85% citizens surveyed support NMC guidelines prohibiting Doctors from receiving gratification from various companies and establishments; Only 7% approve of the guideline that mandates Doctors to only write name of salt in prescription

August 18, 2023, New Delhi: The National Medical Commission (NMC) on August 2 issued a directive to all doctors to prescribe generic salts or drugs, not branded generic drugs, failing which they will be penalized, including their license to practice could be suspended on repeated violations. Earlier doctors working in central government hospitals, CGHS wellness centres, and polyclinics have been directed repeatedly by the Ministry of Health and Family Welfare to only prescribe generic drugs, and write the names legibly, preferably in capital letters, so that there is no confusion. This is the first time that NMC in its 'Regulations Relating to Professional Conduct of Registered Medical Practitioners' has introduced penal provisions, which was earlier restricted to warnings. Further, the NMC directive will apply to all medical practitioners and not just to government employed doctors. "Every RMP (registered medical practitioner) should prescribe drugs using generic names written legibly and prescribe drugs rationally, avoiding unnecessary medications and irrational fixed-dose combination tablets," the NMC regulation states in yet another attempt to break the doctors and pharmaceutical companies’ nexus which has long been a major problem globally, not just in India, leading to several medical malpractices.

In July 2022, the Ministry of Health and Family Welfare had admitted that "the Government of India is aware that, despite Court orders and relevant regulations of the Medical Council of India, generic medicines are not being prescribed by the majority of medical practitioners". The Central government has also directed that any information about a new launch should be communicated to the hospital/ doctors only via e-mail as visits by medical representatives to hospitals are to be strictly restricted. Though the law prohibiting pharmaceutical companies from giving “freebies” to doctors has been in place since January 1, 2015, they remained voluntary. The new NMC regulations categorically bar doctors and their families from receiving any gifts, travel facilities, hospitality, cash or access to recreation from pharma companies or their representatives, commercial healthcare establishments and medical device firms under any pretext. It also bars doctors from endorsing any drug brands, medicine and equipment or advertise them.

Reacting to the NMC directives on generic medicines, the Indian Medical Association (IMA) has stated that the “measure is just shifting the choice from a medical practitioner who is primarily concerned, trained and responsible for the patients’ health than a chemist/ person sitting in a chemist shop, who is selling drugs. This naturally wouldn’t be in the best interest of the patient.”

The LocalCircles platform has been receiving complaints and suggestions on the need for stringent rules and penalties to break the commission nexus between doctors and labs, nursing homes and hospitals, pharmaceutical companies, chemists, etc. Some citizens have also reported real life experiences about how the commission nexus has led to them or their family becoming victims of medical malpractices and profiteering like having to undergo unnecessary and repeated testing as well as paying more for medicines and hospitalisation.

Striving to understand citizens’ concerns and inputs, LocalCircles has conducted a national survey to find out people’s perception of the commission nexus and malpractices. It also sought their views on the latest NMC guidelines especially in regards to restrictions on such malpractices and the use of generic salt names by Doctors in prescriptions. The survey received over 43,000 responses from citizens located in 326 districts of India. 65% respondents were men while 35% respondents were women. 44% respondents were from tier 1, 35% from tier 2 and 21% respondents were from tier 3, 4 and rural districts.

72% citizens believe their doctor(s) are receiving commissions from several sources like labs, nursing homes & hospitals, pharmaceutical companies, chemists, etc

It is not uncommon for many doctors to recommend certain laboratories or diagnostic clinics when asking the patients to get various tests done. Many of these labs or clinics may well have tie-ups with the hospital or individual doctors. The survey first sought to know from citizens about their understanding of commission nexus between doctors and path labs, nursing homes, chemists, etc. The survey asked respondents “Who all do you believe are providing incentive/commissions in cash or kind to the doctors/specialists that you generally consult?” In response, 8% of citizens surveyed said “some pathology and diagnostic labs”, 1% said “some private nursing homes & hospitals”, and 6% said “some pharma companies”. In total, 49% of citizens believe “most of the above or all of them”, and 23% said “most or all of the above and a few others” are providing incentives to the doctors. Only 4% said “none of them”, and 9% couldn’t say. On an aggregate basis, 72% of citizens believe their doctor(s) are receiving commission income from several sources like labs, nursing homes & hospitals, pharmaceutical companies, chemists, etc. This question in the survey received 10,401 responses.

Only 7% of citizens surveyed approve of the NMC’s new regulation that mandates Doctors to only provide name of the salt or generic drug when prescribing medicines

India is one of the biggest manufacturers of generic medicines yet many people end up buying more expensive branded drugs or even generic branded drugs prescribed by doctors, even though cheaper and effective alternatives are available in the market. “The National Medical Commission guidelines say that Doctors who fail to prescribe the name of the salt and instead prescribe branded drugs can be issued a warning and in case of repeated violations, their license can be suspended. A large number of concerns were received from citizens after they read media reports on the subject. To understand the same, the survey asked respondents “As a patient, what would you want your doctor to prescribe for your ailments?” This query received 20,706 responses with only 7% of citizens surveyed approving the NMC’s new regulation that the doctors should only provide the name of the salt or generic drug when prescribing the medicines. Among the remaining respondents to this query 60% said they wanted their doctors writing names of the branded drug along with the name of the salt “in case I want to opt for generic medicine”; 22% favoured that the doctors should “name the salt and as an example mention name of a branded drug”; 7% want the doctors to just prescribe “the branded drug” and in addition, 4% of the respondents mentioned “can’t say”.

With 60% being in favour of knowing what the Doctor suggests as well as knowing the name of the salt will help them go for an alternative medicine in case the recommended medicine was not available. Also, many citizens expressed that in addition to the branded medicine, knowing the salt name will allow them to purchase an affordable generic in case the branded medicine was very expensive. Some citizens in the community discussions also cited that the Doctor over time gathers experience about which medicine brand has been most effective for majority of their patients and tends to use that as a datapoint in their decision of what to prescribe to the next patient. By having the name of the specific medicine in the prescription along with the salt name, they benefit from a Doctor’s knowledge and experience while the final decision of what to buy still resides with them. A few citizens also cited the concern about prevailing high chemist margins on generic drugs versus branded medicines could also lead to misleading and profiteering by the chemists, unless trade margins were capped. All in all, the strong sentiment that came out in this poll and the community discussions was that people want to be informed by having both the names i.e. recommended branded drug and the salt, and make the decision based on recommendation, availability, affordability instead of a doctor or a chemist making it for them.

85% of citizens surveyed in support of the NMC guidelines that restrict doctors and their family members from receiving any kind of commission or gratification

The survey next asked respondents about the guideline that restricts Doctors from receiving any gratification in cash or kind, directly or indirectly from any entity. It asked them, “The National Medical Commission guidelines restrict doctors and their family members from receiving gifts, grants, commissions, hospitality and other forms of gratification from pharmaceutical and medical device companies, pathology/ diagnostic labs, hospitals, other commercial establishments, etc. Do you support this move?” Of the 12,393 citizens who responded to this query 85% indicated support for the NMC guidelines that restrict doctors and their family members from receiving any kind of commission or gratification from pharma, medical devices companies or pathology/ diagnostic labs, hospitals or other commercial establishments. Remaining 15% of citizens surveyed did not agree with the NMC’s guidelines on this issue.

​In summary, the findings of the survey indicate that 72% of citizens believe their doctor(s) are receiving commission income from several sources like labs, nursing homes & hospitals, pharmaceutical companies, chemists etc., for use of their products or services. The outcome of this sentiment is that 85% of those surveyed indicated support for the NMC guidelines that restrict doctors and their family members from receiving any kind of commission or gratification from pharma, medical devices companies or pathology/ diagnostic labs, hospital or other commercial establishments On the issue of how Doctors should prescribe medicines, only 7% of citizens surveyed support the NMC’s new regulation that the doctors should only provide name of the salt or generic drug when prescribing the medicines. Of the remaining respondents to this query 60% want their doctors to write names of the branded drug along with the name of the salt 22% favoured that the doctors should name the salt and as an example mention the name​ of a branded drug. The findings in the survey and the community discussions indicate that people want to be informed by having both the names i.e. recommended branded drug and the salt, and make the decision based on recommendation, availability, affordability, etc. instead of a doctor or a chemist making it for them.

The Central Government and the NMC’s efforts to bring about more accountability through stricter rules is welcomed by the people. What remains to be seen is how effectively the new regulations are implemented and whether those violating the regulations are indeed barred from practicing. The key to success is first making the guidelines and rules practical and then enforcing them effectively. An easy mechanism will be needed for citizens to report non-compliances which should then be investigated swiftly along with fast action against the violators. While all of this is being done, the complainant must be updated with status of the grievance to build faith in the process and redressal mechanism.

LocalCircles will escalate the findings of this study with the key stakeholders involved with NMC guidelines such that the public view and concerns are given the due consideration.