E-DRUG: Why Tamil Nadu's drug supply is (and should be) the envy of all other states
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WARNING: This is a VERY LONG MESSAGE. Many issues are raised.
Please fell free to begin a discussion on any point that is covered.
copied as fair use
posted by
Dr Gopal Dabade,
57, Tejaswinagar,
Dharwad 580 002, INDIA
Dr Gopal Dabade <dabadedr@yahoo.com>
Why Tamil Nadus drug supply is (and should be) the envy of all the other states
Behold a rare object. A system that works.
By Margot Cohen | Grist Media Mon 9 Jun, 2014
[Margot Cohen is a writer from New York. Her interest in India follows
previous reporting stints in Indonesia, Vietnam and the Philippines.]
Let's coin a new term: drug envy. This should not apply to dissipated individuals who covet
another's stash of narcotics. Instead, the term could describe the mindset of
frustrated pharmacists in Karnataka, Gujarat, Uttar Pradesh and other states
who envy the way that Tamil Nadu ensures a steady supply of free medicines to
patients at government-run clinics and hospitals.
At the moment, drug envy runs rampant on Bangalore's Magadi road.
This is the site of the Karnataka State Drugs Logistics & Warehousing Society,
the designated mother lode of free generic drugs for patients throughout the state.
Behind the shelves, pharmacists Vasudev K and Beena HM reminisce about their recent visit to a warehouse in
Chennai, where they got a close look at how their neighboring state takes care
of business. What did they see? 'It was full of stocks' exclaims Vasudev.
Yes, all those lovely cartons, containing no less than three months of buffer
stocks. They also heard about Tamil Nadu's reliable system of bottom-up
indenting, which allows primary health centers (PHCs) to request the drugs they
need on a quarterly basis, with rolling stocks at the ready. Tenders are
completed on time.
In most other states, stalled tenders, expired
products and drug shortages known as 'stock-outs' plague the system. It's
generally a quiet plague, spreading behind the rusted bars of dispensaries at
PHCs across India. Perhaps such nitty-gritty issues of drug procurement and
distribution seem less dramatic than a story about a mysterious new virus
called MERS, or a tale of a miraculous number of heart surgeries performed at a
leading hospital. Logistics are for geeks. And generics might be perceived as a
little unfashionable, a little old-school, with all the talk of breakthrough branded
drugs.
But there is something very dramatic about the
way that broken state procurement systems compel poor people to spend money on
medicine that they are entitled to receive for free. And these are not small
sums. One widely cited statistic is that medicine comprises 70 percent of
household spending on health, a major out-of-pocket expense. 'People are
spending substantial portions of their meager disposable income on highly
priced medicines from the private sector,' concludes a March 2014 study from
the Public Health Foundation of India (PHFI). The economic and physical burdens
of disease remain as closely intertwined as any strand of DNA.
The Bharatiya Janata Party's (BJP) election
manifesto spoke vaguely of making drugs more accessible and affordable. Now,
post-election, it remains to be seen whether the notion of 'affordable' will be
augmented by the urgency of 'free'. But the idea does seem to be back on the
table. On May 30, newly appointed Health Minister Harsh Vardhan announced a
plan to meet with ministers of health from various states to discuss the possibilities of streamlining
procurement and distribution of generics. An honest assessment of problems
would be a refreshing start.
In Karnataka, for example, follow the trail of amlodipine, an essential
medicine to treat high blood pressure and prevent angina chest pain. As of late
May, only one warehouse in Belgaum had any remaining supply, with thirteen
other warehouses bereft. At a clinic in Bethamangala village, pharmacist Shanta
Kumari says the stock-out has persisted for three months. Her appeals to the
nearby warehouse in Kolar went unheeded. In Bangalore, Vasudev explains that an
unfortunate mix of personnel transfers and the recent elections delayed the
tender for amlodipine.
With health services vulnerable to the caprice of bureaucratic appointments and
political events, reliability falls by the wayside. In fact, the overall
procurement process for essential medicines in Karnataka was not finalized
until December 2013, eight months behind schedule. Meanwhile, another bad
combination of budget constraints and poor judgment in annual indenting is
creating havoc at the grassroots.'We can't predict, exactly, what drugs we
need,' confesses Amarnath, the sole doctor on duty in Bethamangala's crowded
community health center, a facility meant to employ five doctors.
Down the road, at a PHC in Kysambhalli village, a whiteboard hoisted above the
entrance displays a host of little Xs to mark various drugs that are
unavailable from month to month.
There is supposed to be a safety net. Public clinics and hospitals are now
empowered to use certain emergency funds to run out and buy drugs on the open
market - notwithstanding prices that would be higher than the bulk purchases
sanctioned in Bangalore. Common items like iron pills, vitamins and disposable
syringes are often subject to such piecemeal sourcing. Yet the bureaucratic
approvals for some 'emergency' purchases, such as drugs to treat diabetes, can
also languish in the files. As a result, patients are asked to purchase the
drugs elsewhere. 'People do get aggressive, but we try to convince them to buy
outside,' says Surekha S, a pharmacist at the Bangarapet taluk hospital. Private
pharmacies opposite the hospital confirm that they regularly fill prescriptions
written at the government facility.
Less than 70km south of Bangarapet lies Bargur, a town across the border in the
boulder-strewn Krishnagiri district of Tamil Nadu. Udaya Suryan, the doctor in
charge of Bargur's local clinic, says that he never buys items on the open
market. The clinic handled 1,38,000 patients last year, and everyone got free
medicine. 'We have everything available. Why should we purchase outside?' he
asks. For example, when he ran low on lignocaine injections recently, the
doctor dispatched the pharmacist in a van to the Dharmapuri warehouse (part of
an extensive network of decentralized storage facilities). The pharmacist left
in the morning and returned with the item by the end of the day.
Drug distribution did not always run so smoothly in Tamil Nadu. Fifty-three
year-old Suryan can still remember the horrors of the old system in place 15
years ago, when top-down planning prevailed and waste was endemic. 'They just
dumped the drugs and left, whether we needed them or not,' recounts the doctor.
These days, his clinic attracts loyalists like 35-year old Vijaya, who supports
her disabled husband by selling saris. This time she has come to remedy a persistent
pain in her heel. 'Even if I had more money, I would prefer to get medicine
here,' she says. 'I feel I will get cured.'
* * *
For years, health activists across India have tried to transform drug procurement into a political issue.
Well-aware of the Tamil Nadu model, they have campaigned for its widespread
adoption, often rebuffed in the process. 'It's very, very frustrating,' reports
Anant Phadke, a doctor and public health activist based in Maharashtra. 'I am