In 2015, Vivek Sharma walked into Max Super Speciality Hospital in Gurugram and launched a trade war.

Three years later, the social worker’s actions have resulted in a wide-ranging inquiry into sales practices at super-specialty hospitals in New Delhi, particularly as they relate to medical devices.

Sharma, whom The Ken could not reach, bought a 10-mL disposable syringe made by the American manufacturer Becton Dickinson and Company (BD) from the hospital pharmacy at the maximum retail price (MRP) of Rs 19.50 ($0.27). The syringe had a green stopper and the brand name “Emerald”. Then, Sharma went to a medical shop outside the hospital and asked for a BD Emerald syringe, 10-mL. The MRP was Rs 11.50 ($0.16); Sharma got a discount and paid Rs 10 ($0.14).

Sharma’s next stop was the Competition Commission of India (CCI), the competition regulator, where he lodged a complaint against the hospital and the syringe-maker. The two were colluding to fleece customers by setting a higher MRP for a product that is available more cheaply in the open market, he alleged. CCI referred the case to the Director General (DG), and on 31 August, the DG ruled there was no specific collusion between BD and the hospital. Further, the DG ruled the syringe Sharma had bought at the hospital was different than the one he had bought at the medical shop.

The Scenario

What gives? Isn’t a 10-mL syringe of a company, bought from any shop, still a 10-mL syringe of the same company? And how does a hospital get off charging Rs 19.50 on a syringe that costs much less elsewhere?

If you’re an average Indian, chances are you get three needle pricks every year. In 2012, some 3 billion injections were administered nationwide, according to the World Health Organisation. At an average MRP of Rs 6 ($0.08) a syringe, that conservatively makes a Rs 1,800 crore ($245 million) market. So it’s unsurprising that what began as a crusade by a social worker for consumer rights has morphed into a fierce fight between manufacturers to protect and increase their business. On one side are predominantly Indian companies, and on the other are foreign companies.

They are ostensibly fighting over how much medical consumables—the syringe, in specific—cost to you, the consumer. But in reality, this is about market share, profit margins and bottom lines.

The Indian government is deciding whether it should play referee. If it does, its regulations could determine which heart implant, syringe, and other such devices a patient receives in a hospital. This, in turn, would shape the Indian medical device sector, which is expected to reach Rs 60,200 crore ($8 billion) by 2020.

“The problem is not only in syringes, the problem is universal in all medical disposables, consumables and implants,” said Rajiv Nath, joint managing director of Hindustan Syringe & Medical Devices Ltd (HMD), one of India’s oldest syringe companies. “You, as a consumer – have you gained in the last five years? The prices of many medical disposables have come down because customs duties came down, the [manufacturing] price came down because of competition—did you gain from this?”

The syringe, deconstructed

The syringe begins as a choice of polymer granules and stainless steel in factories in Haryana, which is the locus of low-tech medical device manufacturing in India. Workers pour molten polypropylene, a medical grade plastic, into moulds to make the barrel and plunger. They gently heat up rubber, place it in a heated mould and compress it to make the rubber piston. Stainless steel is stretched into tubes called cannula to make fine needles, with bevelled tips sharp enough to pierce the skin. The tip can be ground or cut. Sometimes, lubrication is added to the needle. The pain of a needle prick comes from the puncture as well as how smoothly the needle enters the tissue.

“One of the biggest determinants is the quality of the needle. At the end of the day, that’s something that hits the patient. You would rather pay a little more for a needle that doesn’t make a patient scream every time you stick it in him or her,” said Probir Das, chairman of the Federation of Indian Chambers of Commerce and Industry (FICCI) and a former executive at BD.