Access to Quality Medicines and Health Products in Rajasthan

Access to health stands as fundamental to human rights under UN charter. In India, health spending by the State is very low (nearly 1% of the GDP) and 79% spend on health is out-of-pocket with major spending (about 80%) is on cost of medicines. Almost 30% of the households slide into poverty due to high treatment costs. It is imperative that access to quality essential medicines directly affects the access to health. Though, India is considered as pharmacy for developing countries, yet due to poor regulatory control there is huge price variation in offpatent branded generics, making the affordability at the mercy of prescribers and dispensers. Basically, essential medicines are not costly but are made expensive. By adopting and improving Tamil Nadu model, the Government of Rajasthan has launched a scheme called Mukhyamantri Nishulk Dawa Yojana (MNDY), i.e., Chief Minister’s Free Drug Distribution Scheme (CMFDDS) for providing free essential medicines to all irrespective of their economic status through establishing an autonomous Rajasthan Medical Services Corporation (RMSC). Utilization of available pricing information of quality medicines along with transparent pooled procurement through prequalification measures for products and suppliers and proper distribution system, RMSC, has made it possible to make free access to medicines, especially underserved population. Educational, managerial and regulatory strategies have been used to promote compliance by stakeholders. Resistance by healthcare providers on pretext of quality of supplies and confusion created in public was countered with proper information, education and communication (IEC) activities. Strong political will with proper administrative and technical support has made it possible to reach the unreached, as a first step towards universal access to health.


Introduction
Access to health stands as fundamental to human rights under UN charter. Ensuring its safeguards is a major difficulty in developing countries due to several factors like illiteracy, poverty, corruption, non-affordability, medicine shortage and shortage of health workers. In India, health spending by the State is very low (nearly 1% of the GDP) and 79% spending on health is out of pocket with major spending (about 80%) is on cost of pharmaceuticals (which include vaccines, diagnostics, contraceptives, diagnostics, contraceptives, health supplies, devices, etc.) [1,2]. It constitutes the second highest outlay in any given health system after manpower. As these commodities are the interface between a patient and health services, their availability has a direct impact on health. Health science has evolved in all areas, yet pharmaceuticals still play a main role in healthcare and are likely to continue to do so. Therefore, access to essential medicines would be prerequisite to enforce "Right to Health". Almost 30% of the households slide into poverty due to high treatment costs. It is imperative that access to quality

ARCHIVOS DE MEDICINA ISSN 1698-9465
Journal of Healthcare Communications ISSN 2472-1654 essential medicines directly affects the access to health. As per the UN initiative for Universal Healthcare Coverage (UHC), for a healthcare system to function optimally with access to quality medicines and healthcare products, proper selection and use, affordable pricing, sustainable financing and a reliable supply system must be ensured. According to WHO, two-third of developing nations' population inclusive of India lack orderly access to essential medicines. Despite the accomplishments of the Indian pharmaceutical industry, there is still a greater need to make medicines affordable to people. Medicines are still beyond the means of most people, with the belief that expenditure on medicines makes people poor & sickness leads to poverty. It is undeniable that medicines are overpriced and are beyond the reach of most people thanks to the differential drug pricing and promotion of non-essential drugs. If you analyze the top 300 selling products in the Indian pharmaceutical market, you'd be surprised that only 38% medicines fall under the National Essential Medicines List. Many brands of non-essential drugs that are expensive alternatives without a clear therapeutic gain are in market. These non-essential, irrational, and sometimes hazardous drugs are promoted by the industry, approved by the regulators, prescribed by the doctors and consumed by the unaware patients [3,4].

India-'Pharmacy of the Developing World'
India is among the top five bulk drugs producers in the world, ranking 3 rd in terms of volume (10% in global sales) and 14 th (1.5% in terms of value). India contributes about 20% of the world's drugs production the with one of the most prosperous pharmaceutical industries with over 500 manufacturing plants being US FDA approved which is only second to the United States. There are over 1000 WHO GMP approved companies and the country is widely regarded as the "Pharmacy of the Developing World". The unfortunate irony is that this statistical success has not translated into real availability or affordability of medicines for the masses in India. Indian Pharmaceutical market in general, is free for all players that take advantage of complete asymmetry about the pricing information. In May 2013, a new Drug Price Control Order (DPCO) based on market average price formula replaced the previous cost basis formula. The gap between average wholesale price (which include manufacturer and wholesalers margins) retail prices is huge and is unparalleled to any other industry. Price analysis reveals that this gap is not due to the actual costs of making medicines being high, but rather due to promotional activities of the industry resulting in the retail prices being exorbitantly high which ultimately leads to not only impeding the access to medicines, but irrational promotion of medicines. Most companies, even same companies are selling off-patent product with same ingredients in different branded generics names with different prices (Table 1).

Access to medicines initiatives in India
India is country of many federal States. There are 33 federal States/Union Territories in India ruled by different elected governments of different political parties. Health is under concurrent list of Constitution of India, thereby, both the central government as well as the state governments have roles in management of health with major expectations from State governments as the implementation agencies at grass root levels. It would be beyond the scope of this paper to discuss all prevailing models of medicine accessibility in India, but a state sponsored initiative by the Rajasthan State with population over 70 million is being discussed here highlighting IEC activities for its successful implementation.

Addressing "Availability of Quality Generic Medicines" in Rajasthan
Under the encouragement of Delhi (DSPRUD) initiative "WHO-India Essential Drugs Programme", Rajasthan Society for Promotion of Rational Use of Drugs (RSPRUD) was formed in 1999, which started series advocacy workshops. This facilitated "Rajasthan State Essential Drugs List" in 1999, followed by Low cost medicine initiative, evolution based on medicines wholesale prices and printed retail prices information: Efforts to make medicines accessible at affordable prices started as a pilot project in 2006 in one of the 33 districts of Rajasthan, named "Jhalawar" by Dr. Samit Sharma, a pediatrician by qualification, serving as Administrative Officer. This was an "Initiative to establish low cost medicine shops" which eventually evolved as the "Chittorgarh Model"-Making Medicines Affordable" when he became District Magistrate. He devised a mechanism to bring down the prices of medicines and common surgical items to its minimum, so that even the poor can have access to them. Medicines were procured by generic names based on prevailing wholesale prices using a transparent open tender system and were dispensed through Government run Cooperative Medical Stores as Fair Price outlets at maximum 20% margins. It was a district based chain of fair price medicine stores that serve OPDs and Indoor patients of Government hospitals and also general public at dispensaries and Primary Healthcare Centers (PHCs). Such low cost drug and surgical items sale outlets were not subsidized, they were self-sustainable as they were able to generate enough revenue and hence external aid was not required [5]. The purpose of this initiative was to make medicines affordable and accessible to everyone, especially the poor, and the disadvantaged section of the society to limit out of pocket expenses people made on health and to increase the accessibility of drugs. For examplea pneumonia patient who may not have been able to afford injection Amikacin 500 mg as it was sold in the market at about Rs. 70 (printed Maximum Retail Price (MRP) whereas it was priced at about Rs. 7 only in wholesale and this injection could be supplied through these fair price shops at Rs. 8 to 9. Thus, all patients could afford treatment and many more human lives could be saved). This was facilitated by making almost all commonly prescribed drugs available at low cost, ensuring stricter quality control and helped in monitoring, establishing chain of low cost stores in district and covering the rural areas to make them available and accessible to all. However, this initiative was opposed by the prescribing doctors and retailers raising questions on the quality of generic products, although hidden agenda was reduced perverse financial incentives by the pharmaceutical industry. To convince doctors harmoniously to prescribe by generic names and limiting prescription of unnecessary drugs, which costs a lot, seminars and workshops, were organized as face-to-face communication strategy highlighting importance of Rational Use of Medicines (RUM) and conveying necessity of prescribing generics to comply with Code of Ethics. All misconceptions and myths on quality issues were addressed on the basis of similarity of analysis reports on pharmacopeia basis of branded and generic products. To dispel fears about efficacy and quality of generic medicines among people educational awareness programs along with media campaign were also launched, besides putting big display boards outside every fair price co-operative stores and public health facilities illustrating price comparisons of generic products in these stores with prevailing market prices in private retail pharmacies. This compelled private retailers (Pharmacies) to provide generic drugs for sale in almost same price range. As a ripple effect, another 17 districts of the Rajasthan adopted this successful model. This way medicines and surgical items were provided at inconceivably low prices; much below the printed market rate (i.e. MRP) as per illustrative lists under Table  2, leading to huge reduction in out-of-pocket expenditure on treatment. in "Economies of Scale" the Rajasthan State government has been able to procure medicines at unbelievable low prices as compared to prevailing market prices (Table 3).

Challenges for Change of Behavior of Doctors and Public Education
As expected, serious questions were raised by the medical doctors about quality of generic medicines with additional contention of loss of freedom in prescribing under motivation of pharmaceutical lobbies and doubts were planted in the media as misinformation campaign. Piramal Healthcare, Sun, Cipla, Intas, Sanofi Aventis gets their products manufactured by Akums (unknown to doctors) and same manufacturing company is RMSC supplier. Therefore, there is no question of compromise on quality issues. Further, the State has developed and published Standard Treatment Guidelines (STGs) for rational prescribing with a provision for Prescription audit. Specific orders were issued by the Government to all facilities requesting that carbon copy of prescriptions to be retained to have record for monitoring prescription behavior by the DTCs while dispensing and giving original copy to the patient. Prescribing drugs not included in essential drugs list are required to be justified by the concerned doctor, patients be counselled and dispensing be monitored were additional safeguards.

Public awareness generation
By using NGOs like "Prayas" with support of Action Aid, IEC interventions were encouraged by RMSC to educate public for their entitlement to receive free medicines from the health facilities. Patients are free to call helpline number if they do not get medicines from the health facilities. Various meetings/ seminars, etc. were organized. Following discussions encouraged major empowerment of public: basic understanding of right to health and health equity, health care scenario in the country and in Rajasthan, out-of-pocket expenditure on treatment and its consequences, drug market in the country, regulation of drug prices, difference between generic and branded medicines, etc.

Impact of free drug scheme
The scheme has improved the availability of essential medicines and supplies, considerably reduced treatment cost and out of pocket expenses. Large number of patients, who did not seek treatment till it, gets very serious for non-availability of money, has started availing health care. Emphasis on RUM saved patient from heavy load of unreasonable and unnecessary drugs which are the cause of rising drug resistance and other iatrogenic morbidities and money saved in turn can be used to improve nutrition and condition of other social determinants of health in the country. The impact can be briefly put together as: Increase in access and equity of the underserved, and reaching out to the unreached, savings to Government, smiling patients and thousands of lives saved. Availability of medicines in Rajasthan (on survey day) stock-outs of medicines in 112 government facilities across 10 districts of Rajasthan were surveyed using a structured questionnaire and found overall availability of supplies at PHCs, CHCs and district hospitals as 71, 69 and 88% respectively. This WHO and PHFI Study findings have revealed.

External evaluation by WHO and PHFI
Reduction in out-of-pocket expenditure (OOP) and increased per capita health expenditure: The per capita health expenditure before the free-MNDY scheme was estimated to be Rs. 5.70 which now stands close to Rs. 50.
Increased utilization of public health facilities: Another positive spin-off from this initiative is the rapid increase in outpatient visits and considerable increase in inpatient admissions.
Decreased absenteeism: As medicines are available free now, absenteeism appears to have reduced considerably, putting pressure on the health system infrastructure to improve further.
• Ensured Availability of Medicines.
• Positive influence on prescription/dispensing patterns.  Table 3 Comparison of procurement/tender price of selected few medicines by RMSC with market prices of corresponding branded products and ceiling prices under Price Control Order (DPCO) 2013.