Medicine Prices and Affordability Survey in West Bengal, India (2004 - 2005)

Medicine Prices and Medicine Prices and Affordability SurveyAffordability Survey

inin West Bengal, IndiaWest Bengal, India

(2004 - 2005)(2004 - 2005)

Local Survey LeadershipLocal Survey Leadership

• CUTS, Kolkata– Ms. Dalia Dey– Mr. Santanu Banerjee

Supported bySupported byWorld Health OrganizationHealth Action International

• CDMU, WB– Prof. S. K. Tripathi– Dr. Avijit Hazra

With special thanks toWith special thanks toDr. 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

indicates surveyed districts

Geographic Regions Surveyed

Sectors Surveyed & SamplingSectors Surveyed & Sampling

Public sectorPublic sector

Initial plan was to survey 3 public facilities in each of the 7 Initial plan was to survey 3 public facilities in each of the 7 districts. Accordingly a list of 3 (+ 3 for backup) facilities, not districts. Accordingly a list of 3 (+ 3 for backup) facilities, not below the level of rural hospital, was drawn up for each district below the level of rural hospital, was drawn up for each district through convenience sampling.through convenience sampling.

It was decided It was decided a prioria priori that if < 50% of the target number of that if < 50% of the target number of medicines (total 32) were available at any facility, that would be medicines (total 32) were available at any facility, that would be dropped and replaced by a standby facility. Later this figure was dropped and replaced by a standby facility. Later this figure was modified to < 25%.modified to < 25%.

Private retail sectorPrivate retail sector

5 retail pharmacies were identified in and around the public 5 retail pharmacies were identified in and around the public facilities selected and surveyed. The selection was done on facilities selected and surveyed. The selection was done on spot. Minimum availability criterion was fulfilled for all outlets. spot. Minimum availability criterion was fulfilled for all outlets.

Public SectorPublic Sector

Procurement is central through open tender system. Procurement is central through open tender system. Procurement prices are therefore uniform. However, small Procurement prices are therefore uniform. However, small variations in price were encountered, presumably because variations in price were encountered, presumably because medicines were procured in different financial years and in medicines were procured in different financial years and in case of some manufacturers tax components (e.g. Excise case of some manufacturers tax components (e.g. Excise Duty and Sales Tax) were not applicable.Duty and Sales Tax) were not applicable.

Private Retail SectorPrivate Retail Sector

Procurement is by individual outlet from preferred stockists / Procurement is by individual outlet from preferred stockists / distributors (wholesalers). Price of same product could vary distributors (wholesalers). Price of same product could vary because of procurement of different batches, differences in because of procurement of different batches, differences in retail margins, or rounding off of tax components.retail margins, or rounding off of tax components.

Special Features in Survey SettingSpecial Features in Survey Setting

Core Medicines Dropped

Drug Strength Reason for non-inclusion

Artesunate 100 mg tab Strength not available, NAPF

Beclometasone50 mcg/doseinh

Strength not readily available, NAPF

Captopril 25 mg tab Drug not readily available, NAPFDiclofenac 25 mg tab Strength not readily available, NAPFFluphenazinedecanoate

25 mg/ml inj NAPF

Indinavir 400 mg tab Drug not readily available, NAPFLovastatin 20 mg tab Drug not readily available, NAPFNevirapine 200 mg tab Drug not readily available, NAPFZidovudine 100 mg tab Drug not readily available, NAPF

NAPF = Not available in public facilities.NAPF = Not available in public facilities.

Supplementary Medicines Added

Drug Strength Reason for inclusion

Albendazole 400 mg tab Widely used, may be found in PFDiclofenacsodium

50 mg tab EC Widely used, may be found in PF

Doxycycline 100 mg cap Widely used, may be found in PFEnalapril 5 mg tab Widely used, may be found in PFFluconazole150

150 mg cap / tab Strength different from that in Core List

Furosemide 40 mg tab Widely used, may be found in PFGentamicin 80 mg / 2 mL inj Widely used, may be found in PFHaloperidol 5 mg / mL inj Widely used, may be found in PFIbuprofen 400 mg tab Widely used, may be found in PFIsosorbidedinitrate

5 mg tab SL Widely used, may be found in PF

Metronidazole 400 mg tab Widely used, may be found in PF

PF = Public facilities.PF = Public facilities.

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.

Implementation of Survey

Problems Encountered: Planning, Implementation & Data Analysis

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.

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:

• 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 salary1 = 79.9% live on less than $2US per day.

1 Source = According to WB Development Report, 2004 - Newsweek Magazine, May 23, 2005, pg 10.

Affordability Baseline

Public Sector Procurement Prices (measured as Median Price Ratios)Public Sector Procurement Prices

(measured as Median Price Ratios)

--

--

--

--

IB

0.09--MPR for Omeprazole

0.16--MPR for Ceftriaxone

0.93--MPR for Amoxicillin

0.75--Median MPR for all medicines

LPGMSG

-- 1.44--MPR for Doxycycline

0.93

--

--

2.86

IB

0.890.89MPR for Salbutamol inhaler

0.620.64MPR for Ceftriaxone

5.435.60MPR for Amoxicillin

2.171.84Median MPR for all medicines

LPGMSG

Median Price Ratios in the Private Retail Pharmacy Sector - 1


17.13 8.408.75MPR for Doxycycline



0 2 4 6 8 10 12 14

Aciclovir

Atenolol

Diazepam

MPR

Lowest price gen. Most sold gen. Innov. Brand

Availability and Affordability of Lowest Price Generics – Availability and Affordability of Lowest Price Generics – Acute and Chronic Conditions - 1Acute and Chronic Conditions - 1

0.1

1.3

0.5

0.3

0.3

Affordability in Private

Sector (# days work for unskilled

government worker)

1 / 26 (3.8%)

Co-trimoxazole suspension

Pediatric ARI

25 / 26 (96.2%)

AmoxicillinAdult ARI

4 / 26 (15.4%)

AtenololHypertension

0 / 26Hydrochloro-thiazide

Hypertension

1 / 26 (3.8%)

GlibenclamideDiabetes

Availability in Public Sector

(no. of facilities out of 26

surveyed)

MedicineCondition


0.3

0.6

0.9

0.8

0.1



government worker)

0 / 26RanitidinePeptic ulcer

0 / 26Salbutamol inhaler

Bronchial asthma, chronic

5 / 26 (19.2%)

AmitriptylineDepression

0 / 26Diclofenac sodium

Osteoarthritis

0 / 26CiprofloxacinGonorrhea

Availability in Public Sector(no. of facilities

out of 26 surveyed)

MedicineCondition


0.1

7.7



government worker)

0 / 26MetronidazoleAmebic dysentery

5 / 26 (19.2%)

CeftriaxoneAdult meningitis

Availability in Public Sector

(no. of facilities out of 26

surveyed)

MedicineCondition

Affordability in the Private Retail Affordability in the Private Retail Pharmacy SectorPharmacy Sector

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6

Hypertension(Atenolol)

Adult ARI(Amoxicillin)

Peptic ulcer(Ranitidine)

Lowest price gen. Most sold gen. Innov brand

Availability: Availability: Public vs. Private Retail Sectors - 1Public vs. Private Retail Sectors - 1

Private retail Sector

Public SectorMedian availability (%)

--

--

--

MSG

19.2%

96.2%

0.0 %

LPG

0.0 %

5.7 %

68.6%

IB

85.7%

77.1%

20.0%

MSG

--

--

--

IB

85.7%Ceftriaxone

94.3%Amoxicillin

31.4%Aciclovir

LPG

Availability: Availability: Public vs. Private Retail Sectors - 2Public vs. Private Retail Sectors - 2

Private retail Sector

Public SectorMedian availability (%)

--

--

--

MSG

0.0 %

0.0 %

0.0 %

LPG

0.0 %

94.3 %

60.0%

IB

91.4%

94.3%

85.7%

MSG

--

--

--

IB

91.4%Phenytoin

94.3%Metronidazole

85.7%Salbutamol inhaler

LPG

Brand Premium - 1Brand Premium - 1

• Brand Premium (BP) is the increased cost Brand Premium (BP) is the increased cost to be borne by the consumer in choosing to be borne by the consumer in choosing an innovator brand over the corresponding an innovator brand over the corresponding low price generic equivalents.low price generic equivalents.

• BP varied from < 0 to > 100 % with BP varied from < 0 to > 100 % with majority in the 10 – 40 % range.majority in the 10 – 40 % range.

Brand Price

Generic Price

Brand Premium

Metronidazole 3.41 3.41 0.00 %

Albendazole 13.16 9.62 36.80 %

Doxycycline 17.13 8.4 103.93 %


Statistical analysis showed a strong direct Statistical analysis showed a strong direct correlation (Rhocorrelation (Rho = 0.948) between brand = 0.948) between brand price and generic price and a good price and generic price and a good correlation (Rho = 0.602) between brand correlation (Rho = 0.602) between brand price and brand premium.price and brand premium.


Other Interesting FindingsOther Interesting Findings

1. In many private retail outlets only the Innovator Brand (IB) and 1. In many private retail outlets only the Innovator Brand (IB) and the Most Sold Generic (MSG) equivalent were available. The IB the Most Sold Generic (MSG) equivalent were available. The IB was cheaper than MSG (e.g. DAONIL cheaper than EUGLUCON). was cheaper than MSG (e.g. DAONIL cheaper than EUGLUCON). However, since IB price could not be repeated in any cell of the However, since IB price could not be repeated in any cell of the worksheet, MSG was taken as the LPG available, and thus in worksheet, MSG was taken as the LPG available, and thus in these instances LPG becomes costlier than IB.these instances LPG becomes costlier than IB.

2. Some of the supplementary medicines initially proposed (e.g. 2. Some of the supplementary medicines initially proposed (e.g. Paracetamol and ORS) could not be taken because of the Paracetamol and ORS) could not be taken because of the difficulty in locating Innovator Brand or MSH reference price. difficulty in locating Innovator Brand or MSH reference price. These medicines are, in general, available in public facilities in These medicines are, in general, available in public facilities in West Bengal. The public sector availability picture would have West Bengal. The public sector availability picture would have been slightly better if these could have been included.been slightly better if these could have been included.

Conclusions - 1Conclusions - 1

1. This cross-sectional survey of availability and public 1. This cross-sectional survey of availability and public procurement or private retail prices in West Bengal is procurement or private retail prices in West Bengal is perhaps the only one of its kind in recent times.perhaps the only one of its kind in recent times.

2. The survey used a basket of 32 indicator drugs, all of 2. The survey used a basket of 32 indicator drugs, all of which are essential medicines intended for common which are essential medicines intended for common health problems.health problems.

3. Public health facilities in West Bengal use only low-3. Public health facilities in West Bengal use only low-priced generic (LPG) equivalents for free distribution.priced generic (LPG) equivalents for free distribution.


4. Availability situation in the public sector is far from 4. Availability situation in the public sector is far from satisfactory, with 19 of the 32 medicines (59.4%) not satisfactory, with 19 of the 32 medicines (59.4%) not being available.being available.

5. Procurement in the public sector is quite economical 5. Procurement in the public sector is quite economical with the median MPR (in comparison with MSH 2003 with the median MPR (in comparison with MSH 2003 median prices) for all medicines being 0.64 and the 25th median prices) for all medicines being 0.64 and the 25th to 75th percentile range being 0.37 to 0.92.to 75th percentile range being 0.37 to 0.92.

6. Availability is evidently better in the private retail 6. Availability is evidently better in the private retail sector, with the median availability of all the 32 sector, with the median availability of all the 32 medicines being 70% in terms of most sold generic medicines being 70% in terms of most sold generic (MSG) equivalents and 77.1% as LPG.(MSG) equivalents and 77.1% as LPG.


7. The median MPR and the 25th to 75th percentile range 7. The median MPR and the 25th to 75th percentile range of MPRs of MSG and LPG equivalents in the private of MPRs of MSG and LPG equivalents in the private sector indicate that medicines are costlier than the sector indicate that medicines are costlier than the international reference prices but not too costly. international reference prices but not too costly. There is some price variation for the same product.There is some price variation for the same product.

8. Standard treatments are likely to be affordable to 8. Standard treatments are likely to be affordable to individuals who draw at least the minimum daily individuals who draw at least the minimum daily wages.wages.

9. Medicine price mark-ups and components could not be 9. Medicine price mark-ups and components could not be ascertained through the field survey.ascertained through the field survey.

Preliminary Thoughts on Implications Preliminary Thoughts on Implications for Policy - 1for Policy - 1

1. With the government committed to providing universal 1. With the government committed to providing universal access to essential medicines, serious investigation is access to essential medicines, serious investigation is needed into the causes of the low availability in the needed into the causes of the low availability in the public sector.public sector.

2. It remains to be ascertained whether medicines 2. It remains to be ascertained whether medicines selected for the public list do not cover some common selected for the public list do not cover some common health problems or whether the public distribution health problems or whether the public distribution system for medicines in West Bengal is not system for medicines in West Bengal is not functioning well.functioning well.

Preliminary Thoughts on Implications Preliminary Thoughts on Implications for Policy - 2for Policy - 2

3. The reason for small variation in prices of the same 3. The reason for small variation in prices of the same brand in the private sector needs to be explored.brand in the private sector needs to be explored.

4. It is difficult to ascertain price mark-ups and 4. It is difficult to ascertain price mark-ups and components in the private retail sector through field components in the private retail sector through field surveys. The proper source will have to be determined surveys. The proper source will have to be determined first if this information is required.first if this information is required.

5. Quality issue should also be addressed.5. Quality issue should also be addressed.

Thank you for a patient hearingThank you for a patient hearing

Medicine Prices and Affordability Survey in West Bengal, India (2004 - 2005)

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