Sponsorship , public private partnership and medical professionals

Individual influence Doctors in favour of maintaining links with drug companies are said to be of strong belief that they are immune and invulnerable to promotional influences. They attribute such resistance to the type of training they receive where patients‘ interest take priority above other concerns. In addition they are said to feel that patients benefit from such relationships through a two pronged process. One is through advancement of knowledge of the prescribing doctor which has a direct bearing on patient care and the other through offer of free drug samples. The latter has advantages such as ability to help indigent patients, availability of drugs to commence therapy immediately and the opportunity to test for drug reactions before full prescriptions are issued.


Introduction
We as doctors have a moral obligation to the patients as well as to the society to equip ourselves with the latest advancements of medicine, which are for the benefit of the patients and this is pursued through continuing medical education (CME).In the modern version of the Hippocratic oath it is expressed as -I will continue with diligence to keep abreast of advances in medicine‖ 1 .The corporate sector has intervened and extends a hand to facilitate achievement of this goal by creating a conducive environment.This has lead to a situation where we as a profession are caught in the dilemma between the need to promote continuing professional development utilizing this generosity and on avoiding conflict of interest.
The interaction established between the pharmaceutical industry and the doctors is two fold.One is at the individual and the other at the organizational level through the professional bodies.
Free drug samples, meals, free travel and lodging for educational events, financial incentives to participate in clinical trials, honoraria for delivering lectures, lavish leisure trips, expensive text books and items of low monetary value such as pens and notepads are some of the benefits received at individual level.Sponsorship of annual scientific meetings and special projects and funding of research are the organizational activities supported by them 2 .
The word -Sponsorship‖ has many definitions and are based on the objective of the organization that deals with it.A more widely applicable definition describes it as a -business relationship between a provider of funds, resources or services and an individual, event or organization which offers in return, rights and association that may be used for commercial advantage in return for the sponsorship invest-ment‖ 3 .Therefore, it is evident that the corporate sector involvement with the medical profession is with the aim of influencing the prescription behaviour 3 .
It is not only the cash incentives and offer of other services and gifts that could influence the prescription behaviour.Friendship and flattery combined with food are considered as powerful tools, instru-We need to be aware that it is the patient who is at the mercy of the doctor, who pays for it, which is not by choice ironically, but due to lack of a choice when it comes to his/her health.Falling ill and the need to seek medical help cannot be compared to purchasing an item that one fancies, where he/she has the option of reconsidering, if it is not with in the means of the pocket.Sadly, this choice is not available in regard to illness.

Research.
According to Ray Moynihan 4 a visiting editor of the British Medical Journal, a quarter of university researchers in the USA receive industry funding and a third have established personal ties with them.As quoted 4 Arnold Ralman, a Harvard professor and a former editor of the New England Journal of Medicine feels disgraced that the pharmaceutical industry has bought over the medical profession in terms of practice, research and teaching and that the academic institutions act as paid agents of the industry.
Further, ambitious academics embracing drug company hospitality are said to have the advantages such as organization of lecture tours and having much wanted publications which are essential to build up successful medical careers 4 .

CME
Controversies also surround the corporate involvement in conducting medical meetings.It has the advantage of the ability to invite speakers from outside the local area and from abroad (which elevates the conference standards to international levels), as the travelling costs of such speakers are borne by the sponsors.This may not be feasible with out such funds.
Despite the above, the main concern as Ray Moynihan 14 describes in his write up in the British Medical Journal, is the influence exerted by drug companies in the selection of speakers and the topics of these meetings, so that the content of these are more in favour of the company products or in the least does not contradict the company's message 14,15 .However, the drug companies and the educational providers who obtain sponsorship deny this allegation 14 .
In addition, the dependence exerted on the individual doctor on company sponsorship can also be immense.A deputy editor of the Journal of American Medical Association (JAMA) Drummand Rennie, who is also a researcher attached to University of California in San Francisco has expressed his concerns that there will come a day when -doctors won't walk fifty yards at a big medical meeting without being transported in a drug company bus‖ 4 .This reflects the extent of the entanglement between doctors and sponsorship by industry and the future plight, in the absence of regulations imposed.

Measures of regulation
While appreciating the role of drug companies in the advancement of medicine [16][17][18] several measures have been suggested to regulate the liaison between doctors and the corporate sector to overcome the untoward consequences that have arisen.
One option recommended is the -pooled approach‖ where the funds received are combined and the sponsoring company has no involvement in deciding the event funded by their contributions 19 . .Other measures include disclosure of conflict of interest and establishment of a code of practice (COP).The most drastic is to sever all ties and the CME to be totally independent of industry sponsorship 2,17 .According to Blumenthal 2 the only professional group to support this view is the American Medical Student Association which has already requested the physicians to do so.
As a measure of transparency some industry representatives themselves have suggested to disclose their involvement when they have any.The opinion of a member of the pressure group -No free lunch‖ as quoted is that such explicit disclosures will not be a reality and that the sponsored events are merely -marketing masquerading as education‖ 14 .
Several professional organizations including the American Medical Association and various interest groups in the USA had made an attempt to address the above concerns by revising the existing COP.However, it has been observed that apart from direct receipt of cash payments which is illegal and amounts to bribery, other forms of interactions are more or less endorsed by these professional bodies 2,4 .This stand reflects the belief that some of these relationships are -ethical, often beneficial and certainly unavoidable‖ 2 .However, Mildred Cho a biomedical ethicist at the Stanford university disagrees with the above assumption 4 .
The Editorial in the BMJ by Abbasi and Smith 17 had been critical of formulating COP which they refer to as -mere window dressing‖ and insists on distancing from the industry.In India, there is a call for doctors to pay their own conference fees citing examples of such conferences held in clinical fields, which will help maintain academic independence and uphold the integrity of the profession 10 .
According to the Canadian Paediatric Society (CPS) which is the national association of paediatricians, all sponsored activities are ones that are consistent with the Code of Ethics of the CPS 20 .
In the UK the relationship between pharmaceutical industry and the doctors are governed by a COP where the level of hospitality provided at meetings is suggested to be -appropriate and not out of proportion to the occasion and costs must not exceed that level which the recipients would normally adopt when paying for themselves‖ 21 .
Capozzi and colleaugeus 22 who hold a moderate view with regard to the corporate involvement, suggests that the product of interest should initially be independently evaluated through review of literature and other means.Assistance of the industry should be sought only when further exploration is warranted, and that information is available only through industry.This seems a rational proposition.

Local situation
With respect to the local industry, the situation is not different to the above and the pharmaceutical industry has openly criticized the policy on -rational drug use‖ put forward by the famous pharmacologist Professor, Senake Bible 23,24 , stating that it is archaic and does not agree with the open economy policy currently in operation.
We must applaud companies who provide funds with no anticipation of any form of reciprocation, not in the least the display of their company name.Without the benefits of reciprocation it does not qualify to be referred to as sponsorship according to its' definition.However, isn't it self deception that we as beneficiaries enjoy their hospitality but take a concerted effort to make it invisible to the outside world?
We preach on the concept of -self reliance‖ but behave to the contrary by continuing with this unholy nexus between the doctors and the corporate sector expecting CME to be provided free of charge?As quoted -The doctors being some of the most well off in the society being unable to pay for their lunches, education and conferences should be ashamed of themselves when the poorer people have to pay every step of the way‖ 16 .
Corporate sponsorship and its influence on individual prescribing patterns has no direct relevant to us as public health personnel because we are not involved with prescribing, apart from those few of us who are engaged in private practice after working hours, which is their legitimate right as those in the curative sector.However, we do involve ourselves in CME.Therefore, we have a moral obligation towards the society to suggest corrective measures.

Suggested measures
One of the main issues that concerns everyone is the high cost of drugs.Efforts made to control drug prices have failed and would not be a reality in the foreseeable future.
However, if the medical profession is either directly or indirectly responsible through its entanglement with pharmaceutical companies, then it is essential that we distance ourselves from such association, in order to orchestrate a reduction in the drug prices.This is certain to bring down the health care costs drastically.However, from the wealth of literature available and the debate that goes on, it is evident that this too is not easy 25 .
As a compromise, we should attempt to divert the sponsorship money for the benefit of the society at large.The next option then should be to adopt the concept of public private partnership, referred to as PPP or P3 which describes a government service or private business venture which is funded and operated through a partnership of government 26 .It is also defined as a method of procuring public services and infrastructure by combining the best of the public and private sectors with an emphasis on value for money and delivering quality public services 27,28 .It is important to discern the differences between sponsorship and PPP which are totally unrelated concepts.Sponsorship entails reciprocation but PPP is formation of partnerships to achieve a common goal.
Concerning industry, PPP amounts to -corporate social responsibility‖ which is imperative for their long term survival.It will be a great relief to the government which is committed to provide a free health care service to the masses and thus struggling to provide minimum facilities required, leave aside quality care.It is still the patient who pays for this money, but the knowledge that this money is spent for the benefit of other patients and the country at large and not to provide for the comfort of a handful of doctors could be more consoling, justifying and morally satisfying.
A classical example of PPP is the contribution made by the drug company -Novartis‖ in the elimination of Leprosy in Sri Lanka and other developing countries.Another is the Global Alliance for Vaccines and Immunization (GAVI) initiated by the Bill and Melinda Gates Foundation.Government of Sri Lanka receives its hepatitis B vaccines, the auto disabled syringes, cold chain monitors and many more through this partnership.
There are hospitals in Sri Lanka which experience perennial shortages of essential drugs, stationery and other basic requirements.Routine investigations are very often done at the private sector owing to shortages in the laboratory equipment, reagents etc. Due to non affordability of health insurance schemes, these costs are often borne by the individual patients.Provision of basic sanitary facilities in the hospitals is a fundamental human requirement and is elementary to prevention of communicable diseases.How many government hospitals in Sri Lanka can afford to provide a decent sanitary service?
Thus it is proposed that corporate funding on doctors be diverted to establish a sustainable PPP with the Ministry of Health which will enable to solve many of the problems faced in maintaining basic health care facilities.
The guidelines adopted by the UK 22 mentioned above, may be used in setting standards for us to determine where the line should be drawn when soliciting any form of sponsorship, may it be from pharmaceutical or food industry or the international agencies such as the World Health Organization, UNICEF, UNFPA etc. Accepting funds from the UN agencies may also be perceived as unethical.However, the benefits of such funding are not self directed as in corporate funding but meant for the society at large.
In conclusion I am of the view that as a professional body we should steer clear of the controversies surrounding sponsorship related to drugs, food and other industrial products, which has a direct bearing on health, because we as experts are relied upon by the community, to express an honest and evidence based view with regard to the associated health implications of those products.We should make a conscious effort to avoid the extremes of too little and too much and resort to the ‗middle path‖ in conducting our professional activities.Our College has been esteemed as a professional body which did not depend on sponsorship by industry but stood on our feet (with the limited funds provided through UN agencies) and yet conducted our academic events in a decent, glamorous and fruitful manner.Let us join hands to trek on the same path our predecessors chose, leaving no space for us to be the centre of discussions and controversy related to ethicality of accepting corporate sponsorship.