A study of pricing and availability of Children’s medicine in Orissa state Trupti rekha Swain,...
-
Upload
rosaline-lamb -
Category
Documents
-
view
215 -
download
0
Transcript of A study of pricing and availability of Children’s medicine in Orissa state Trupti rekha Swain,...
A study of pricing and availability of Children’s medicine in Orissa stateTrupti rekha Swain, Rath B, Dehury S, Samal S, Tarai A, Nayak H , Jena JDept. of Pharmacology,SCB Medical College, Cuttack, Orissa, India,E mail: [email protected] 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
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
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?
MethodsSurvey 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.
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
Mean percentage availability of Medicines in different Health Sectors of Orissa
Public sector (n = 82 outlets)
Private sector (n = 82 outlets)
NGO/Mission Sector(n= 5 Outlets)
All medicines(n = 34 medicines)
All medicines (n = 34 medicines)
All medicinesN=34 medicines
Central Procurement by
Govt.
Highest-priced
product
Lowest- priced
product
Highest- priced
product
Lowest- priced
product
Mean Availability(Standard deviation)
0.0%
17.0%26.3%
10.8%17.9%
38.5%31.6%
0.0%
21.8%30.9%
Percentage availability of antibiotics in the public and private sectors
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Amoxicillin + clavulanic acid dry syrup
Amoxicillin + clavulanic acid tab
Azithromycin dispersible tablet
Amoxicillin dispersible scored tablet
Chloramphenicol powder for injection
Procaine penicillin injection
Benzylpenicillin injection
Gentamycin injection
Amoxicillin suspension
Co-trimoxazole suspension
Ofloxacin tablet
Private (n=79) Public (n=79)
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
Comparison of Govt. procurement price and private sector price
Public sector
Product type Median MPR
25th percenti
le
75th percent
ile
Lowest price generic(n = 14
medicines) 0.52 0.39 0.74
Private sectorProduct
typeMedian MPR
25 %ile 75 %ile
Highest-priced(n = 9 )
1.83 1.57 2.67
Lowest price
generic(n = 23) 1.46 1.06 2.29
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.
Medicine NameMedicine
Type
Median Price Ratio
(MPR)
25%
ile
75%
ile
% difference, 25%ile vs.
75%ile
Ofloxacin tabLowest-priced 2.15 1.89 2.83 50
Azithromycin dispersible tabletLowest-priced 1.47 1.20 1.86 55
Phenobarbital injectionLowest-priced 2.67 1.70 2.71 60
Albendazole suspensionLowest-priced 1.27 1.27 2.41 91
Amoxicillin suspensionLowest-priced 3.83 2.26 4.52 100
Amoxicillin + clavulanic acid tabHighest-priced 0.94 0.79 1.88 139
Amoxicillin + clavulanic acid tabLowest-priced 1.29 0.65 1.75 170
Medicines showing large price variations across outlets (Private Sector)
Comparison of percentage contribution of price component to final price of Paracetamol Originator brand Branded generic
65%4%
8%
19%
4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: Wholesale Stage 4: Retail
Stage 5: Dispensed price
31%
2%2%61%
4%
Manufacturer's selling price Stage 2: Landed price
Stage 3: Wholesale Stage 4: Retail
Stage 5: Dispensed price
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’ wages to 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 %.
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 .
Thankfully Acknowledge support of
Dr Dhaneswari JenaDr Abinash PandaDr Ayaskant Sahoo, Dr Ajitesh Sahu,
Dr Debasish Bisoi Dr Santwana Mahar, Dr Monalisa Jena, Dr Ramachandra Giri Dr Himanshu S. Sahu, Dr Sudhira Ku Parida,
Prof. B. MohapatraProf. S MohantyDr Priti DasDr Rajashree SamalDr Gaurav KumarDr Sansita Parida
SCB Medical College, Cuttack
VSS Medical College, Burla
MKCG Medical College, Berhampur