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Re: E-DRUG: Mandatory generic prescribing vs trade mark rights


Regarding your message on mandatory generic prescribing vs trade mark rights:

>You state that the private practitioner should be able to prescribe whatever
>they want (or rather whatever the patient wants). Private medicine differs
>from state medicine (public health system).

>I am glad we agree that the public sector is different to the private sector
>and if the government or as happens in the US the insurance company insists
>on generic prescribing they have the authority to do so.

I beg to differ. Here we are talking about a Public Health Care system.
The Hospital Ordinance defines a state patient as one who decides on entering 
a state health facility and not to be a private patient. A private patient is
who on entering a state health facility decides not to be a state patient :-)-O.

And they can not change their choice for this particular diagnosis...

Now, a state patient has a right to reasonable health care, but no right to
chose at what health facility and by what salaried health care provider he
is treated. In other words, we have a Primary Health Care setup and the
nursing practitioners refer to the doctor, or not.

Our state patients pay at entry into the system but not if referred. For
a followup visit at the clinic 30 cents US are to be paid (1.50 $NA).

No I do not agree with the statement that the government or the insurance 
company has the right to insist on generic prescribing. This limits therapeutic
freedom of practitioners. Why did they sent me to school for then? :-)-O

In our case however, this is not the issue, because the patients get the
medication for the 1.50$NA. It is not the government doing a regulatory
exercide but a provider offering reasonable treatment, virtually free of

>... private practitioners should be able to prescribe whatever they want is
>not really true. If the drug is not registered in the country the private
>doctor cannot prescribe it. Also, do you believe that a private primary care
>provider (a GP) should be able to prescribe cytotoxics or some of the new
>protease inhibitors? Clearly some drugs should be prescribed by specialists.
>So some limitations always occur. The issue is how much limitation should
>there be.

Come on, of course we talk only about registered drugs. In this country the
Medicines Control Act does not limit the prescription (or dispensing) of 
drugs, under the presumtion that doctors here know what they are doing.
But then we do deliver, do Cesarean Sections and other operations and also
give anaesthetics, because of the few specialists being concentrated in
the centers. In fact the job description of a state Medical Officer (such
as me) requires this (and forensic work).

But I still feel very strongly that a GP or Medical Officer should be able 
to prescribe anything he is experienced with. In fact we have succeeded in
convincing the Ministry to allow certain trained practitioners to prescribe
drugs which are normally not prescribable in a district hospital.

>What you describe of your ministry tendering for drugs and then dispensing
>whichever drug wins the tender is generic substitution. I would advocate
>however that it would be less confusing for the patient if the nifedipine
>was labelled nifedipine and not Adalat. Next year a different company may
>win the tender and the patient could be confused if they think they are
>getting a different drug.

And you have been in Zimbabwe, you say?

So what, they come to my BP clinic and say: "Doctor, the tablets are red now,
not yellow any more." So I tell them: "Don't worry, different company" and they
usually believe me...

Here the tablets are dispensed in yellow bags with a little drawing where
one can mark how many tablets they have to take when. Very few worry about 
what is written on the outside, many can't even read it.

And in fact our pharmacists' assistants dispensing the drugs notice these
changes in tender and tell the patients that the tablets are red now.

>Your point about the total profit for the pharmacist being higher selling
>brand name drugs at a lower percentage markup on a higher base price is
>true. However many pharmacists have a cash flow constraint and a higher
>percentage mark up may be attractive. Also the value of the stock which
>needs to be held and possibly expire is far greater when selling a range of
>brand name products rather than a single generic which would turn over rapidly.

Nope. Just ain't so. A course of Chloroquine lasts 4 days, whether you write
Chloroquine or Nivaquine. The same doctor sees the same amount or patients
and prescribes the same amount of drugs, so I fail to see how a generic
should increase the turnover.

In fact there is a big debate going on about dispensing, many of the GPs do
this and they usually dispense generics. Now the pharmacists try and make
our MPs believe that you need to study for a B.Pharm. in order to be able
to count 12 Chloroquine tablets and that a GP knows enough about prescribing
the drug, its pharmacology, pharmakocinetics, side effects, contraindication
and interaction, but not enough to count to 12.

The real issue is of course profit. 50% of the end user price is markup and
this just is much more money if you dispense expensive drugs.

>Your point about the great price differential between generic chloroquin and
>Nivaquin or diazepam and Valium is a good one. Are we doing our patients any
>good selling drugs at 5 to 10 times the price for what pharmacologically are
>the same products. At the very least the patient, the consumer, should be
>given the choice.

>I look forward to further comments on this issue.

Well, then they speak about galenics and pharmacokinetics and bioavailability.

I can not see a difference really. Theophylline has been mentioned, and
Carbamazepine. But first of all it's not the generic that makes the patient
have an attack, its the compliance. One can do levels and increase the dose
if necessary, or in the case of Theophylline lower it and give Salbutamol 
and Beclomethasone inhalers.... Malaria Prophylaxis? When I go north I 
take our own generic stuff, and I do treat visitors having used Lariam or 
Nivaquine. Strict enforcement of compliance has reduced the number of
Hypertensive related deaths (in our district of 20000 people) from 25 per year
to 8 so far. And we use Alpha-Methyldopa, Moduretic first, add Prazosine
and then go to long acting Ca Antagonists (a brand name won the tender)
if there are side effects or it doesn't work. We can add a modern ACE inhibitor
but like beta blockers they don't seem to work in our predominantly
black hypertensives.

I feel that this essential drug thing is becoming Politically Correct. People
in Europe or the US worry about what is written on the label outside, when many 
hospitals on this continent don't even have what is supposed to be inside...

We are fortunate in Namibia that we have an economy which allows us to spend 
almost 50% of our annual national budget  for the public health and education 
services and a good infrastructure which makes delivery of drugs to the clinics
and disctrict hospitals possible, though logistsics in some regions are not as
good as they could or should be. 

Dr. Eberhard W. Lisse   \         /                Swakopmund State Hospital
<el@lisse.NA>            *        |                 Resident Medical Officer
Private Bag 5004          \      / +264 64  461503 (p) 461005 (h) 461004 (f)
Swakopmund, Namibia        ;____/         Zone/Domain Contact for the NA-DOM
Vice-Chairman, Board of Trustees,   Namibian Internet Development Foundation,
an Association not for Gain. NAMIDEF is the Namibian Internet Service Provider.

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