Script mystery: Healthcare professionals are often paid by pharmaceutical companies for speaking engagements and research. The lack of disclosure of these transactions in SA means patients are not aware if drug companies may be influencing the decisions of a prescriber. Picture: ISTOCK
Script mystery: Healthcare professionals are often paid by pharmaceutical companies for speaking engagements and research. The lack of disclosure of these transactions in SA means patients are not aware if drug companies may be influencing the decisions of a prescriber. Picture: ISTOCK

South African patients are oblivious of the hidden hand of the pharmaceutical industry, which every year pays millions of rand in speakers’ fees, free meals and research grants to doctors and research institutions.

There is no legal requirement for the companies to reveal the perks they give to medical professionals, nor are they willing to volunteer the information.

In contrast, US law requires these same firms to publicly disclose their payments to doctors and teaching hospitals. They do so voluntarily in the UK as part of a Europe-wide move towards greater transparency, as well as in Japan and Australia.

The lack of disclosure in this country leaves consumers in the dark about whether drug companies may be inappropriately influencing the prescribing habits of doctors.

speaking and consulting fees

The database, which has been operating since 2014, shows that more than 618,000 physicians and 1,100 teaching hospitals collectively received more than $7.52bn from drug and device makers last year. More than half that amount ($3.9bn) funded research — the rest went to speaking and consulting fees, meals and gifts

Nor do they know what conflicts of interest the experts may experience who advise the Medicines Control Council (MCC) whether or not to allow drugs onto the market, or those who draw up treatment guidelines for diseases such as hypertension and asthma or compile the government’s list of approved medicines for hospitals and clinics.

"There is global debate about the impact of this funding on the independence of those receiving the funds," says Medical Research Council senior scientist Tamara Kredo.

Citing treatment guideline development as an example, she says poor reporting on conflicts of interest potentially erodes the trust that patients and the public place in clinicians.

Recent analysis of the US Open Payments database found that doctors who received free meals from drug companies were more likely to prescribe their medicines than cheaper generic rivals, and that fancier meals were associated with the highest prescribing rates.

The study, published earlier this year in the journal JAMA Internal Medicine, examined 63,000 payments made to nearly 280,000 doctors over a five-month period. Most received fairly cheap meals, ranging between $12 and $18.

The database, which has been operating since 2014, shows that more than 618,000 physicians and 1,100 teaching hospitals collectively received more than $7.52bn from drug and device makers last year.

More than half that amount ($3.9bn) funded research — the rest went to speaking and consulting fees, meals and gifts.

Huge sums are paid out in other countries too: the top 10 pharmaceutical companies in Japan spent $1.63bn on healthcare professionals and researchers in 2013, while Medicines Australia recorded $A64m in similar payments in the 12 months to April 2016.

Industry sources say drug makers still pay hefty fees to individuals they identify as ’key opinion’ leaders

Business Day asked six multinational pharmaceutical companies to disclose the nature and size of the payments they made to doctors and researchers in SA in 2015. None were willing to do so.

Abbott ignored several e-mailed requests for comment. Novo Nordisk and Eli Lilly said they could not disclose the information because it would breach confidentiality agreements and data privacy laws such as the Protection of Personal Information Act.

Pfizer said there was no legal requirement to publish payments to researchers. However, this information was fully disclosed in clinical trial applications to the MCC and to the ethics committees that approve these projects. "We therefore recommend that you consider approaching the relevant ethics committees for that information," said Pfizer spokeswoman Charmaine Motloung.

Picture: ISTOCK
Picture: ISTOCK

Sanofi-Aventis would need consent from all the healthcare professionals involved to publish the data, said its spokeswoman for SA, Prudence Selani. She declined a request to provide aggregate data that masked the identities of the healthcare professionals.

GlaxoSmithKline, which discloses payments to doctors in the US, Japan, Australia and Europe, declined to provide data for SA. "We will work with the industry and government when they are ready," said its GM for South and Southern Africa, Davies Gichuhi.

Eli Lilly’s MD for SA and sub-Saharan Africa, Ann-Marie Hosang, said in principle the company supported public disclosure of payments to healthcare professionals in SA, provided it was governed by an appropriate regulatory framework. She declined to provide information on its payments to healthcare professionals in SA.

Local generic drug manufacturer Adcock Ingram was equally reticent.

Spokeswoman Vicki St Quintin would not provide details of the payments the company made to doctors, but said the company complied with the guidelines drawn up by the Marketing Code Authority, a voluntary industry association.

Aspen Pharmacare, another local generic manufacturer, was the most forthcoming. The company paid R883,000 in speakers’ fees to healthcare professionals last year, said head of strategic trade Stavros Nicolaou.

Some scientists, such as MCC chairwoman Helen Rees, have consistently refused to take funding from the pharmaceutical industry.

"I never do it, and never have. No one asks me anymore," she says. "I’ve said no since I was a medical student. I always thought good drugs must be used on the basis of their benefits to the patient, not on marketing ploys."

Others regard it as a legitimate source of income.

"I know there often is suspicion about the influence of the pharmaceutical companies on the profession," says David Marais, chairman of the Lipid and Artherosclerosis Society of SA. "However, my personal experience is that working together has ensured translation of therapeutics to patients with serious disease."

He credits pharmaceutical companies with helping to provide state-of-the art treatment for patients with severe disorders and enabling university researchers to keep up to date with global scientific advances by paying for them to attend academic meetings.

"Conflicts of interest have to be declared at all academic presentations and publications to indicate potential bias, but amounts are not.

"My feeling is that this is enough and doing more, though superficially attractive, will not really be worthwhile: we are overburdened with administration and the system may not accurately reflect what is going on," Marais says.

Conflicts of interest have to be declared at all academic presentations and publications to indicate potential bias, but amounts are not. 

Southern African HIV Clinicians Society president Francesca Conradie is frank about the payments she receives from pharmaceutical companies. She says she participates in training events — such as panel discussions to debate the pros and cons of different HIV/AIDS medications — as well as advisory boards. Fees typically range between R5,000 and R15,000 a session, she says.

"My area of interest is narrow and the choice of drugs is usually determined by the funders. I can’t see how it [the payments] would make a difference. I have never been asked directly or indirectly to sell a product," says Conradie.

She says researchers have to declare their conflicts of interest when they attend conferences and when they provide expert advice to the MCC.

The head of the University of Cape Town’s ethics committee, Marc Blockman, says pharmaceutical industry support for doctors is not necessarily wrong. However, the lack of transparency in the South African system is a problem.

"No one does a lecture tour without being paid for it. We need a discussion about regulation: can we allow people to make extra money in a way that is not prejudicial to patient care?" he says.

The Department of Health and the MCC are moving towards greater transparency.

The MCC is exploring its options for making its members’ conflicts of interest available to their peers and to the public, says Rees.

The department’s deputy director-general for regulation and compliance, Anban Pillay, says the experts who help draw up the Essential Drug List for hospitals are required to declare their conflicts of interest to the committee chair, who can ask people to recuse themselves from specific discussions.

The information is not made public, but the Essential Drug List committee should consider making it so, he says.

It would be impractical to try to ban payments from drug makers to healthcare professionals, so the Department of Health supports the global move towards greater transparency, says Pillay.

"Public disclosure should happen. It will temper the way the profession acts," he says.

The Innovative Pharmaceutical Association of SA’s CEO, Konji Sebati, says she sees no harm in public disclosure of payments to doctors. "There’s nothing to hide. We are pushing the health department to legislate," she says

In the absence of legislation, the only strictures on the payments pharmaceutical companies make to healthcare professions are those imposed by the Marketing Code Authority.

It has published a code that curtails some of the more egregious payments such as free overseas trips for spouses.

Sebati says the authority regularly deals with complaints from its members. However, only a handful of cases are to be found in the complaints section of the authority’s website, and none related to payments to healthcare professionals.

Despite the constraints imposed by the marketing code, industry sources say drug makers still pay hefty fees to individuals they identify as "key opinion leaders".

These are people at the top of their profession who wield influence over their peers’ prescribing habits.

They get paid for services such as participating in advisory board meetings, speaking at conferences, and providing training. Advisory board meetings are sometimes used to help guide research into medicines or launch new products.

Some prescribers also make money by becoming involved in clinical trials and receive payment for meetings to plan, monitor and evaluate the research.

Opinion is divided over the extent to which these payments are justified.

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