Availability and Pricing of Children's Medicine in Orissa State: A Study

1. A study of pricing and availability of Children’s medicine in Orissa state Trupti rekha Swain, Rath B, Dehury S, Samal S, Tarai A, Nayak H , Jena J Dept. of Pharmacology,SCB Medical College, Cuttack, Orissa, India,E mail: drtruptiswain@yahoo.com Problem Statement: More than 50% of the population of Orissa depends on public health sector for their health care needs. The state has very poor health indicators with infant mortality rates of 65 per 1000 live births. The essential drugs list of 2009 had very few children’s formulations on the list. The Better Medicines for Children Project in India was initiated in Orissa to improve availability and access to safe, child-specific medicines for all children of Orissa. Objectives: To assess the availability and pricing of a list of essential children’s medicines in public and private sectors of Orissa. This was the initial step necessary to improve access to essential medicines for children Design: Cross sectional study was conducted for duration of six months in the year 2010. Setting: Community based survey in the rural and urban areas of six geographically different districts of Orissa - Cuttack, Ganjam, Sambalpur, Kalahandi, Kandhamal and Balasore. Study population: Information on availability was collected from a total of 28 outlets from each district. 14 were from public sector, twelve from private sector and two outlets from other sectors such as non-governmental organizations (NGO) and mission sector. Data were collected from all different levels of health care facilities including 10 primary, 3 secondary and one tertiary health care level. Twelve outlets were surveyed from private sector including one each of doctor associated clinic and nursing home associated clinic. Two outlets from NGO/Mission sectors were also included which constituted as other sectors. Policy(ies): 34 essential children’s medicines based on the disease profile of Orissa State was chosen for the survey using standard WHO-HAI methodology for pricing and availability surveys. Outcome Measure(s): Intervention(s): The availability of these 34 medicines in the public, private and other sectors as well as the prices of medicines, affordability of standard treatment regimens by the lowest paid government worker and the price components. Results: mean availability of medicines in Public, and other sectors were17.0 ± 26.1, & 21.8 ± 30.7 respectively. In the private sector, the mean availability of highest priced medicines and lowest priced medicines was 10.8% and 38.5% respectively Only 3-6 health care facilities in the public sector (n=82) had medicines such as injections penicillin, phenobarbitone, gentamicin and beclomethasone inhaler. A few essential medicines like diazepam rectal gel, chloramphenicol injection, benzyl benzoate lotion, carbamazepine chewable tablets and zinc dispersible tablets were not available even in the private sector. Life saving medicines like amoxicillin+clavulanic acid and artemether+lumefantrine combination was not available in the public sector. They showed very high variation in price, (private sector) i.e., Indian rupees 1.45 - 7.94, and 8.50 - 25.66 respectively making treatment regimens unaffordable for poor patients. Private sector prices to patients were, on average, 244.2% higher compared to the lowest price equivalents. In treating common conditions (fever & diarrhea) lowest paid government worker in Orissa would need between 0.1 (fever, diarrhea) to 0.7 days’ wages (respiratory infection) Intervention:Not applicable Conclusions: Availability of pediatric essential medicines is poor in Orissa State in all sectors. Unavailability of many of the essential medicines in the public health sector means that patients will be forced to purchase them from private sector outlets, which is out of reach for the common man. This deprives children of Orissa access to effective and safe medicines. Funding Source: World Health Organization, SEARO, NEW DELHI

2. Background • Orissa Government procures medicine centrally which is made available in Govt. outlets free of cost. • Price of any medicine in India is governed by Central Ministry through an independent body, National Pharmaceutical Pricing Authority. • Orissa like few other states of India has introduced a system of levying tax on MRP at a single point i.e. first sale in the state. • Price is subjected to VAT on the basis of MRP. • Complicated role of different stake holders in controlling medicines price, the money actually paid by patients, varies in different situation

3. Study Objectives/ Questions • What is the percentage availability of child specific medicines in different health sectors of Orissa ? • What is the % availability of lowest priced and highest priced medicines in private and other sector? • What is the difference in price between highest priced and lowest priced branded products of important child medicines and their generic equivalents? • What different charges get added on to the price of medicines as they proceed from manufacturer to patient? • How do the prices of medicines in Orissa, a resources poor state compare to those in other countries?

4. Methods • Survey conducted in six randomly selected Districts (regions) • Data on 34 essential medicines in the public, private and NGO/Mission sectors of each district, collected in medicine outlets using a validated sampling frame. ( 14 facilities each) • Highest-priced and lowest-priced medicine available on the day of visit to that facility noted. • Data was also collected on government procurement prices. • Medicine prices expressed (median price ratio or MPR) (as ratios relative to MSH reference prices 2010). • Data entered to Excel workbook • Affordability calculated as the number of days' wages lowest-paid unskilled government worker, needs to purchase standard treatments.

5. Method ( Price component) • Price components survey conducted to identify the add-on costs in the supply chain contributing to final patient prices. • Data collection on central policies related to price components, &Tracking specific medicines through the supply chain • Medicine tracking conducted in two districts: Cuttack ( Urban) and Balasore ( rural). • Six medicines tracked backwards in public and private sectors to identify add-on costs

6. Mean percentage availability of Medicines in different Health Sectors of Orissa

7. Percentage availability of antibiotics in the public and private sectors

8. Essential Paediatric medicines with low availability (< 25%) in all three sector: • Chloramphenicol powder for injection • Diazepam rectal solution • Beclomethasone inhaler • Benzyl Benzoate lotion • Zinc dispersible tablet • Ferrous sulfate suspension • Benzyl penicillin G injection • Isoniazid + rifampicin + pyrazinamide dispersible tab • Phenobarbital injection • Procaine penicillin G injection • Carbamazepine chewable tab • Carbamazepine suspension

9. Comparison of Govt. procurement price and private sector price Public sector Private sector

10. Price (Private Sector ) • Out of 34 no’s of medicines, 23 medicines are lowest priced compared to MSH price Final patient prices for highest price and lowest priced medicines in the Private sector are about 1.83 and 1.46 times than their international reference prices, respectively • Lowest paid government worker requires 0.1 days’ wages (fever) & 0.3 days’ wages (Falciparum malaria) to purchase medicines from the private sector whether highest-priced or lowest price generics are used. • However, many people in Orissa earn much less that the lowest government wage; even treatments which appear affordable are too costly for the poorest segments of the population. • Given that 42% - 47% ( rural India) of the population are living below the international poverty line of less than $1/day, even treatments which appear affordable are financially out-of-reach for a substantial number of people.

11. Medicines showing large price variations across outlets (Private Sector)

12. Comparison of percentage contribution of price component to final price of Paracetamol Originator brand Branded generic

13. Summary • Mean availability of essential pediatric medicines in the public sector of Orissa is only 17.0%. • In Private sector, the mean availability of highest price and lowest priced medicines is 10.8 % and 38.5%, respectively. • Availability of Children’s medicine is 21.8% in Other sectors • Out of 34 no’s of medicines, 23 medicines constituted lowest price compared to that of MSH price and only 9 No’s were found from high priced medicine • Final patient prices for highest price and lowest priced medicines in the private sector are about 1.83 and 1.46 times than their international reference prices, respectively • In treating common conditions using standard regimens, the lowest paid government worker would need between 0.1(fever) and 0.3 (Falciparum malaria) days’ wagesto purchase medicines from the private sector • Cumulative % mark-ups for individual medicines ranged from 9.78 % to 326% for different child specific medicines available in Orissa. In private sector, price variation was 53% to 326% • In public sector, Govt. procurement price vary between 9.78 % to 11.09 %only. But in other sectors cumulative mark up was 22.25 -22.59 %.

14. Implications & Conclusion • Government of Orissa should procure children’s medicine on a priority basis looking at the very high childhood morbidity and mortality. The procurement of medicines should be from prepared Essential Medicines List for children (EMLC 2011) • Regulatory authorities should import more child specific formulations for the state. • It should be made mandatory to keep essential life saving medicines for children in every private shop. • The cost of medicines in private sector should be lowered by regulatory authorities through specific policy change. The results of the survey proves that availability, price and affordability of child specific medicines in Orissa state should be improved for ensuring equity in access for basic medical treatments. This requires multi-faceted interventions including review / refocusing of policies and regulations for essential lifesaving drugs for children .

15. Thankfully Acknowledge support of MKCG Medical College, Berhampur SCB Medical College, Cuttack VSS Medical College, Burla Dr Dhaneswari Jena Dr Abinash Panda Dr AyaskantSahoo, Dr AjiteshSahu, Prof. B. Mohapatra Prof. S Mohanty Dr Priti Das Dr RajashreeSamal Dr Gaurav Kumar Dr SansitaParida Dr DebasishBisoi Dr SantwanaMahar, Dr Monalisa Jena, Dr RamachandraGiri Dr Himanshu S. Sahu, Dr Sudhira Ku Parida,