The greater use of generic drugs could motivate better long-term adherence to essential therapies. Higher out-of-pocket costs for patients have consistently been associated with lower rates of long-term medication adherence.

Medicines are one of the five necessities of life, we have enough supply, unlike electricity, pure water, food or jobs for everyone. The private healthcare sector is responsible for most of healthcare in India. Most healthcare expenses are paid out of pocket by patients and their families, rather than through insurance. In fact, recent world health statistics have indicated that India has the highest out of pocket private healthcare costs for families, among many other comparable developing nations. However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure (CHE), which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living. India’s constitution guarantees free health care for all its citizens and all government hospitals are required to provide free of cost healthcare facilities to the patients.

Public health care is free for those below the poverty line. The public health care system was originally developed to provide a means to healthcare access regardless of socio-economic status. Implementation of universal healthcare was delayed due to budgetary reasons. Karnataka is one of the most advanced state in medical education and health care, first in the country to introduce new bill on Universal Health Coverage from November 1, 2017, bringing all health schemes under one umbrella. While the use of generic drugs has increased over time in developed countries, prescribers in India, often continue to prescribe more expensive brand name drugs when equally effective, well proven, and less expensive generic versions are available from the same manufacturer. Generics are accepted by almost every country in the world. The US imports one thirds of its generic medication. Generic substitution is legal USA, Canada, Europe, Australia and many more countries.

Prescriptions for highly priced branded drugs are almost thrice as likely to be "abandoned" (i.e., never picked up) than generic. How often brand name drugs are used when generic versions are available, how the use of generics influences adherence, whether brand names and generics have similar clinical effects, the barriers to increasing the use of generics, and strategies that can be used to promote greater use of generics. Skepticism about generic drugs was especially prevalent in patients, owing to the perception that lower cost signified lower quality or incorrectly interpreted as inferior. A generic drug has the same active ingredient of an original branded drug, but is less expensive as it does not include the cost of research and development.

The US makes most of the discoveries, the US taxpayer funds 85 per cent of the basic research. It is a dual mission; Pharmaceutical companies export generic drugs and make profit and sell the same drug under a brand name in India makes higher profit. They can help patients and at the same time make a reasonable profit, I think they have lost their moral compass. Pharmaceutical companies have marketed brand name medication to both doctors and (in some countries) consumers, so they are far more memorable and palatable – for instance Viagra, rather than the generic term sildenafil. Prescribers rely on using brand names that can be confusing at times and can lead to serious medication errors, by not knowing the active ingredients in those medications or mixing up brand names, which are becoming increasingly difficult to recognize when written in Prescribers’ handwriting, to avoid confusion, medication errors and allowing for patient control over purchasing decisions, prescribers use generic terms when prescribing unless a specific reason exists.

Many drug companies still employ questionable marketing and price practices. All drug companies in the US are required to report payments to doctors under the terms of the Physician Payments Sunshine Act, who receive payments for promotional talks, consulting, meals, and other activities. Corruption and unethical practices are endemic at every step of the pharmaceutical business, according to WHO. Corruption in the pharmaceutical sector occurs throughout all stages of the medicine chain, from research and development to dispensing and promotion. One should not prescribe or dispense medication to gain the greatest profit rather than to produce the greatest benefit for the patients. The pharmaceutical industry should consider adopting more ethical business strategies that benefit patients, address this negative perception and instill a greater awareness of ethical behaviour. If that isn’t possible, then consumers should urge government to act.

Approximate annual sales in India for brands RS. 90,000 crores (90 per cent), as opposed to nine out of 10 prescriptions filled in the same year in the United States are for generic medication and three out of nine generic medications dispensed in the US are made in India. There is only one generic name for each medication, but sold under a hundred different brands from different manufactures. As health care costs continue to increase both nationally and globally, cost-containment methods such as generic-drug substitution will continue to be an essential part of efforts to lower health care costs.  A script that contains the generic term for a medication allows that person to decide exactly what type of medication they wish to purchase, rather than that be influenced by what brand the prescriber writes on the script.

Prescribers often prescribe more expensive brand name drugs when equally effective, high quality, and less expensive generics are available. The main problem is for all these multiple names is the potential for confusion, especially for those most likely to use multiple medications. As a result, patients are at risk of not understanding which medications they are taking or why they are taking them. This often leads to doubling-up of a certain drug (taking two brands of the same medication), or forgetting to take them because the name on the package doesn’t match the script. This problem of some patient’s poor medication literacy significantly affects prescribers, nurses and pharmacists, who need to know which medications people are using. Although generic substitutions generally are cheaper, there are situations where generic substitution is not possible and the use of brand name drugs is clinically appropriate. Additionally, educating of patients and the prescriber is essential to improving the use and perception of generic medications

In addition to being a more affordable alternative to brand drugs, generics also have been shown to contribute to medication adherence. Education of prescribers and consumers remains a key to improving acceptance of generic substitution. Patients’ willingness to approve a switch to a generic has been shown to increase adherence. Prescribers’ inclusion of patients in substitution decisions can increase patients’ confidence in generics. Branded drug samples appear to be associated with the greater prescribing of brand name products, providing doctors with free samples of generics to provide to their patients could increase the use of generic medications. Use of interactive forms of continuing medical education, such as academic detailing, promotion, quality assurance and superior packaging are effective methods of changing prescribers behaviour, and therefore could promote generic prescribing. Public awareness and TV advertising campaign about the quality assurance might help to alter patient perceptions about generics.

We can only hope that prescribers keep patient’s best interest in mind, prescribe more and more generic medications to improve compliance, adherence and improve overall quality of life and reduce the unnecessary financial burden on the families.                                 

(The author is  President, Indian American Pharmacist. com and Consultant Clinical Pharmacist, Riverside CA, USA)