C^^6^^Sc^QTCadTQdcCadTCOVER STORY                          Retail Sale of Generic Drugs at Low Prices by the              ...
Low-Cost Medicines Initiative                     Chittorgarh District-Level Interventions: The Model   We knew that the a...
cost medicines to the patients. Rates must be displayedprominently outside the stores. If these low-cost genericmedicines ...
with the amount of awareness and consciousness amongthe local politicians, the media and the general public, itmay be diff...
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Chittorgarh Generic Drug 2011k

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

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Chittorgarh Generic Drug 2011k

  1. 1. C^^6^^Sc^QTCadTQdcCadTCOVER 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. 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. 3. cost medicines to the patients. Rates must be displayedprominently outside the stores. If these low-cost genericmedicines are made available at government storecounters, the cost of medicines can be reduced to morethan half in most cases and this price-fall will comedown to the extent of one tenth of the prevailing marketrate in certain cases, like cetrizine and nimesulide. Oncethe choice of low-cost drugs is available to the consumer,market competition will ensure that private medical shopsalso reduce their prices.” The table below gives a sample list of price reductionsachieved. For a complete list of comparisons and pricereductions achieved, the reader is encouraged to see:http://chittorgarh.nic.in/generic/Drugs23.03.2009.xls. Obviously, treatment cost of most illnesses fall with anincrease in number of patients getting free drugs fromhospital supply. A byproduct is decrease in expenditurefor the Rajasthan Pensioners Medical Fund (RPMF), somore patients are now benefited. All these of coursedepend 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 RajasthanGovernment. 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 successmajor drugs, about 200 in number, put upfront in the but for the dynamic leadership of the District Collectorcooperative shop – so that no body is left in doubt. The Dr Samit Sharma, a qualified pediatrician, a person quitecooperative runs at least 6 such stores in the Chittorgarh sanguine of the political economy of medicines andtown, supplies to government public health facilities of medical practice; and with of course the cooperationseveral neighbouring districts as well as CHCs of and efforts of senior medical doctors of the districtChittorgarh District. The drugs at these prices are also administration who saw wisdom in Dr Sharma’savailable 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 areHealth Action z September 2009 15
  4. 4. with the amount of awareness and consciousness amongthe local politicians, the media and the general public, itmay be difficult to undo these gains. It is heartening tosee advertisements by the District Collectorate at severalplaces in the town – so much so ‘generic dawaiyan’, orgeneric medicines, has passed into common parlance ofeven the ordinary people of the town, this writer talkedto. As also in the media discourse (see for examplescartoons). Of course, if the Rajasthan government would adoptthis model all over Rajasthan – that is if generic drugsare procured and made available at these prices to allusers of the Government’s health facilities plus madeavailable through a chain of retail stores, a revolution indrug pricing as if people mattered is in the offing and one crores per year – the order of expenditures for thewhich 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 Julyof Rajasthan Government health facilities were to be 2009 and this is his reportgiven 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 aremeans a new drug which is slightly different in its two classical, well established medicines to control bloodchemical composition compared to the older drug. Its sugar. There is no justification to use newer anti-diabeticeffect as well as side-effects are hardly different from medicines unless these two have been tried properly inthose 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 whethersuperior to the older medicine. Hence many doctors these new medicines have a distinct advantage overnowadays tend to prescribe these ‘me too’ drugs, these two older, classical anti-diabetic agents. As seenneglecting the fact that they are twice, four times in the Table, these newer medicines are very muchcostlier. 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 themphysicians tend to prescribe. This is in preference to only when really necessary and thereby they can saveenalapril, the older, well researched, scientifically a lot of money of the patients. Patients can comeestablished medicine. All these four medicines belong together and collectively appeal to doctors not to useto a class of medicines called ‘ace-inhibitors’ and there these newer medicines as a first line treatment; but onlyis 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 governmentbetween 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 measuresbranded version costs around Rs. 20. Compared to the to save patients’ money from being wasted on brandedbranded 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; Emailremember that there is no justification for choosing any anant.phadke@gmail.com)Health Action z September 2009 16

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