The Role Of Medical Representatives In Rm Marketing Essay

Published Date: 23 Mar 2015

In Relationship marketing, role of Medical representative is changing. Medical representative is the pharmaceutical missionary sales person (FIG: 1.9), or drug representative who provides information on drugs and product samples to physicians. Also, it is the pharmaceutical representative who keeps an eye on the physician's prescribing pattern in a particular area and get back to his or her company with the details. Pharmaceutical representative works for a single or a group of drugs and meet the physician's practising in that specific field only.

A medical representative is naturally expected to achieve the product-wise, unit-wise and value-wise sales target monthly and cumulatively. A Medical rep. is a vital communication link between the drug manufacturer and the medical professional. He is the most reliable source of feedback on what is happening to company's products in the competitive market, customers perception and sales strategies etc. Medical representative act as a link between a company, stockiest and customers and ensures the smooth working of the network.

Now days, Indian pharmaceutical companies are outsourcing a portion of their medical representative work force, in a bid to become more competitive. The move supports expansion into newer geographies in the domestic market and could be aimed at reducing the hold of trade unions. Also, outsourcing medical representatives can prove to be cost effective as Pharma Company has a zero liability and moreover it's the medical rep., who is responsible for sales through good relationships with medical practitioners.

Issue of medical sales force outsourcing.

Bangalore based Charak pharma was among the first companies in India to outsource medical representatives through franchisees. According to industry sources, the companies Uttar Pradesh's franchise employs over 50 medical representatives, while its Chennai franchisee employs around 40 medical representatives.

According to a National Trade Union, Federation of Medical and Sales representatives association of India (FMRAI) - In India, Novartis, e-Merck, USV, IDPL, Jagsonpal, Cipla, Ranbaxy labs and Nicholas primal outsource part of their sales force to third parties.

Mr. Akshay Nath, executive director, Innovex opines that hiring contracted medical representatives also allows pharma companies to break trade unions, once a very strong force in the industry. The contract sales organization is fully responsible for hiring representatives. The appointment letters is from contract sales organization wherein the medical representative can work for any client with whom contract sales organization ties up.

R.B. Smarta, MD, Interlink (marketing consultancy) opined that many MNC's in India such as e-merck too are outsourcing medical representative's work. MNCs cannot increase their manpower in India due to budget constraints and hiring contracted medical representatives allows them to expand their reach in the market without taking the liability associated with hiring new people.

Amit Guha, joint general secretary, FMRAI had told that Nicholas Piramal also works with franchisee to promote some of its established products and the company had given number of its old products to a franchisee named Jeevan, where the medical representatives do the same work as the direct medical representatives of the company but are maintained under contract.

Amar lulla Joint Managing Director, Cipla had told that CIPLA too has outsourcing part of its medical representatives through franchisee for a certain segment reach, but they will however represent less than 5% of their 3000 sales force.

However, while outsourcing medical representatives, provides flexibility to pharmaceutical companies and can be more effective but benefits are not always there. Doctors take time to acknowledge the third party selling the products for a client and relationship between medical representative and doctor may not be profitable because of high expectations of doctors. Pfizer's experience was not conclusive either. The company entered into an agreement with Innovex in 2003 to hire around 100 people to promote tail-end products, which has a turnover of about Rs 100 crore. Since then, the company no longer works with third parties to promote its products.

Even the legal position of such contractual work has also been challenged by FMRAI in court, as outsourcing medical representative's leads to a significant deterioration of working conditions in many cases as their salary is less and no job security is available. So, contracting medical representatives raises major organizational issues, while it offers flexibility and cost advantages pharma companies will have to look at new alternatives to reach to new territories and segments. The nature of sales force management is changing and challenging. The increasing unionization of medical representatives, militant attitude and approach of some of their associations are causing concern to managements.

MEDICAL REPRESENTATIVE UNIONS AFFECTING RELATIONSHIPS

As medical representatives are our focal point, while studying relationship marketing, as discussed earlier that they, as field sales force are responsible for maintenance and enhancement of profitable relations. So it is necessary to have a study about their social, political aspects apart from professional. The unionization of medical representatives is a big issue in Indian pharmaceutical industry.

Though there are few medical representative unions in states and at national levels but FMRAI (Federation of Medical representatives of India) is the largest one. FMRAI was first formed at Hyderabad in 1962 where it aimed to improve living conditions of the Medical Representatives. It has traveled a long way in building itself as real trade union body, form the idea that the medical representatives are not workers but somewhat like managers to demand and agitate for recognition as workmen took almost a decade. The management of the pharmaceuticals industry always isolated the medical representatives from the other workers in the factory and office. There was inhibition from the medical representatives also to consider themselves as a workman. 

 It was found that the services of the medical representatives (popularly known as field workers) were not regulated under any law. Whenever any attempt of organising was made, the employers used to embark upon them with all kinds of attack. Termination of services particularly those of the leaders was a regular phenomenon. FMRAI demanded of the Govt. to recognise the medical representatives as workmen by clearly defining in the Trade Union Act. It was a lengthy struggle. In 1976 when the democracy of the country was shadowed under state of emergency, a law was enacted as Sales Promotion Employees' (Conditions of Service) Act which was applicable to those medical representatives whose monthly earning was only Rs.650 per month. This deprived a vast number of medical representatives out of the purview of the Act. FMRAI demanded the Govt. to remove the wage ceiling from the Act. Meanwhile, FMRAI in its conference in 1978 included sales representatives of other industries also and demanded the Govt. to extend the benefit of the Act to sales representatives of all industries. In pursuance of these demands FMRAI staged nationwide agitation and several rallies were staged before the Parliament at New Delhi. The Govt. ultimately removed the salary ceiling for the Medical and Sales Representatives who are legally known as Sales Promotion Employees, but the Govt. agreed to extend the benefit of the law only for 11 industries which FMRAI did not agree. FMRAI formulated a 27 point common charter of demands which consists of not only extension of benefits of all labour laws for the field workers but also demands for the people on medicines.

 Nearly 40 large companies including multinational drug companies have recognised FMRAI as trade union for their field workers and regularly signs wage agreement. Regular meeting on day to day grievances of the field workers is also held with these companies. In regional level, some smaller companies also recognise FMRAI through its Zonal Committees.

 FMRAI has become the only national organisation for the field workers in the country having functioning centres known as local units in 300 cities and towns of the country. Its membership has reached nearly 40,000. FMRAI associates its activities with several central trade unions of the country and its members participate to the national programme when jointly called by the central trade unions.

 FMRAI has also joined All India People's Science Network (AIPSN) which is a national organisation for science movement. AIPSN actively work in the areas of health and pharmaceuticals. Jointly with AIPSN and with its own initiative, it has campaigned for a Rational Drug Policy and is considered as an important policy critic on Pharmaceuticals Policy of the Government.

FMRAI in the sates actively worked with health action groups and local branches of Indian Medical Association, convened seminars, conventions and other campaigned in different occasions. It has several publications on the health and drug situation of India. It is the only national trade union which observed nationwide strike against attempt of changing the patents act.

There are also some parallel associations and unions working in every state which are also communicating and helping each other in achieving their goals.

MARKET

-C&F agents

-Wholesalers

-Retailers

PATIENTS

(End users)

DOCTOR

(Customers)

Pharmaceutical

Company

PHARMACEUTICAL

COMPANY REPRESENTATIVE

(M.R)

(FIG: 1.8) Pharmaceutical marketing representative interactions

PHARMACEUTICAL RELATIONSHIP MARKETING MODELS:

Evert Gummesson in his book had described thirty types of relationships marketing which exist in the market directly or indirectly in various contexts has been already mentioned earlier. Though many experts had developed and discussed many models of relationship marketing but only few are relevant in pharmaceutical industry as per our study.

In this section we will discuss three relationship models which are felt relevant within the pharmaceutical market. They are as follows -

The interaction model of buyer-seller relationships.

In the interaction model the relationship of two organizations - the buyer and the seller is analysed. According to this model the relationship corresponds to a series of interactions between the parties. Fig: 1.9 shows the Interaction model of buyer - seller relationships.

Figure1.9: Interaction model of buyer - seller relationship

(Source: simplified scheme of CAMP-bell (4), p.268.)

The interaction model (fig: 1.9) is based on the following statements:

Both the buyer and seller are active participants in the market; both of them make efforts to find the suitable partner in order to achieve the goals.

These relationships are long term, close involving a complex pattern of interactions between and within each organization. It is more than simple sale or purchase.

The links between buyer and seller often becomes institutionalized in to a set of roles that each party expects the other to perform. Adaptations often occur when one of the parties makes modification in the product, in financial arrangements or in inventory routines etc.

The interaction model assumes continuous supply of the products.

The whole interaction process is embedded in the interaction environment. The environment has several aspects like the market structure, dynamism, internationalization, position in manufacturing channel and the social system. In the business environment the buyer's involvement in the product development process has also an effect on the interaction.

In pharmaceutical market, the market characteristics (strict regulations) and the product's special characteristics have dominant impact on the relationships.

The Key account management model of relationship.(KAM)

The technology had enabled us to reach maximum customers and consumers and get hold of their database to be utilized as per our convenience. The K.A.M. model provides pharmaceutical companies to get hold of profitable relations with its customers and end users.

A systematic key account management is made up of eight fundamental elements that answer core questions to the company specific set up of an account management program, before implementing of KAM model& they are:

Objectives and terminologies

what is the overall objective that should be achieved with the KAM program? Which company specific terminologies will be used?

Identification of key accounts

who are the key accounts and how are they going to be identified?

Packages for key accounts

what do we do differently for the important key accounts? Which products or services will they get that other accounts will not get?

Organization and account teams

how is the KAM integrated into the overall company organization?

How to set up and manage interdivisional (mostly virtual organized) key account teams?

Personal

what is the job profile of a key account manager? How to reimburse key account managers? How to set up a career path for people in the KAM organization?

Processes

How to set up KAM specific processes (e.g. budget planning process) and how to integrate them into the company processes?

Tools

which tools are provided to the key account managers to manage the business relationship with their customers? (Example: Key Account Plan)

Steering & feedback

How to set up a multi dimensional scorecard to steer the KAM?

No matter how large the organization and how good the knowledge management is, each key account management has to be built from scratch since the combination of customers for each company provides a unique scenario. In other words, once a program is put into place, make sure that you incorporate a feedback loop that allows constant tweaking.

Fig: 1.10 KAM Model (Source: SIECK consulting)

The KAM model is based on customer portfolio of the enterprise. Strategic importance of each customer can be determined using sales volume, future potential and prestige etc. A key account manager is a customer who:

a) Purchases a significant volume as a percentage of a seller's total sales

b) Involves several people in the purchasing process

c) Buys for a geographically dispersed organization

d) Expects special attention such as logistical support, inventory management, price discounts and customized applications

Others define key accounts as customers that have strategic importance to the seller, purchase a large volume from seller, and have the potential to lower the seller's costs. These numerous characteristics can lead to different approaches of key customers.

THE CORE MODEL: PUSH & PULL.

This core push and pull strategy model has its general relevancy in Indian pharmaceutical market. As a matter of fact, pharmaceutical companies are merging and through the merging process, the portfolio of the new companies changes. Medical representatives are rearranged throughout the new companies. New, bigger, pharmaceutical companies are competing more and more with one another and in order to stress their products, might adopt a more aggressive sales strategy. As a result of the new, aggressive strategy companies representatives tend to have more frequent visits to encourage doctors to prescribe drugs and thus increase sales. The push and pull strategy models of pharmaceutical relationship marketing came in to limelight. They are as follows:

Pull strategy model of pharmaceutical relationship:

Pull strategy as the name suggests (fig: 1.11), aims at pulling the customer towards the product .it aims to create demand of the product with in a channel of distribution by appealing directly to the consumers. Advertising rather than personal selling is the primarily promotional tool used for this strategy.

In this model medical representatives are the key actors for example in a small oncology unit almost 40 sales representatives interacting with doctors, and most of them are coming for a visit on a regular once-a-month basis as this is the restriction put by doctors of meeting only once in a month that to on a fix time only, in order to stress the usefulness of their products and push clinicians towards the use of their drugs. This means that, basically, there are at least two representatives every day in busy clinic asking for a 'short' meeting to support their product.

Pharmaceutical marketing is a specialized field where medical representatives form the backbone of entire marketing effort. Pharmaceutical companies also appoint medical representatives and assign them defined territories. Medical representatives meet doctors, chemists and stockiest as per company norms. Medical representatives try to influence prescription pattern of doctors in favor of their brands.

The pharmaceutical distribution channel is indirect with usually three channel members i.e. depot/C&F, stockiest and chemist. Pharmaceutical companies appoint one company depot or C&F agent usually in each state and authorized stockist in district across the country. Company depot/C&F sends stocks to authorized stockist as per the requirement. Retail chemists buy medicines on daily or weekly basis from authorized stockiest as per demand. Patients visit chemists for buying medicines either prescribed by a doctor or advertised in the media. Here patient is end customer and doctor is direct customer for any pharmaceutical company. But for doctor customer is more important so he wants an effective supply chain management from prescribed company, and for pharmaceutical companies their customer that is doctor is more important that's why they emphasize more on supply chain management. Ultimately end-customer is benefited out of this.

For marketing of these types of products companies require more and more skilled field force to develop good rapport with their direct customer (doctor). Moreover field force should have good product knowledge and USP of their products over other so as to convince doctors and PULL the demand for their products i.e. from Doctor to Retailer to Stockiest to CFA to company.

CORE CUSTOMER

(Doctor)

END CUSTOMER

(Patient)

NON CORE CUSTOMER

(Retailer)

CUSTOMER

(Stockiest)

CUSTOMER

(C&FA)

(Fig: 1.11) Pull System Working In Chronic Therapy Segment

In this system, doctors are the core customers and the major thrust is given to build and retain these customer because they are pulling the demand for products hence companies also give main emphasis in building and retaining these customers. For retaining and developing customers, the companies normally provide gifts like sponsorship for various conferences like RSSDI, FOGSI, APICON, UPCON etc. For example Dabur having PASS (Professional Acedemic and Scientific Services) activities for promoting its chronic therapy range.

Closing stock x 2 - opening stock =orderAlso it is interesting to note that since this is a pull system demand is being pulled in to the market so generally representatives place product orders from their stockist on the basis of following formula:

In normal practices there are no chances of dumping of products at retailer level or stockiest level as secondary sales as well as primary sales are reported to the company and payment recovery is also timely and efficiently.

Push strategy model of pharmaceutical relationship

The push strategy got its name because it involves pushing or urging members of marketing channel to sell a product by recommending it to consumers or by giving it an adequate display (fig:1.12).

In present scenario companies are focusing more and more on the availability of products so as to enjoy good image in their cutomer's (doctors) chamber. Many companies such as Glaxo, Pfizer, Dabur, FDC, Aventies and Cipla etc. are known for their availability of products. For marketing of these types of products companies require more and more field force to remind their products on daily basis to their direct customer (doctor). Moreover field force should have good knowledge of product schemes and offers. Also field force is required to have a good rapport with retailers. Field force also required to ensure good availability of their products to convince doctors and push their products i.e. from to Stockist to Retailer to Doctor. It has been observed that sometimes there are more than fifteen or sixteen representatives in a day are meeting with their customers and requesting for same type of products. Although field force visits are important for an update on drugs and their use. The doctors are in general, sneaking away, trying to hide from sales representatives, since there are too many and they are too pushy and there is too little time. Also the representatives probably have noticed that the reluctant doctors have always less time for short meetings and less interest and tend to reduce the time of the visit.

The relationship between clinicians and representatives has always been good and pharmaceutical companies have provided and still provide the major economical support for customers' continuous medical education. Something needs to be done to find a solution to this problem that takes into account the needs of both pharmaceutical companies and their representatives on one side and physicians on the other, for a better professional interaction.

In this system, doctors and retailers are the core customers and the major thrust is given to build and retain these customers. Here retailers are also core customer as most of the times they are substituting the products based on their own discretion.

For retaining and developing customers, the companies normally provide gifts like sponsorship for various conferences like small gifts & sponsorship to remind the products on daily basis.

CORE CUSTOMER

(Doctor)

END-CUSTOMER

(Patient)

CORE CUSTOMER

(Retailer)

CORE CUSTOMER

(Stockiest)

CUSTOMER

(C&FA)

(FIG: 1.12) Push System Working In Acute Therapy Segment

Also it is interesting to note that since this is a push system products are being pushed into the market so generally representatives place product orders from their stockiest on the basis of SKUs sold and schemes.

Normally the chances of dumping of goods at stockiest and retailer level are reported also payment recovery of companies is also not very good. Supply Chain Managers can provide considerable value to their companies by understanding the customers' delivery requirements. A very powerful tool for understanding these requirements is account segmentation. A company can use account segmentation to identify market segments such as Acute & Chronic therapy market which is well positioned to serve and then organize its product range and even SKU's and service in a superior way. Companies are fighting (for customers) like never before and if anything is certain then it is further intensification of this war. Because of this companies are increasingly looking at Logistics as a weapon to gain Competitive Advantage and it is true that Logistics has the potential to do so.

Customer relationship management & sales force automation

Customer satisfaction in the pharmaceutical industry is highly related to speed, accuracy and efficiency of a company's research response times. This calls for pharmaceutical companies to have a comprehensive medical information system. This would allow them to fulfill their legal, contractual and ethical obligations while supporting their sales and business partner relationships. The system must service a variety of communication methods in order to connect with a broad spectrum of customers with varied needs throughout their product life cycle, while enabling staff to deliver consistent, accurate and current information in timely manner.

The system also need to simplify the method of information sharing, assist with the identification of market trends and issues and finally, run on secure and scalable platform to continuously accommodate growth.

A good CRM system allows pharmaceutical companies to collect, track, organize, prioritize and respond to caller events. Using the comprehensive knowledge repository, automated responses via letters, fax or e-mails can be generated and edited within minutes. Urgency levels can be employed to define specific target response timeframes. Once a call sheet is closed, it can be archived for statistical reporting purposes.

This allows a company to identify and report on immediate and long-term calling trends related to its pharmaceutical products. It can also track drug related events and capture critical patient data on-line.

The company is also able to handle a major increase in the number of medical queries more efficiently. It can maintain frequent caller and demographic information on health care professionals that can be reviewed by the sales team while maintaining a detailed audit trial of customer correspondence and exchanges. The centralization of up-to-date medical information makes it easy to retrieve and disseminate while the provision of statistical reorts allow users to constantly reassess product profiles and performance improvement.

A CRM system provides a company with an effective mechanism to support continous improvement to its internal business practices. Utilizing the system's reporting facilities; it can provide strategic information regarding the health care professional's interests and concern to their sales team.

Sales force automation (SFA) is a subset of customer relationship management. A SFA system allows for easy management of a pharmaceutical company's vast sales force. It provides sales representatives with relevant updated information when they are on the field and also allows managers to track their activities to make sure that things are going fine.

In an SFA system, information is constantly updated with data that is replicated quickly and securely on their sales reps, managers and corporate HQ systems. Field forces communicate with the corporate HQ when and where they choose. A web based SFA system reduces communication cost and time.

Some of features of good SFA system are:

Mantaining Customer profile - The system maintains detailed and up-to-date profiles, in structured and easy to use form. Information in the profile can be tailored to specific corporate needs, providing accurate, up-to-date comprehensive view on important customers and business opportunities.

Mantaining hospital profile - The system also maintains detailed hospital profiles which are helpful in targeting specific areas and making effective sales strategies. The system provides with sales calendar so that activities are better coordinated and managed.

Activity planning - The system allows individual team members to plan their activities and managers to assign and track specific tasks.

Daily Calls and promotion reporting (DCR) - The system provides detailed information about each call and promotion so that future activities can be planned and tailored to meet specific needs.

Analysis and reports - The system provides detailed statistical data about the activities of sales force to enable better planning and strategy.

Since sales force forms major portion of pharmaceutical company's marketing efforts, a good sales force automation system can go a long way in reducing marketing cost and increasing effectiveness of marketing. Web applications can enable pharmaceutical companies in deriving tangible benefits by leveraging their traditional expertise. Web applications like e-mails, websites etc .helps them cut costs, manage existing market more effectively and make forays in to new markets. There are many more aspects of pharmaceutical companies, which could also benefit from new technologies.

Pharma marketing emerging trends in context of RM A research conducted by Boston University School of Public Health (BUSPH) reveals that brand name drug makers in the US employ 81 percent more people in marketing than in research and the gap has been growing. It was also found that total staff in marketing has been increased by 59 percent between 1995 and 2000, while number of research staff decline by 2 percent. Quiet clearly drug companies are taking their marketing activities more seriously than before. As compared to Indian market, where less research activities were prevalent and more concentration on marketing is always there. We have observed the following challenges are faced by pharmaceutical companies in formulation and implementation of marketing strategies:

Regulation with respect to marketing tactics

Pressure from public, government and insurance companies for price control

Defining the target group from among physicians, consumers, wholesalers, pharmacy chains, independent pharmacists, hospital personnel and HMOs

Targeting Customers i.e Doctors:

Drug companies are trying to promote their products in many ways. Sometimes the doctors are paid by the pharmaceutical companies to attend or speak at dinners. Medical representatives come in with an arrays of gifts such as pens, pen stands, calendars, notepads, mouse pads, various computer accessories etc. depicting name of their brands so as to position it in the mind of doctors. Also as discussed earlier another powerful tool is free samples of the products. Most doctors receive it from representatives and pass in on to their patients. When free samples eventually run out and when prescription needs to be written, often doctors write the prescriptions for the same drug even though they might have actually considered a different drug. As companies spend more and more money for pampering doctors, the ethical dimensions of some of their actions are coming under scrutiny and criticism. So marketers have to employ their marketing tools judiciously. Most of the doctors claimed that they are not influenced by marketing ploy but research has shown otherwise. According to a study conducted by the Journal of American Medical Association (JAMA), doctors who made specific request to insurance companies that a particular drug be added to the formulatory list were thirteen times more likely to have met with pharmaceutical representative promoting the drug than doctors not making any such requests.

Targeting end consumers i.e. patients:

Now a day another important segment is arising, which also play an important role in promoting drugs. Today drug marketers are pitching their products directly to the consumers instead of relying on doctors to spread the word. There was a time when consumers were illiterate and depend on doctors for treatment but as awareness and self medications are increasing. We can find the effect on the nature of prescriptions by doctors. Increasing lifestyle diseases, increasing OTC products, creating increasing awareness through technology had made end consumers i.e. Patients to request their doctors for medicines of their choices. Many pharmaceutical companies like Johnson & Johnson (J&J), Cipla, Dr Reddy's lab, Morpen labs etc had even set up their toll free telephone numbers for patient support. As life style diseases like diabetes, blood pressure is increasing it is more important for patients to monitor & regulate their diet and medicine dosages so that they can remain healthy and fit. In the whole case Doctors can have advisory role only in promoting equipments like glucometers, B.P. apparatus or certain OTC medicines etc., that is why pharmaceutical companies are establishing their Business processing units (BPO) so that they can reach end consumers i.e. patients directly and even provide lifelong support and advises from their expert team for maintaining their health. Anyone with access to TV, newspaper or the internet can get in to prolonged discussions on many ailments.

There is also new form of advertising called DTC (Direct to consumers), to date only United states, New Zealand are the only countries that allows DTC in pharmaceuticals, although Canada and Mexico are also considering DTC policy in their market. DTC aims at embedding the name of a drug on the mind of patients so that patient will carry it in to the doctor's office, often with a request to try it. DTC advertising has increased drastically since the FDA loosened regulations in 1997. Those marketing efforts has been credited with driving patient enquiries, encouraging better doctor-patient dialogues and increasing consumer health awareness.

Targeting specific customer segments:

Many Companies are segmenting their customers and going for niche marketing. The niche gives them the power that differentiates them from the rest of the crowd and makes them effective. Many companies have created niche for themselves and took a lead, some of them are;

Dr. Reddy's lab has carved out a superior, hi-tech niche. It has been living up to its corporate theme of the national company with an international reach. It has become a force to reckon with in the international bulk drug market.

Torrent niche power had already earned it a reputation as a company that is among the first to launch all new drugs. Its record of new product launch is really inviable which had led it to fourteenth position Indian pharmaceutical industry with revenue of $380.2 million in 2010.

NATCO fine pharmaceutical establishes a niche by specializing in control and sustained release of oral solid dosage form and later had sold all its formulations to sun pharma.

Citadel fine pharmaceutical has established itself in ampicilline and amoxycilline market. The Company had for the first time introduced these drugs in dispersible tablet form. The niche had helped their presmox and prescillin.

American remedies which were later acquired by Dr. Reddy's lab had made its niche with a product differentiation in the market and had shown unprecedented growth rate from a mere rs. 1crore to rs 18 crores in about five years.

Loyalty programmes for patients: Many companies are also planning to start loyalty programmes for their patients but nothing much has been done. As per estimates loyalty card market size for consumer brands in India is around rs 5000 crores and going to increase upto rs 8000 crores by 2015.In these loyalty programmes customers are provided with loyalty cards which they can use for their purchases. On every one time purchase, consumers are awarded purchase points which they can redeem after certain limit.

These loyalty /club membership programmes in relationship marketing are the tools to offer discounts/rewards to consumer to encourage them to frequent to a store and spent more. Consumers accrue the reward point by shopping up to a certain limit, which they can redeem through discounts or gifts via the loyalty card. According to colloquy cross cultural loyalty study conducted on shoppers in India, 83% of non members who were not yet part of any loyalty programme were willing to join any such programs and India is still in nascent stage at this level with pharmaceutical industry completely remained untouched but holds the promising prospects in respect of PRM and CRM.

SECTION-III

EFFECTS OF RM: IRRATIONAL PRACTISES IN INDIAN PHARMACEUTICAL & HEALTHCARE MARKET

Irrationality is like a dowry -a social evil that is easy to detect, yet difficult to define in an individual case, perpetuated by human avarice, impossible to eradicate and if unchecked may have fatal consequences. Like all social evils, multiple factors are responsible and all the key issues needs to be addressed, if a dent has to be made in irrational practices related to healthcare and pharmaceuticals.

As already discussed in earlier chapters regarding cut throat competitions in pharmaceutical market, the relationship of a healthcare professionals and pharmaceuticals have shown a high bonding for profit maximization resulting in exploitation of patients and unethical practises which is a curse to a civilized society.

The first and best known, part of irrational practices in healthcare is related to irrational prescribing of drugs. W.H.O has defined irrational prescribing as use of a therapeutic agent when the expected benefit is negligible or nil or when its usage is not worth the potential harm or the cost.

Irrational drug prescriptions occur when the medication prescribed is incorrect, inappropriate, excessive, unnecessary or inadequate .accordingly the types of irrational prescribing are:

Incorrect prescribing: This means the use of wrong medicine to treat a disease or the use of medicines when no medicines are required.

Inappropriate prescribing: This pertains to use of drugs that are not suitable or inappropriate for the particular patients, viz use in pregnancy, in children or in older people etc.

Over prescription: This relates to the use of too many different ind of drugs to treat a disease, when fewer (or just one) drugs would have sufficed. It also includes use of drugs for long period, when shorter course of treatment is adequate.

Multiple prescription: This means the prescription of more than one drug of same kind (i.e drugs which have the same effect) to treat a disease.

Under prescription: This has to do with prescribing medicines for too short or inadequate dosage.

Nexus of pharmaceutical and healthcare practitioners

The reasons of unethical practices operating in Indian healthcare market are many folds. One is to do with the proliferation of large number of drugs in the Indian market that are either irrational or useless. There is rapid rise in the availability of drugs in the market but unfortunately only a small minority of drugs entering the market offers an advantage over existing drugs. A study in U.S market showed that of the 348 new drugs introduced from the 25 largest U.S. drug companies between 1981 and 1998 only 3% made an important contribution to the existing therapies, 13% made a modest potential contribution and 84% made a little or no contribution. A French study of 508 new chemical entities marketed in the world between 1975 and 1984 found 70% offered no therapeutic improvement over existing products. The situation of Indian market is no different and probably worse, given the fact that our drug control mechanisms are much more lax than in developed countries. The only reason why Indian studies are not available is because there is virtually no mechanism in India to monitor the use of irrational and hazardous drugs. Moreover very few drugs are actually developed in our country, but introduced here after their introduction in the west.

As a consequence there are an estimated 60,000 to 80,000 brands of various drugs available in the Indian market. On the other hand the WHO lists a little over 270 drugs which can take care of an overwhelming majority (over 95%) of the health problems of a country. In this situation of extreme anarchy, the task of an already overstretched drug control authority becomes almost impossible to cope with. A majority of the estimated 80,000 products in the market are either hazardous, or irrational or useless.

The pharmaceutical companies and the government regulatory bodies are both to blame for allowing such a situation to develop in this country. But all this would not be possible without the active involvement of medical profession, who contribute by prescribing such irrational and useless drugs. One reason for this is the fact that there is almost no source of regular unbiased, authentic information on drugs available in the country.

Given the rapid changes in the treatment procedures and introduction of large arrays of new drugs, medical practitioners need to update their knowledge regularly. Such a system of continuing medical education is largely absent in this country and most doctors do not find the need to take time out of their busy practice to update their knowledge by reading the most recent books and journals. Thus we have the sad practice of a bulk of medical practitioners depending on promotional material supplied by pharmaceutical companies.

Obviously such promotional material only provides biased information to doctors, with a view to maximize the sale of the products being promoted. It thus makes it possible to sell a large number of useless and irrational drugs.

Some of the few common irrational or hazardous drugs are mentioned below:

Anxiolytics & Hypnotic drugs

Barbiturates were first used as hypnotics as anxiolytics, but as time went on Benzodiazepines were developed in the 1960s and 1970s. Eventually they led to billions of doses being consumed annually. Originally thought to be non-dependence forming in therapeutic doses unlike barbiturates, as prescriptions increased problems with addiction and dependence came to light. Benzodiazepines have widely supplanted barbiturates for treatment of almost all conditions in developed countries due to a much greater therapeutic ratio and less proclivity for overdose and toxicity. Their irrational use causes over dependence and habit forming in patients. They are in scheduled-H drug categories and cannot be sold without prescription but due to laxaty in regulation & control in Indian market they are easily available from any medical counter, even without prescription. Commonly used salts in this category are alparazolam, dizapam, lorezapam and chlordiazepoxide etc.

Some irrational drug combinations with dizapam with antacids are also available:

TABLE: 1.2: Irrational Drug Combination with diazepam with antaacid

Combinations

Irrationality

Status

1) Diazepam+ dried aluminium + hydroxide gel+ aluminium glycenate+ oxyphenonium

2) Diazepam+ dried aluminium hydroxide gel +magnesium trisilicate + dimethylpolysiloxane

Antacids raise the gastric pH and reduces the absorption of benzodiazepines

No.1& 2 has been banned in the market

( source: Indian J Pharmacology, June 2006, Vol. 38, Issue 3 169-70)

Oral Rehydration Salts (ORS)

ORS is a combination of sodium chloride, sodium bicarbonate or trisodium citrate, potassium chloride and glucose in a fixed ratio. This solution is used to treat the situation of dehydration. Inspite of extreme importance of this product the quality norms for ORS are not rigorous in India. There are a large number of ORS brands available in the market which do not confirm to the WHO Formula. Most irrational ORS solutions available have low sodim content and high glucose content but high glucose content actually worsen diarrohea. Low salt content doesn't suppliment the sodium loss and sodium loss is the main cause of death due to dehydration. Such solutions thus can infact not saves life but endanger them further. Yet even the brand leader electral doesn't confirm the WHO formula. One of the brand of ORS is marketed by name of Zelect had added zinc sulphate in it. Zelect is promoted based on some research of a doctor of AIIMS, New Delhi which had revealed the importance of Zinc, but the irony is that it doesn't confirm to WHO standards.

Antipyretics and Analgesics:

ANALGIN

The drug can cause agranulocytosis, a fatal blood disease. The drug can also cause rashes and serious life threatening cerebral coma. Large dose can cause renal tubular necrosis, degenerative diseases of the kidneys. In India Analgin is used in trivial case and can be procured from most chemists without a prescription. Few other combinations which we found present in Indian market are as follow, in table1.3:

TABLE: 1.3: Irrational Drug Combination with antipyrrtic

Salt Combinations in the market

Irrationality/side effects

Market status

1) Nimesulide+diclofenac

2) Nimesulide+dicyclomine+ simethicone

3) Nimesulide+paracetamol

4) Nimesulide+cetrizine+ pseudoephiderine

5) Nimesulide+ paracetamol + Tizanidine

Nimesulide is a controversial drug and has been banned in many countries.It is a sorry state of affair that it is available as OTC.

Combining two NSAID may increase the side effects of both the NSAIDs. There is little documentary evidence that a preparation containing more than one analgesic is more effective than a single ingredient preparation.

Available

(source: Indian J Pharmacology, June 2006, Vol. 38, Issue 3 169-70)

Clioquinol

Clioquinol belongs to group of drugs called halogenated hydroxyl quinolines. In the sixties this drug was found responsible for a massive epidemic of syndrome called SMON associated with progressive muscular weakness, degeneration of nerves and loss of vision. As a result the drug was banned in many countries and original manufacturer Ciba Geigy, withdrew it from world market. Yet in India it continues to be freely available under various brand names - like Entroquinol.

Fixed dose combinations

The main reason of proliferation of Indian pharmaceutical market is the presence of huge number of fixed dose combinations that is a single formulation containing two or more drugs in a fixed ratio. Most of these combinations are without any rational except the motive to make profit. The WHO says in this context: "In the great majority of cases essential drugs should be formulated as a single compound. Fixed - ratio combination products are acceptable only when the dosage of each ingredient meets the requirement of a defined population group and when the combination provides advantage over single compounds administered separately in therapeutic effect, safety and compliance" (WHO technical report series, 722). The WHO list of essential drugs includes only 7 drugs in a total of 270 drugs. All drugs may be called useful poision. Fixed dose combinations add an unnecessary load of adverse effects on the patients and in addition add to the cost of therapy-in the ultimate analysis. They help no one but the drug manufacturers in most cases. There is a need to seriously examine and weed out all unnecessary combinations from the Indian market.

Some combination products which should be urgently weeded out include:

Cough syrups

There are a large number of cough syrups available in Indian market a majority of which are irrational, many of these combine cough suppressants with expectorants (i.e. an ingredient which facilitates expulsion of sputum). Moreover cough syrups are seldom effective in treating cough and only in rare circumstances is their use justified. The British national formulatory says: "the drawbacks of prescribing cough suppressant are rarely outweighed by the benefits of treatment and only occasionally are they useful as, for example, if sleep is disturbed by a dry cough". Cough suppressants may cause sputum retention and this may be harmful in patients with chronic bronchitis, etc. Cough syrups, hence are usually not only irrational in that they combine ingredients with opposing therapeutic aims, but it is doubtful whether the ingredients are capable of exerting the effects they are supposed to i.e. as cough suppressant or cough expectorants. So, all the cough mixtures need to be critically reviewed.

Combinations of antibiotics:

A large number of combinations of two different antibiotics are available in the market. Two categories of these are rational - combination of trimethoprim and sulphametoxazole as co-trimaxole and combination of anti T.B drugs. These are the only two combinations mentioned in the WHO list of essential drugs. Most other combinations carry the risk and disadvantages associated with combination products related earlier. In the case of antibiotics the disadvantages are greater - one because the side effects tend to be more pronounced; two because the increase in the cost is greater; and three because of the added risk of developing antibiotic resistance. The commonest irrational combination available is a combination of cloxacilline with some ampicillin. Details have been given in table: 1.4.

TABLE: 1.4: Some common combinations available in Indian market

Salt Combinations in the market

Irrationality/side effects

Market availability status

1) Norfloxacine+ metronidazoles

2) Norfloxacine+Tinadizole

3) Norfloxacine + tinadizole +Loperamide

4) Norfloxacine +Tinadizole+Dicycloamine

5) Norfloxacine+ornidazole

6) Ciprofloxacine+tinidazole

7) Ofloxacine+Tinidazole

8) Ofloxacine+Metronidazole

9) Ofloxacine+Ornidazole

10) Gatifloxacine+Ornidazole

Though claimed to be broadspectrum,combining(antiamoebic) with fluruquinolone(antibacterial) is irrational because patient suffers from one type of diarrohea.using these combinations adds to cost, adverse effects and may encourage drug resistance

No-3,4,8,10 HAS BEEN BANNED

1.Amoxycilline+cloxacilline

Amoxicillin is inactive against staphylococcus as most strain produces B-lactamase and cloxacillin is not so active against streptococci.for any given infection ,one of the combination is useless but adds to cost and adverse effects.since the amount of each drug is halved,efficacy is reduced and chances of selecting resistant strains is increased.

cloxacilline has been changed to dicloxacilline and is now available

Roxithromycin+ambroxol

Ciprofloxacin+ambroxol

Gatifloxacin+ambroxol

Cefadroxil+ambroxol

Cefixime+ambroxol+lactobacillus

Many trials have failed to show superior efficacy of combination over use of ambroxol alone in respiratory tract infection. Gatifloxacin is withdrawn

No.-2,3,4,5 has been banned

Fuconazole + tinidazole

Doxcycycline + tinidazole

Tetracycline + metronidazole

Combining two antimicrobial agents to increase the spectrum of activity is irrational, as the patient may need only one drug. The key point is to make correct diagnosis.

Available

Table: 1.16: Source: Gautam.et.al, Indian J Pharmacology, June 2006, Vol. 38, Issue 3 169-70

Barbiturates combined with anti asthma drugs (viz.ASMAPAX)

Barbiturates were once a principal drug used as sedatives and their use was restricted in epilepsy & in anesthesia, after introduction of new drugs. The main reason of restrictions is their potential for misuse as they are habit forming and popularity as 'Suicidal' drug. Sale of single ingredient formulations of barbiturates is under severe restrictions in this country. Yet, ironically Barbiturate combinations can freely purchased even over the counter. They are commonly combined with anti-asthma drugs. This is dangerous practice as barbiturates can depress respiration which can be life threatening in asthma patients.

Vitamin B1, B6, B12 combination (Viz. Neurobion)

One of the most irrational drug combination is of vitamin B1 (Thiamine), B6 (Pyridoxine) and B12 (Cynocobalamine). Both vitamin B6 & B12 have specific use in diseases caused by deficiencies of these drugs then why they should be combined along with vitamin B6 is anybody's guess. This combination cannot be found in any standard work of medicine or pharmacology. Yet a large number of these combinations as injections or tablets are propogated. They are propagated as general "health tonics" and for large variety of obscure to common neurological problems.

TABLE: 1.5: Miscellaneous irrational drug single/combinations in the market

DRUG COMBINATIONS

POTENTIAL SIDE EFFECTS

MARKET STATUS

1.Cetrizine+propanolamine+

dextromethorpan

2.Cetrizine+phenylpropanolami-ne+paracetamol 3.Levocetrizine+paracetamol+

Phenylpropanolamine

Phenylpropanolamine is a banned drug: yet it is a part of many cough and cold remedies. besides its potential to cause stroke(more to in hypertensives).it can aggravate diabetes, glaucoma and prostate enlargement.

Available

1.Domeperidone + Rabiprazole

2.Domeperidone+Esomeprazole

Increased incidences of rhabdomyolysis.

Available

1.Enalapril + locating

Combining the two drugs affecting the same pathway is irrational: it doesn't add to efficacy.

Available

Cisapride + omeprazole

Mosapride +pantaprazole

Ondansetrone+pantaprazol

In patients with gastroesophageal reflux disease,the useof this combination has shown no benefit due to the addition of prokinetic drugs.

No.1 & 2 has been banned.

.

1.Droperidol

Used as an anti depressant but can cause irregular heartbeat

Available

(Gautam.et.al,Indian

gautam et.

TABLE: 1.6: Some of internationally banned drugs but freely available in Indian market

Furazolidone

Used as Anti-diarrhoeal but can cause cancer

Available

Oxyphenbutazone.

Used as NSAID but cause bone marrow depression

Available

Piperazine

It's an anti worm, but can cause nerve damage

Available

Quinodochlor

Used as antidiarroheal but can cause sight damage.

Available

Rosiglitazone

Its an antidiabetic but can cause cardiac failure.

Available

Cerivastatin

Antihyperlipidemic can cause fatal rhabdomylosis

Available

Tegaserod

Indication in bowl syndrome with constipation but can cause stroke and heart attack

Available

Pergolide

Indication in Parkinson disease but can cause damage to heart valve.

Available

(Source: www.drugsupdate.com&Gautam.et.al: Indian J Pharmacology, June 2006, Vol. 38)

Combination of drugs from different systems

Today there is a new trend in marketing of combination of drugs from the allopathic system along with drugs from the allopathic system along with drugs from other system viz. Ayurveda, siddha, unani and even Chinese, Korean, Tibetan systems. It is obvious that such systems are grossly irrational as each of these systems differ in therapeutic as well as treatment approach to diseases. Infact no practitioner is likely to have the knowledge of all the systems to be competent enough in prescribing such combinations on the basis of scientific knowledge.

Recently, Amway company had launched its product under 'Nutrailite' segment by various brands viz. Nutrilite protein powder, kids calcium&magnesium, concentrated fruit and vegetable, cheweable iron, salmon omega-3, garlic heart care, iron folic, bone health with ipriflavon, glucosamine HCl with boswelia , cal mag D which includes calcium and magnesium. The company claims it to be safe but without medical practitioner advice it would be unsafe for a consumer to take these nutrailite products. It can also be the best example of company reaching directly to its consumers i.e. patient relationship marketing (PRM) is working, but in reality its unethical and highly dangerous practice for a consumer to take products like protein, salmon-omega D-3, glucosamine, multivitamins etc without any medical advice, as excess consumption of a particular nutrient in human body may cause various health related ailments.

Irrational prescribing

Irrational prescribing by medical practitioner under the influence of pharmaceuticals needs to be clearly understood that the problem is not limited to just a question of irrational or harmful drugs. Rational or even lifesaving drugs can be used in an irrational manner. The commonest problem is the unnecessary use of drugs. Thus often we see expensive antibiotics being used for trivial infections. Moreover this is often accompanied by wrong dosage schedules. Another problem is the prescription of a large number of drugs for a simple ailment, when one or few drugs would be sufficed. Doctors, in many cases, when they are not sure of the diagnosis prescribe a large number of drugs to cover all the possibilities. Thus a patient coming with fever may be given some antibiotics, a drug to treat malaria, a drug to treat typhoid etc. It may turn out that the patient was just suffering from viral fever, which could have been treated with some paracetamol tablets only. Such prescription increase the cost to the patient, unnecessarily exposes the patient to the potential side effects and in the case of antibiotics leads to drug resistance i.e a situation when these antibiotics become useless when they are really required.

A patient should not be impressed by doctors who prescribe a large quantity of drugs. 'All illnesses do not require drugs', infact a large number of illnesses are self limiting, i.e. the body or immune system has the ability to cure itself without the use of drugs.

So a patient should not be impressed by a doctor who prescribes a large number of expensive drugs, in most of the cases the doctor is hiding his inability to reach a correct diagnosis by trying to cover for all eventualities. Patient must realize that if a doctor advice no drugs, he is giving a valuable advice than someone who prescribe a large number of drugs.

Preference for injectables

This is also a common irrational practice going on in the market. Under normal circumstances, injections are not required to be given, except in case of drugs that can be only given by injections like insulin. Some penicillin's, streptomycin etc. Most drugs are available in both forms i.e can be given by injections and can be taken by mouth as well. A drug that is given orally may take from 15 minutes to two hours to start acting, while an injected drug may take only a few minutes. Otherwise, usually the effects of both are similar. So injections are required only when a patient is seriously ill i.e when one cannot afford to wait for half and hour before a drug start acting. On the other hand, injections have many disadvantages. They are always more expensive, they can cause more severe side effects (even life threatening ones). Also, as reported in some remote or backward areas, where sterile precautions are inadequate they can cause infection and abscess formation at the site of injection, and they can even transmit deadly diseases like Hepatitis-B, AIDS etc.

Use of I.V. (Intra-venous) solutions.

It is another prevalent practice today in the market. The use of intravenous solutions of glucose, saline etc to treat a wide range of ill defined ailments like weakness, exhaustation, dehydration etc. Such intravenous solution are needed in cases where the patient cannot take water and ailments by mouth viz. unconsious patients, patients who have been recently operated, patients who are extremely weak and unable to swallow, those with continuous vomiting, etc. They may also be necessary in severly dehydrated patients, those patients who are in shock state, where fluid inside body need to be replaced very fast. But if a person is conscious and not severly dehydrated and is able to drink fluids then in that case intravenous fluids are gross waste of money. Practitioners normally charge 200-300 rupees for administering one bottle of such solutions.This solution contains about half a litre of water and some salt and sugar. The total cost of same ingredient, if taken by mouth will come to only 5-8 rupees and benefit would be the same, as in the case where it is given by intravenous injection.

When a patient is treated, the practitioner is legally bound to provide the patient with a prescription which must contain the following things: 1) Name, age & sex of the patient ;2) findings made by the practitioner on examining the patient viz. pulse rate, blood pressure, condition of chest abdomen, cardiac system, etc ;3) Diagnosis arrived at by the practitioner; 4) list of drugs prescribed with the dosage schedule and duration of use advised (this is required even if practitioner himself dispensed the prescribed drug) ;5) signature and name of the patient. In a large number of instances patients are not provided with prescription at all or with incomplete prescriptions. This is a dangerous practice as a patient is not left with any record of treatment given and an assessment of the illness he is suffering from. In future, in case of emergency (due to disease worsening or due to side effect of drug) it becomes impossible to determine the real cause of patients worsening condition. Lack of proper record is also a handicap. ,If a patient decides to switch doctors or if he falls ill again.

Rational use of diagnostics

Using WHO definition of irrational drug therapy as the basis, irrational use of diagnostics (including laboratory tests of blood, urine, sputum,etc ;X-Rays, scans, etc.) may be defined as : "a diagnostic test is irrationally use when the expected benefit is negligible or nil or when it is not worth the potential harm or the cost", while there is some awareness about the use of irrational drugs but attention on irrational use of diagnostics have also not been given,resulting in the mal practices . Cases have been reported in many Indian cities that local private Labs had given test reports and heavily charged the patient pocket in the name of sending samples to the reputed pathological labs situated outside the cities. The relationship network plays an important role in it, if one realizes that irrational CT scan is equivalent in wastage to about 100 bottles of irrational tonic. The myth of laboratory proof has to be realized by all, especially the professionals. Most doctors unfortunately use laboratory test for support rather than illumination. Very few tests can make or break diagnosis by giving absolute proof that a disease is present or absent. Most test only affect the probability of a disease being present or absent. It is worth mentioning that almost all the diagnostic & testing labs have fixed commission ratio base for a medical practitioners who recommend and sends patients for laboratory testings.

Finally, another dangerous practice is that of making drugs available over the counter (OTC) i.e directly by a chemist to consumer without any prescription. Most drugs can legally be sold by a chemist only if the buyer produces a prescription. It is a dangerous practice to sell drugs without prescription as all drugs can have side effects, and have very specific do's and dont's.

All these irrational practices continue to flourish in the Indian market because the five actors in this drama: the government as regulatory authority, the drug companies as a producers of drug, the doctors as prescribers of drugs, chemist as the sellers of the drugs, and finally consumers as the buyers of the drugs. The relationship network of the above five at some level or other, do not fulfill the required obligations and are unmindful of the potential harm that inappropriate use can also take lives. It is estimated that 20-30% of illness, especially in the aged and in children are caused by the use of drugs.

If we expect ethical services from healthcare professionals, it is most urgent and necessary to involve pharmaceutical companies and their representatives in the process so that an effective feedback can be generated. Also, motivate the pharmaceuticals to stop the production and marketing of such irrational combinations.

GOOD PHARMA RELATIONSHIP MARKETING- PRACTICES & REGULATION

While many pharmaceutical companies have successfully deployed a plethora of strategies to target the various cu