Transcript Preliminary findings from a medicine prices survey in West

Medicine Prices and
Affordability Survey
in
West Bengal, India
(2004 - 2005)
Local Survey Leadership
• CUTS, Kolkata
– Ms. Dalia Dey
– Mr. Santanu Banerjee
• CDMU, WB
– Prof. S. K. Tripathi
– Dr. Avijit Hazra
Supported by
World Health Organization
Health Action International
With special thanks to
Dr. Anita Kotwani - Dept. of Pharmacology, VPCI, University of Delhi
CUTS behalf - Mr. Ranajit Dey, & Dr. Pranabesh Chakraborty
CDMU behalf - Mr. Amitava Guha, Dr. Amitava Sen, & Mr. Sushanta Roy
Geographic Regions Surveyed
indicates surveyed districts
Sectors Surveyed & Sampling
Public sector
Initial plan was to survey 3 public facilities in each of the 7
districts. Accordingly a list of 3 (+ 3 for backup) facilities, not
below the level of rural hospital, was drawn up for each district
through convenience sampling.
It was decided a priori that if < 50% of the target number of
medicines (total 32) were available at any facility, that would be
dropped and replaced by a standby facility. Later this figure was
modified to < 25%.
Private retail sector
5 retail pharmacies were identified in and around the public
facilities selected and surveyed. The selection was done on
spot. Minimum availability criterion was fulfilled for all outlets.
Special Features in Survey Setting
Public Sector
Procurement is central through open tender system.
Procurement prices are therefore uniform. However, small
variations in price were encountered, presumably because
medicines were procured in different financial years and in
case of some manufacturers tax components (e.g. Excise
Duty and Sales Tax) were not applicable.
Private Retail Sector
Procurement is by individual outlet from preferred stockists /
distributors (wholesalers). Price of same product could vary
because of procurement of different batches, differences in
retail margins, or rounding off of tax components.
Core Medicines Dropped
Drug
Strength
Reason for non-inclusion
Artesunate
100 mg tab
50 mcg/dose
inh
25 mg tab
25 mg tab
Strength not available, NAPF
25 mg/ml inj
NAPF
400 mg tab
20 mg tab
200 mg tab
100 mg tab
Drug not readily available, NAPF
Drug not readily available, NAPF
Drug not readily available, NAPF
Drug not readily available, NAPF
Beclometasone
Captopril
Diclofenac
Fluphenazine
decanoate
Indinavir
Lovastatin
Nevirapine
Zidovudine
Strength not readily available, NAPF
Drug not readily available, NAPF
Strength not readily available, NAPF
NAPF = Not available in public facilities.
Supplementary Medicines Added
Drug
Strength
Reason for inclusion
Albendazole
Diclofenac
sodium
Doxycycline
Enalapril
Fluconazole
150
Furosemide
Gentamicin
Haloperidol
Ibuprofen
Isosorbide
dinitrate
Metronidazole
400 mg tab
50 mg tab EC
Widely used, may be found in PF
Widely used, may be found in PF
100 mg cap
Widely used, may be found in PF
5 mg tab
Widely used, may be found in PF
150 mg cap / tab Strength different from that in Core List
40 mg tab
80 mg / 2 mL inj
5 mg / mL inj
400 mg tab
5 mg tab SL
Widely used, may be found in PF
Widely used, may be found in PF
Widely used, may be found in PF
Widely used, may be found in PF
Widely used, may be found in PF
400 mg tab
Widely used, may be found in PF
PF = Public facilities.
Implementation of Survey
 Date of Training - Sep 4-6, 2004.
 Background of Data Collectors - All graduates with
past experience of market survey. Area supervisors
were from medical representative background.
 Dates of Data Collection - Sep to Nov, 2004. Some
residual data gathered beyond Nov, 2004.
 Other Information - Approval letters had to be sought
from DHS, Govt. of W.B. Copies were forwarded and
carried by data collectors. Individual letters of
introduction provided by SKT (one of the authors), in
his official capacity, also helped in facilitating access.
Problems Encountered: Planning,
Implementation & Data Analysis
In general the planning and implementation of the survey
proceeded smoothly through a MOU between the two
implementing bodies - CUTS and CDMU. Problems were
encountered in the following areas:
 Getting access to a few public health facilities.
 Procurement prices at public health facilities could not be
obtained from the facility itself in most cases but were
ascertained later from the CMS list of Govt. of WB.
 In cross-checking prices from medicine strips in a few
private retail facilities.
 Some confusion during data entry due to the changing
versions of the worksheet.
Affordability Baseline
• Daily salary of lowest paid unskilled
government worker = Rs. 131.73
The minimum daily wage of unskilled labor, in the
unorganized sector, should be Rs. 97/- [Govt. of West
Bengal - Labor department].
• Estimated proportion of population on less
than this salary = 79.9% live on less than
$2US per day.
1
1
Source = According to WB Development Report, 2004 - Newsweek Magazine, May 23, 2005, pg 10.
Public Sector Procurement Prices
(measured as Median Price Ratios)
IB
MSG
LPG
Median MPR for all medicines
--
--
0.75
MPR for Amoxicillin
--
--
0.93
MPR for Ceftriaxone
--
--
0.16
MPR for Omeprazole
--
--
0.09
MPR for Doxycycline
--
--
1.44
Median Price Ratios in the Private
Retail Pharmacy Sector - 1
IB
MSG
LPG
2.86
1.84
2.17
MPR for Amoxicillin
--
5.60
5.43
MPR for Ceftriaxone
--
0.64
0.62
MPR for Salbutamol inhaler
0.93
0.89
0.89
MPR for Doxycycline
17.13
8.75
8.40
Median MPR for all medicines
Median Price Ratios in the Private
Retail Pharmacy Sector - 2
Diazepam
Atenolol
Aciclovir
0
2
4
6
8
10
12
14
MPR
Lowest price gen.
Most sold gen.
Innov. Brand
Availability and Affordability of Lowest Price
Generics – Acute and Chronic Conditions - 1
Condition
Medicine
Availability in
Public Sector
(no. of facilities
out of 26
surveyed)
Affordability
in Private
Sector (# days
work for unskilled
government worker)
Diabetes
Glibenclamide
1 / 26
(3.8%)
0.3
Hypertension
Hydrochlorothiazide
0 / 26
0.3
Hypertension
Atenolol
4 / 26
(15.4%)
0.5
Adult ARI
Amoxicillin
25 / 26
(96.2%)
1.3
Pediatric ARI
Co-trimoxazole
suspension
1 / 26
(3.8%)
0.1
Availability and Affordability of Lowest Price
Generics – Acute and Chronic Conditions - 2
Condition
Medicine
Availability in
Public Sector
(no. of facilities
out of 26
surveyed)
Affordability
in Private
Sector (# days
work for unskilled
government worker)
Gonorrhea
Ciprofloxacin
0 / 26
0.1
Osteoarthritis
Diclofenac
sodium
0 / 26
0.8
Depression
Amitriptyline
5 / 26
(19.2%)
0.9
Bronchial
Salbutamol
asthma, chronic inhaler
0 / 26
0.6
Peptic ulcer
0 / 26
0.3
Ranitidine
Availability and Affordability of Lowest Price
Generics – Acute and Chronic Conditions - 3
Condition
Medicine
Availability in
Public Sector
(no. of facilities
out of 26
surveyed)
Adult
meningitis
Ceftriaxone
Amebic
dysentery
Metronidazole
Affordability
in Private
Sector (# days
work for unskilled
government worker)
5 / 26
(19.2%)
7.7
0 / 26
0.1
Affordability in the Private
Retail Pharmacy Sector
Peptic ulcer
(Ranitidine)
Adult ARI
(Amoxicillin)
Hypertension
(Atenolol)
0
0.2
Lowest price gen.
0.4
0.6
0.8
1
Most sold gen.
1.2
1.4
1.6
Innov brand
Availability:
Public vs. Private Retail Sectors - 1
Median availability (%)
Public Sector
IB
MSG LPG
Private retail
Sector
IB
MSG LPG
Aciclovir
--
--
0.0
%
68.6
%
20.0
%
31.4
%
Amoxicillin
--
--
96.2
%
5.7
%
77.1
%
94.3
%
Ceftriaxone
--
--
19.2
%
0.0
%
85.7
%
85.7
%
Availability:
Public vs. Private Retail Sectors - 2
Median availability (%)
Public Sector
IB
MSG LPG
Private retail
Sector
IB
MSG LPG
Salbutamol inhaler
--
--
0.0
%
60.0
%
85.7
%
85.7
%
Metronidazole
--
--
0.0
%
94.3
%
94.3
%
94.3
%
Phenytoin
--
--
0.0
%
0.0
%
91.4
%
91.4
%
Brand Premium - 1
• Brand Premium (BP) is the increased cost
to be borne by the consumer in choosing
an innovator brand over the corresponding
low price generic equivalents.
• BP varied from < 0 to > 100 % with
majority in the 10 – 40 % range.
Brand Premium - 2
Brand Generic
Price Price
Brand
Premium
Metronidazole
3.41
3.41
0.00 %
Albendazole
13.16
9.62
36.80 %
Doxycycline
17.13
8.4
103.93 %
Brand Premium - 3
Statistical analysis showed a strong direct
correlation (Rho = 0.948) between brand
price and generic price and a good
correlation (Rho = 0.602) between brand
price and brand premium.
Other Interesting Findings
1. In many private retail outlets only the Innovator Brand (IB) and
the Most Sold Generic (MSG) equivalent were available. The IB
was cheaper than MSG (e.g. DAONIL cheaper than
EUGLUCON). However, since IB price could not be repeated in
any cell of the worksheet, MSG was taken as the LPG available,
and thus in these instances LPG becomes costlier than IB.
2. Some of the supplementary medicines initially proposed (e.g.
Paracetamol and ORS) could not be taken because of the
difficulty in locating Innovator Brand or MSH reference price.
These medicines are, in general, available in public facilities in
West Bengal. The public sector availability picture would have
been slightly better if these could have been included.
Conclusions - 1
1. This cross-sectional survey of availability and public
procurement or private retail prices in West Bengal is
perhaps the only one of its kind in recent times.
2. The survey used a basket of 32 indicator drugs, all of
which are essential medicines intended for common
health problems.
3. Public health facilities in West Bengal use only lowpriced generic (LPG) equivalents for free distribution.
Conclusions - 2
4. Availability situation in the public sector is far from
satisfactory, with 19 of the 32 medicines (59.4%) not
being available.
5. Procurement in the public sector is quite economical
with the median MPR (in comparison with MSH 2003
median prices) for all medicines being 0.64 and the 25th
to 75th percentile range being 0.37 to 0.92.
6. Availability is evidently better in the private retail
sector, with the median availability of all the 32
medicines being 70% in terms of most sold generic
(MSG) equivalents and 77.1% as LPG.
Conclusions - 3
7. The median MPR and the 25th to 75th percentile range
of MPRs of MSG and LPG equivalents in the private
sector indicate that medicines are costlier than the
international reference prices but not too costly.
There is some price variation for the same product.
8. Standard treatments are likely to be affordable to
individuals who draw at least the minimum daily
wages.
9. Medicine price mark-ups and components could not be
ascertained through the field survey.
Preliminary Thoughts on
Implications for Policy - 1
1. With the government committed to providing universal
access to essential medicines, serious investigation is
needed into the causes of the low availability in the
public sector.
2. It remains to be ascertained whether medicines
selected for the public list do not cover some common
health problems or whether the public distribution
system for medicines in West Bengal is not
functioning well.
Preliminary Thoughts on
Implications for Policy - 2
3. The reason for small variation in prices of the same
brand in the private sector needs to be explored.
4. It is difficult to ascertain price mark-ups and
components in the private retail sector through field
surveys. The proper source will have to be determined
first if this information is required.
5. Quality issue should also be addressed.
Thank you for a patient hearing