Universal access to health care- generic drugs in Rajasthan by Narendra Gupta

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COVER STORY
Retail Sale of Generic Drugs at Low Prices by the
Government in Chittorgarh Dt
S.Srinivasan
W
e all know that one of the solutions for
making medicines affordable to people is
to make available only essential generic drugs
at lower prices, that is if your doctor prescribes them in
the first instance. Procurement prices of generic drugs
by Governments like that of Tamil Nadu and Delhi have
revealed that prices of generics are 1.5 % to 10 % of the
maximum retail price (MRP) of branded equivalents at
the retail level. However, to get a retail pharmacist to
stock these low-priced generics is easier said than done
because in the private sector no trader wants to forego
margins (profits); low-priced generics have low profits;
and of course there is a 4 lakh-strong retail pharmacists’
lobby in India. And also since high-priced brand name Photo Source: DM Sharma’s Presentation
drugs sell more, a retail pharmacist will most likely hand Generic Medicine Retail Shop of the Govt Coop Store, Chittorgarh
you the costliest brand of a medicine.
This writer is glad to report of a relatively recent
Patients and end-users too are persuaded by doctors, innovation in the public sector at Chhitorgarh District of
drug companies, pharma industry and trade, and by the Rajasthan and one that is of a much bigger scale. It is
general discourse in the media and amongst the public, the public sector that is in some senses as difficult, if not
that a costlier version of the same drug is of better quality more difficult, to get things done as compared to say the
and good quality drugs cannot come low-priced. But what voluntary health private sector. (See box)
if the same ‘good quality’ drug manufacturer makes the
For the purpose of procurement and supply, the
same drug and sells it at a costlier price for a branded
management of the entire effort is done by a specially
version and much cheaper for the generic version? Even
established government cooperative. Rajasthan
then prescribers would not be convinced and therefore
Government itself has a history of starting such initiatives:
they would not prescribe. Even if prescribers do, where
“In Rajasthan, the life-line fluid stores run by RMRS in
can they direct the patient to buy them?
government hospitals are already providing cheap
There have been few solutions for this dilemma in this injections and IV fluids. In 2004, the government
vast country. A few modest examples of retailing low- instructed to upgrade these fluid stores to life-line drug
priced generics abound however: the organization stores, i.e., apart from fluids they will also sell other drugs
Lokayat in Pune stocks medicines from LOCOST, the as well but these drug stores have come up only in a few
Vadodara-based low-priced generic manufacturing NGO, cities. Moreover, these are procuring and supplying
and makes available these medicines when Lokayat’s medicines by brand names which are costly.”
in-house GPs prescribe them to OPD patients. Rayat
But the fallout envisaged by the current effort is what
Pharmacy in Nanded amd Meera Medicals in Kolhapur
is interesting: “If such stores are opened in all government
Dt cater to GPs prescribing low-priced medicines from
hospitals and they procure and provide all essential drugs
LOCOST.
by generic name, then it will improve the supply of low-
Health Action z September 2009 13

2. Low-Cost Medicines Initiative
Chittorgarh District-Level Interventions: The Model
We knew that the actual cost of most of the drugs is very [ Government can put a ceiling on MRP?
low. But, these were not available to patients at low rates This cannot be done at the state government level. Central
because of three obstacles: government can do it using the provisions of Essential
Q The doctors prescribe medicines by brand name of a Commodities Act and Drug Price Control Order. Doctors
particular drug company. This prevents competition and were convinced that by the time a ceiling on MRP is put
creates monopoly in the drug market and enables the drug by the central government they should not wait and start
company to put a very high MRP. helping their patients, specially the poor.
Q As very high MRP is printed on the drugs, the chemists J Government Cooperative Medical Stores and Life-
charge the same amount from the patient. line Drug Stores (run by RMRS) provide low-cost
Q Consumers are not aware that the actual cost of production medicines of well reputed companies
of most of the drugs is very low. Moreover, once the doctor Q Medicines which are commonly used by the patients and
prescribes a particular brand, the patient has got no option, prescribed by doctors were listed after discussions with
but to buy it, even when other low-cost brands are available various medical specialists.
in the market. For example, if the doctor prescribes a brand Q A committee of doctors was consulted which recommended
Glivec to a patient of blood cancer, a month’s course will that drugs of reputed companies like Cipla, Cadila, Ranbaxy,
cost Rs.1,14,400/- to the patient. Whereas, the same anti- German Remedies, Alembic, etc. can be purchased . (Initially
cancer drug, but with a different brand name Veenet costs 22 and now 57 companies are approved).
just Rs.11,400/-. And Cipla supplies the generic equivalent
Q Finally, the tender was floated for these medicines. The
of this drug (imitib) at Rs. 8,000/- Gelnmark supplies it
tender included 564 generic medicines and more than 100
for Rs. 5,720/-!!!
surgical and I.V. fluids. Cooperative store invited bids to
So, the district administration adopted the following strategy purchase the drugs of these companies from the local
to provide low-cost medicines to the patients. Generic stockists at competitive prices, after preparing comparative
medicines are on an average 5 times less the cost of branded statement and finding out the most economical company
medicines. We broke the monopoly of drug manufacturers (L1).
by pursuing doctors to prescribe by the salt name and we
Q The medicines are then sold at 20% profit margin to the
made arrangements to sell medicines below the MRP at
patients. This money goes to the cooperative department
government drug counters and made consumers aware. This
and will make the project self-sustainable.
was done in three steps:
Q Thus, medicines of reputed drug manufacturers (which are
J Ensuring that doctors prescribe drugs by generic
unthinkably cheap) were made available at government co-
(salt) name, as directed by the state government op. medical stores for sale.
The state government has issued various circulars/ orders,
Q Pricelists are displayed outside the cooperative stores to
directing all government doctors to use generic names,
advertise the rates and educate the patients.
instead of brand names.
Q Once choice of low cost drugs is available to the consumer,
The following issues were addressed before the project
market competition will ensure that private medical shops
could take off.
also reduce their prices.
[ Quality?
Q Awareness generation: Doctors were sensitized by
A team of doctors was constituted to suggest the organizing discussions. Training of co-op. pharmacists was
companies, which they believe, produce good quality carried out. The consumers were made aware by displaying
drugs. Only these were procured and supplied at co-op. boards showing comparative price lists and positive use of
stores. local electronic and print media.
[ Combination preparations?
Commonly-used combination generic drugs were made J Quality control and audit
available at co-op. stores. The quality control Officer is Dr. Dinesh Vaishnav who is
assisted by Drug Inspector Sh. Jain. This team ensures that
[ Chemists will give brand of his choice and will charge
the drugs of the companies approved by the committee of
the printed MRP?
doctors only are available. So far, 33 samples of generic drugs
If the patient gets medicine from hospital supply or is
from various shops have been tested and all of them have
educated to buy low-cost drugs from co-op. store, the
been found to be of standard quality.
problem is no more. Once, patients understand that the
same drugs are available at a co-operative store at much Source: Making Medicines Affordable: Reaching the Unreached.
cheaper rate, market competition ensures that the Documentation by Dr. Samit Sharma, Collector District
chemists also sell at lower rates. Eventually the patient Magistrate, Chittorgarh, Rajasthan. See also: http://
chittorgarh.nic.in/Generic_new/generic.htm.
benefits.
Health Action z September 2009 14

3. cost medicines to the patients. Rates must be displayed
prominently outside the stores. If these low-cost generic
medicines are made available at government store
counters, the cost of medicines can be reduced to more
than half in most cases and this price-fall will come
down to the extent of one tenth of the prevailing market
rate in certain cases, like cetrizine and nimesulide. Once
the choice of low-cost drugs is available to the consumer,
market competition will ensure that private medical shops
also reduce their prices.”
The table below gives a sample list of price reductions
achieved. For a complete list of comparisons and price
reductions achieved, the reader is encouraged to see:
http://chittorgarh.nic.in/generic/Drugs23.03.2009.xls.
Obviously, treatment cost of most illnesses fall with an
increase in number of patients getting free drugs from
hospital supply. A byproduct is decrease in expenditure
for the Rajasthan Pensioners Medical Fund (RPMF), so
more patients are now benefited. All these of course
depend on rational prescription and correct diagnosis by
Source for Photos: Making Medicines Affordable:
prescribers and as far as possible as per Standard
Reaching the Unreached, op.cit.
Treatment Guidelines brought out by the Rajasthan
Government.
free for BPL and other deserving groups like
Table 1: Sample List of Price Reductions Achieved by the single women, orphans, aged persons, etc.
Chittorgarh Model The charge list of investigations even for
Generic Name of Drug Chittorgarh Unit MRP Printed paying patients are very nominal – starting
Bhandar Rate* on pack / at Rs 5 for an Hb (iron content of blood) or
(Rs.) strip (Rs.) an Malarial Parasite test and going up to Rs
Albendazole Tab IP 400 mg 1.37 1 tablet 25.00 300 for a total lipid profile (the only such test
Alprazolam Tab IP 0.5 mg 1.75 10 tablets 14.00 costing Rs 300). The laboratory and the X-
Arteether 2 ml Inj 11.72 1 Injection 99.00 Ray Unit function 24x7 and reports are made
Amlodipine Tab 5 mg 3.12 10 tablets 22.00 available at 12 noon and 5 pm. OPD/IPD
Cetrizine 10 mg 1.50 10 tablets 35.00 registration charges are Rs 2 and Rs 10
Ceftazidime 1000 mg 64.90 1 Injection 370.00 respectively and there are no other charges
Atorvastatin Tab 20 mg 22.59 10 tablets 170.00 for beds and treatment and surgery.
Diclofenac Tab IP 100mg 2.75 10 tablets 25.00 Photos Above: The Positive Effect of the
Diazepam Tab IP 5 mg 1.90 10 tablets 29.40 Government Initiative on Private Retailers:
Amikacin 500 mg 8.67 1 Injection 70.00 Even Private Medical Shops Announce
Availability of Low Priced Generics!
Source: Making Medicines Affordable: Reaching the Unreached, op.cit.
Enabling Factors
This writer was most glad to see all the prices of the
The Chittorgarh model could not have been a success
major drugs, about 200 in number, put upfront in the
but for the dynamic leadership of the District Collector
cooperative shop – so that no body is left in doubt. The
Dr Samit Sharma, a qualified pediatrician, a person quite
cooperative runs at least 6 such stores in the Chittorgarh
sanguine of the political economy of medicines and
town, supplies to government public health facilities of
medical practice; and with of course the cooperation
several neighbouring districts as well as CHCs of
and efforts of senior medical doctors of the district
Chittorgarh District. The drugs at these prices are also
administration who saw wisdom in Dr Sharma’s
available for the indoor and outdoor patients of the
initiatives. Will this outlast Dr Sharma’s inevitable transfer,
Sanwaliyaji Government District Hospital at Chittorgarh
sooner or later, as he is an IAS officer? Well we hope so,
town – at this hospital, medicines and investigations are
Health Action z September 2009 15

4. with the amount of awareness and consciousness among
the local politicians, the media and the general public, it
may be difficult to undo these gains. It is heartening to
see advertisements by the District Collectorate at several
places in the town – so much so ‘generic dawaiyan’, or
generic medicines, has passed into common parlance of
even the ordinary people of the town, this writer talked
to. As also in the media discourse (see for examples
cartoons).
Of course, if the Rajasthan government would adopt
this model all over Rajasthan – that is if generic drugs
are procured and made available at these prices to all
users of the Government’s health facilities plus made
available through a chain of retail stores, a revolution in
drug pricing as if people mattered is in the offing and one crores per year – the order of expenditures for the
which pharma industry wallahs would ignore only at their NREGA scheme per district!„
peril.
(All unreferenced quotes are from Making Medicines
Dr Narendra Gupta of Prayas, Chittorgarh and Affordable: Reaching the Unreached, op.cit.)
colleagues have calculated that if all the OPD patients The author visited Chittorgarh during last week of July
of Rajasthan Government health facilities were to be 2009 and this is his report
given free medicines, the cost would be only Rs 493 (1 Tejas Apts, 53 Haribhakti Colony, Old Padra Rd,
Baroda 390 007; Email: sahajbrc@youtele.com)
(Continued from page 10)
Say ‘No’ to ‘me too’ drugs of these newer medicines unless enalapril has been tried
Lastly, a socially-conscious doctor can decide that adequately.
she will not prescribe a ‘me too’ drug. A ‘me too’ drug In case of diabetes, metformin and glibenclamide are
means a new drug which is slightly different in its two classical, well established medicines to control blood
chemical composition compared to the older drug. Its sugar. There is no justification to use newer anti-diabetic
effect as well as side-effects are hardly different from medicines unless these two have been tried properly in
those of the older drug. But pharma companies mislead adequate dosage or unless there is some specific reason.
the doctors in believing that this ‘new’ medicine is far This is because, barring exception, it is doubtful whether
superior to the older medicine. Hence many doctors these new medicines have a distinct advantage over
nowadays tend to prescribe these ‘me too’ drugs, these two older, classical anti-diabetic agents. As seen
neglecting the fact that they are twice, four times in the Table, these newer medicines are very much
costlier. For example, lisinopril, ramipril, perindopril are costlier. For example, piozone costs at least four times
‘me too’ drugs for lowering blood pressure which as much as metformin. Hence doctors must use them
physicians tend to prescribe. This is in preference to only when really necessary and thereby they can save
enalapril, the older, well researched, scientifically a lot of money of the patients. Patients can come
established medicine. All these four medicines belong together and collectively appeal to doctors not to use
to a class of medicines called ‘ace-inhibitors’ and there these newer medicines as a first line treatment; but only
is hardly any difference among them as regards effects, to use them if they are necessary.
or side-effects to justify the huge price-difference In summary, we can say that till the government
between enalapril and others. Generic version of improves its policy, conscious citizens, and socially-
enalapril 5 mg costs Rs. 5 per strip of 10 tablets; its oriented doctors can come together to take measures
branded version costs around Rs. 20. Compared to the to save patients’ money from being wasted on branded
branded versions of lisinopril, ramipril and perindopril formulations and ‘me too’ drugs.„
their equivalent doses cost around Rs. 35, around Rs.70 (8, Ameya Ashish Society, Kokan Express Hotel Lane,
and around Rs.100 respectively per strip! Doctors must Kothrud, Pune 411 038; Email
remember that there is no justification for choosing any anant.phadke@gmail.com)
Health Action z September 2009 16