Yet, despite an increased allocation of spending on healthcare by the government in the past few years, out of pocket expenditure by patients at the point of service delivery has shown little respite. In this context, India’s role as a leading manufacturer of generic drugs could offer great potential for decreasing healthcare expenditure—by both the people and the government.
However, patients’ and healthcare workers’ perceptions of generic medicines influences their use. In this blog, I will discuss these perceptions and its implications on healthcare expenditure. I also include some personal reflections from my work in training health workers, while promoting the use of good quality generic medicines in health services.
Last year (2014), as part of a research study on access to medicines, the Institute of Public Health (IPH), Bengaluru, conducted household surveys on drug access, utilization, and health seeking behavior in Karnataka—a state in south India. We randomly selected villages that were situated within close proximity of several primary healthcare centers (PHC), which were participating in the study. We found that general awareness of generic medicines was very poor in rural India; less than one per cent had heard about such medicines.
The most disheartening part of our exercise was that most of the people we interviewed reported that the medicines supplied at the government facilities were of poor quality. Many interviewees shared a common perception that “anything you get for free is not of good quality.” And many of them compared such free government medicines to other government supplied materials, such as the monthly ration of food grain, which they also considered to be generally of poor quality. We found that many of the government health workers also concurred with this opinion. It seemed that this was a strongly and widely held perception in rural communities in the areas we surveyed.
Subsequently, when we were training health workers at the PHCs on the rational use of medicines and other non-drug, lifestyle based treatment options for NCDs, we found a similar pattern of perceptions; only a couple of them knew that generic medicines are low cost. However, they had no idea about where such cheaper alternatives to expensive branded drugs were available. The level of awareness among the village based community health workers (called accredited social health activists, or ASHAs, in most parts of India) was similarly low.
After this, we thought we may find some illumination (in contrast to health workers’ total lack of awareness) among private sector pharmacists. Most medicines are purchased in private pharmacies in India. We wanted to explore their role in stocking generic medicines. We also wanted to assess if the promotion of generic medicines by government health services could be perceived by them as affecting their business interests.
Most of the pharmacists we interacted with, however, were confident that generic medicines are ineffective. They thought that most patients prefer good quality medicines (which in their opinion were synonymous with branded medicines) and that very few patients, according to them, obtained their medicines from generic drug stores or PHCs. In their assessment, even if inexpensive generic medicines were promoted, this would not have a major impact on their revenue.
Preliminary analysis of our survey reveals that an average household spends up to 600 Indian rupees ($10) per month on procuring drugs for hypertension and diabetes, which is more than a week’s wages for many people in rural India. Many families discontinue medication because of financial difficulties; see, for example, my colleague’s experience visiting a poor family with an elderly diabetic patient in southern India. Many of these families have no knowledge about generic drugs, where to buy them, their quality, and how they can be helpful in their NCD care.
An important component of good NCD care is sustained provision of good quality, low cost medicines, which should be accessible without further barriers. Several years after launching generic medicines and other schemes to improve access, medicine availability is still poor in rural India. This affects those with NCDs even more because of the need for lifelong medication in some conditions.
Good quality generic medicines supplied through the government’s PHCs could be a simple, yet effective, solution to this problem. Yet, PHC health workers struggle with a shortage of medicines, as well as the adverse perceptions of generic drugs among communities and health workers. We need better promotion and regulation of drug quality by the government if we want to improve access to medicines for poor patients in rural India.
Written by – Bhanu Prakash, Researcher Officer at the Institute of Public Health, Bengaluru.
This article originally appeared on BMJ Blogs on February 26, 2015 under the same title.
AYUSH—an acronym for Ayurveda, Yoga, Unani, Siddha, and Homeopathy—is a system of medicine that has been integrated into the Indian national healthcare delivery system to strengthen public health in rural India. In 2005, when the Indian government launched the national rural health mission (NRHM) to improve healthcare delivery especially for the rural population,integration of AYUSH was an important strategy that was adopted. This was done with the objective of offering treatment choice to people as well as a strategy to overcome the human resource shortage in the government health facilities. The planning and implementation of AYUSH differs across various states, depending upon the existing level of development of AYUSH services in the state and the development emphasis of the state.
Here I am sharing some of my reflections on the status of AYUSH medical officers who are posted in the government primary health centres. I have had opportunities to meet many AYUSH practitioners who are posted in government run primary healthcare centres during field visits for my research into access to medicines for the rural poor in Karnataka. As per the official mandates and guidelines, these practitioners are supposed to practice Indian systems of medicines at the primary healthcare centres and they are also supposed to manage different national programmes. But often what happens in practice is different. Due to the shortage of trained MBBS doctors, they are posted to primary health centres and are expected to manage outpatient and administrative responsibilities. The AYUSH medicines supplied to the primary healthcare centres are very minimal, most of the time there is no stock of any AYUSH medicines and they are forced to prescribe allopathic medicines due to the patients’s demands as well as the pressure from the district and sub district health authorities which is often “off the record.” Several times these AYUSH doctors have asked the health authorities to allow them to prescribe basic allopathic medicines in more legitimate manner, but the authorities keep rejecting their plea. While narrating his plight, one of the doctors sighed and said “we are forced to do quackery in our health system,” referring to the fact that he is being forced to prescribe and practice the allopathic system of medicine (which is not his area of expertise).
It is an irony when the official mandate expects these doctors to manage the patient load and implement national health programmes, but they do not have the legitimacy to prescribe the allopathic system of medicines which are often very basic and used to manage minor elements. The NRHM is almost a decade old and the problem still has not been addressed.
Allowing the AYUSH practitioners to undergo a bridge course to better orient them to allopathic system of medicine and then legitimize them to use at least some basic allopathic drugs would legitimize their position in PHCs. It is pity that in a country where a chemist can sell allopathic drugs over the counter boldly without any prescriptions, AYUSH doctors are finding themselves unsafe to prescribe allopathic medicines in existing health system.
Written by – Dr.Praveenkumar Aivalli, Research Officer at Institute of Public Health Bengaluru.
IPH has been working with Tumkur district in trying to strengthen various components of the district health system. One of the key interventions here has been to work with private practitioners in the district to better understand their integration into the National Tuberculosis control programme.This project being led by our Faculty and PhD Fellow, Vijayashree Yellappa. Earlier this month, her proposal was one of 26 proposals selected (from 460 submissions!) for the WHO-TDR IMPACT grants, a global grant-making mechanism to support innovative research on neglected priority needs for disease control. WHO-TDR is a special Programme of the WHO for research and training in Tropical Diseases and sponsored by UNICEF, the UNDP, the World Bank and WHO.
Tuberculosis (TB) is a major public health problem in Tumkur district. As elsewhere in the country, private health sector in Tumkur city dominates in the provision of TB care. As per the government order issues in May 2012, all private health providers should notify TB cases diagnosed and/or treated by them to the district TB officer .
As part of Dr.Vijayashree’s PhD study (on how to optimise the involvement of Private health providers in the National TB programme), GPS mapping of the Private allopathic providers was carried out in Tumkur city. District TB officer and his team, with technical assistance from the Institute of Public Health, Bangalore, carried out the mapping.
I am pretty well known in the country and constantly have a presence in news making headlines against the multibillion Pharmaceutical industries. I still struggle on a daily basis convincing people that I’m as good as the BIG BRANDS, and to start including me in their daily lives so to help them keep their diseases under control. This is a series of stories about me and a group of generics when we started our journey in K.G.Halli (Bangalore) through a primary care clinic in January 2014.
Every Monday, I sit there for few hours seeing people scan me with a close eye and have a skeptical look towards me and the idea of taking me home and start including me, to fight their war against the disease.
Along with me there are two doctors, two community health assistants bombarded with questions for being a generic drug, is there even a possibility of me being a generic drug?
The questions they encounter “Why is the color of the packet not green”? , Why do I have to take two medicines instead of one? , Why is it so cheap? Is it cheap because the strength is less? Do I actually help in controlling the disease? How can I be so affordable? Medicines for my disease always cost me a lot, how can the expenses suddenly be so less for a month, why are you people doing this work for the community? What do you get out of this? There are a lot of whys? There is lot of how can this be a real.
A lady sits across me , picks me up and says , this is not the same medicine for my disease, the shape is different, the cover is different, when I get two medicines in one tablet why should I take two separate tablets, will this cheap medicine help me control my disease?
The doctor sitting close by me answers with a comfortable ease and politely, that the packet color is different I agree, so is the shape. But the medicine which is required to cure your disease is inside this packet. Only the cover is different. The patient continues “but why can’t I get the combination?
Out in the community I’m an unspoken truth, or something which is never acknowledged, I’m a shadow amongst the big brands, the family physician when they see me pretend like I’m nobody. While the struggle continues, I choose to embark on a journey of my own in the community along with my dedicated team of doctors and community health assistants. I will introduce myself and promote myself that I too exist amongst the multibillion pharmaceutical industries, barring the fancy covering, huge promotion and marketing strategies.
Every journey begins with one small step, while I have embarked on this long journey, hoping it will be a successful in KG Halli.