Viable road to affordable health care

After subjecting a large number of drug formulations, which come under the national list of essential medicines and coronary stents to price control, the government has now indicated that it plans to make it obligatory for doctors to prescribe medicines only by their generic or molecular names and not brand names (e.g., ciprofloxacin and not Cifran). An indication of which way the government’s thinking is going was already available in the Union Budget.
 
While dwelling on the need to use generic names in prescriptions so as not to promote costlier branded products, the prime minister referred to the exorbitant cost of health care in India and how middle class families are in distress once they have to pay for a major illness. (What happens to a poor family can only be imagined.) He also referred to a new health policy coming after 15 years. Clearly the government wishes to make health care more affordable across sections. This focus on a key social sector is to be appreciated. What needs to be examined is that after understanding the seriousness of the ailment, whether the government is administering the right medicine.

 
Let’s first take the issue of doctors using only generic names in writing prescriptions. The reality is that a doctor may write what he likes but in India it is the pharmacist who is most often the ultimate arbiter. This is because poor uneducated people (it is they who are of foremost concern) often skip going to a doctor and go straight to the pharmacist, describe the symptoms and get some medicines. Those who know a little better can and do take a prescription to the pharmacist but ask for a branded generic of the same molecule so as to use the drug manufactured by a firm he can trust.

 

What is of importance is not only that a person is able to get a drug which is affordable but is of appropriate quality. This opens another can of worms as there are quality issues with a good bit of drugs manufactured in India and the real assurance of quality lies in a drug being manufactured by a pharmaceutical company you can trust. The problem of product quality stems from the fact that the quality of supervision of good manufacturing practices varies across states. A chemist acting on a prescription with a generic name can and will mostly supply the product of the pharmaceutical firm which offers him the best trade margin. This will often not be of the right quality.

 
Price control can at best take care of the price but not the quality. This brings us to the issue of price control being imposed on stents. It is well known that there has been a massive markup in the price charged by hospitals compared to what the manufacturer charges. Hence it makes sense for the government to impose price control so that the markup is reduced. Hospitals also have to now bill the stent separately so that its price to the patient can be easily determined.
 
The most obvious result of this will be hospitals levying the right price for the stent but loading the balance on the hospitalisation charges claimed separately. Another result is that some stent makers have sought to withdraw their high-end stents because of the way the prices of these have been slashed. What is being said is that the only stents which will be readily available will be low-priced Chinese stents, reported to be of rather indifferent quality.

 
In the first place, the Chinese stents should not be available in the Indian market unless the government considers them to be of a minimum quality. As for the costly stents, sometimes priced over a lakh, their availability in the market will be only of notional interest to most Indians as they will be simply unaffordable. Thus we find that in the case of both generic drugs and stents, price control (with use of generic names in the case of drugs) in itself does not ensure availability of what is affordable and of acceptable quality.
 
If price control and generic name prescriptions do not work then what can? In fact, both the aims of price and quality can be met by the government procuring in bulk at negotiated prices generic medicines as well as stents from manufacturers who have been shortlisted on quality parameters. Once procured, these can be made available through the public health service. Drugs are already available through jan aushadhi stores. These can be better stocked and there can be more of them. Stents can also be made available at these stores.

 
Here again we come across the problem of varying standards among states. The procurement systems in Tamil Nadu and Rajasthan are considered to be well functioning but this only highlights the fact that procurement across states should be rid of the malpractices that bedevil them. Once the public health service makes available drugs and devices of acceptable quality at affordable prices, there will be no need to maintain a huge bureaucratic set-up to control prices. And once these supplies are available the private sector will be free to charge the prices it likes from those who can afford them.

 subirkroy@gmail.com