Saturday, July 25, 2009

Our tryst with medicines

- The investigations of a community worker

Vani earns her living, working as a domestic help in different houses in Bangalore. Her husband, a daily wage earner working in the construction industry, abandoned her and her children two years ago. She now works double time to ensure that they don’t go hungry, and that her children can go to school. Her younger son developed severe stomach pain some time ago. She did a round of the doctors, including the state-run hospital. Each day of absence from work meant a cut in her wages. In a bid to balance her work, income, taking care of her older child and taking the younger one to hospitals, she had to finally settle for a clinic close to her house. The boy was finally responding to treatment, but by then she had lost all her savings, and could not afford to buy the prescribed medicines.

We met Vani at this stage, when she approached our organisation for help, through a women’s Self Help Group which we had organised in her area. It was an all too familiar story for us. We had heard it over and over again – child after child, woman after woman, family after family slipping into poverty because of high medical costs, especially the costs of medicine. A closer look at the prescriptions she carried revealed the pathway to ruin – overpriced, irrational and unscientific medicines taken consistently over a period of time. When we told Vani that half the medicines that she had bought for her child were irrational, and that the other half could be bought at a fraction of a cost if she chose other trusted manufacturers, she was very agitated. She wondered how the doctor who treated her child could prescribe these medicines even after knowing that they were on the brink of bankruptcy.

How indeed? Was she a victim of the deeply embedded doctor-pharma industry nexus? Did the doctor not know the generic equivalents of the costly branded drugs he had been prescribing? Were these medicines prescribed because the doctor’s continuing education about new drugs was from the marketing literature provided by medical representatives of different companies? These questions and many others which arose as we worked in the community led us to investigate a bit more into the drug industry.

Our first shock came when we realised that the all-important issue of policy making in medicines was not handled by the Health ministry, but by the Chemicals and Fertilizer Ministry. This explained the vast difference in the goals of the Pharmaceutical Policy 2002 and the National Health Policy 2002. And it perhaps also explained why health care was the second-most leading cause of rural indebtedness in India, with medicines constituting 50 to 80 percent of health care costs (Medicine Prices and Affordability, AIDAN, March 2009).

The second shock came when we realised that the prices of the same type of medicine in India varied drastically, sometimes as much as 20 times more than the lowest-priced one. For instance, Risperidone 2 mg, a medicine used for psychiatric ailments which cost only Rs.1.69, was priced at Rs.27.00 by another company (16 times). Letrozole 2.5 mg – a medicine used in cancer treatment, which was priced at Rs.9.90 by one company was priced at Rs.181.50 by another (18 times). Sildenafil citrate 100 mg – a medicine used for Erectile Dysfunction was priced at Rs.29.16 by one company, while another company priced it at Rs.584.00 (20 times). With the way medical knowledge has been constructed, if a doctor chose to prescribe a costlier medicine, the patient had no way to determine if a cheaper equivalent was available in the market. That made us wonder why there was no rule which made it compulsory for medical practitioners to prescribe medicines by its generic name. Our research shows that it is already happening in India, in Chittorgarh, Rajasthan.

This discovery also led us to the whole issue of pricing of medicines in our country. We found out that even the so-called free market countries of the EU and UK have some form of control over medicines, such as price controls, volume controls or cost-effectiveness controls. On the other hand, in India the case was different, with the number of medicines under price control steadily declining over the years. Even if individual medicines were under price control, manufacturers found a way around it to get out of price control. In this situation, the very least the Government could do was to bring in price regulation on atleast all medicines in the National List of Essential Medicines based on therapeutic class rather than on individual drugs. Why has this not happened yet? Well, our investigations are still proceeding, and we are searching for the answer. If you get to know why, or how it can be done, do let us know.

- Naveen I. Thomas

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