his is a response to Professor Dr Zafar Mirza’s column published on January 24, Bribed Doctors, explaining findings of a study (he was part of) published in the BMJ Global Health 2024.
These findings are insightful and open room for reviewing existing practices within the country and provide an opportunity to suggest possible solutions. Primary healthcare providers in private practice are an important part of our healthcare system and an asset. The focus here is on proposing some solutions to deal with incentive-linked prescribing.
In order to provide a solution, let’s look at some of the important areas that need addressing prior to minimising pharmaceutical-led prescribing.
1- First and foremost, it’s the doctors’ earnings. In most cases, trainee doctors and those who qualify as primary care physicians after spending years in training do not earn more than $350 per month. This is true, especially in the initial years of practice. This amount is not much different from the $170-180 per month salary earned by someone who has only completed primary school education. Ensuring a substantial pay package for doctors is worth considering. Adequate compensation to physicians by the government can be linked to their overall performance, clinical services, quality of care, regular quality assurance and assessments.
2- There are a number of medical conferences held per year. For them to be an effective educational resource, they must be arranged in educational institutions rather than hotels. This will be hugely cost effective and finances can be diverted for other uses like: scholarships/ bursaries etc for deserving students for presenting their scientific research papers at national and international conferences. In addition, no pharmaceutical drug promotional banners should be displayed within educational institutions or healthcare facilities. We must set standards and protect our students and young professionals from such promotions and practices. When making a decision about such issues it might be worth considering the slippery slope argument (ethics) in order to reach a reasonable solution.
3- We can set an example through the regularly arranged continuous professional development (CPD)/ continuous medical education (CMEs) sessions. In such events presenters/ speakers can ensure that their contents are not influenced by pharmaceutical businesses. It must not appear like a drug promotional event with large banners occupying the event hall. Gifts and sponsored trips offered by pharma companies must not be encouraged either. We must be clear on what is acceptable and when we must politely refuse. We must remind ourselves of the Hippocratic Oath in which we pledge that we will serve with integrity and honesty and will act in the best interest of our patients.
World Health Organisation encourages prescribing by generic name. Drug Regulatory Authority of Pakistan issued a notification to healthcare professionals in both the public and private sectors to prescribe medications using non-propriety names.
4- Compulsory postgraduate training for primary care physicians. Such programmes must include workshops, clinical assessments, feedback on consultations and discussions on clinical scenarios with ethical issues and conflicts of interest. Primary care physicians who are more aware and empowered and have developed advocacy and leadership skills, will be able to support the cause more proficiently.
5- Mandatory annual appraisals for physicians to ensure can ensure they are up-to-date with skills and knowledge. This also offers an opportunity to provide feedback to physicians on their performances and clinical skills.
6- World Health Organisation encourages prescribing by generic name. Drug Regulatory Authority of Pakistan has issued a notification to healthcare professionals in both the public and private sectors asking them to prescribe medications using non-propriety names.
7- Mandatory inclusion of family medicine in the undergraduate medical curriculum. The curriculum must be developed and taught by qualified primary care physicians. This will enable better understanding of the discipline and what it can offer for the betterment of healthcare system.
8- Regular clinical audits at both public and private sector healthcare facilities will streamline the implementation of antibiotic stewardship.
9- Family medicine faculty should be supported by the degree awarding institutions, specialty colleagues, policymakers and important stakeholders with governments in implementing high-quality primary care education. There are examples of primary care outpatients being successfully managed within secondary care facilities. This approach should be explored further to deal with the problem at hand.
10- The government should engage private general practitioners in a meaningful dialogue to achieve desired outcomes in non-communicable disease (NCD) management, communicable disease (CDs) handling nd antenatal care provision at the community level.
11- Advocacy and support from relevant stakeholders (politicians, regulatory authorities, healthcare commissions, policymakers) in supporting a robust and resilient primary care system to strengthen the overall health system of the country and achieve universal health coverage us crucial.
The writer is an associate professor in family medicine at Health Services Academy, Islamabad
