In this review, we grouped HCCs’ perceptions into three broader categories: understanding of pharmaceutical incentivisation of physicians, perceptions of risks linked to ILP, and suggestions to improve the transparency of physicians. Our synthesis of the existing research has several important messages. First, HCCs had a mixture of good and patchy knowledge about the pharmaceutical incentivisation of physicians, having important implications for the healthcare system perspective. HCCs’ awareness of pharmaceutical incentivisation to physicians leads to several perceptions of hazards linked to it such as distorted prescribing behaviour, growing mistrust in physicians, and a lack of attention paid to patients. In many studies, HCCs believed that when physicians were incentivised, they would aim to meet pharmaceutical sales targets, even if they would need to prescribe medications unnecessarily. (10, 19, 20, 24, 27) The sense of incentive-driven prescriptions can further produce contexts for HCCs to reduce their trust in physicians. There is strong evidence that HCCs who lose trust in physicians are less likely to adhere to medical treatments recommended to them – something that may place a significant morbidity and financial burden on healthcare systems. (31–33) The presence of pharmaceutical sales representatives and promotional items in physicians’ offices, while HCCs wait to see their physicians, as explained in Ammous et al.’s (10) study, is one of the ways that may contribute to HCCs’ awareness of pharmaceutical incentivisation. Hence, trust is a basic element of a healthy and respectful relationship between physicians and patients. Even if patients are reasonably health literate, they rely on physicians who are experts in the field of medicine. (34) The reduction in HCCs’ trust is a clear sign of how the acceptance of pharmaceutical incentives can affect physicians’ reputations in society. Therefore, HCCs in many studies expressed their interest in knowing whether their physicians had any financial ties with pharmaceutical companies, as the non-disclosure might be taken as an injustice.

Second, we also found that HCCs in most of the studies were reasonably aware of the mechanisms through which pharmaceutical incentivisation takes place and the types of incentives that physicians typically receive from pharmaceutical companies. This finding is consistent with several empirical studies with physicians, pharmaceutical companies, and other relevant stakeholders who testify to the unethical exchanges between physicians and pharmaceutical companies in various parts of the world. (4, 8, 13, 35, 36) This means that even though physicians and pharmaceutical companies may attempt to establish financial ties discretely, HCCs have a reasonable awareness of this practice.

Third, the acceptance of incentives from pharmaceutical companies was also deemed against professional medical ethics. This has implications for not only developing clear-cut guidelines on the ethics of dealing with pharmaceutical companies but also ensuring that physicians can fully understand and follow them. In many LMICs, such as Pakistan, no clear guidelines on professional medical ethics exist, and physicians often find it difficult to determine ethical boundaries when they interact with pharmaceutical sales representatives who visit them to promote drugs. (7) Therefore, the development of guidelines on ethics should be the prime responsibility of states to help physicians recognise potential conflicts of interest while dealing with physicians.

Fourth, a few studies also showed that HCCs maintained their trust if their physicians accepted incentives of lesser value or small payments in exchange for lecturing or researching for pharmaceutical companies. This means that HCCs are aware of the importance of the interaction between the pharmaceutical industry and physicians, which happens around knowledge exchange and scientific development.

We limited our search to English-language scholarly journal articles indexed in the databases like Scopus, Medline (OVID), EMBASE (OVID), and a search of Google Scholar. The extension of the search to include research in other languages, and the inclusion of grey literature could help to discover more information. Studies that we included in the review varied in terms of settings and methods, which we analysed to present a general landscape of the published literature on HCCs’ perceptions of pharmaceutical incentivisation to physicians. A full systematic review would provide a more rigorous analysis of the studies.

Our review has several implications for future research. One of our major findings is that most of the empirical studies conducted with HCCs are underpinned by a positivist approach. Quantitative methods were useful in that they helped researchers to determine the distribution of the sampled HCCs about their beliefs and knowledge about pharmaceutical incentivisation and how their beliefs/knowledge might affect their attitudes toward physicians. However, qualitative research can prove more useful in explaining social conditions and contexts linked to HCCs’ perceptions, which can further provide rich insights for policy and practice. More than half of the studies in our review came from high-income countries such as the USA and Australia. The problem of pharmaceutical incentivisation is more critical in LMICs due to weak regulatory controls. More future studies in LMICs are required for a better understanding of the dynamics of pharmaceutical incentivisation to physicians, so appropriate interventions are developed to address this problem.