Disputing Distribution: Ethics and Pharmaceuticals in Nepal Nabin Rawal , Ian Harper and Madhusudan

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• Disputing Distribution Ethics and
  Pharmaceuticals in NepalNabin Rawal , Ian Harper
  and Madhusudan Subedi

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Pharmaceutical Industry in Nepal

• 100 million per year in Nepal and increasing
• Approx. 30 of the market Nepali products, but
  still dominated by India
• Over 45 Nepali companies
• No export (as of yet)

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The Context

• On July 19th 2007, the Government of Nepal,
  through its Department of Drug Administration
  (DDA) released its Guidelines on Ethical
  Promotion of Medicine
• The objective of this guideline is to promote
  ethical promotion of medicine to support and
  encourage the improvement of healthcare through
  the rational use of medicine and discourage
  unethical practices.
• (Drug Bulletin of Nepal, Ethical promotion of
  medicine Benefit to consumers, 2007)

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• The guideline dwells on a number of issues, for
  instance
• information to physicians and health related
  professionals
• Information to general public
• Advertisments
• Company procedure and responsibilities
• Medical Representatives (MRs)
• Free sample of medicine for promotional purposes
• Symposia and other scientific meetings among
  others
• But what is interesting is that the issue of
  bonus has come to take center stage.

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Antecedents of the Guideline

• In 1988, WHO had published a concept on Ethical
  Criteria for Medicinal Drug Promotion.
• DDA commissioned a group of pharmacists to
  conduct a study on the Promotional Practices of
  Pharmaceuticals in Nepal.
• With the consent from all the stakeholders, DDA
  put the guideline into effect on Shrawan 3, 2064
  (2007/07/19).

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Guideline Claims and Counterclaims
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Graduate Pharmaceuticals Association of Nepal
(GPAN)

• The Why of the Guideline
• Wide variation in bonus scheme offered (Offers
  ranged from 10 percent to 100 percent depending
  on the product)
• No offer system in sale of some product
• Conclusion Business practices should meet high
  standards of ethics and legal compliance

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Nepal Chemist and Druggist Association (NCDA)

• The Guidelines on Ethical Promotion of Medicine
  2007 should be abrogated (why??)
• Drawn up unilaterally
• Reduction in bonus must give way to reduction in
  prices of the pharmaceuticals ( DDA in cahoots
  with producers)
• Guidelines not in consonance with the context of
  the country (Regulation of unregulated market
  with paramedics expansion into this trade)
• DDA focused on deal bonus but did not attend to
  other issues put forth by NCDA when the president
  was called just before the guideline was to be
  issued

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Nepal Medical and Sales Representative
Association (NMSRA)

• NMSRA should be registered in the DDA
• Foreign companies distributing drugs in Nepal
  should either open their office in Nepal or the
  importer is made responsible on their behalf.
• APPON and individual manufacturing companies want
  to make our job less secure. (uniformity in
  salaries and benefits)
• Link between pay and sales levels rescinded

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Association of Pharmaceutical Producers of Nepal
(APPON)

• Rise of competition gave way to rise of gifts and
  bonuses
• Regulatory mechanism of Nepali pharmaceutical
  market is yet to be developed.
• Different pharmaceutical producers--various
  companies to be consulted before developing the
  code of conduct for ethical marketing in Nepal.
• Deals make it easy to competeopen border and
  Indian companies offering bonus
• We will abide by the government (less bonus means
  the price in medicines will decrease)

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Nepal Medical Association (NMA)

• Doctors not to blame for the anomalies
• Giving calendars, pens, diary is widely
  acceptable all over the world
• Doctors and retailers not taking gifts but pushed
  by the manufacturers
• A body consisting of all stakeholders must work
  to eliminate malpractices.
• DDA has started a correct move

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Nepal Medical Association (NMC)

• We are bound by our own Code of Ethics
• DDA responsible body for quality control
• APPON should ensure fair business within the
  companies.
• NMC ready to punish corrupt doctors if found
  indulging in malpractices

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Department of Drug Administration (DDA)

• Guideline responsibility of the companies but no
  action lead to DDAs issuance of the guideline to
  control anomalies in the market
• Formation of a committee to look a the issue of
  fixing of prices for 22 items
• Bonus has been capped to 10-20 percent upon the
  request of the producers
• Some companies under the table activities have
  discouraged companies adhering to the code

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• Currently, trying to curb unethical promoting
  in the form of bonus and substitution
• Importer- Onus on imported drugs
• Currently, guidelines watered down on the bonus
  issue at the expense of others.

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Discussion

• Public welfare Vs Business (The Paradox)

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• 2. Ethicsa relative positioning

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• 3. Blame game rather than self-introspection of
  ones practices

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• 5. What is at stakeIn the face of emergent
  Nepali pharmaceutical industry is it about
  struggle and capture of generic market?

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• 5. Different Actors different stances How then
  should regulation be undertaken?