“caught in each other’s traps”: factors perpetuating incentive-linked prescribing deals between physicians and the pharmaceutical industry

Background  despite known adverse impacts on patients and health systems, “incentive-linked prescribing,” which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. we investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors – pds), using pakistan as a case study.  methods  our mixed-methods study synthesised insights from a survey of 419 systematically sampled pds and 68 semistructured interviews with pds (n = 28), pharmaceutical sales representatives (srs) (n=12), and provincial and national policy actors (n = 28). for the survey, we built a verified database of all registered pds within karachi, pakistan’s most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach. results  our survey showed that 90% of pds met pharmaceutical srs weekly. three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate an over-saturated pharmaceutical market. conclusion  regular interactions between pharmaceutical companies and pds are normalised in our study setting. progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and pharmaceutical industry employees. a first step towards addressing the entrenchment of incentivelinked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policy-makers concerned about curtailing growth of the pharmaceutical industry.