So close and yet so far away
Access to drugs in India
Von Apurba Ghosh & Chandon Chattopadhyay / Calcutta Project Basel
Drug supply in India is ruled to a large extent by the laws of the free and unregulated market: demand and supply are its cornerstones. But as a bitter consequence, the poor carry the burden created by counterfeit drugs, whereas people from the middleclass see their economical foundations weakened by expensive medicines. Finally, even the rich are affected - they have to cope with the side effects of all the drugs that result from over-prescription.
India - the land of contrasts, where a four thousand year old culture meets the age of computer virtuality, where the tremendously rich and the horribly poor live door to door and where eternal peace and the overwhelming chaos are omnipresent in the streets. This subcontinent with its one billion inhabitants always understood it to take up new influences and to amalgamate it with its own culture. And yet, the last ten years brought a dramatic change to daily life. The principles of economical independence, which were strongly influenced by the thoughts of Mahatma Gandhi and Nehru, had to be left to a large extent and were replaced by the ideals of the open market and the globalisation. This has led to considerable economical growth, since business mentality has strong roots in India. Of course, the health sector and with it the market of drugs has been heavily influenced and considerably changed.
The health system in India is divided in three major classes which each have completely different structures: There is the Government sector which still officially is free of charge and open for all. It is mainly frequented by the people from the lower socio-economic classes. Of course, there are by far not enough funds available to maintain the services with high population coverage, and therefore supplies are chronically low and drugs are very often not available. The part of the health sector, which is covered by NGOs, generally is a little bit better off. Services mostly are not for free, but they are subsidized to a large extent. Still, a considerable part of the cost has to be borne by the patient and his family - and therefore, these services can only be used by people who at least have a minimum of a regular income, they usually come from the upper lower class or the middle class. The private sector is the one, which has undergone the strongest change. Everything is available if you are living in the urban area and if you have enough money! The Indian market is big enough to be interesting for the profit oriented providers of sophisticated medical services and of the latest drugs of the producer pipeline. But the prices are high; they very often reach a level, which is close to the one of Europe or USA. As a consequence, the ratio between price and performance is rather poor, especially because the availability of a sophisticated service or drug does not automatically ensure its quality.
Everything is available if...
The problems that arise from a health system with several classes in a globalised market can be deduced logically and there is only little imagination needed. The population living in the rural area is highly dependent on the services provided by the government, in one or the other village, there may be an NGO working as well. The private sector, especially pharmacies, can only be found in larger villages where there are enough people, who can afford to pay for medicines. In the rural field, this is even a smaller proportion of the population than in the cities, since even families who cannot be considered to be poor do not have cash money. One does not need to be a prophet to foresee, that the governmental rural health services are about to suffer a tremendous crisis: the opening of the national market has already increased the cost in general, on top of it there will be the patent bill of the World Trade Organization, which is going to be enforced in India by 2005 (1). As a consequence, prices of drugs will continue to rise at a quick pace and the already deficient and only partially maintained public primary health care services will be further destabilized. Practically, this means that many of the rural dispensaries will have to be given up leaving the local population with no health care services at all.
Different problems are to be faced in the urban setting. The strong private sector always will provide all desired drugs to the ones who can afford it. Doctors have to make their prescriptions facing a huge and highly competitive pharmaceutical market, where essential drugs are flooded by a wave of new and fancy products. It has become a challenge to keep the overview on which medicines are really essential and which brands have a good price performance ratio, and therefore, the process of rational treatment, which follows the algorhythm of drug efficacy, safety, cost and suitability, can very often not be followed. But not enough with that. Once the patient has the prescription in his hand, he has to cope with the risk of buying counterfeit drugs in the pharmacy. Thus, all the efforts of the patient to get an appropriate treatment may be in vain. The problem of fake drugs is widely spread all over India, although clear data are not available. The country’s huge population and the overwhelming poverty nearly make it impossible to ensure quality control and to enforce legislation. And again, people of the lower and middle socio-economic class are more likely to be affected, even in two ways. Counterfeit drugs do not only cause serious health damage to the patient, but they have also a strong negative impact on his economical situation, since families very often spend their whole fortune in order to afford the treatment of one of their members.
But not only drugs of the school medicine are involved. Counterfeit homoepathic drugs boosted with steroids can be found, too, which are given in order to respond to the patient’s wish for quick response to treatment. This later desire for rapidly effective medication leads, of course, to another series of problems, which are well known in developed countries, too: there is a considerable tendency to over-prescription of drugs - specially antibiotics - along with a lack of monitoring and critical re-evaluation of treatment. On the other hand, patients stop medication as soon as they feel better and prefer a fancy quick shot treatment to a regular follow up with repeated consultations.
Improving access to drugs
The question arises, which measures would help to improve the general access to drugs. Definitely, there is no simple answer to it, but interventions at different levels are possible. The government can contribute by having a committed essential drugs policy and by developing measures to combat counterfeit drugs (2). Generics need to be promoted and quality control institutions are to be established at regional level. Much will depend on the negotiations of the government with the pharmaceutical industry for reasonable prices of drugs. India has the big advantage of having a huge potential market - this is a strong argument during negotiations, which must not be given away too easily. There will be a direct impact on whether treatment will be possible for millions of patients or not. The WTO should keep this in mind, too, when it will enforce its patent bill in developing countries.
The NGO sector with its non-profit hospitals and dispensaries will do well, if it maintains treatment guidelines and essential drug lists in its institutions. A unity of doctrine will improve quality of treatment as well as cut down the cost, since it will be possible to choose appropriate medication at the lowest possible price avoiding over-prescription and fancy drugs. Some NGO’s may even be in the position to supply medicines themselves - they do not necessarily need to be given for free or at subsidized rates but price-arrangements with whole sellers may already reduce the cost considerably.
Medical colleges and providers of continuous medical education can contribute by establishing a focus on good prescribing(3) and on rational use of drugs. In collaboration with the pharmacies they would be in a position to change the currently rather careless prescription practices. Consumers’ organisations could take up the initiative of labelling and certifying pharmacies that provide genuine products together with quality service. But this way of market intervention is not yet established at all in India.
Last but not least pharmaceutical companies as well as the pharmacies could invest in self-regulation and control mechanisms in order to fight counterfeit drugs and to ensure supply of essential drugs at affordable prices. But after all, such a code of honour most probably rather belongs to the world of wishful thinking than to the world of business. Nevertheless, it can be concluded, that only joint action with the necessary commitment at all levels will solve the problem of the insufficient access to drugs.
* Apurba Ghosh, Prof Dr., DCH (Cal), MD (Cal), MRCP (IRE), MRCP (UK), FRCP (Child Health), is the Director of the Institute of Child Health, Kolkata. Chandon Chattopadhyay, Dr., holds a MD in Paediatrics (Switzerland) and completed a Master Degree in International Health (TropEdEurope). He currently works at the Institute of Child Health. He is a founder member and a foundation board executive of the Calcutta Project Foundation of the University of Basel, which runs a joint development project in Kolkata since 1991. Comments welcome to firstname.lastname@example.org
1. Richard Gerster, People before Patents. The Success Story of the Indian Pharmaceutical Industry, Medicus Mundi Bulletin 1, 2002
2. WHO, Counterfeit Drugs, Guidelines for the Development of Measures to Combat Counterfeit Drugs, WHO/EDM/QSM/99.1, 1999
3. WHO, Guide to Good Prescribing, A Practical Manual, WHO/DAP/94.11, 1994