002 from: http://www.ama-assn.org .




Harris, G. (2004). As doctors write prescriptions, drug company writes a check. New York Times, June 27, 2004. Retrieved July 2, 2004 from: http://www.nytimes.com/2004/06/27/business/27DRUG.final.html?ex=1089337894&ei=1&en=c0877fb1c152b62

Haxby, D. G., Rodriguez, G. S., Zenchnich, A. D., Schuff, R. A., Tanigawa, J. S. (1995). Manufacturers’ distribution of drug samples to a family medicine clinic. American Journal of Health Systems Pharmacology, 52, 496-499.

Healthy Skepticism (2002). About Healthy Skepticism Inc. Retrieved June 21, 2002 from: http://www.healthyskepticism.org/index.htm .

Hodges, B. (1995). Interactions with the pharmaceutical industry: Experiences and attitudes of psychiatry interns, residents and clerks. Canadian Medical Association Journal, 153, 553-559.

Holmer, A. F. (1999). Direct-to-consumer prescription drug advertising builds bridges between patients and physicians. JAMA, 281(3), 380-382.

Holmes, D.R., Firth, B.G., James, A., Winslow, R., Hodgson, P.K., Gamble G.,

IMS Health. (2002). Free pharmaceutical sample distribution. Retrieved June 24, 2002 from: http://www.ims-global.com/cgi .

Ingelfinger, F. J. (1972). Advertising: informational but not educational. New England Journal of Medicine, 286, 1318-1319.

Kessenich, C. R., Westbrook, M. H. (1999). Pharmaceutical companies and the prescriptive practices of nurse practitioners. Journal of the American Academy of Nurse Practitioners, 11 (12), 533-538.

Lane, R. D. (2000). Levels of emotional awareness. In R. Bar-On & J. D. A. Parker. (Ed.),The handbook of emotional intelligence (pp. 171-191). San Francisco: Jossey-Bass.

Lexchin J. (1992), “Pharmaceutical promotion in the third world”, Journal of Drug Issues; 22(2):417-422.

Lexchin J. (1995), “Deception by design: pharmaceutical promotion in the third world”, Consumers International, Malaysia.

Lidstone, J. MacLennan, J. Marketing Planning for the Pharmaceutical Industry, 2nd ed. Gower Publishing

Lurie, N., Rich, E. C., & Simpson, D. E. (1990). Pharmaceutical representatives in academic medical centers: Interaction with faculty and housestaff. Journal of General Internal Medicine, 5, 240-243.

Manning, R. & Keith, A. (2001). The economics of direct-to-consumer advertising of prescription drugs. In Manning, R. L. & Masia, N. A. (Eds.) Economic Realities in Health




Care Policy, 2 (1), 10-15. Retrieved May 13, 2002 from: http://www.Pfizer.com/pfizerinc/policy/Erhealthcare.pdf .

Manning, R. L. & Masia, N. A. (Eds.) (2001). Economic Realities in Health Care Policy, 2 (1), 10-15. Retrieved May 13, 2002 from: http://www.Pfizer.com/pfizerinc/policy/Erhealthcare.pdf .

Mathieu MP, editor. Parexel’s pharmaceutical R & D statistical sourcebook 1998. Waltham, Massachusetts: Parexel International Corporation, 1999.

Mintzes, B. (1998). Blurring the boundaries: new trends in drug promotion. Amsterdam: HAI-Europe. Retrieved February 1, 2003 from: http://www.haiweb.org/pubs/blurring/blurring.intro.html .

Mintzes, B., Barer, M. L., Kravitz, R. L., Kazanjian, A., Bassett, K., Lexchin, J. et al. (2002). Influence of direct to consumer pharmaceutical advertising and patients’ requests on prescribing decisions: two sites cross sectional survey. British Medical Journal, 324, 278-279.

Mixed Reaction to Consumer Advertising. (2003, March). Clinician News, 7(2), 13.

Murray, D. (2002, October 11). Gifts what’s all the fuss about? Medical Economics, 79 (9), 119-120.

National Institute for Health Care Management. (2001, November). Advertised prescription drugs are the hottest sellers. Washington, DC: Mahoney, A., Findlay, S.Retrieved February 15, 2003 from: http://nihcm.org/DTC2001PR.html .

National Institute for Health Care Management. (2002, May). Prescription drug expenditures in 2001: Another year of escalating costs. Washington, DC: Research and Educational Foundation. Available from: http://www.nihcm.org/spending2001.pdf .

No Free Lunch (2002a). About Us. Retrieved September 15, 2002 from: http://www.nofreelunch.org/aboutus.htm .

Parmar & Jalees (2004), “Pharmaceutical Industry in Hyderabad, Unethical Practices in Drug Promotion”, Independent Study for MS, Shaheed Zulfiqar Ali Bhutto Institute of Science & Technology, Karachi, May.

Paul Komesaroff and Ian Kerridge, “Ethical issues concerning the relationships between medical practitioners and the pharmaceutical industry”, MJA 2002; Vol. 176: P. 118-121

Phatak A (1998), “The pharmaceutical industry and the medical profession”, Indian Journal of Medical Ethics, Oct-Dec, 6 (4).

PhRMA (2002b). PhRMA Code on Interactions with Healthcare Professionals. Washington, D.C.: Authors.




PhRMA. (2002a). Media Room Press Release, April 19, 2002. PhRMA adopts new marketing code. Retrieved October 16, 2002 from: http://www.phrma.org/mediaroom/press/releases/19.04.2002.390.cfm .

Poor judgment in spite of high intellect: Neurological evidence for emotional intelligence. In Bar-On, R., Parker, J. D. (Ed.). (2000). The handbook of emotional intelligence. San Francisco: Jossey-Bass.

Popp, R.L., Harrington. R.A. (2004). Conflict of interest, American Heart Journal, 147(2); 228-237.

Sandberg, W. S., Carlos, R., Sandberg, E. H., Roizen, M. F. (1997). The effect of educational gifts from pharmaceutical firms on medical students’ recall of company names and products. Academic Medicine, 72, 916-918.

Sharpe, V.A. (2002). Science, bioethics, and the public trust, Hastings Center Report, 32(3); 23-26.

Sibbald H. (2004) Legal Action against GSK over SSRI data CMAJ. July 6; 171(1): 23.doi: 10.1503/cmaj.1040982

Socolar, D., Sager, A. (2001, October). Pharmaceutical marketing and research spending: The evidence does not support PhRMA’s claims. Paper presented at American Public Health Association Annual Meeting (session 2018.0), Atlanta, GA.

Steinman, M. A., Shlipak, M. G., & McPhee, S. J. (2001). Of principles and pens: Attitudes and practices of medical house staff toward pharmaceutical industry promotions. The American Journal of Medicine, 110, 551-557.

Stolberg, S. G., & Gerth, J. (2000, November 16). High tech stealth being used to sway doctor prescriptions. New York Times. From http://nytimes.com/2000/11/16/science/16PRES.html .

T. Brennan et al., Health Industry Practices That Create Conflicts of Interest, 295 JAMA 429 (Jan. 25, 2006).

Tomlinson H (2004) AstraZeneca sued for ulcer drug profits. The Guardian, 24 November

Tutor2u. (2004). Buyer Behavior - Stimulus-Response Model. Retived June 25, 2004 from: http://www.tutor2u.net/business/marketing/buying_stimulus_model.asp.

Wang, T. J., Ausiello, J. C., & Stafford, R. S. (1999). Trends in antihypertensive drug advertising, 1985-1996. Circulation, 99(15), 2055-2057.

Waud, D. R. (1992). Pharmaceutical promotions-a free lunch? New England Journal of Medicine, 327, 351-353.

Wazana, A. (2000). Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA, 283(3), 373-80.




Westfall, J. M., McCabe, H., & Nicholas, R. A. (1997). Personal use of drug samples by physicians and office staff. JAMA, 278:141-143.

Westfall, J. M., McCabe, H., & Nicholas, R. A. (1998). Reply to Drug samples: Benefit or bait? JAMA, 279(21), 169-1699.

Willimack, D. K., Schuman, H., Pennell, B. E., & Lepkowski, J. M. (1995). Effects of pre-paid non-monetary incentive on response rates and response quality in a face-to-face survey. Public Opinion Quarterly, 59, 78-92.

Wolf, B. (1998). Drug samples: Benefit or bait? JAMA, 279(21), 1698-1699.

Wolfe, S. M. (2002). Direct-to-consumer advertising – Education or emotion promotion? New England Journal of Medicine, 346(7), 524-526.

Zaidi SH, Niaz U, Jafary MH & Jawaid SA, (1995), "Medical Ethics in the Contemporary Era" (Eds) Pakistan Medical Journalists Association, Karachi, Pakistan.

Ziegler, M. G., Lew, P., & Singer, B. C. (1995). The accuracy of drug information from pharmaceutical sales representatives. JAMA, 27, 1296-1298.

ETHICAL AND NON-ETHICAL PHARMACEUTICAL MARKETING PRACTICES: CASE STUDY OF KARACHI CITY

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