A Study on Availability and Prices of Medicines in India

1st Quarter 2002 Conducted by

Voluntary Organisation in Interest of Consumer Education (VOICE)

F-71, Lajpat Nagar-II, New Delhi-110024

Ph: +91-11-6918969,  +91-11-6315375  Fax: +91-11-4620455

Website: www.consumer-voice.org

Supported by

National Pharmaceutical Pricing Authority,

Department of Chemical and Petrochemicals,

Ministry of Chemicals and Fertilizers,

Government of India

Author

Bejon Misra, Adviser, Consumer VOICE

E-mail:

Assisted by Prof. Sanjay K. Jain, Marketing Research Consultant

And Mr.Yuvraj Mehta, Consultant

1st Quarter 2002

ACKNOWLEDGEMENT

This study could not have taken place without the active support of many key players involved in the Regulatory Mechanism involving the availability of medicines in India. We wish to thank each and every one involved in making this study possible. We also seek similar support in future from all organizations involved in making medicines accessible at affordable prices to consumers especially the poor and disadvantaged citizens in the developing world.

We wish to record our special thanks to

Mr.Vasanth Kumar Parigi, Managing Trustee, Consumer Education Centre, Bangalore,Mr.Kishan Parmar, Secretary General, UP Upbhokta Kalyan Parishad, Agra and Mr.Arun Kumar Misra, President, Indian National Consumer’s Federation, Lucknow for assisting in conducting the field survey in Karnataka and Uttar Pradesh respectively.

AND

The officials in the Department of Chemicals and Petrochemicals,
Ministry of Chemicals and Fertilizers, Government of India.

Mr. Arun Kumar, IAS (Retd.)

Past Chairman, NPPA

Mr. B.S.Baswan, IAS

Chairman, NPPA

Mr. Pradip Mehra

Member Secretary, NPPA

Dr. P.V.Appaji

Director (Tech.)

Mr. G.G.Mitra

Asst. Director (Cost)

To all the office bearers and staff of VOICE

FOREWORD

The National Pharmaceutical Pricing Authority (NPPA) has been established in August 1997 under the Ministry of Chemicals & Fertilizers as an expert body on pricing of medicines. Its responsibilities include monitoring the availability of medicines in the country and to fix/revise the prices of medicines falling under the “Price Controlled” category. The manufacturers of medicines are required to sell the price controlled drugs at the prices fixed/revised by NPPA. It is estimated that there are about 60,000 medicines sold by over 2,30,000 retail chemists in trade channel. NPPA does not have its own field force for enforcing of Drugs (Price Control) Order under which the price of controlled medicines are fixed.

In this background, NPPA thought it worthwhile to assess the field position by assigning a study to a Non-Government Organisation (NGO) and has chosen “Voice” for this purpose. The study has been conducted in two states; i.e., Uttar Pradesh and Karnataka. It has thrown up many interesting findings.

It is necessary for NPPA to enhance its visibility. In the time to come. NPPA should launch a national campaign to educate civil society about its role in protecting the interests of the consumer and also the pharmaceutical industry, in order to make essential medicines available at affordable prices. As a regular, we have a responsible role not only to regulate market conditions and practices as per our existing laws but also to bring about the neccessary changes in an appropriate manner in consultation with the consumer and the industry.

We appreciate the efforts made by “VOICE” in successfully completing the project.

(P. K. MISHRA) Chairman

TABLE OF CONTENTS

 

Chapter No.	Chapter Name	Page No.
--	About VOICE	iv
--	Executive Summary	v
1	Indian Healthcare Sector and Drug Policies: An Introduction	1
2	Objectives of the Study	4
3	Research Methodology	6
4	Executive Summary Relating to Uttar Pradesh	8
4(a).	Findings Relating to Uttar Pradesh	9
4(b).	Field Staff’s Observations on Uttar Pradesh	26
4(c).	Summary Findings of Uttar Pradesh	27
5.	Executive Summary Relating to Karnataka	29
5(a).	Findings Relating to Karnataka	30
5(b).	Field Staff’s Observations on Karnataka	48
5(c).	Summary Findings of Karnataka	51
6.	Executive Summary Relating All India	53
6(a).	Findings of All India	54
6(b).	Summary Findings of All India	63
7.	Conclusions	65
8.	Recommendations	71
--	Annexures (a). Questionnaire (b). Terms of Reference	--

 

About Voice

(Voluntary Organization in Interest of Consumer Education)

Our Vision

VOICE works towards protecting consumer rights by creating synergy between technological advances, traditional knowledge and right policies through its educational and research activities.VOICE believes that forging beneficial links amongst consumers, market and government interests will promote sustainable and ethical consumption and
production now and in future.

Our Mission

To promote right choices in a volatile and dynamic market place by providing consumer education for all through integrating experiential good practices and scientific knowledge for the safety and health of consumers and the environment.

VOICE is actively involved in the Comparative Testing of Consumer Products for consumer awareness and education. VOICE generates and disseminates the information to Indian consumers for informed decisions while buying consumer products. VOICE was established in 1983 with the help of Professors and Students of Delhi University. It was registered in 1986 as a voluntary non-profit, non-political consumer group. It was registered as a public charitable trust and subsequently registered as a “Recognised Consumer Association” under the MRTP Act.

Other main activities at present are :

• Promoting consumer education through awareness programs.
• Scientific interventions to make the market place better and consumer oriented.
• Mobilize public opinion to change the laws for the benefit of the consumers.
• Providing legal advocacy and guidance.
• Networking with other consumer groups on public interest issues.
• Spreading the consumer movement to new areas to benefit the poor and disadvantaged patients.
• Empowering women consumers to exercise their rights.

As a full member of Consumers International, VOICE has been actively involved on various consumer issues globally and at the national level in India. It has shown demonstrative results in the area of food safety for nearly a decade. VOICE is a member of various sub-committees set up under Central Committee for Food Standards by Ministry of Health, Government of India. VOICE is also working actively on Codex related issues and biotechnology.

VOICE was commissioned by the World Bank and various Government of Indian Ministries to conduct studies on various issues concerning consumers concerns on delivery of health services, accessibility of medicines for the poor and implementation of the national laws on food safety, labeling and packaging. Similarly VOICE has been working in the telecommunication sector with the Ministry of Communication and the Telecom Regulatory Authority of India. Since 1999 VOICE has been working with Consumer Co-ordination Council (CCC) New Delhi and Ford Foundation on the Electricity sector with Delhi Vidyut Board as the part of the ongoing programme on Good Governance and Citizen’s Charter. A new area for VOICE has emerged in the area of human resource development by training public service organisations on customer care and complaints handling.

EXECUTIVE SUMMARY

BACKGROUND

The National Pharmaceutical Pricing Authority (NPPA) during the last two years has tried to perform its main task of fixing/revising the prices of Scheduled Formulations and also tried to make the drug available at reasonable prices to the consumers. As part of its regular interaction with consumers and to understand the availability and prices of drugs in the respective regions, NPPA commissioned VOICE to undertake a study on the prices and availability of essential, life saving and prophylactic medicines of good quality in India. The objective of this study is to look for a viable solution in effectively monitoring the prices of essential medicines and make them available to the patients at affordable prices

RESEARCH METHODOLOGY

In order to understand the problems pertaining to availability, price variation and drug quality, VOICE carried out a study of three types of respondents: first, patients visiting hospitals and chemist shops; secondly, retailers selling medicines and thirdly, service providers such as hospitals/nursing homes both in the private and public sectors.

The study was carried out in two major regions of India, viz., southern and northern regions In each region, a state was identified as per the advice of experts and NPPA. In northern zone, the survey was carried out in Uttar Pradesh, and for the southern zone, Karnataka was the selected state. VOICE in mutual understanding with NPPA identified one city, one town and one block in both these states. The selected cities and towns in these two states were Gorakhpur and Deoria respectively in Uttar Pradesh, Hubli and Mandya respectively in Karnataka. In Uttar Pradesh the total sample size covered was 352 and for Karnataka it was 371.

RESULTS

The study finds that almost fifty percent of the patients avoid seeking service from government hospitals due to poor quality of service and non-accountable practices, even though the facilities are highly subsidized and at times free to the users. 97% patients confirmed that drug availability is not a problem and the chemists keeps the consumers duly informed about the medicines being substituted. There is a constant mistrust prevailing between the service providers and the patients. The study also points towards the sale of drugs without proper prescription. More than 60% of the patients consult chemists rather the doctors to decide as to which medicine(s) to buy. Such practice establishes the fact that the consumers find it difficult to access professional medical counseling which compels the consumers to seek advice from chemists. This is a serious barrier for the consumers and could lead to the growth of unsafe medical practices. The interesting data is only 4% patients said that the drugs are sold at more than the maximum retail price (MRP) but as high as 24% chemists admitted that they overcharge due to various market conditions. They are also aware about the price differences in some medicines of the same brand in the same town.

The study reveals that awareness about the role of NPPA is non-existent, as 98.5% of the surveyed patients are not aware about NPPA. The incidence of such unawareness among the chemists and doctors are also as high as 76% and 64% respectively. The lack of infrastructure is also a serious problem in proper dispensation of medicines to the customers, as 30% chemists in UP still do not invest in mandatory requirements like refrigeration facilities. The scene concerning knowledge about spurious drugs is alarming as 43% doctors did mention about instances of spurious drugs in the market place. But only 7% patients reported to have experienced the same. This implies that due to lack of testing facilities and awareness among the consumers on spurious drugs, consumers are unable to detect and report on sub-standard medicines. The fact emerges that there is a need for consumer education supported by adequate support facilities for detecting spurious drugs.

The need for encouraging traditional medical practices gets highlighted in this study as 99% patients have mentioned that they opted for allopathic science of medical practice but at the same time they also showed willingness to opt for the traditional form of medicines. They all have felt that the Government must focus on providing alternate medical facilities based on traditional forms of medical science in all the towns and villages of India. It is disconcerting to note that only 40% patients visit local doctors for consultation. Furthermore, only 20% visit the doctors attached to hospitals. It means the health facilities are still not easily accessible and affordable to the patients, even though the government is investing huge resources in providing medical facilities to the citizens in India. Last but not the least is the concern regarding the pricing of medicines.

RECOMMENDATIONS

A number of recommendations have been made in the study. Benchmarking service standards of healthcare and monitoring it regularly by ensuring accountability of the existing system to provide minimum standards defined by NPPA in consultation with other service providers is one such recommendation. The study also recommends that availability and accessibility of medicines should be a priority item in the Government’s agenda and it should not be looked at simply the business proposition for investment by the private sector. The private sector should be given encouragement, but not at the cost of the poor and disadvantaged consumers. The business of manufacturing medicines can encourage profiteering, as it is evident today in many developing countries. There is also a need to standardize the prices of medicine by incorporating the applicable sales tax in the printed label to display the total price to be charged to the customers, instead of the existing practice of charging taxes as extra on the agreed printed Maximum Retail Price (MRP). Most of the customers feel cheated with the existing law as very little can be done on sale of medicines in the same location with higher price in the grab of sales tax. Patients do not find price differences in the same medicine, in case the dealer charges the applicable sales tax.

The study also recommends attracting investment from the private sector on developing quality infrastructure facilities like cold chain, testing facilities for the medicine, training of various levels dealing with medicine distribution and prescription dissemination and similar activities. Any loss or damage caused to the patients due to medical negligence or ignorance should be adequately compensated. Above all, a mass education campaign needs to be undertaken to make the Indian patients aware about their rights on medical information in an easy and understandable language.

The study elaborates the role and responsibilities that the NPPA should take to protect the consumer interest and also urges the Government to implement the recommendations of the study so as to empower the citizens of India to protect their health interests.

Chapter 1

INDIAN HEALTH CARE SECTOR AND DRUG

 POLICIES: AN INTRODUCTION

1.1       INDIAN HEALTH CARE SECTOR

India’s development cannot be complete until it develops its social and healthcare sector. For this a strong regulatory mechanism is required to monitor prices and availability of essential medicines. It also needs to ensure quality service in the healthcare sector especially so when 40% of India’s population are illiterate and 30% living below the poverty line.  Unfortunately in India the health care deliveries are not only inadequate but also antagonistic to patient.

Indian pharmaceutical industry today is one of the largest and most advanced industries among the developing countries.  During nineties it has been steadily growing at a rate of 18% from Rs. 4,600 crore in 1991 to Rs. 15,000 crore in 1998 with over 20,000 player in the market. It has manufacturing facilities of bulk drugs belonging to several major therapeutic groups, requiring complex manufacturing processes. The industry has developed excellent facilities for production of all dosage forms like tablets, capsules, liquids, orals and injectables.  Added to this achievement is the assurance with regard to quality of products.

Over the last several years, various policy inputs have been directed towards promoting the growth of the industry and in helping it to achieve a broad base in terms of the range of the products and technologies needed to produce them from as basic a stage as possible.  The results have been very encouraging.  As on date, there are about 250 large units and about 8000 small-scale units in operation, which form the core of the industry.  These units produce complete range of formulations and about 350 bulk drugs.

Although today’s patients are highly health conscious and know importance of health, but many a times in rural and semi-urban town due to lack of knowledge and medical care resources, non-availability of medicines and high amount of money required for treatment, patient face many problems. As a strategy to tackle the problems of poor Indian patients who are unable to access quality medicines at affordable price and easy and assured availability, it is hoped that the study conducted by VOICE will go a long way in building awareness within the patient groups in India and also among the government agencies to tackle the problems faced by Indian patients.

1.2       INDIAN DRUG POLICY 

The development of Indian pharmaceutical industry during the protected regime from seventies to nineties is much due to the drug policy in which the report of the Hathi Committee (1975) is an important landmark. The Hathi Committee in particular emphasized the need for achieving self-sufficiency in medicines and ensuring abundant availability of essential medicines at reasonable prices. Since 1975, the Indian Pharmaceutical Industry has grown to be the most diversified and vertically integrated pharmaceutical industry in the entire Third World. The country has achieved self-sufficiency in formulations and also in a large number of bulk drugs. The main objectives of the Drug Policy of 1986 which was titled as “Measures for Rationalization, Quality Control and Growth of Drugs Pharmaceuticals Industry in India” were:

• Ensuring abundant availability, at reasonable prices, of essential and life saving and prophylactic medicines of good quality;
• Strengthening the system of quality control over drug production and promoting the rational use of drugs in the country;
• Creating an environment conducive to channelising new investments into the pharmaceutical industry with a view to encourage cost-effective production with economic sizes and introducing new technologies and new drugs; and
• Strengthening the indigenous capability for production of drugs.

1.3       HISTORY OF DRUG (PRICES CONTROL) ORDER (DPCO)

Drug prices have been under government control since 1970 under the Drug (Prices Control) Order 1970. Successive orders have been issued in 1979, 1987 and 1995 with more liberalized and industry oriented view. While issuing these orders, it was also kept in the mind that the Indian pharmaceutical industry undergoes transformation from process to patent era. On this date, only 74 drugs are covered under DPCO.

DPCO controls the domestic prices of major bulk drugs and their formulations with an aim to provide patients with medicines at affordable prices. It is applicable only to allopathic drugs where DPCO ascertains the bulk drugs (and their formulations) to be kept under price control.

DPCO came into being for the first time in 1970. At that time, the Indian pharmaceutical industry predominantly comprised of multinational (MNC) affiliates and subsidiaries. In its introductory form, DPCO was more of a control on the profitability of a pharmaceutical business, and thereby it indirectly sought to control the prices of pharmaceuticals. Also, with individual product prices not requiring approval from the government, bureaucratic hurdles were relatively low. The Indian Patents Act 1970 gave an impetus to local players to reverse engineer drugs and foray into various therapeutic segments. Overall, the Indian pharmaceutical industry prospered from 1970 to the next DPCO in 1979.

In its 1979-revised version, the DPCO stipulated ceiling prices for controlled categories of bulk drugs and their formulation. In fixing the price, the Government continued to advocate profitability ceiling. In the case of bulk drugs, this was through a limit on the company’s return on networth or capital employed.

The Drugs Prices Control Order, 1995 is an order issued by the Government of India under Section 3 of the Essential Commodities Act, 1955 to regulate the prices of drugs. Its basic structure remains same as that under the  prior two orders of ’79 and ’87, but it did liberalize the span of control considerably. For the purpose of implementing provisions of DPCO, powers of the government have been vested in National Pharmaceutical Pricing Authority (NPPA) as per notification S.O. 637(E) dated 04.09.1997.

1.4  ROLE OF NATIONAL PHARMACEUTICAL PRICING AUTHORITY

National Pharmaceutical Pricing Authority (NPPA) was established on 29th August 1997 as an independent body of experts as per the decision taken by the Cabinet Committee in September 1994 while reviewing Drug Policy. The Authority, inter alia, has been entrusted with the task of fixation/revision of prices of pharmaceutical products (bulk drugs and formulations), enforcement of provisions of the Drugs (Prices Control) Order and monitoring of the prices of controlled and decontrolled drugs in the country. The organization is also entrusted with the task of recovering the amounts overcharged by the manufacturers for the controlled drugs. The main functions of NPPA are to:

• Implement and enforce the provisions of the Drugs (Prices Control) Order in accordance with the powers delegated to it;
• Deal with all legal matters arising out of the decisions of the Authority;
• Monitor the availability of drugs, identify shortages, if any, and to take remedial steps;
• Collect/maintain data on production, exports and imports, market share of individual companies, profitability of companies etc., for bulk drugs and formulations;
• Undertake and/or sponsor relevant studies in respect of pricing of drugs/ pharmaceuticals;
• Recruit/ appoint the officers and other staff members of the Authority, as per rules and procedures laid down by the Government;
• Render advice to the Central Government on changes/ revisions in the drug policy; and
• Render assistance to the Central Government in the parliamentary matters relating to the drug pricing.

Chapter 2

OBJECTIVES OF THE STUDY

The National Pharmaceutical Pricing Authority (NPPA) during the last two years has tried to perform its main task of fixing/revising the prices of Scheduled Formulations and making the drugs available at reasonable prices in the country. As part of its regular interaction with consumers and to gain understanding about the availability and prices of drugs in select regions, it appointed VOICE to undertake market survey on the prices and availability of essential life saving and prophylactic medicines of good quality in India. The idea underlying this study has been to get a feedback from the patients, doctors and chemists so as to effectively monitor the prices of essential medicines and make then available to the patients at affordable prices. The need for such a study primarily arose from the paucity of knowledge about the current system. More specifically, the terms of reference (see Appendix – I for details) include the following aspects:

2.1       AVAILIBILITY OF MEDICINE

(a)    Whether the medicines normally required are available or not? In case of non-availability/shortage, collecting names of the medicines, which are not available. Investigating whether shortage is temporary or continues for prolonged periods?

(b)   Whether substitute medicines of same drug or other therapeutic equivalent available in the case of shortages?

2.2       PRICE OF MEDICINE

(a)    Comparison of prices of some medicines at different locations. Whether they are available at same price or not (after adjustment for variations due to local taxes)?

(b)   Whether medicines are sold as per the maximum retail price (MRP) printed on the label of the medicine? In the case of overcharging, details of such instances.

(c)    Whether in the perception of the qualified medical practitioners, the drugs are available at reasonable and affordable prices? If some medicines are found to be high priced, identifying names of some reputed brands indicating the pack size and their MRP.

(d)   Are there any instances of frequent, substantial price increases effected by the manufactures in the perception of pharmacists?

(e)    Whether doctors/hospitals are charging prices in excess of printed prices on labels of medicines used during the course of hospitalization?

2.3     QUALITY OF MEDICINE AND ALTERNATIVE MEDICINE PRACTICES 

(a)    Prevalence of other systems of medicines in the area, and if so, collecting the details like percentage of people opting for such systems and reasons for it.

(b)   Determining instances of spurious/substandard drugs being sold in the market? If so, collecting details in consultation with the practicing doctors, medical representatives and trade.

(c)    Collecting other relevant information and observations like:

• Types of doctors (general physicians/specialists) available in the surveyed localities in the private and government hospitals.
• Nature of availability of medical aid in the area.
• Facilities available for refrigeration with chemists in the rural areas.
• Whether drugs like antibiotics, injections, IV fluids, etc., used rationally or indiscriminately?
• Quality of drugs marketed in the area. In case drugs of suspected quality (spurious or of substandard nature) are reported, collecting samples.
• Availability of licensed manufacturing units in the local areas and making a visit to such units.
• Endemic diseases of the area and the extent of use of appropriate medicines.

Chapter 3

RESEARCH METHODOLOGY

3.1       SAMPLE DESIGN

In order to understand the problems pertaining to availability, price variation and drug quality, three separate surveys were conducted:

• Survey of patients visiting hospitals and chemist shops.
• Survey of retailers selling medicines.
• Survey of service providers such as doctors and key officials of the hospitals/nursing homes both in the private and public sectors.

To reduce biasedness in sample selection, the respondents were selected from two major zones of India, i.e., southern and northern zones. In each zone, a state was identified as per the advice of NPPA. In northern zone, the survey was carried out in Uttar Pradesh, and for the southern zone, Karnataka was the selected state.  VOICE in mutual understanding with NPPA identified one city and one town in both these states. VOICE also identified a block in each of the states for conducting the field survey.  The selected city and town in these two states are:  Gorakhpur and Deoria respectively in Uttar Pradesh, Huble and Mandya respectively in Karnataka. In Uttar Pradesh, the total sample size covered was 352 and for Karnataka it was 371. The category-wise sample for each state is given in the Table 1. The details of hospitals selected for study in each state are given in Table 2. Interviews were conducted with the patients, chemists, private practitioners and doctors in the nursing homes and hospitals.

TABLE 1: DISTRIBUTION OF SAMPLE: STATE-WISE PROFILE

Category	City		Town		Block		Total
	Gorakhpur	Huble	Deoria	Mandya	UP	Karnataka	UP	Karnataka
Patient	126	120	50	54	25	26	201	200
Chemist	45	52	20	21	5	6	70	79
Doctor	25	25	15	17	6	4	46	46
Hospital/NH	20	28	10	12	5	6	35	46
TOTAL	216	225	95	104	41	42	352	371

In Uttar Pradesh, 201 patients were contacted, out of which 126 patients were contacted in city, 50 in town and 25 in block. 70 chemists were contacted, out of which 45 were at city level, 20 at town level and 5 at block level. A total of 35 hospitals/ nursing homes were contacted in Uttar Pradesh out of which 20 at city level, 10 at town level and 5 at block level. It was always kept in mind to collect the data from all the types of hospitals such as private, government and nursing homes. A total of 46 doctors were contacted at Uttar Pradesh, out of which 25 at city level, 15 at town level and 6 at block level.

In Karnataka, 200 patients were contacted out of which 120 patients were contacted in city, 54 in town and 26 in block. In all, a total of 79 chemists were contacted, 52 at city level, 21 at town level and 6 at the block level. A total of 46 hospitals in Karnataka were surveyed for the study, out of which 28 at the city level, 12 at the town level and 6 at the block level. A total of 46 doctors were contacted out of which 25 at the city level, 17 at the town level and 4 at the block level.

TABLE 2: DISTRIBUTION OF HOSPITAL SAMPLE: STATE-WISE PROFILE

Sector	Uttar Pradesh				Karnataka
	Nursing Home	Private Hospital	Govt. Hospital	Total	Nursing Home	Private Hospital	Govt. Hospital	Total
City	17	1	2	20	24	2	2	28
Town	4	6	–	10	9	2	1	12
Block	1	1	3	5	2	3	1	6
Total	22	8	5	35	35	7	4	46

3.2       QUESTIONNAIRE DEVELOPMENT AND FIELD SURVEY

The complete study was divided into three phases as outlined below:

STAGE I :  To begin with, a detailed list of all the information required for the study was drawn up.  Once all the information necessary to attain the objectives was listed, experts were identified in each of the segments and discussions were held with them.  Three sets of the questionnaires were prepared in December 2000 for pilot testing with the Nursing Homes / Hospitals, Doctors, Chemists and Patients.

STAGE II :  In the second stage, the questionnaires were suitably modified based on pilot testing and expert suggestions received. face to face interviews were carried out in February 2001 among the targeted respondents on the basis of structured questionnaire (see Appendix – II).

STAGE III :  In the third stage, the consultant and the field staff were asked to make their observations. This observational study was done during February-March 2001 in order to further reduce the discrepancies that might have crept in during the field survey and assess the reliability of the responses given by the respondents in Stage-II.

Chapter 4

EXECUTIVE SUMMARY RELATING TO UTTAR PRADESH

In Uttar Pradesh, 201 patients, 70 chemists, 35 hospitals/ nursing homes and 46 doctors were contacted. It was always kept in mind to collect the data from city, town and block level.

The study shows that patients avoid going to government hospital. Dirtiness, lack of facilities, presence of fewer doctors and absence of even the primary treatment related facilities deter the patients from availing the service of government hospital. This practice is highly prevalent at block level where more than 67% patients said that they avoid going to government hospital. There is only one hospital at Deoria block of Uttar Pradesh and that too is in a very bad shape. Even private hospitals are shying away from investing at block level because of low return on investment and lack of proper incentives from government. 83% doctors at block level said that there are no private hospitals or nursing home in their area. All these only deprive the block level patients from availing basic healthcare facilities.

There is no shortage of any prescribed medicine from the manufacturers. At the block level although some temporary shortages are seen but those are purely due to the lack of fund. Although few chemists also complained that frequently new drugs are introduced in the market and it is really difficult to stock all of them. Incase the prescribed medicines are not available chemists normally substitute them after informing the patients.

There is that rarely price change by the manufacturer neither there is any incidence of printing different price of same medicine at different locations. But it is seen that price of some drugs differ location to location and that is purely because of high demand and short supply, which is temporary phenomenon. Few patients felt that the drugs are costly and the prices are neither reasonable nor affordable.

Patients have the habit of avoiding doctors and consulting chemists for the medicine. These are highly prevalent at block level. They also seek alternative therapy and other than allopathic medicine patients also go for homeopathic and ayurvedic system of therapy. Patients of city and block level have difference in opinion on the importance of price and quality. City patients are more concerned about the quality of drugs than that of price, whereas at town and block levels patients are more prices sensitive than the quality. But over all the awareness about healthcare services are low. Awareness about the NPPA is also at its dismal low. Most of the doctors, patients and chemists are totally unaware about NPPA and its role.

Drugs are normally used rationally except vitamins and injectable minerals that are seen more as treatment for any ailment. So there are some cases of vitamin tablets and injectable minerals used irrationally.

The most alarming thing in this study is that most of the chemists avoid issuing of cash memo. Clearly violating drug policy norms they also agreed that refrigerator is not available in their shop for storage of medicines and at block level refrigeration of medicine was not done in most of the shops. There are incidences of spurious drugs but neither the patients, the chemists nor the doctors are willing to divulge any information about the shops that are selling such medicines.

Chapter 4(a)

FINDINGS RELATING TO UTTAR PRADESH

4.1       PATIENTS’ VIEW POINT

4.1.1    PATIENTS DEMOGRAPHIC PROFILE

In all, 201 patients were contacted out of which 126 patients were contacted in city, 50 in town and 25 in block in Uttar Pradesh. The demographic profile of patients contacted is given in Table 3.

TABLE  3: DEMOGRAPHIC PROFILE OF PATIENTS CONTACTED

IN UTTAR PRADESH*

Percentage of respondents

Characteristic of patients surveyed		City (126)	Town (50)	Block (25)	Total (201)
Age	18 – 25 yr.	29	28	44	34
	26 – 35 yr.	38	24	24	28
	36 – 45 yr.	20	20	16	19
	45 + yr.	13	28	16	19
Sex	Male	73	94	56	74
	Female	27	6	44	26
Occupation	Service	24	24	20	23
	Business	21	14	8	14
	Professional	9	8	0	6
	Agriculture	10	32	16	19
	Housewife	15	4	44	21
	Others	21	18	12	17
Education	Illiterate	5	18	28	17
	Upto 8th	14	24	20	19
	Upto 12th	27	36	44	36
	Graduate & above	54	22	8	28
Monthly Family Income	< Rs.6,000	40	84	92	72
	Rs.6,000 – 12,000	58	14	8	27
	Rs.12,000 – 20,000	2	2	0	1
	>Rs.20,000	0	0	0	0

*Figures in parentheses are actual number

As seen in the above table, respondents were selected in the age group of 18 to 45+ years with 74% of them being male and 26% female. Patients from all walks of life such as service class, business class, professionals, agriculturist and housewives have been included in this study. They were either illiterates or above graduates, with monthly income varying from less than Rs. 6,000 to more than Rs. 20, 000 per month. 

4.1.2    DOCTOR/HOSPITAL VISITING HABIT OF PATIENTS

Out of 201 patients contacted for the study, 42% of patients consult doctors in the case of illness, 22% of them go to hospitals and 36% patients go to both doctors and hospitals (see Table 4). This is same across city, town and block. So far as the frequency of visit to government hospital is concerned, city patients visit the government hospital more often than the block patients. 51% of city patients said they visit government hospital whereas only 33% at the block level reported that they visit government hospital. Lack of responsiveness towards patients, non-availability of doctors and medicines, and poor empathy towards the patients in the government hospitals deter the patients from availing the existing facility.

TABLE 4: DOCTOR CONSULTATION: PROFILE OF CONSUMERS*

Percentage of respondents

Questions	City (126)	Town (50)	Block (25)	Total (201)
Whom do you visit in case of illness? ·         Doctor Clinic ·         Hospital ·         Both	44 23 33	36 18 46	44 24 32	42 22 36
If visiting hospital, how often you go to govt. hospital? ·         Always ·         Mostly ·         Sometimes ·         Never	3 48 45 4	33 11 34 22	17 16 67 0	18 25 49 8

*Figures in parentheses are actual number

4.1.3    AVAILABILITY OF MEDICINE

As the survey shows, there are absolutely no problems in getting the medicines prescribed by doctors. These are readily available with the chemists of that particular area. Around 95% of patients replied that medicines prescribed by the doctors are readily available as and when required (see Table 5 and Figure I).

TABLE 5: AVAILABILITY OF MEDICINE *

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Are the medicines prescribed readily available? Yes No	96 4	94 6	88 12	95 5

*Figures in parentheses are actual number

If the prescribed medicines are not available in their area, doctors do mention the name of the shop from where the patients can get it easily. Overall, only in 2% cases patients reported that they came back to doctor when they did not get the prescribed medicine.

Chemists do suggest substitution for the prescribed medicines but the incidence of substitution is interestingly more in city than either in town or block as seen in Table 6.  Forty one per cent of the respondents in the city said that the chemists mostly suggest buying substitute medicines whereas at the town and block levels the incidence of such cases was only 10% and 8% respectively. More than 50% respondents at the town and block levels said that chemists never suggest them the substitute medicines, but at the city level only 18% of the respondents reported on the substitution.

TABLE – 6: SUBSTITUTION OF MEDICINE *

Percentage of respondents

Questions	City (126)	Town (50)	Block (25)	Total (201)
Chemist suggests you to buy substitute medicines? ·      Always ·      Mostly ·      Sometimes ·      Never	1 40 41 18	4 6 32 58	0 8 40 52	1 28 39 32
Does chemist give you substitute without informing you? ·      Always ·      Mostly ·      Sometimes ·      Never	0 2 45 53	0 2 14 84	0 0 20 80	0 2 34 64

*Figures in parentheses are actual number

Although chemists suggestion for substitute is there, but whenever they substitute the medicine they clearly inform the patients about the substitution. While at the town and block levels more than 80% respondents said that the chemists inform them when they give substitute medicines, however only 53% respondents said so at the city level. When asked about the names of the medicines that are in short supply and name of medicines whose substitute are not available respondents did not endowed our field staff  with any useful information.

4.1.4    PRICE OF MEDICINES

In the opinion of respondents, drug manufacturers do not resort to frequent price changes (see Table 7). Almost 98% of the respondents said that manufacturers do not frequently change prices. Only 2% patients replied that they find frequent and substantial increases in medicine prices by the manufacturers.  During this study, there were no reported cases of manufacturers printing different prices for the same medicine at different locations.

TABLE   7 : PRICE OF MEDICINE *

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Is there a frequent price change by manufacturers? Yes No	3 97	2 98	0 100	2 98

*Figures in parentheses are actual number

But the instances of price differences for the same medicine at different locations as well as different shops in the same location were reported.  25% of the patients reported of such differences. The prices were reported to be higher in those areas where fewer numbers of chemist shops were set up.

So far as the appropriateness of medicine prices is concerned, majority of the respondents felt that prices are reasonable and affordable. While 69% consumers said that prices are both reasonable and affordable, only 11% of felt that medicine prices are not affordable and 20% felt those prices are not reasonable.

4.1.5    PROCUREMENT AND PURCHASING PATTERN OF MEDICINE

There is a wide variation among respondents regarding availability of medicine free of cost at the place of treatment (see Table  8). Whereas 78% and 83% of the patients at the town and block levels respectively reported that they get medicine free of cost, only 35% said so at the city level. It implies that hospitals in the cities often avoid giving medicines to the patients and leave that task to the chemists.

There are only limited instances of doctors giving medicines to the patients. Furthermore, 90% patients in the city reported that in case doctors give them medicines they do charge extra. But the scene is opposite at the block level where only 25% respondents said that doctors charge for the medicines, presumably because of low awareness.

TABLE 8: MEDICINE PROCUREMENT BEHAVIOUR OF CONSUMERS*

Percentage of respondents

Questions	City (126)	Town (50)	Block (25)	Total (201)
Are medicines available free of cost at the hospital (government or private) where you visit for illness? Yes No	35 65	78 22	83 17	65 35
Does private practicing doctor gives you medicines? Yes No	27 73	33 67	36 64	32 68
If yes, is it charged or free? Charged Free	90 10	50 50	25 75	65 35

*Figures in parentheses are actual number

4.1.6    AVAILABILITY OF ALTENATIVE THERAPY

Patients do go for alternative therapy and many of them adopt more than one medication system. Among 201 patients surveyed, almost 99% are adopting allopathic medicines, 56% adopting homeopathic medicines and 27% following auryvedic systems (see Table 9). City patients are more open in using other systems of medicine than the block or town patients. While 68% patients in city said that they use homeopathic system, at the town and block levels only 36% and 32% respectively said to be using homeopathic system.

TABLE 4: DOCTOR CONSULTATION: PROFILE OF CONSUMERS*

Percentage of respondents

Questions	City (126)	Town (50)	Block (25)	Total (201)
Whom do you visit in case of illness? ·         Doctor Clinic ·         Hospital ·         Both	44 23 33	36 18 46	44 24 32	42 22 36
If visiting hospital, how often you go to govt. hospital? ·         Always ·         Mostly ·         Sometimes ·         Never	3 48 45 4	33 11 34 22	17 16 67 0	18 25 49 8

*Figures in parentheses are actual number

4.1.3    AVAILABILITY OF MEDICINE

As the survey shows, there are absolutely no problems in getting the medicines prescribed by doctors. These are readily available with the chemists of that particular area. Around 95% of patients replied that medicines prescribed by the doctors are readily available as and when required (see Table 5 and Figure I).

TABLE 5: AVAILABILITY OF MEDICINE *

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Are the medicines prescribed readily available? Yes No	96 4	94 6	88 12	95 5

*Figures in parentheses are actual number

If the prescribed medicines are not available in their area, doctors do mention the name of the shop from where the patients can get it easily. Overall, only in 2% cases patients reported that they came back to doctor when they did not get the prescribed medicine.

Chemists do suggest substitution for the prescribed medicines but the incidence of substitution is interestingly more in city than either in town or block as seen in Table 6.  Forty one per cent of the respondents in the city said that the chemists mostly suggest buying substitute medicines whereas at the town and block levels the incidence of such cases was only 10% and 8% respectively. More than 50% respondents at the town and block levels said that chemists never suggest them the substitute medicines, but at the city level only 18% of the respondents reported on the substitution.

TABLE – 6: SUBSTITUTION OF MEDICINE *

Percentage of respondents

Questions	City (126)	Town (50)	Block (25)	Total (201)
Chemist suggests you to buy substitute medicines? ·      Always ·      Mostly ·      Sometimes ·      Never	1 40 41 18	4 6 32 58	0 8 40 52	1 28 39 32
Does chemist give you substitute without informing you? ·      Always ·      Mostly ·      Sometimes ·      Never	0 2 45 53	0 2 14 84	0 0 20 80	0 2 34 64

*Figures in parentheses are actual number

Although chemists suggestion for substitute is there, but whenever they substitute the medicine they clearly inform the patients about the substitution. While at the town and block levels more than 80% respondents said that the chemists inform them when they give substitute medicines, however only 53% respondents said so at the city level. When asked about the names of the medicines that are in short supply and name of medicines whose substitute are not available respondents did not endowed our field staff  with any useful information.

4.1.4    PRICE OF MEDICINES

In the opinion of respondents, drug manufacturers do not resort to frequent price changes (see Table 7). Almost 98% of the respondents said that manufacturers do not frequently change prices. Only 2% patients replied that they find frequent and substantial increases in medicine prices by the manufacturers.  During this study, there were no reported cases of manufacturers printing different prices for the same medicine at different locations.

TABLE   7 : PRICE OF MEDICINE *

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Is there a frequent price change by manufacturers? Yes No	3 97	2 98	0 100	2 98

*Figures in parentheses are actual number

But the instances of price differences for the same medicine at different locations as well as different shops in the same location were reported.  25% of the patients reported of such differences. The prices were reported to be higher in those areas where fewer numbers of chemist shops were set up.

So far as the appropriateness of medicine prices is concerned, majority of the respondents felt that prices are reasonable and affordable. While 69% consumers said that prices are both reasonable and affordable, only 11% of felt that medicine prices are not affordable and 20% felt those prices are not reasonable.

4.1.5    PROCUREMENT AND PURCHASING PATTERN OF MEDICINE

There is a wide variation among respondents regarding availability of medicine free of cost at the place of treatment (see Table  8). Whereas 78% and 83% of the patients at the town and block levels respectively reported that they get medicine free of cost, only 35% said so at the city level. It implies that hospitals in the cities often avoid giving medicines to the patients and leave that task to the chemists.

There are only limited instances of doctors giving medicines to the patients. Furthermore, 90% patients in the city reported that in case doctors give them medicines they do charge extra. But the scene is opposite at the block level where only 25% respondents said that doctors charge for the medicines, presumably because of low awareness.

TABLE 8: MEDICINE PROCUREMENT BEHAVIOUR OF CONSUMERS*

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Are medicines available free of cost at the hospital (government or private) where you visit for illness? Yes No	35 65	78 22	83 17	65 35
Does private practicing doctor gives you medicines? Yes No	27 73	33 67	36 64	32 68
If yes, is it charged or free? Charged Free	90 10	50 50	25 75	65 35

*Figures in parentheses are actual number

4.1.6    AVAILABILITY OF ALTENATIVE THERAPY

Patients do go for alternative therapy and many of them adopt more than one medication system. Among 201 patients surveyed, almost 99% are adopting allopathic medicines, 56% adopting homeopathic medicines and 27% following auryvedic systems (see Table 9). City patients are more open in using other systems of medicine than the block or town patients. While 68% patients in city said that they use homeopathic system, at the town and block levels only 36% and 32% respectively said to be using homeopathic system.

TABLE   9 : AVAILABILITY OF ALTERNATIVE MEDICINE *

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
System of medicines prevalent in area ·               Allopathic ·               Homeopathic ·               Ayurvedic ·               Unani ·               Traditional	100 68 37 0 2	98 36 12 0 0	100 32 4 0 0	99 56 27 0 1

*Figures in parentheses are actual number

4.1.7        INCIDENCE OF SPURIOUS DRUGS

The instances of spurious and sub-standard drugs noticed by the patients are very rare (see Table 10). Around 90% patients across the city, town and block said that they have never noticed any spurious drugs in the market. The majority of the respondents also said that in case they notice any shop selling spurious and substandard drugs, they never go to that particular shop again for purchasing the medicines.

TABLE  10 : INCIDENCE OF SPURIOUS DRUGS*

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Any instance of spurious drugs noticed by you? ·               Many a times ·               Sometime ·               Rarely ·               Never	0 2 4 94	0 8 8 84	4 8 4 84	1 4 5 90

4.1.8    PATIENTS’ AWARENESS

All the surveyed patients reported that they are not only well aware of the chemist shops in their area but also aware of 24-hour open chemist shops. But patients are hardly aware about any patient forums, consumer organizations or NPPA. So in the case of any problem of spurious drugs or high priced drugs, they do not know whom to approach. Around 99% of the patients do not even know what NPPA is and what is its role. NPPA needs to promote social marketing and advertising to increase the awareness about its role in curbing discrepancies in drug prices and controlling supply of spurious drugs.

A very interesting point, which emerged from this study, is that around 58% patients do not demand the chemist to give the bills or cash memos. This shows that there is no interest among the patients to check whether the extra money, which is being charged from them, is in the form of tax or the chemists are over-charging them. This also shows lack of awareness among the patients on the importance of cash memo and how it can be used to create evidence in case of litigation or complaints concerning consumer rights.

The various suggestions given by the patients to bring the desired changes in the medical care sector are:

¨Government should control prices of medicines and price list of life saving drugs should be prominently displayed at the chemist shops.

¨Quality of medicines must be improved by introducing the latest technology.

¨Choice of same variety of medicines should be made available at all the chemist shops.

¨Medicine should be distributed free to the poor consumers living below the poverty line.

¨Competent doctors should be encouraged to work in the rural areas.

¨Medicines should be sold by prescriptions only.

¨License for chemist shops should be given to adequately educated and knowledgeable persons and regular checks should be conducted to ensure adherence of our rules and regulations as per the existing national laws.

4.2       CHEMISTS VIEW POINT IN UTTAR PRADESH 

4.2.1    AVAILABILITY OF MEDICINE

Chemists are the most important link between the patients and doctors. They ensure availability of medicines to the patients by stocking adequate amount of all different types of medicines. With the number of pharmaceutical manufactures increasing daily, it is becoming difficult for the chemists to stock all the types and brands of medicines which are being prescribed by different doctors. The ultimate sufferer is the patient.

TABLE  11 : AVAILABILITY OF PRESCRIBED MEDICINE *

Percentage of respondents

Question	City (45)	Town (20)	Block (5)	Total (70)
Required medicine available ·         Always ·         Mostly ·         Sometimes	4 89 7	10 80 10	0 60 40	6 84 10

*Figures in parentheses are actual number

Out of 70 chemists surveyed, 90% chemists reported that medicines demanded by the patients are mostly available (see Table 11 and Figure II). At the block level there seems some shortage of prescribed medicines. 40% chemists responded that there are sometimes shortages of prescribed medicines. They also agreed that there is no problem in the medicine supply from the manufacturers but they are not stocking all the medicines. Majority of them, 94% said that the main reason for not stocking all the medicines are :

• Lack of funds.
• Frequent introduction of new medicines in the market and its difficulty to stock all of them.

They stock only those medicines, which the doctors in their area generally prescribe.

But 57% chemists said that they do have substitutes of the prescribed medicines available with them. They also reported that in their opinion around 63% of patients do take substitutes in case the prescribed medicines are not available. The chemists reported that they stock only those medicines, which are being prescribed by the doctors practicing in their area. But if a patient comes to them with the prescription of doctors practicing in other area, chemists are unable to provide the medicines. Although they do guide the patients to the right shop where the prescribed medicine will be available.

4.2.2    AVAILABILITY OF OVER THE COUNTER (OTC) DRUGS

Chemists reported that there are a number of medicines that are being sold in high volume without prescription. The most commonly sold medicines without prescription are: Combiflam, Zinetac, Crocin, Disprin, Navalgin, Becosules, Ultragin, Amclox, Flexon, Enteroquinol and similar. These are the drugs that provide faster relief, are easily available over the counter (OTC) and are common ailment medicines.

4.2.3    INCIDENCE OF SPURIOUS DRUGS

Hardly 2% of city chemists reported that they noticed instances of spurious drugs. But at the town and block levels the reported incidence of spurious dug is high. 35% chemists in the town and 20% at the block level reported that they have noticed spurious and sub-standard drugs (see Table 12). They were, however, reluctant to share their experiences in this respect. This clearly reflects the fear existing among patients of town and block and how they are ill-informed patients and become an easy prey to spurious and sub-standard drugs.

TABLE 12: INCIDENCE OF SPURIOUS DRUGS*

Percentage of respondents

Question	City (45)	Town (20)	Block (5)	Total (70)
Instances of spurious drugs? ·    Many a times ·    Sometimes ·    Rarely ·    Never	2 0 0 98	15 20 10 55	20 0 0 80	7 6 4 83

*Figures in parentheses are actual number

4.2.4    CONSULTING CHEMISTS FOR MEDICINES

It has also been observed during the study that patients do consult chemists for the medicine especially for common ailments. This is true for all the three levels, viz., city, town and block. As can be seen from Table 13, 71% of the city chemists, 40% of the town chemists and 80% of the block level chemists replied that patients do consult them for medicines. In case of common ailments, patients try to avoid doctors and consult chemists because it not only saves doctor’s consultation fee but also the hassle of waiting for the turn for meeting the doctor. In the case of block, the poor presence of doctors also forces the patients to consult chemists.

TABLE  13 : CONSULT CHEMIST FOR MEDICINE*

Percentage of respondents

Question	City (45)	Town (20)	Block (5)	Total (70)
Does the customer consult chemist for medicines? ·            Many a times ·            Sometimes ·            Rarely ·            Never	18 53 11 18	10 30 45 15	20 60 0 20	16 47 20 17

*Figures in parentheses are actual number

4.2.5    PRICE OF MEDICINE

As per the responses of chemists, there is hardly any price variation in MRP printed on the label for the same medicine sold at different locations (see Table-14). Out of 70 chemists surveyed, 84% of them replied that there is no difference in price of the same medicine at different locations. Out of rest 16% who agreed on price difference, 82% said that even if there is a difference in price, it is only in respect of few medicines. These are those medicines that are either less stocked due to non-availability or are critical life saving drugs. There is hardly any difference in the responses of chemists at the city, town and block levels.

88% chemists replied that medicines are sold at MRP (see Figure IV).  (As per the DPCO norms, during the study MRP has been taken as maximum retail price plus sales tax.). At the town and block levels, some chemists reported that medicines are being sold at prices either more than MRP or less than MRP. While at the city level, 98% chemists replied that medicines are sold at MRP, at the town and block levels the corresponding figures were 75% and 60% respectively.

The chemists are thus found to be overcharging the town and block level patients over and above the sales tax and exploiting the poor consumers who are medically unaware about the law. 10% chemists at the town level and 20% at the block level said that the chemists charge more than MRP and sales tax. There are also incidence of chemists charging less than MRP at the town and block levels. 15% town level chemists and 20% block level chemists said that they charge less than MRP. High competition prevalent in the concerned areas might be the reason compelling the chemists to give discounts to customers.

TABLE   14: PRICE DIFFERENCE OF PRESCRIBED MEDICINE

Percentage of respondents*

Questions	City (45)	Town (20)	Block (5)	Total (70)
Does price differ from location to location? Yes No	13 87	20 80	20 80	16 84
Is difference is in all or some medicines? Some All	83 17	75 25	100 0	82 18
At what price are the medicines sold? ·         At MRP (MRP + S. Tax) ·         Less than MRP ·         More than MRP	98 0 2	75 15 10	60 20 20	88 6 6

*Figures in parentheses are actual number

4.2.6    DRUGS USAGE AND DISTRIBUTION PATTERN

Most of the chemists agreed that drug usages are rational. 97% chemists replied that usage of antibiotic is rational, 99% replied that usage of injection is rational and 97% replied that usage of IV fluid is rational. But there are a few reported cases of irrational drug usage in the case of vitamins and minerals. 19% chemists replied that usage of vitamins is irrational and 11% found the usage of injectable minerals as irrational. This is largely due to the usage pattern of these types of drugs. Vitamins and minerals are widely recommended and used with any antibiotics. They also find wide application for any type of diseases and weakness.

The distribution system of medicine is very simple. It is either through distributor or company salesmen or directly from the distributor. Chemists mostly procure the required medicines themselves because of the irregular visits of the manufacturer and distributor’s salesmen making them highly non-reliable. 81% chemists said that they themselves procure the required medicines and hardly depend on the manufacturer or the distributor’s salesmen. Only 19% chemists said that they fully depend on the manufacturer or the distributor’s salesmen for the supply of medicine.

4.2.7    CHEMISTS AWARENESS AND SELLING PRACTICES

Awareness about NPPA is at dismal low across city, town and block levels (see Table 15). Out of 70 chemists surveyed, only 2% chemist was aware of NPPA. NPPA needs promote a national mass campaign to increase the awareness about their role and responsibilities.

TABLE 15: AWARNESS ABOUT NPPA*

Percentage of respondents

Question	City (45)	Town (20)	Block (5)	Total (70)
Awareness about NPPA? Yes No	0 100	5 95	0 100	2 98

*Figures in parentheses are actual number

So far as the practice of issuing bills and cash memos is concerned, only 8% shops were always issuing the bills or cash memos. In 78% shops, bills or cash memos were issued either in some cases or not issued at all (se Table 16).

TABLE  16 : CASH MEMO ISSUED WITH THE SALE OF MEDICINE*

Percentage of respondent

Question	City (45)	Town (20)	Block (5)	Total (70)
Is cash memo issued? ·      Always ·      Some cases ·      None ·      No Response	7 40 38 15	15 40 40 5	0 20 40 40	8 39 39 14

*Figures in parentheses are actual number

The situation with regard to the issuance of bills and cash memos is quite disconcerting at the city as well as town and block levels. About 40% of chemists have themselves reported that they do not issue the bills or cash memos at all. This clearly indicates that chemists take the advantage of the lack of awareness among patients who have no mechanism to check whether chemists are selling sub-standard or the expired drugs at arbitrary prices. If in case any unfortunate incidence happens, the patients can never claim the compensation because of lack of evidence on account of non issuance of bills or cash memos by the retailer.

During the study it was also observed that in most of the chemist shops, prescribed medicines are properly stored.  Around 94% chemist shops stored medicines in proper cupboard. But clearly violating the drug policy norms, around 30% chemists said that refrigerator is not available for storage of medicines and at block level refrigeration of medicine was not done in most of the shops. The reason cited by the chemists are:

·        Poor power supply.

·        Low awareness.

·        Extra cost.

·        No servicing available for refrigerator.

4.2.8    PATIENTS’ AWARNESS: CHEMISTS’ VIEWPOINT

City and town level patients are more aware than block level patients. About 90% to 100% city chemists replied that their customers check MRP before buying the prescribed medicines, whereas only 40% block level chemists said so (see Table 17).

Patients are also aware of the benefits linked with the batch number and the expiry date as most of the consumers check these aspects before buying medicines. At the aggregate level, 72% of the chemists replied that customers do check batch number and the expiry date before buying medicines. This clearly indicates that patients are aware about their rights although the percentage is not yet hundred per cent. Some ways should be found to further educate the patients and make them aware about the need for checking the MRP especially at block level.

TABLE 17 : PATIENTS AWARNESS*

Percentage of respondents

Question	City (45)	Town (20)	Block (5)	Total (70)
Do the patients check MRP? ·   Always ·   Mostly ·   Sometimes ·   Never	36 64 0 0	45 45 10 0	20 20 60 0	37 56 7 0
Do the patients check batch no/expiry date? ·   Always ·   Mostly ·   Sometimes ·   Never	62 36 2 0	25 45 30 0	5 40 55 0	31 41 28 0

*Figures in parentheses are actual number

Chemists’ response also points towards one interesting phenomenon. City patients are more concerned about the quality of drug than that of price, whereas at town and block levels patients are more concerned about price than the quality. While only 36% city patients said that they always check MRP but 62% of them reported that they check batch number and the expiry date. In the case of town, 45% reported that they always check MRP and only 25% always check the batch number and the expiry date. The figure goes down further at the block level where only 20% always check the MRP and only 5% always check the batch number and the expiry date.

4.3       HOSPITAL DOCTORS’ VIEW POINT IN UTTAR PRADESH

In all 35 hospitals were contacted in Uttar Pradesh. Doctors in these hospitals reported that they prefer to prescribe medicines keeping patients economic conditions in mind. 74% doctors in hospital replied that they keep the patients economic condition in mind while prescribing the medicine. But doctors are not happy with the government hospital services and feel that it is not adequate to meet the demands of the local patients.  More than 57% said that number of government hospitals are not adequate and 52% replied that numbers of government dispensaries are not adequate. Lack of government ambulances and vans only makes the matter worse. Around 86% doctors replied that the government vans are not adequate.  But the scene relating to private hospitals and nursing home is different. Hardly 17% doctors replied that private practitioners are not adequate and 34% doctors replied that nursing homes not adequate.

Poor management, low priority to healthcare, lack of proper vigilance and lack of funds aggravate the matter. With poor management and maintenance of government hospitals, private nursing homes and hospitals become the only providers of healthcare services and start charging the poor consumers arbitrarily. Ultimately it is the patients who bear the burnt of the government’s apathy and lackluster performance.

According to the doctors, there do exist cases of sub-standard and spurious drugs. 45% doctors said that they had heard of spurious and substandard drugs sold in the market. None of the doctors reported awareness about any licensed drugs manufacturing units located in the local areas. Although awareness about NPPA is low among the doctors also, but compared to patients and chemists the awareness level is slightly higher among the doctors. 28% doctors replied that they are aware of NPPA. This low awareness about NPPA among the doctors clearly indicates the lack of publicity by NPPA about their activities. Lack of knowledge among doctors also implies that it will be a daunting task for NPPA to reach the common citizens and make them conscious of the role of NPPA in enforcing their rights to safe and affordable medicines.

98% of doctors replied that all the medicines that they prescribe are easily available in the market. Furthermore, as many as 93% doctors opined that medicines are sold at the same price at different locations. Only 17% said that there is difference in price of medicine and this might be due to the pricing policy of the manufacturers.  82%, agreed that medicines are being sold at the MRP.

4.4       GENERAL DOCTORS’ VIEW POINT IN UTTAR PRADESH 

4.4.1    PRESCRIPTION AS PER PATIENTS’ ECONOMIC CONDITION

In Uttar Pradesh, out of 46 doctors surveyed only 65% doctors replied that they always keep patients’ economic condition in mind before prescribing medicines for them. Excepting the case of city where only 48% doctors said yes, majority of doctors, 93% and 67% respectively, at the town and block levels said that they keep patients’ economic condition in mind before prescribing medicines. This difference might be there because of the reason that the city patients are economically more well off than their town and block counterparts.

TABLE  18: MEDICNE AS PER PATIENTS’ ECONOMIC CONDITION*

Percentage of respondents

Question	City (25)	Town (15)	Block (6)	Total (46)
Do you keep the patients’ economic condition in mind while prescribing medicines? Yes                                                                                                       No	48 52	93 7	67 33	65 35

*Figures in parentheses are actual number.

4.4.2    AVAILABILITY OF MEDICAL AID IN THE AREA

Mixed responses turned out when the doctors were asked about the adequacy of various service providers in the area (see Table 19).

TABLE  19 : DOCTORS’ OPINION ABOUT MEDICAL AID*

Percentage of respondents

Question	City (25)	Town (15)	Block (6)	Total (46)
Opinion about medical aid in area? Govt. Hospital Yes No	32 68	53 47	67 33	43 57
Govt. Dispensary Yes No	44 56	33 67	33 67	39 61
Govt. Vans Yes No	16 84	13 87	0 100	13 87
Pvt. Hospital Yes No	64 36	67 33	17 83	59 41
Nursing Homes Yes No	88 12	100 0	17 83	83 17
Private Practitioners Yes No	96 4	100 0	83 17	96 4

*Figures in parentheses are actual number

The survey shows an opposite trend in the case of distribution of public and private hospitals in the city and in block. In the case of city, about 68% and 56% doctors said that the government hospital and government dispensaries respectively are not adequate. But around 60% to 80% doctors said that private hospital and private nursing home are adequately available in the city. It shows that private doctors and businessman are taking the advantage of insufficient government hospitals in the city and investing more. But the scenario is opposite at the block level where private parties are shying away from investing because of low return on investment. At the block level, 67% doctors said that the government hospital facility is adequate, but 83% said that the number of private hospitals and private nursing homes is inadequate. Government should come out with incentives and policies to promote private investments in these areas.

So far as the availability of government vans at the city, town and block levels, majority of the doctors (more than 80 per cent) said that the government vans are not available in adequate number. Apropos the availability of private practitioners, the response pattern is just opposite. 96% doctors in city, 100% doctors in town and 83% doctors in the block said that there are adequate numbers of private practitioners. Especially at the block level where the private nursing home and hospitals are few in numbers, the private practitioners fill the gap. 

4.4.3    PREVALENT DISEASES OF THE AREA AND MEDICINES PRESCRIPTION

The most prevalent diseases of the area include Gastro Entritis, TB, Gastritus, High and Low Blood Pressure, Malaria, etc. The detail list is given in Table 20.

TABLE 20: PREVELANT DISEASES AND THE MEDICINES PRESCIRBED*

S. No.	Endemic Disease	Medicine Prescribed
1.   2. 3. 4.	Gastroenteritis   Gastritis Goitre Filariasis	IV Fluid, Oxytetracycline, Tinidazole, Metrogyl, Ciprofloxacin, Norfloxacin, Tetracycline IV Fluid, Antacid Oral Iodine Hetrazan, Unicarbazan, Banocide forte, Banocide Syrup
5. 6. 7. 8.	Sugar Fractures Liver Pain HBP / LBP	Euglucon, Protamine Zinc Combiflam, Flexon, Protamine Zinc Beptazine-H, Cimetin, Clodex, Tenelol, Timizol
9. 10.	TB Viral Fever	Combutol, Tab. INH, Tab. IHD, Pyrazinamide, Isonex, Isoniazid Amclox, Calpol Syrup, Indomethacin, Ciprofloxacin
11. 12. 13. 14.	Malaria Dysentry Headache Cold/Vomitting	Chloroquine, Metacin, Paracetamol, Quinine Blumox, Metronidazole Amaebecide, Brufen Benadyle, Ceff-250, Siquil
15. 16.	Diarrhoea R.T.I	Metrogyl, Norfloxacin, Ciprofloxacin, Ringerlactate, Electrol Amoxycillin, Cephalexin, Ampicillin, Cloxacillin
17.	Eczema	Betnovate-N
18. 19.   20.	Enchephelities Typhoid   Pneumonia	Destrose, Dexona, Monocef Ciprofloxacin, Calpol, Paraxin, Chloramphenicol, Septran, Ofloxacin, Amoxycillin, Ceff-250 / 500, Cetazone, Cephalexin
21.	Amoebiasis	Anti-M, Tinidazole
22.	Conjunctivitis	Ciplox eye drop, Mycin eye drop
23. 24.	Entrocolitis Viral Hepatitis	Tinidazole, Metrogyl, Ciprofloxacin Paracetamol, Crocin
25. 26	Stomach Pain Headache	Spasmizol-K Brufen
27	Migrane	Ibumax, Calpol
28	Cancer	Vincristine Sulphate, Methotrexate, Bleomycin
29	Jaundice	Liv 52, Livoerb, Glucose Powder
30	URTI	Cephalexin
31	Hydrosyel	Banocide

* The prescribed medicines against the respective disease are as per the views of the respondents. Although on actual checking with some senior doctors it is found that some medicines are wrongly prescribed.

Although almost 98% doctors replied that they use the drugs rationally, yet there are few instances of indiscriminate usage of Vitamins, Minerals and IV Fluids. The main reasons sited for the high usage of the drugs are:

• Making money through prescription of these medicines.
• Wide usage especially for anemia, weakness, etc.
• These medicines go with any antibiotic and are widely recommended.
• Quacks prescribe such medicines irrationally
• Lack of knowledge and education among the patients.

4.4.4    AVAILABILITY AND PRICE OF MEDICINE

There is no problem in the availability of medicines in the opinion of the doctors. 97% of doctors replied that all the prescribed medicines are easily available. In the same vein, 87% opined that medicines being sold at the same price at different locations and 85% said that medicines are sold at the MRP. 13% doctors said that the difference in price at different locations is because of pricing policy of manufacturers.

4.4.5    AVAILABILITY OF SPURIOUS DRUGS

43% doctors said that they have heard of spurious/substandard drugs being sold in the market. As can be seen from Table 21, incidence of spurious and sub-standard drugs is reportedly more at the block level where around 67% doctors confirmed the incidence of spurious drugs. But it is slightly low in both the town and city where around 40% doctors confirmed the incidence of spurious drugs. The low quality checking by the respective drug authorities, lack of proper drug awareness campaign and low literacy rate make the spurious/fake drugs market flourish. Especially the block level patients are more vulnerable to spurious drugs. It may be noted that in the present study it is the doctors rather than the patients and chemists who have in greater proportion identified the problem of spurious. As the doctors are medically more informed, they can identify the incidence of spurious and sub-standard drugs more easily than the patients and chemists. Whereas around 43% doctors said that there are instances of spurious drugs in the market, only 17% chemists and 10% patients felt so.

TABLE  21 : AVAILIBILITY OF SPURIOUS DRUGS*

Percentage of respondents

Questions	City (25)	Town (15)	Block (6)	Total (46)
Are there any instances of spurious drugs marketed in the area? ·   Always ·   Mostly ·   Sometimes ·   Never	0 4 36 60	0 13 27 60	17 0 50 33	2 6 35 57

*Figures in parentheses are actual number.

4.4.6    DOCTORS AWARENESS

Only 15% doctors are aware of NPPA (see Table 22) and the awareness is more or less the same across the city, town and block. With such a low awareness among the doctors, NPPA needs to increase its presence among the doctors and make them one of the media for promoting its role among the common patients.

TABLE 22 : AWARNESS OF DOCTORS*

Percentage of respondents

Questions	City (25)	Town (15)	Block (6)	Total (46)
Aware of licensed drug manufacturing unit in local area? Yes No	0 100	0 100	0 100	0 100
Aware of NPPA Yes No	20 80	7 93	17 83	15 85
Any idea on prices of drugs? Yes No	100 0	87 13	67 33	91 9

*Figures in parentheses are actual number

None of the doctors was found aware about any licensed drug-manufacturing units in the locality. Almost all of them have thorough knowledge about the prevailing market prices of the medicines.

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
System of medicines prevalent in area ·               Allopathic ·               Homeopathic ·               Ayurvedic ·               Unani ·               Traditional	100 68 37 0 2	98 36 12 0 0	100 32 4 0 0	99 56 27 0 1

*Figures in parentheses are actual number

4.1.7        INCIDENCE OF SPURIOUS DRUGS

The instances of spurious and sub-standard drugs noticed by the patients are very rare (see Table 10). Around 90% patients across the city, town and block said that they have never noticed any spurious drugs in the market. The majority of the respondents also said that in case they notice any shop selling spurious and substandard drugs, they never go to that particular shop again for purchasing the medicines.

TABLE  10 : INCIDENCE OF SPURIOUS DRUGS*

Percentage of respondents

Question	City (126)	Town (50)	Block (25)	Total (201)
Any instance of spurious drugs noticed by you? ·               Many a times ·               Sometime ·               Rarely ·               Never	0 2 4 94	0 8 8 84	4 8 4 84	1 4 5 90

4.1.8    PATIENTS’ AWARENESS

All the surveyed patients reported that they are not only well aware of the chemist shops in their area but also aware of 24-hour open chemist shops. But patients are hardly aware about any patient forums, consumer organizations or NPPA. So in the case of any problem of spurious drugs or high priced drugs, they do not know whom to approach. Around 99% of the patients do not even know what NPPA is and what is its role. NPPA needs to promote social marketing and advertising to increase the awareness about its role in curbing discrepancies in drug prices and controlling supply of spurious drugs.

A very interesting point, which emerged from this study, is that around 58% patients do not demand the chemist to give the bills or cash memos. This shows that there is no interest among the patients to check whether the extra money, which is being charged from them, is in the form of tax or the chemists are over-charging them. This also shows lack of awareness among the patients on the importance of cash memo and how it can be used to create evidence in case of litigation or complaints concerning consumer rights.

The various suggestions given by the patients to bring the desired changes in the medical care sector are:

¨Government should control prices of medicines and price list of life saving drugs should be prominently displayed at the chemist shops.

¨Quality of medicines must be improved by introducing the latest technology.

¨Choice of same variety of medicines should be made available at all the chemist shops.

¨Medicine should be distributed free to the poor consumers living below the poverty line.

¨Competent doctors should be encouraged to work in the rural areas.

¨Medicines should be sold by prescriptions only.

¨License for chemist shops should be given to adequately educated and knowledgeable persons and regular checks should be conducted to ensure adherence of our rules and regulations as per the existing national laws.

4.2       CHEMISTS VIEW POINT IN UTTAR PRADESH 

4.2.1    AVAILABILITY OF MEDICINE

Chemists are the most important link between the patients and doctors. They ensure availability of medicines to the patients by stocking adequate amount of all different types of medicines. With the number of pharmaceutical manufactures increasing daily, it is becoming difficult for the chemists to stock all the types and brands of medicines which are being prescribed by different doctors. The ultimate sufferer is the patient.

TABLE  11 : AVAILABILITY OF PRESCRIBED MEDICINE *

Percentage of respondents

Question	City (45)	Town (20)	Block (5)	Total (70)
Required medicine available ·         Always ·         Mostly ·         Sometimes	4 89 7	10 80 10	0 60 40	6 84 10

*Figures in parentheses are actual number

Out of 70 chemists surveyed, 90% chemists reported that medicines demanded by the patients are mostly available (see Table 11 and Figure II). At the block level there seems some shortage of prescribed medicines. 40% chemists responded that there are sometimes shortages of prescribed medicines. They also agreed that there is no problem in the medicine supply from the manufacturers but they are not stocking all the medicines. Majority of them, 94% said that the main reason for not stocking all the medicines are :

• Lack of funds.
• Frequent introduction of new medicines in the market and its difficulty to stock all of them.

They stock only those medicines, which the doctors in their area generally prescribe.

But 57% chemists said that they do have substitutes of the prescribed medicines available with them. They also reported that in their opinion around 63% of patients do take substitutes in case the prescribed medicines are not available. The chemists reported that they stock only those medicines, which are being prescribed by the doctors practicing in their area. But if a patient comes to them with the prescription of doctors practicing in other area, chemists are unable to provide the medicines. Although they do guide the patients to the right shop where the prescribed medicine will be available.

4.2.2    AVAILABILITY OF OVER THE COUNTER (OTC) DRUGS

Chemists reported that there are a number of medicines that are being sold in high volume without prescription. The most commonly sold medicines without prescription are: Combiflam, Zinetac, Crocin, Disprin, Navalgin, Becosules, Ultragin, Amclox, Flexon, Enteroquinol and similar. These are the drugs that provide faster relief, are easily available over the counter (OTC) and are common ailment medicines.

4.2.3    INCIDENCE OF SPURIOUS DRUGS

Hardly 2% of city chemists reported that they noticed instances of spurious drugs. But at the town and block levels the reported incidence of spurious dug is high. 35% chemists in the town and 20% at the block level reported that they have noticed spurious and sub-standard drugs (see Table 12). They were, however, reluctant to share their experiences in this respect. This clearly reflects the fear existing among patients of town and block and how they are ill-informed patients and become an easy prey to spurious and sub-standard drugs.

TABLE 12: INCIDENCE OF SPURIOUS DRUGS*

Percentage of respondents

Questions	City (45)	Town (20)	Block (5)	Total (70)
Instances of spurious drugs? ·    Many a times ·    Sometimes ·    Rarely ·    Never	2 0 0 98	15 20 10 55	20 0 0 80	7 6 4 83

*Figures in parentheses are actual number

4.2.4    CONSULTING CHEMISTS FOR MEDICINES

It has also been observed during the study that patients do consult chemists for the medicine especially for common ailments. This is true for all the three levels, viz., city, town and block. As can be seen from Table 13, 71% of the city chemists, 40% of the town chemists and 80% of the block level chemists replied that patients do consult them for medicines. In case of common ailments, patients try to avoid doctors and consult chemists because it not only saves doctor’s consultation fee but also the hassle of waiting for the turn for meeting the doctor. In the case of block, the poor presence of doctors also forces the patients to consult chemists.

TABLE  13 : CONSULT CHEMIST FOR MEDICINE*

Percentage of respondents

Questions	City (45)	Town (20)	Block (5)	Total (70)
Does the customer consult chemist for medicines? ·            Many a times ·            Sometimes ·            Rarely ·            Never	18 53 11 18	10 30 45 15	20 60 0 20	16 47 20 17

*Figures in parentheses are actual number

4.2.5    PRICE OF MEDICINE

As per the responses of chemists, there is hardly any price variation in MRP printed on the label for the same medicine sold at different locations (see Table-14). Out of 70 chemists surveyed, 84% of them replied that there is no difference in price of the same medicine at different locations. Out of rest 16% who agreed on price difference, 82% said that even if there is a difference in price, it is only in respect of few medicines. These are those medicines that are either less stocked due to non-availability or are critical life saving drugs. There is hardly any difference in the responses of chemists at the city, town and block levels.

88% chemists replied that medicines are sold at MRP (see Figure IV).  (As per the DPCO norms, during the study MRP has been taken as maximum retail price plus sales tax.). At the town and block levels, some chemists reported that medicines are being sold at prices either more than MRP or less than MRP. While at the city level, 98% chemists replied that medicines are sold at MRP, at the town and block levels the corresponding figures were 75% and 60% respectively.

The chemists are thus found to be overcharging the town and block level patients over and above the sales tax and exploiting the poor consumers who are medically unaware about the law. 10% chemists at the town level and 20% at the block level said that the chemists charge more than MRP and sales tax. There are also incidence of chemists charging less than MRP at the town and block levels. 15% town level chemists and 20% block level chemists said that they charge less than MRP. High competition prevalent in the concerned areas might be the reason compelling the chemists to give discounts to customers.

TABLE   14: PRICE DIFFERENCE OF PRESCRIBED MEDICINE

Percentage of respondents*

Questions	City (45)	Town (20)	Block (5)	Total (70)
Does price differ from location to location? Yes No	13 87	20 80	20 80	16 84
Is difference is in all or some medicines? Some All	83 17	75 25	100 0	82 18
At what price are the medicines sold? ·         At MRP (MRP + S. Tax) ·         Less than MRP ·         More than MRP	98 0 2	75 15 10	60 20 20	88 6 6

*Figures in parentheses are actual number

4.2.6    DRUGS USAGE AND DISTRIBUTION PATTERN

Most of the chemists agreed that drug usages are rational. 97% chemists replied that usage of antibiotic is rational, 99% replied that usage of injection is rational and 97% replied that usage of IV fluid is rational. But there are a few reported cases of irrational drug usage in the case of vitamins and minerals. 19% chemists replied that usage of vitamins is irrational and 11% found the usage of injectable minerals as irrational. This is largely due to the usage pattern of these types of drugs. Vitamins and minerals are widely recommended and used with any antibiotics. They also find wide application for any type of diseases and weakness.

The distribution system of medicine is very simple. It is either through distributor or company salesmen or directly from the distributor. Chemists mostly procure the required medicines themselves because of the irregular visits of the manufacturer and distributor’s salesmen making them highly non-reliable. 81% chemists said that they themselves procure the required medicines and hardly depend on the manufacturer or the distributor’s salesmen. Only 19% chemists said that they fully depend on the manufacturer or the distributor’s salesmen for the supply of medicine.

4.2.7    CHEMISTS AWARENESS AND SELLING PRACTICES

Awareness about NPPA is at dismal low across city, town and block levels (see Table 15). Out of 70 chemists surveyed, only 2% chemist was aware of NPPA. NPPA needs promote a national mass campaign to increase the awareness about their role and responsibilities.

TABLE 15: AWARNESS ABOUT NPPA*

Percentage of respondents

Questions	City (45)	Town (20)	Block (5)	Total (70)
Awareness about NPPA? Yes No	0 100	5 95	0 100	2 98

*Figures in parentheses are actual number

So far as the practice of issuing bills and cash memos is concerned, only 8% shops were always issuing the bills or cash memos. In 78% shops, bills or cash memos were issued either in some cases or not issued at all (se Table 16).

TABLE  16 : CASH MEMO ISSUED WITH THE SALE OF MEDICINE*

Percentage of respondent

Questions	City (45)	Town (20)	Block (5)	Total (70)
Is cash memo issued? ·      Always ·      Some cases ·      None ·      No Response	7 40 38 15	15 40 40 5	0 20 40 40	8 39 39 14

*Figures in parentheses are actual number

The situation with regard to the issuance of bills and cash memos is quite disconcerting at the city as well as town and block levels. About 40% of chemists have themselves reported that they do not issue the bills or cash memos at all. This clearly indicates that chemists take the advantage of the lack of awareness among patients who have no mechanism to check whether chemists are selling sub-standard or the expired drugs at arbitrary prices. If in case any unfortunate incidence happens, the patients can never claim the compensation because of lack of evidence on account of non issuance of bills or cash memos by the retailer.

During the study it was also observed that in most of the chemist shops, prescribed medicines are properly stored.  Around 94% chemist shops stored medicines in proper cupboard. But clearly violating the drug policy norms, around 30% chemists said that refrigerator is not available for storage of medicines and at block level refrigeration of medicine was not done in most of the shops. The reason cited by the chemists are:

·        Poor power supply.

·        Low awareness.

·        Extra cost.

·        No servicing available for refrigerator.

4.2.8    PATIENTS’ AWARNESS: CHEMISTS’ VIEWPOINT

City and town level patients are more aware than block level patients. About 90% to 100% city chemists replied that their customers check MRP before buying the prescribed medicines, whereas only 40% block level chemists said so (see Table 17).

Patients are also aware of the benefits linked with the batch number and the expiry date as most of the consumers check these aspects before buying medicines. At the aggregate level, 72% of the chemists replied that customers do check batch number and the expiry date before buying medicines. This clearly indicates that patients are aware about their rights although the percentage is not yet hundred per cent. Some ways should be found to further educate the patients and make them aware about the need for checking the MRP especially at block level.

TABLE 17 : PATIENTS AWARNESS*

Percentage of respondents

Questions	City (45)	Town (20)	Block (5)	Total (70)
Do the patients check MRP? ·   Always ·   Mostly ·   Sometimes ·   Never	36 64 0 0	45 45 10 0	20 20 60 0	37 56 7 0
Do the patients check batch no/expiry date? ·   Always ·   Mostly ·   Sometimes ·   Never	62 36 2 0	25 45 30 0	5 40 55 0	31 41 28 0

*Figures in parentheses are actual number

Chemists’ response also points towards one interesting phenomenon. City patients are more concerned about the quality of drug than that of price, whereas at town and block levels patients are more concerned about price than the quality. While only 36% city patients said that they always check MRP but 62% of them reported that they check batch number and the expiry date. In the case of town, 45% reported that they always check MRP and only 25% always check the batch number and the expiry date. The figure goes down further at the block level where only 20% always check the MRP and only 5% always check the batch number and the expiry date.

4.3       HOSPITAL DOCTORS’ VIEW POINT IN UTTAR PRADESH

In all 35 hospitals were contacted in Uttar Pradesh. Doctors in these hospitals reported that they prefer to prescribe medicines keeping patients economic conditions in mind. 74% doctors in hospital replied that they keep the patients economic condition in mind while prescribing the medicine. But doctors are not happy with the government hospital services and feel that it is not adequate to meet the demands of the local patients.  More than 57% said that number of government hospitals are not adequate and 52% replied that numbers of government dispensaries are not adequate. Lack of government ambulances and vans only makes the matter worse. Around 86% doctors replied that the government vans are not adequate.  But the scene relating to private hospitals and nursing home is different. Hardly 17% doctors replied that private practitioners are not adequate and 34% doctors replied that nursing homes not adequate.

Poor management, low priority to healthcare, lack of proper vigilance and lack of funds aggravate the matter. With poor management and maintenance of government hospitals, private nursing homes and hospitals become the only providers of healthcare services and start charging the poor consumers arbitrarily. Ultimately it is the patients who bear the burnt of the government’s apathy and lackluster performance.

According to the doctors, there do exist cases of sub-standard and spurious drugs. 45% doctors said that they had heard of spurious and substandard drugs sold in the market. None of the doctors reported awareness about any licensed drugs manufacturing units located in the local areas. Although awareness about NPPA is low among the doctors also, but compared to patients and chemists the awareness level is slightly higher among the doctors. 28% doctors replied that they are aware of NPPA. This low awareness about NPPA among the doctors clearly indicates the lack of publicity by NPPA about their activities. Lack of knowledge among doctors also implies that it will be a daunting task for NPPA to reach the common citizens and make them conscious of the role of NPPA in enforcing their rights to safe and affordable medicines.

98% of doctors replied that all the medicines that they prescribe are easily available in the market. Furthermore, as many as 93% doctors opined that medicines are sold at the same price at different locations. Only 17% said that there is difference in price of medicine and this might be due to the pricing policy of the manufacturers.  82%, agreed that medicines are being sold at the MRP.

4.4       GENERAL DOCTORS’ VIEW POINT IN UTTAR PRADESH

4.4.1    PRESCRIPTION AS PER PATIENTS’ ECONOMIC CONDITION

In Uttar Pradesh, out of 46 doctors surveyed only 65% doctors replied that they always keep patients’ economic condition in mind before prescribing medicines for them. Excepting the case of city where only 48% doctors said yes, majority of doctors, 93% and 67% respectively, at the town and block levels said that they keep patients’ economic condition in mind before prescribing medicines. This difference might be there because of the reason that the city patients are economically more well off than their town and block counterparts.

TABLE  18: MEDICNE AS PER PATIENTS’ ECONOMIC CONDITION*

Percentage of respondents

Question	City(25)	Town (15)	Block(6)	Total (46)
Do you keep the patients’ economic condition in mind while prescribing medicines? Yes                                                                                                       No	48 52	93 7	67 33	65 35

*Figures in parentheses are actual number.

4.4.2    AVAILABILITY OF MEDICAL AID IN THE AREA

Mixed responses turned out when the doctors were asked about the adequacy of various service providers in the area (see Table 19).

TABLE  19 : DOCTORS’ OPINION ABOUT MEDICAL AID*

Percentage of respondents

Question	City (25)	Town (15)	Block (6)	Total (46)
Opinion about medical aid in area? Govt. Hospital Yes No	32 68	53 47	67 33	43 57
Govt. Dispensary Yes No	44 56	33 67	33 67	39 61
Govt. Vans Yes No	16 84	13 87	0 100	13 87
Pvt. Hospital Yes No	64 36	67 33	17 83	59 41
Nursing Homes Yes No	88 12	100 0	17 83	83 17
Private Practitioners Yes No	96 4	100 0	83 17	96 4

*Figures in parentheses are actual number

The survey shows an opposite trend in the case of distribution of public and private hospitals in the city and in block. In the case of city, about 68% and 56% doctors said that the government hospital and government dispensaries respectively are not adequate. But around 60% to 80% doctors said that private hospital and private nursing home are adequately available in the city. It shows that private doctors and businessman are taking the advantage of insufficient government hospitals in the city and investing more. But the scenario is opposite at the block level where private parties are shying away from investing because of low return on investment. At the block level, 67% doctors said that the government hospital facility is adequate, but 83% said that the number of private hospitals and private nursing homes is inadequate. Government should come out with incentives and policies to promote private investments in these areas.

So far as the availability of government vans at the city, town and block levels, majority of the doctors (more than 80 per cent) said that the government vans are not available in adequate number. Apropos the availability of private practitioners, the response pattern is just opposite. 96% doctors in city, 100% doctors in town and 83% doctors in the block said that there are adequate numbers of private practitioners. Especially at the block level where the private nursing home and hospitals are few in numbers, the private practitioners fill the gap.

4.4.3    PREVALENT DISEASES OF THE AREA AND MEDICINES PRESCRIPTION

The most prevalent diseases of the area include Gastro Entritis, TB, Gastritus, High and Low Blood Pressure, Malaria, etc. The detail list is given in Table 20.

TABLE 20: PREVELANT DISEASES AND THE MEDICINES PRESCIRBED*

S. No.	Endemic Disease	Medicine Prescribed
1.   2. 3. 4.	Gastroenteritis   Gastritis Goitre Filariasis	IV Fluid, Oxytetracycline, Tinidazole, Metrogyl, Ciprofloxacin, Norfloxacin, Tetracycline IV Fluid, Antacid Oral Iodine Hetrazan, Unicarbazan, Banocide forte, Banocide Syrup
5. 6. 7. 8.	Sugar Fractures Liver Pain HBP / LBP	Euglucon, Protamine Zinc Combiflam, Flexon, Protamine Zinc Beptazine-H, Cimetin, Clodex, Tenelol, Timizol
9. 10.	TB Viral Fever	Combutol, Tab. INH, Tab. IHD, Pyrazinamide, Isonex, Isoniazid Amclox, Calpol Syrup, Indomethacin, Ciprofloxacin
11. 12. 13. 14.	Malaria Dysentry Headache Cold/Vomitting	Chloroquine, Metacin, Paracetamol, Quinine Blumox, Metronidazole Amaebecide, Brufen Benadyle, Ceff-250, Siquil
15. 16.	Diarrhoea R.T.I	Metrogyl, Norfloxacin, Ciprofloxacin, Ringerlactate, Electrol Amoxycillin, Cephalexin, Ampicillin, Cloxacillin
17.	Eczema	Betnovate-N
18. 19.   20.	Enchephelities Typhoid   Pneumonia	Destrose, Dexona, Monocef Ciprofloxacin, Calpol, Paraxin, Chloramphenicol, Septran, Ofloxacin, Amoxycillin, Ceff-250 / 500, Cetazone, Cephalexin
21.	Amoebiasis	Anti-M, Tinidazole
22.	Conjunctivitis	Ciplox eye drop, Mycin eye drop
23. 24.	Entrocolitis Viral Hepatitis	Tinidazole, Metrogyl, Ciprofloxacin Paracetamol, Crocin
25. 26	Stomach Pain Headache	Spasmizol-K Brufen
27	Migrane	Ibumax, Calpol
28	Cancer	Vincristine Sulphate, Methotrexate, Bleomycin
29	Jaundice	Liv 52, Livoerb, Glucose Powder
30	URTI	Cephalexin
31	Hydrosyel	Banocide

* The prescribed medicines against the respective disease are as per the views of the respondents. Although on actual checking with some senior doctors it is found that some medicines are wrongly prescribed.

Although almost 98% doctors replied that they use the drugs rationally, yet there are few instances of indiscriminate usage of Vitamins, Minerals and IV Fluids. The main reasons sited for the high usage of the drugs are:

• Making money through prescription of these medicines.
• Wide usage especially for anemia, weakness, etc.
• These medicines go with any antibiotic and are widely recommended.
• Quacks prescribe such medicines irrationally
• Lack of knowledge and education among the patients.

4.4.4    AVAILABILITY AND PRICE OF MEDICINE

There is no problem in the availability of medicines in the opinion of the doctors. 97% of doctors replied that all the prescribed medicines are easily available. In the same vein, 87% opined that medicines being sold at the same price at different locations and 85% said that medicines are sold at the MRP. 13% doctors said that the difference in price at different locations is because of pricing policy of manufacturers.

4.4.5    AVAILABILITY OF SPURIOUS DRUGS

43% doctors said that they have heard of spurious/substandard drugs being sold in the market. As can be seen from Table 21, incidence of spurious and sub-standard drugs is reportedly more at the block level where around 67% doctors confirmed the incidence of spurious drugs. But it is slightly low in both the town and city where around 40% doctors confirmed the incidence of spurious drugs. The low quality checking by the respective drug authorities, lack of proper drug awareness campaign and low literacy rate make the spurious/fake drugs market flourish. Especially the block level patients are more vulnerable to spurious drugs. It may be noted that in the present study it is the doctors rather than the patients and chemists who have in greater proportion identified the problem of spurious. As the doctors are medically more informed, they can identify the incidence of spurious and sub-standard drugs more easily than the patients and chemists. Whereas around 43% doctors said that there are instances of spurious drugs in the market, only 17% chemists and 10% patients felt so.

TABLE  21 : AVAILIBILITY OF SPURIOUS DRUGS*

Percentage of respondents

Question	City (25)	Town (15)	Block (6)	Total (46)
Are there any instances of spurious drugs marketed in the area? ·   Always ·   Mostly ·   Sometimes ·   Never	0 4 36 60	0 13 27 60	17 0 50 33	2 6 35 57

*Figures in parentheses are actual number.

4.4.6    DOCTORS AWARENESS

Only 15% doctors are aware of NPPA (see Table 22) and the awareness is more or less the same across the city, town and block. With such a low awareness among the doctors, NPPA needs to increase its presence among the doctors and make them one of the media for promoting its role among the common patients.

TABLE 22 : AWARNESS OF DOCTORS*

Percentage of respondents

Questions	City (25)	Town (15)	Block (6)	Total (46)
Aware of licensed drug manufacturing unit in local area? Yes No	0 100	0 100	0 100	0 100
Aware of NPPA Yes No	20 80	7 93	17 83	15 85
Any idea on prices of drugs? Yes No	100 0	87 13	67 33	91 9

*Figures in parentheses are actual number

None of the doctors was found aware about any licensed drug-manufacturing units in the locality. Almost all of them have thorough knowledge about the prevailing market prices of the medicines.

Chapter 4(b)

EXPERTS AND FIELD STAFF’S OBSERVATIONS

 ON UTTAR PRADESH

Following are the observations made by field staff during the course of the survey conducted in Deoria Sadar (Town), Rampur, Karkhana and Baitalpur (Block) in Uttar Pradesh

4.1       DUPLICATE MEDICINES

Deoria Sadar is a backward area in Uttar Pradesh adjoining Bihar. Duplicate and pirated medicines of reputed brands are available freely. Many respondents reported that these medicines are manufactured and sold through district Siwan of Bihar. In the duplicate medicines, they mix atta, besan and similar food products. These medicines are available at cheap prices and patients do get diverted to these medicines and buy them frequently. Price differences and fluctuations happen because of these medicines.

4.2       SHORTAGE OF CAPABLE DOCTORS

In Deoria Sadar, there are shortages of qualified and competent doctors. 80% doctors are either quarks or those who are just BUMS and similar degrees. These doctors also give consultancy on sexual problems and sometimes taking the advantage of illiteracy even black mail the patients.

4.3       LACK OF AWARENESS AMONG CONSUMERS

In Deoria Sadar, about 50% of patients are not aware of their rights. These patients go to quacks and buy the medicines prescribed by them just to save money. It also came as a surprise to the experts and field staff that even well educated people does take duplicate medicines prescribed by these doctors. Above all there is no voluntary organization in this area working to educate the patients on their rights.

4.4       BAD SHAPE OF GOVERNMENT HOSPITAL

There is only one government hospital in Deoria and that too is in a very poor condition,  few doctors, unhygienic conditions and lack of facilities, which compels the patients from not visiting such hospitals. Even the primary treatment facilities are not available in this hospital.

4.5       MISUSAGE OF SAMPLED MEDICINES

During the survey it came to light that doctors do misuse the medicines given to them as samples by the pharmaceutical companies. Pharmaceuticals companies might be selling the medicines under the guise of samples just to save tax. And perhaps it is due to this practice that the price difference has been existing for some medicines in the area.

Chapter 4(c)

SUMMARY FINDINGS OF UTTAR PRADESH

PATIENTS VIEW POINT

POSITIVE ASPECT:

• 95% patients said that the prescribed medicines are available.
• 98% patients said that in case the prescribed medicine is not available chemists give them substitute medicine only after informing them.
• 98% patients said that there is no frequent price change in the medicine by the manufacturer.
• 99% adept allopathic system.
• 90% patients said that there is no incidence of spurious drugs and 5% said it’s a rare phenomenon.

NEGATIVE ASPECT:

• 67% of patients at block level said that they rarely visit govt. hospitals during their illness.
• 57% patients at city level visit government hospital regularly.
• 12% said that the prescribed medicines are not regularly available at the block level.
• 57% adopt homeopathic system and 27% adopt ayurvedic therapy.
• 25% patients said that medicines are not available at same price at different locations.
• 20% patients found that the price of medicine is not reasonable
• 11% patients felt that the medicines are not affordable.
• 99% patients are unaware about NPPA and its role.

CHEMISTS VIEW POINT

POSITIVE ASPECT:

• 100% respondents agreed that medicines are available in the market and there is no problem in the supply of medicine from the manufacturers
• 82% chemists said that there is no difference in the price of the same medicine at different locations.
• 100% chemists said that there is no price variation in MRP printed on the label for same medicine sold at different locations.

NEGATIVE ASPECT:

• 40% chemists at the block level said that sometimes there are shortages of medicines, which are due to the lack of fund.
• 57% chemists said that they do have substitute of prescribed medicine available with them.
• 45% chemists at town level and 20% at block level reported instances of spurious drugs but were reluctant to divulge any further information on it.
• 80% chemists at block level said that patients consult them for medicine.
• 10% chemists at town level and 20% at block level said that medicines are sold at MRP plus Sales tax.
• 19% chemists said that usage of vitamins and 11% said that usages of injectable minerals are irrational.
• 98% chemists said that they are not aware about NPPA.
• 39% chemists said that they do not issue bills or cash memo during the sale of medicine
• 30% chemists said that refrigerator is not available at their shop for storage of medicines.
• 60% chemists at block level said that sometime patients check MRP, batch number and the expiry date.

DOCTORS VIEW POINT

POSITIVE ASPECT:

• 98% doctors replied that they use the drugs rationally.
• 97% doctors replied that all the prescribed medicines are easily available.
• 87% doctors said that medicines being sold at the same price at different locations.
• 85% doctors said that medicines are sold at MRP.

NEGATIVE ASPECT:

•  83% doctors at block level said that there are no private hospitals or nursing home in their area.
• 67% doctors at block level confirmed the incidence of spurious drugs but refused to divulge any further information.
• 85% doctors are not aware of NPPA.

Chapter 5

EXECUTIVE SUMMARY RELATING TO KARNATAKA

In Karnataka, 200 patients, 79 chemists, 46 hospitals and 46 doctors were contacted from city, town and block level. The survey shows that contrary to Uttar Pradesh, in Karnataka both the government and private hospitals are in good shape and are sufficient in number. Almost 96% doctors agreed that there are private nursing homes in their area. Even most of the patients avail the facilities of government hospital.

Almost all the doctors, chemists and patients agreed that all the prescribed medicines are easily available and incase of some shortage chemists give them substitute medicine after informing the patients.

There is no frequent price change by the manufacturers and neither there is any incidence of printing different price of same medicine at different locations. Medicines are normally available at the same price at different location. All the chemists and doctors said that medicines are sold at MRP plus Sales tax only.  None of the patients complained of any high priced medicine and they found prices of medicine both reasonable and affordable.

Patients have the habit of avoiding doctors and consulting chemists for the medicine. These are highly prevalent at block level where 67% chemists said that patients sometime consult them for medicine. Alternative medicine therapy is almost non-prevalent in Karnataka and all the patients only prefer allopathic system of therapy. Contrary to Uttar Pradesh, patients of Karnataka are highly conscious about their rights and majority of them checks the MRP, the batch number and the expiry date of the medicine. Awareness about the NPPA is again at its dismal low especially among common patients, but its recall among doctors and chemists are slightly better.

Drugs are normally used rationally except vitamins and injectable mineral that are seen more as treatment for any ailment. Hence, there are some cases of irrational usage of vitamin tablets and injectable minerals.  The most alarming finding in this study is that most of the chemists avoid issuing cash memo after the sale of medicine. Overall, in total 53% chemists said that they rarely issue cash memo but at the block level the figure is as high as 83%. Being socially developed state, incidences of spurious drugs are found to be very negligible.

Chapter 5(a)

FINDINGS RELATING TO KARNATAKA

5.1       PATIENTS’ VIEW POINT

5.1.1    PATIENTS DEMOGRAPHIC PROFILE

In all, 200 patients were contacted out of which 120 patients were contacted in city, 54 in town and 26 in block in Karnataka. Demographic profiles of the contacted patients are given in Table 23.

TABLE  23: DEMOGRAPHIC PROFILE OF PATIENTS CONTACTED

IN KARNATAKA*

Percentage of respondents

Characteristics of patients surveyed		City (120)	Town (54)	Block(26)	Total(200)
Age	18 – 25 yr.	18	11	31	20
	26 – 35 yr.	29	11	19	20
	36 – 45 yr.	22	24	23	23
	45 + yr.	31	54	27	37
Sex	Male	79	76	65	73
	Female	21	24	35	27
Occupation	Service	32	11	8	17
	Business	14	9	25	16
	Professional	4	2	4	3
	Agriculture	14	50	37	34
	Housewife	18	20	27	22
	Others	18	8	15	14
Education	Illiterate	18	35	23	25
	Upto 8th	30	37	38	35
	Upto 12th	23	15	27	22
	Graduate & above	29	13	12	18
Monthly Family Income	< Rs.6,000	74	98	96	89
	Rs.6,000 – 12,000	19	2	4	8
	Rs.12,000 – 20,000	3	0	0	1
	>Rs.20,000	4	0	0	1

*Figures in parentheses are actual number

As can be observed from the table, respondents were selected in the age group of 18 to 45+ years with 73% of them being male and 27% female. Patients from all walks of life have been taken for this study. These include service class, business class, professionals, agriculturist, housewives, etc. They were both illiterates or above graduates, with monthly income varying from less than Rs. 6,000 to more than Rs. 20, 000 per month.

5.1.2    DOCTOR/HOSPITAL VISITING HABITS OF PATIENTS

Out of 200 patients contacted for the study in the hospitals and at the chemist shops, 39% patients said that they go to private doctor clinic, 18% of them go to hospital and 43% patients go to both doctor clinic and hospital in case of illness (see Table 24). The percentage of patients visiting hospitals in the case of illness is hardly 19% at the block level and 6% at the town level, although at city the situation is slightly better at 24%. This shows that there is lack of proper hospital facility at the block and town levels and government should look into this matter. Majority of patients visiting hospitals prefers government hospitals during illness. Around 60% patients reported that they often visit government hospitals during illness. Government should also encourage private parties to set up hospitals at the block and town levels.

TABLE  24 : DOCTOR CONSULTATION PROFILE OF CONSUMERS*

Percentage of respondents

Questions	City (120)	Town (54)	Block (26)	Total (200)
Whom do you visit in case of illness? ·      Doctor Clinic ·      Hospital ·      Both	30 24 46	37 6 57	81 19 0	39 18 43
If visiting hospital, how often you go to government hospital? ·      Always ·      Mostly ·      Sometimes ·      Never	31 28 41 0	67 0 0 33	0 60 20 20	33 29 20 18

*Figures in parentheses are actual number.

5.1.3    AVAILABILITY OF MEDICINES

As the survey shows, there are absolutely no problems in getting the medicines prescribed by the doctors. These are readily available with the chemists of that particular area. Around 99% of patients replied that medicines prescribed by the doctors are readily available as and when required as shown in Table 25.

TABLE  25 : AVAILABILITY OF MEDICINE *

Percentage of respondents

Question	City (120)	Town (54)	Block (26)	Total (200)
Are the medicines prescribed readily available? Yes                                                                                          No	100 0	100 0	92 8	97 3

*Figures in parentheses are actual number

If the medicines which doctors prescribe are not available in the area, doctors do mention the name of the shops from where the patients can easily get them. Overall only in 5% cases patients come back to doctor when they do not get the prescribed medicines.

Chemists do sometimes suggest the patients to buy substitute medicines and the incidence of this practice is more or less same across the city, town and block levels (see Table 26). 66% of the patients in the city said that the chemists sometimes suggest buying substitute medicines whereas in town and block the corresponding percentages are 74% and 92% respectively.

TABLE  26 : SUBSTITUTION OF MEDICINE *

Percentage of respondents

Questions	City (120)	Town (54)	Block (26)	Total (200)
Chemist suggests you to buy substitute medicines? ·      Always ·      Mostly ·      Sometimes ·      Never	0 0 66 34	0 4 74 22	0 0 92 8	0 1 72 27
Does chemist give you substitute without informing you? ·      Always ·      Mostly ·      Sometimes ·      Never	0 0 11 89	2 0 2 96	0 0 0 100	1 0 7 92

*Figures in parentheses are actual number

It can also be seen that the chemists never give substitutes without informing the patients. Although in city 11 percent patients said that chemists do sometimes give substitute medicines without informing them, but almost 100% patients at the block level and 96% at town level said that whenever chemists substitute the medicines they clearly inform them about the substitution.

5.1.4    PRICE OF MEDICINE

In the opinion of the patients, drug manufacturers do not frequently change their prices (see Table 27). The result is same as found in Uttar Pradesh and Karnataka. Almost 94% patients said that manufacturers do not frequently change prices. Only 6% patients replied that they find frequent/substantial price increases in the medicines by the manufacturers.

TABLE 27 : PRICE OF MEDICINE*

Percentage of respondents

Questions	City (120)	Town (54)	Block (26)	Total (200)
Is there a frequent price change by manufacturers? Yes No	0 100	2 98	15 85	6 94
Is there any price difference for same medicine at different locations? Yes No	5 95	2 98	4 96	4 96

*Figures in parentheses are actual number

There are also no reported cases of manufacturers printing different price for the same medicine at different locations and majority of them adhere to this practice in Uttar Pradesh as well as in Karnataka (see Figure VI).

Again patients hardly find any price differing for the same medicine at different locations. 96% of patients replied that they never found any price difference in medicine at difference locations and the scene is same across city, town and block levels. 4% who said that the shortages are there, is mostly in the case of those medicines that are in short supply. But there is no reported incidence of manufacturers printing different price for different locations.

 

In respect of reasonableness of prices, all the patients felt that prices are both reasonable and affordable. The general opinion, which patients shared, was that they have to take medicines prescribed by the doctors and reasonable price do help them to afford fully prescribed medicines.

5.1.5    PROCUREMENT AND PURCHASING PATTERN OF MEDICINES

There are some differences found in response in regard to the question whether the patients get the medicines free of cost at the place of treatment (see Table 28). Whereas 100% and 80% patients at the town and block levels respectively said that they get medicine free of cost, at the city level only 69% said so.

TABLE  28 : MEDICINE PURCHASING BEHAVIOUR OF CONSUMERS*

Percentage of respondents

Questions	City (120)	Town (54)	Block (26)	Total (200)
Are medicines available free of cost at the hospital (Government or Private), where you visit for illness? Yes No	69 31	100 0	80 20	83 17
Does doctor give you medicines? Yes No	22 78	0 100	0 100	7 93
If yes, is it charged or free? Charged Free	50 50	0 0	0 0	50 50
If charged, do you get the bill or cash memo? Yes No	75 25	0 0	0 0	75 25
Do you check the prices? Yes No	67 33	0 0	0 0	67 33

*Figures in parentheses are actual number

The table also shows that hospitals often avoid giving medicines and leave that task to the chemists. At the city level, 22% patients said that doctors do give them medicine. But both at town and block levels, 100% patients reported that doctors never give them medicines. 50% patients in city said that in case doctors give them the medicines they do charge for that.

5.1.6    AVAILABILITY OF ALTERNATIVE THERAPY

Unlike patients of Uttar Pradesh, patients in Karnataka avoid going for alternative therapy. Among 200 patients surveyed, 100% of them at the city, town and block levels said that they are adopting allopathic medicines (see Table 29).

TABLE   29 : AVAILABILITY OF ALTERNATIVE MEDICINE *

Percentage of respondents

Question	City (120)	Town (54)	Block (26)	Total (200)
System of medicines prevalent in area. ·         Allopathic ·         Homeopathic ·         Auryvedic ·         Unani ·         Traditional	100 0 0 0 0	100 0 0 0 0	100 0 0 0 0	100 0 0 0 0

*Figures in parentheses are actual number

5.1.7    INCIDENCE OF SPURIOUS DRUGS

The instances of spurious and sub-standard drugs noticed by patients are very rare (see Table 30). Around 100% patients in city said that they have never noticed any instance of spurious drugs. There are few reported instances of spurious and sub-standard drugs at the town and block levels. 94% and 96% patients at the town and block levels respectively said that they have rarely noticed spurious drugs in the market. In case they have noticed any shop selling the spurious/substandard drugs, they have never gone to that particular shop again for purchasing the medicines.

TABLE   30 : INCIDENCE OF SPURIOUS DRUGS*

Percentage of respondents

Question	City (120)	Town (54)	Block (26)	Total (200)
Any instance of spurious drugs noticed by you? ·         Many a times ·         Sometime ·         Rarely ·         Never	0 0 0 100	2 0 4 94	0 0 4 96	1 0 3 96

*Figures in parentheses are actual number

5.1.8    PATIENTS’ AWARENESS

79% patients are well aware of number of chemist shops in their area. Out of these, however, only 13% of them are aware of 24 hour opened chemist shop. Patients are hardly aware about any Patients Forums or NPPA (see Table 31). So in the case of any problem of spurious drugs or charging higher price for medicines, they do not know whom to approach. Around 98% of the patients do not even know what NPPA is and what is its role. NPPA needs to do a lot to increase awareness about its role in curbing discrepancies in drug pricing and sale of spurious drugs.

A very interesting point, which comes out from this study is that more than 50% patients either sometime or never ask for the bill/cash memos and the same is true across block, town and city levels. This shows that there is no interest among the patients to check whether the extra money that is being charged from them is in the form of taxes or just chemists are over-charging them, as they want. This also shows lack of awareness among the patients of the importance of cash memo and how it can be used if something goes wrong.

TABLE 31 : AWARENESS ABOUT NPPA AND CASH MEMO

DEMANDING PRACTICE*

Percentage of respondents

Question	City (120)	Town (54)	Block (26)	Total (200)
Awareness about NPPA? Yes No	2 98	0 100	4 96	2 98
Does patients ask for cash memo on buying medicines? ·      Always ·      Mostly ·      Sometimes ·      Never	12 22 50 16	4 9 37 50	4 0 46 50	9 16 46 29

*Figures in parentheses are actual number

Various suggestions given by the patients to bring the changes in medical care sector are:

• Medicines should be made available at reasonable prices.
• Medicine quality should be good and should keep on improving.
• Medicines should be made easily available at far-flung villages.

5.2       CHEMISTS’ VIEW POINT IN KARNATAKA

5.2.1    AVAILABILITY OF MEDICINES

Chemists ensure the availability of medicine to patients by the amount of vast stock of medicines they carry. Out of 79 chemists surveyed, majority of the chemists, i.e., 96% reported that medicines demanded by the patients are always or mostly available (see Table 32 and Figure VII). At the block level, however, there seems to be slight shortage of prescribed medicines. 17% chemists reported that there are sometimes shortages of prescribed medicines. The main reasons reported by the chemists for not stocking all the medicines are

• Less demanded medicines are not stocked.
• Daily one or other medicine is coming to the market and it’s difficult to stock all of them.
• We don’t keep the stock because of expiry problem and no proper exchange is done from the company to those expired medicines.
• Huge funds are required to stock all the medicines.

TABLE  32 : AVAILABILITY OF PRESCRIBED MEDICINES*

Percentage of respondents

Questions	City (52)	Town (21)	Block (6)	Total (79)
Required medicines available ·      Always ·      Mostly ·      Sometimes	73 23 4	62 38 0	50 33 17	68 28 4

*Figures in parentheses are actual number

Table: 33 (a) NAME OF MEDICINES WHOSE SUBSTITUTE ARE AVAILABLE

S.No	Name of Medicines That Are In Shortage And Whose Substitutes Are Available
1	Ceftum 250
2	Norfloxacin
3	Nimotas – CD
4	Syrup Ossidos – T
5	R – Butol
6	Flugraine
7	PNA
8	Flozen
9	Vidaylin – M Drops
10	Hycal Forte
11	Sormo
12	Monopark
13	Monicor
14	IHD
15	Ciplox
16	Cefadyl
17	Pyrodex
18	Novamox

There are few medicines that are in short supply and for which substitute are also not available are given in Table 61 (b).

Table: 33 (b) NAME OF MEDICINES WHOSE SUBSTITITE ARE NOT AVAILABLE

S.No	Name of Medicines That Are In Shortage And Whose Substitutes Are Not Available
1	Enthro
2	Ranitidine
3	Scoline
4	Helex
5	Adelphane – Esidrex
6	Pyridactil
7	Pantodac – 40
8	Inj. Clexane
9	Angised Tab.
10	Disulfiram

68% chemists said that the substitutes of the prescribed medicines are available and around 63% of patients do take substitutes in case the prescribed medicines are not available. Like found in Uttar Pradesh, chemists of Karnataka also stock only those medicines which are being prescribed by the doctors practicing in their area. But if the patients come to them with the prescription by the doctor of some other area and the chemists are unable to provide the medicines, they do guide the patients to the right shop where the prescribed medicines will be available.

5.2.2    AVAILABILITY OF OVER THE COUNTER DRUGS

In this study, it was also observed that there are number of medicines which are being sold in high volume without prescription. The most commonly sold medicines without prescription are: Crocin, Saridon, Disprin, Navalgin, Vicks Action 500, Brufen, etc. These are those drugs that provide faster relief, easily available over the counter (OTC) and are common ailment medicines sold without prescription.

5.2.3    INCIDENCE OF SPURIOUS DRUGS

Unlike Uttar Pradesh, none of the chemists in Karnataka at the city, town and block levels have noticed any instances of spurious drugs.

5.2.4    CHEMIST CONSULTATION FOR MEDICINE

It has also been observed during the study that patients do consult chemists for the medicines especially for common ailments. This is true for all the three areas, viz., city, town and block. As seen in Table 34, 46% city chemists, 24% town chemists and 67% block chemists replied that patients sometimes consult them for medicines. In case of common ailments, patients avoid doctors and consult chemists because it not only saves doctor consultation fees but also avoids the hassles of visiting the doctors. In the case of blocks, the poor presence of doctors also forces the patient to consult the chemists.

TABLE  34 : CONSULTING  CHEMIST FOR MEDICINES*

Percentage of respondents

Questions	City (52)	Town (21)	Block (6)	Total (79)
Customer consults chemist for medicines? ·         Many a times ·         Sometimes ·         Rarely ·         Never	4 46 35 15	0 24 71 5	0 67 33 0	3 42 44 11

*Figures in parentheses are actual number

5.2.5    PRICE OF MEDICINE

As seen in Table35, there is hardly any price variation of same medicine at different locations especially at the town and block levels.

TABLE  35 : PRICE DIFFERENCE OF PRESCRIBED MEDICINE*

Percentage of respondents

Questions	City (52)	Town (21)	Block (6)	Total (79)
Price difference at different location. Yes No	31 69	5 95	0 100	22 78
Is difference is in all or some medicines. Some All	87 13	100 0	0 0	88 12
What price medicines are sold? ·   At MRP (MRP + S.Tax) ·   Less than MRP ·   More than MRP	96 0 4	100 0 0	100 0 0	98 0 2

*Figures in parentheses are actual number

Out of 79 chemists surveyed, 78% of them in general replied that there is no price difference for the same medicine at different locations. However, at the city level, 31%, said that there is price variation for same medicine at different locations. But the price difference has been found only for select medicines. 87% chemists at city level and 100% chemists at the town level said that even if there is difference in price, it is only for few selected medicines. These are those medicines that are either less stocked due to non-availability or are critical life saving drugs.

There is hardly any difference in the responses of chemists at the city, town and block levels regarding whether the medicines are sold at MRP.  Around 100% chemists across the city, town and block levels agreed that medicines are sold at MRP (see Figure-VIII).

5.2.6    DRUG USAGE AND DISTRIBUTION PATTERN

It was again unanimous opinion on the usage of various types of drugs with regard to which most of the chemists said that the drug usage is rational. 99% chemists replied that usage of antibiotic is rational, 98% chemists replied that usage of injection and IV fluid is rational. 90% chemists replied that usage of vitamins is rational and 92% chemists replied that usage of injection minerals is rational. The negligible instances of irrational drug usage in the case of vitamins and injection minerals are largely due to the wide usage pattern of these drugs. Vitamins and minerals are widely recommended as it can be used with antibiotics, and any type of diseases and weakness.

The distribution system of medicine is again two ways. It is either through distributor/company salesmen or directly from the distributor. But contrary to Uttar Pradesh, chemists of Karnataka mostly procure the required medicines through company/distributor salesmen. 92% chemists depend on company/distributor salesmen for the supply of medicine. Only 4% chemists said that they collect the medicine directly from the distributor.

5.2.7    CHEMISTS AWARNESS AND SELLING PRACTICES

Awareness about NPPA is better in Karnataka than Uttar Pradesh. As seen in Table – 36, out of 79 chemists surveyed, 43% chemists from city, 44% chemists from town and 33% chemists from block are aware of NPPA.

TABLE –36: AWARNESS ABOUT NPPA*

Percentage of respondents

Questions	City (52)	Town (21)	Block (6)	Total (79)
Awareness about NPPA? Yes No	44 56	43 57	33 67	43 57

*Figures in parentheses are actual number

In 38% shops bill/cash memo are being always issued and in 43% shops bills/cash memo were either issued in some cases or were not issued at all (see Table–37).

TABLE –37: CASH MEMO ISSUED WITH THE SALE OF MEDICINE*

Percentage of respondents

Questions	City (52)	Town (21)	Block (6)	Total (79)
Cash memo issued? ·         All cases ·         Some cases ·         None ·         No customer present	56 27 4 13	0 71 29 0	17 83 0 0	38 43 10 9

*Figures in parentheses are actual number

The scene is worse at the town and block levels where 71% and 83% chemists respectively replied that they issue cash memo only in some cases. This clearly indicates that chemists take the advantage of poorly medically aware patients at the town and block levels and might be selling the sub-standard or the expired drugs at arbitrary prices. If in case any untold incidence happens, the patients can never claim the compensation.

During the study it was observed that in all the 79-chemist shops, prescribed medicines are properly stored in cupboard and refrigerator. Unlike Uttar Pradesh, almost all the shops in Karnataka at the city, town and block levels are equipped with refrigerators.

5.2.8    PATIENTS AWARENESS: CHEMISTS VIEW POINT

The city and town patients are more aware than their counter part at block level (See Table-38). 85% city and 86% town chemists said that patient always or mostly check MRP before purchasing the prescribed medicine, but at block level it is only 50%. According to chemists, patients are also aware of batch no/expiry date and mostly check them before buying the medicine. 32% of chemists replied that customer always check and 50% said that patients mostly check batch no/ expiry date before buying the medicine.

Although in Karnataka patients are more aware about their rights, yet government should try to educate the patients and make them more aware about their medical rights.

TABLE-38: PATIENTS AWARNESS*

Percentage of respondents

Questions	City (52)	Town (21)	Block (6)	Total (79)
Does customer check MRP? ·   Always ·   Mostly ·   Sometimes ·   Never	37 48 15 0	24 62 14 0	33 17 50 0	33 49 18 0
Customer checks batch no/expiry date? ·    Always ·    Mostly ·    Sometimes ·    Never	35 48 17 0	24 57 19 0	33 50 17 0	32 50 18 0

*Figures in parentheses are actual number

5.3       HOSPITAL DOCTORS VIEW POINT IN KARNATAKA

In all, 46 hospitals were contacted in Karnataka and all of them reported that medicines are normally prescribed keeping patients economic conditions in mind. Like Uttar Pradesh, doctors of Karnataka hospitals are also not happy with the government hospital services and feel that it is not adequate to meet the demand of the local patients.  More than 59% percent doctors said that number of government hospitals is not adequate and 61% said that number of government dispensaries is not adequate. Lack of government ambulances and vans only makes the matter worse. Around 72% doctors replied that the government vans are not adequate.  But the case of private hospitals and nursing homes are totally opposite. Hardly 17% doctors replied that private hospitals are not adequate and only 3% doctors said that private nursing homes are not adequate.

Poor management, low priority to healthcare, lack of proper vigilance and lack of fund only aggravates the matter.   This is clearly visible from the response as 100% doctors agreed that there are adequate numbers of private practitioners. With poor condition and maintenance of government hospitals, private nursing homes and hospitals become free to charge what they want. Ultimately patients bear the burnt of the governmental lackluster.

According to the doctors, there are reported cases of sub-standard and spurious drugs. 60% doctors said that they had heard of spurious/substandard drugs being sold in the market and this is more or less same across city, town and block level. None of the doctor is aware about licensed drugs manufacturing units in the local areas. Although awareness about NPPA is low among the doctors also, but compared to patients and chemists they are slightly more aware. More doctors of Karnataka are aware of NPPA then that of Uttar Pradesh. Whereas only 28% doctors of Uttar Pradesh said that they are aware of NPPA, incase of Karnataka it is 50%. But still NPPA needs to boost up their publicity campaign and doctors can be one of the effective medium.

100% of doctors replied that all the medicines which they prescribe, are easily available and all agreed upon medicine being sold at same price in different locations. 100% doctors agreed that medicines are sold at MRP.

5.4       GENERAL DOCTORS VIEW POINT IN KARNATAKA

5.4.1    PRESCRIPTION AS PER PATIENT’S ECONOMIC CONDITION   

In Karnataka out of a total of 46 doctors surveyed, more than 96% doctors across city, town and block levels, replied that they always keep patients economic condition in mind before prescribing medicines to them, (See Table-39).

TABLE –39: MEDICINE AS PER PATIENTS ECONOMIC CONDITION*

Percentage of respondents

Questions	City (25)	Town (17)	Block (4)	Total (46)
Do you keep see patient’s economic condition while prescribing medicines? Yes No	96 4	94 6	100 0	96 4

*Figures in parentheses are actual number

5.4.2    AVAILABILITY OF MEDICAL AID IN THE AREA

Mixed response came out with regard to whether the number of various service providers is adequate or not (See Table-40).

TABLE –40: DOCTORS OPINION ABOUT MEDICAL AID*

Percentage of respondents

Questions	City (25)	Town (17)	Block (4)	Total (46)
Opinion about medical aid in area?
Govt. Hospital Yes No	44 56	88 12	75 25	63 37
Govt. Dispensary Yes No	44 56	70 30	25 75	52 48
Govt. Vans Yes No	32 68	59 41	50 50	43 57
Pvt. Hospital Yes No	84 16	65 35	75 25	76 24
Nursing Homes Yes No	88 12	100 0	100 0	96 4
Private Practitioners Yes No	96 4	100 0	100 0	99 1

*Figures in parentheses are actual number

The survey shows that there are adequate number of government and private hospitals in town and block but fewer numbers of government hospitals and dispensaries in city. In the case of city, 56% doctors said that the government hospitals and government dispensaries are not adequate. But 84% doctors said that private hospitals and 88% said that private nursing homes are adequate in the city. It shows that private doctors and businessman are taking the advantage of insufficient government hospitals in the city and investing more. But the scenario is balanced at the block and town levels. At the block levels 75% doctors and at the town levels 88% doctors said that there are adequate numbers of government hospitals, but 75% doctors at block level feels that the government dispensaries are in inadequate numbers. Government should come out with incentives and policies to promote private party investments in these areas.

There is consensus regarding availability of government vans at the city, town and block levels. On an aggregative level 57% doctors said that government vans are not adequate. Although the scenario in Karnataka is better than Uttar Pradesh where there is hardly any proper government van or government hospital at the city level. In the case of private practitioners the response seems to be the same across city, town and block levels, as around 99% feel that there are adequate numbers of private practitioners. Especially at the block level where the government dispensaries are fewer in number, the private practitioners fulfill this gap. Unlike Uttar Pradesh there is no dearth of either private hospitals or private nursing homes at the city, town and block levels in Karnataka. 76% doctors said that there is adequate number of private hospitals and 96% doctors said that there is adequate number of private nursing homes in their area.

5.4.3    PREVALENT DISESASES IN AREA AND MEDICINE PRESCRIBED

The prevalent diseases of this area as per the doctors are: Malaria, Gastroentritis, Respiratory Infections, Tuberculosis, Entritic Fever, Typhoid etc. The detail list is given in the Table- 41, alongwith the list of medicine prescribed for those diseases.

TABLE-41:  PREVELANT DISEASE AND THE MEDICINES PRESCIRBED*

Sn.	Endemic Disease	Medicine Prescribed
1.	Gastroenteritis	Tinidazole, Metronidazole, Ciprofloxacin, Ranitidine, Norfloxacin, Taxim-O, Oframax, Meganeg, Tetracycline, Norflox, Metrogyl, Metromidazole, Nalidixic acid, Furoxone, Cotrimoxazole, Gelusil, Lanzol, Rantac
2.	Malaria	Chloroquine, Amalar, Paraquin, Quinine, Lariago, Reziz, Primodil, Nivaquine, Imol,
3.	Respiratory	Amoxycillin, Penicillin, Analgesic, Vepen, Infections Sparfloxacin, Roxithromycin, Cotrimoxazole, Ampicillin, Cloxacillin
4.	Entric Fever	Ciprofloxacin, Chloromycetin, Analgin, Ciplox 500mg, Perinorm, Ofloxmacin, Sparfloxacin, Paraxin, Alcipro, Norflox
5.	Typhoid	Ofloxmacin, Ciprofloxacin, Chloramphenicol, Cepetroxic Sparfloxacin, Paraxin, Paracetamol Ceftrioxane, Cefixime
6.	ARI	Co-Trimoxazole, Ampicillin, Amoxycillin
7.	Viral Fever	Inj. PFT, Dexona, Quintor
8.	TB	Refobacin, INH, Ethanhite, Ethambutol, Pyrazinamide, Isoniazid
9.	Dental Disease	Amoxycillin, Aeromox
10.	Upper Respiratory	Ampidil, Tab Restyl, Paracetamol, Amoxycillin, Tract Infection             Cotrimoxazole
11.	Lower Respiratory	Paracetamol, Amoxycillin, Cephalexin Tract Infection
12.	Anaemic	Ziferrin-TR, Fezee
13.	Amebic Dysentry	Tinidazole, Ciplox-TZ, Inj.Garamycin, I.V.Dextros
14.	Infection Disease	Ciprofloxacin, Zentamysin
15.	Hepatities	Analiv, Vitamin B.Complex, Tonics, Liv-52
16.	Helmenthis	Albendazole
17.	Acidpeptic Disease	Ranitidine, Omeprazole, Lansoprazole
18.	UTI	Syproxin, Amikacin
19.	Artherities	Doliprane, Ibuprofen, Profentol
20.	Jaundice	Liv-52, Cap.Hepin, Livomyn
21.	Flu	Paracetamol, Crocin, Alcipro
22.	Diarrhoea	Lopamide, Norfloxacin, Flagyl, Ciplox-TZ, Norflox-TZ, Cefuroxime
23.	Bronchopneumonia	Ceftriaxone, Cefuroxime, Amoxycillin
24.	Bronchitis	Roxythromycin, Amoxycillin
25.	Tonsil	Amotid, Novamox

* The prescribed medicines against the respective disease are as per the views of the respondents. Although on actual checking with some senior doctors it is found that some medicines are wrongly prescribed.

5.4.4    AVAILABILITY AND PRICE OF MEDICINE

There is no problem in the availability of medicine and 100% doctors replied that all the medicines, which they prescribe, are easily available. Again all the doctors agreed upon medicine being sold at same price at different locations and are, moreover, sold at MRP. There are rarely any instances of medicines being sold above MRP.

5.4.5    INCIDENCE OF SPURIOUS DRUG

44% doctors said that they had heard of spurious/substandard drugs sold in the market. As seen in Table-42, the incidence of spurious and sub-standard drugs is more at block level where around 75% doctors confirmed the incidences of spurious drugs. But it is slightly lower at town and city level where only 35% and 40% respectively doctors confirmed the incidence. The low quality checking by the drug companies and NPPA, lack of drug awareness campaign and low literacy rate makes these markets, especially at the block level vulnerable to spurious drugs. It is clearly observable from this study that doctors have identified the spurious drugs more than that of patients and chemists.

TABLE –42: AVAILIBILITY OF SPURIOUS DRUGS*

Percentage of respondents

Questions	City (25)	Town (17)	Block (4)	Total (46)
Are there any instance spurious drugs marketed in the area? ·      Always ·      Mostly ·      Sometimes ·      Never	4 12 28 56	0 0 35 65	0 25 50 25	2 9 33 56

*Figures in parentheses are actual number

As doctors are medically more informed, they can identify the spurious and sub-standard drugs more easily than the patients and chemists. Whereas around 44% doctors said that there are instances of spurious drugs in the market, only 1% chemists and 4% patients felt so.

5.4.6    DOCTORS AWARENESS

Unlike Uttar Pradesh, doctors of Karnataka are more aware about NPPA.

TABLE – 43: AWARNESS OF DOCTORS*

Percentage of respondents

Questions	City (25)	Town (17)	Block (4)	Total (46)
Aware of licensed drug manufacturing unit in local area? Yes No	28 72	24 76	0 100	24 76
Aware of NPPA Yes No	48 52	65 35	75 25	57 43
Any idea on prices of drugs? Yes No	88 12	88 12	75 25	87 13

*Figures in parentheses are actual number

As seen in Table-43, 57% doctors are aware of NPPA and surprisingly doctors at block level are more aware than that of city level. Where 75% doctors at block level said that they are aware of NPPA, at city only 48% said so. So, NPPA has to concentrate more at city to increase its awareness.

Only some doctors of city and town are aware of licensed drug manufacturing units in their locality as 24%city doctors and 28% town doctors confirmed this. But 100% block doctors said that they have no idea about any licensed drug manufacturing units in their locality. More than 88% doctors across city, town and block said that they have adequate knowledge about the drug prices.

Chapter 5(b)

EXPERTS AND FIELD STAFF’S OBSERVATIONS IN KARNATAKA

Following are the findings based on the personal observations of the experts and the field staff on the drug availability, price, distribution and patient awareness made by them during the survey conducted in Hubli (city), Chikkaballapur (block) and Mandya (town) in Karnataka.

5.1       PATIENT AWARENESS

Most of the patients do not clearly or correctly remember the names of medicines they buy.  However, old aged patients and those suffering from chronic diseases such as arthritis, asthma, diabetes, cardiac diseases etc., know the names of the prescribed medicines.  But none of them are aware of any substitute drugs.  Sometimes, chemists suggest them the substitute medicine or inform them about the latest arrivals.  Patients then consult the doctors on the information provided by the chemists about substitute or the latest arrived drugs before they use it.  This is the case with educated patients, but others take the advice of the chemist without going back to the doctors. Patients consult chemists for common ailments such as flu, dysentery, headache, bodyaches, fever, stomach pain and other such routine illnesses including cough and cold.  All chemists sell these drugs across the counter without demanding doctors prescription.

5.2       CHEMIST AWARENESS

Chemists said that doctors and hospitals get supply of several drugs directly from manufacturers at prices 60 to 80 per cent less than the MRP.  It is not unusual to find these drugs finding their way into the retail market and thus the prices of some drugs vary in the market. Some doctors also dispense free drug sample to their patients and charge, as they like. They also don’t give any cash memo for those drugs.  According to the version given by some patients in Hubli, the doctors remove the foil/packing/cover of the medicines and pack the medicine in ordinary white paper or newspaper bits and sell it to them

Chemists get supply of drugs through distributors appointed by the manufacturers. Few manufacturers also supply to the to the retailers directly.  Atleast in 30% of chemist shops, the services of advice of trained pharmacists are is available.  These shops are run with absentee chemist, who lends their certificate to the shop owner for a price.

All chemists and patients are unanimous in their opinion that MRP of drugs should include all taxes. The present practice of making extra taxes on MRP is creating confusion in the retail prices of drugs. Retailers are the ultimate gainers as they arbitrarily charge higher prices on MRP. It was found that the same generic drug manufactured by different companies was available at a difference of 500 percent. A few examples are given in Table 44:

TABLE-44: PRICE DIFFERENCE OF SAME MEDICINE

Manufacturers Name	Drug Name	Weight	MRP (Rs.)
Cipla	Salbutamol	4 mg	0.54 each
Eros Pharma Bangalore	Salbid	4 mg	0.17 each
Cipla	Ciplox	500 mg	8.00 each
Ciprofloxacin  (Generics)	–	500 mg	3.00 each
Bluecross	Blumox	–	2.50 each
Amoxycillin (Generics)	–	–	0.50 each
Cadila	Wormin	–	12.00 each
Allindazole  (Generics)	–	–	3.25 each

It is seen that in case of several non-controlled drugs i.e., vitamins, minerals and tonics, the difference between the price charged by the manufacturer to the retailer and the price to the patient is well over 400%. For example:

Drug Name:                Nimesulide

Price to Retailer:        Rs. 6 per 10 tablets

MRP to Patient:         Rs.24.00 per 10 tables

Some of the chemists observed that a cartel exists among major drug manufacturers in the country. They also complained on lack of accountability and transparency at the drug control department due to which rules and regulations as used to take undue favors from the business community on flimsy grounds. Shops dealing with medicine sale are harassed by the Government machinery on such grounds that are legally not maintainable. Some percentage of drugs manufactured by the small-scale sector also comes into the market that avoids excise duty. Through the distributor network, these get into the retail market or supplied to the hospitals at varying MRP leading to price variation and unhealthy competition.

Medicines required by the patients are “mostly” available and non-availability is temporary. Medicines that generally are not available and for which any substitute is also not available are: ANDISED TAB and DISULFURAN. The commonly sold OTC medicines in high volume are shown in Table-45: 

TABLE-45: COMMONLY SOLD OTC MEDICNES IN HIGH VOLUME

Name	Price	No.
Crocin	Rs.6.70	10 tab
Anacin	Rs.3.80	10 tab
Gelusil	Rs.7.30	10 tab
Saridon	Rs.10.50	10 tab
Atenolol	Rs.22.75	14 tab
Anlodepine	Rs.24.95	10 tab
Daonil	Rs.7.20	10 tab
Glyciphage	Rs.8.50	10 tab

Knowledgeable and experienced chemists have remarked that doctors indiscriminately prescribe antibiotics, vitamins and mineral supplements and tonics. It has also been observed that all the chemist shops were crowded throughout their business hours. The chemists complained about the lack knowledge of new drugs that are being introduced in the market.  According to Mr.C.Gundurao, President, Karnataka Pharmacy Council, Bangalore, “a programme of continuos education by the drug manufacturer is a must for the chemists in the retail shops. This will regularly update them with new developments in the drug market.”

5.3       DOCTORS / HOSPITALS

While at Chikkaballapur and Mandya, doctors and hospitals cooperated with the survey; doctors and hospitals in Hubli were difficult to handle.

Several doctors complained of adulteration in I.V. fluids, enzyme preparations, antibiotics, vitamins and tonics.  They are of the opinion that there exists a manufacturer  – distributor mafia in the drug industry who is continuously engaged in distributing adulterated drugs throughout the country.  The doctors felt that the present drug control laws need to be amended and should provide confiscation of assets of such manufacturers and distributors besides imposing death penalty to those proved guilty of adulteration of drugs.

Manufacturers generally supply drugs to the hospitals directly.  Both the MNC’s and medium or small manufacturers supply drugs to this segment at special prices which could be 20% to 60% less than the MRP.  But the hospitals / doctors charge the patients at MRP and thus make huge profits.

Chapter 5(c)

 SUMMARY OF THE FINDINGS OF KARNATAKA

PATIENTS VIEW POINT

POSITIVE ASPECT:

• 97% patients said that the prescribed medicines are available.
• 94% patients said that there is no frequent price change in the medicine by the manufacturer.
• 100% patients agreed that medicines are available in the market and there is no problem in the supply of medicine from the manufacturers.
• 96% patients said that medicines are available at same price at different locations.
• 99% patients said that in case the prescribed medicine is not available chemists give them substitute medicine only after informing them.
• 100% patients found the price of medicine reasonable and affordable.

NEGATIVE ASPECT

• 100% patients said they adopt only allopathic system of therapy.
• 62% patients said that they visit govt. hospitals during their illness.
• 98% patients are unaware about NPPA and its role.

CHEMISTS VIEW POINT

POSITIVE ASPECT

• 100% chemists said that medicines are sold at MRP plus Sales tax.
• 100% chemists said that there is no price variation in MRP printed on the label for same medicine sold at different locations.
• 96% chemists said that required medicines are available.
• 96% patients said that there is no incidence of spurious drugs.
• 100% chemists said that there had been no instances of spurious drugs.
• 82% chemists at said that patients check MRP and batch/ expiry date during the purchase of medicine.

NEGATIVE ASPECT

• 67% chemists at block level said that patients consult them for medicine.
• 68% chemists said that they do have substitute of prescribed medicine available with them.
• 78% chemists said that there is no difference in the price of the same medicine at different locations.
• 10% chemists said that usage of vitamins and 8% said that usages of injectable minerals are irrational.
• 83% chemists at block level said that they issue bills/ cash memo during the sale of medicine only in some cases.
• 57% chemists said that they are not aware about NPPA.

DOCTORS VIEW POINT

POSITIVE ASPECT

• 100% doctors at block level said that there are private hospitals / nursing home in their area.
• 98% doctors replied that they use the drugs rationally.
• 100% doctors replied that all the prescribed medicines are easily available.
• 100% doctors said that medicines being sold at the same price at different locations.
• 100% doctors said that medicines are sold at MRP.

NEGATIVE ASPECT

• 11% doctors confirmed the incidence of spurious drugs but refused to divulge any further information.
• 57% doctors are not aware of NPPA.

Chapter 6

EXECUTIVE SUMMARY RELATING TO ALL INDIA 

At All India level, 401 patients, 149 chemists, 81hospitals and 92 doctors were contacted from city, town and block level. The survey shows that both government and private hospitals are just matching patients need and hardly 52% patients visits govt. hospitals during their illness. Almost 90% doctors agreed that there are private hospitals / nursing home in their area but majority of them said that government hospitals and government vans are not adequate.

More than 95% of chemists, doctors and patients said that the prescribed medicines are available in the market and there is no problem in the supply of medicine from the manufacturers. They also said that in case the prescribed medicines are not available chemists give them substitute medicine only after informing them.

There is no frequent change in the price by the manufacturer, neither there is any incidence of printing different price of same medicine at different locations. There are very few cases of price difference of same medicine at different locations. They are those medicines that are in high demand and costly. Sometime, it also happens due to shortage of fund with the chemists and is purely temporary in nature. Majority of the respondents agreed that medicines are sold at MRP plus Sales tax only.  In this survey hardly any patient complained of high priced medicine, as they all found medicine prices both reasonable and affordable.

Although 98% doctors said that they use drugs very rationally but few chemists complained of irrational usage of vitamins and injectable mineral that are seen more as common treatment for any ailment. 15% chemists said that usage of vitamins and 10% said that usages of injectable minerals are irrational. The most alarming thing in this study is that around 65% chemists said that they do not issue cash memo after the sale of medicine.

In the backward areas and less developed state like Uttar Pradesh, chemists are found violating drug policy norms of storing medicine in the refrigerators. There are few reported incidences of spurious drugs by the doctors, but neither the patients nor the chemists nor the doctors are willing to divulge any information on the shops that are selling those medicines.

Patients have the habit of avoiding doctors and consulting chemists for the medicine. 54% chemists agreed that patients consult them for medicine. Although allopathic form of therapy is widely prevalent but patients are also exploring the facilities of homeopathic and auyurvedic form of medicine. Awareness about NPPA is at its dismal low especially among common patients where 98% said that they have never heard about NPPA. But its recall among doctors was slightly better where 64% of them recognized the name and role of NPPA. But over all the patients are more aware about their rights and around 87% chemists said that patients check maximum retail price (MRP), batch number and expiry date during the purchase of medicine.

Chapter 6(a)

FINDINGS RELATING TO ALL INDIA

In order to have a holistic view, the data collected for the two states were consolidated, and these are presented and analyzed in this chapter. This chapter not only provides an all India view, but it also enables us to have a comparative look at the state of the health care services in the two states.

6.1       PATIENTS’ VIEW POINT

6..1.1   PATIENT’S DEMOGRAPHIC PROFILE

The separate profiles of the surveyed respondents in the two states along with the consolidated picture for the country as a whole are presented in Table 46. Baring a few categories, it can be observed that the percentages of the respondents belonging to different age, sex, occupation, education and monthly income groups are more or less same for the two states.

TABLE  46 : ALL INDIA DEMOGRAPHIC PROFILE OF CONSUMERS*

Percentage of respondents

Characteristic of patients surveyed		City		Town		Block		Total
		U. P. (126)	KAR (120)	U. P. (50)	KAR (54)	U.  P (25)	KAR (26)	U. P (201)	KAR (200)	All India Avg.
Age	18 – 25 yr.	29	18	28	11	44	31	34	20	27
	26 – 35 yr.	38	29	24	11	24	19	28	20	24
	36 – 45 yr.	20	22	20	24	16	23	19	23	21
	45 + yr.	13	31	28	54	16	27	19	37	28
Sex	Male	73	79	94	76	56	65	74	73	74
	Female	27	21	6	24	44	35	26	27	26
Occupation	Service	24	32	24	11	20	8	23	17	20
	Business	21	14	24	9	8	25	14	16	15
	Professional	9	4	8	2	0	4	6	3	4
	Agriculture	10	14	32	50	16	37	19	34	27
	Housewife	15	18	4	20	44	27	21	22	21
	Others	21	18	18	8	12	15	17	14	13
Education	Illiterate	5	18	18	35	28	23	17	25	21
	Upto 8th	14	30	24	37	20	38	19	35	27
	Upto 12th	27	23	36	15	44	27	36	22	29
	Graduate & above	54	29	22	13	8	12	28	18	23
Monthly Family Income	< Rs. 6,000	40	74	84	98	92	96	72	89	80
	Rs. 6,000 – 12,000	58	19	14	2	8	4	27	8	18
	Rs.12,000 – 20,000	2	3	2	0	0	0	1	1	1
	>Rs. 20,000	0	4	0	0	0	0	0	1	1

·         Figures in parentheses are actual number.

6.1.2    DOCTOR/HOSPITAL VISITING HABIT OF PATIENTS

There is a tendency among the people to avoid visiting the government hospitals to the extent possible. While 48% respondents at the all India level reported that they either sometimes or never go to government hospitals, the respective percentages of such respondents in UP and Karnataka are 57 and 38 (see Table 47).

TABLE  47: PATIENTS’ HABIT OF CONSULTING DOCTORS AND VISITING HOSPITALS

Percentage of respondents

Question	Total
	UP	KAR	All India
Whom do you visit in the  case of illness? ·      Doctor Clinic ·      Hospital ·      Both	42 22 36	39 18 43	40 20 40
If visiting hospital,  how often do you go  to government hospital? ·      Always ·      Mostly ·      Sometimes ·      Never	18 25 49 8	33 29 20 18	25 27 35 13

6.1.3    AVAILABILITY OF MEDICINES

There is absolutely no problem in the availability of medicine as 97% patients at an all India level reported that they get their required medicines (see table 48). There, moreover, does not exist much difference in the responses from the two states.

TABLE  48 : AVAILABILITY OF MEDICINE

Percentage of  respondents

Question	Total
	UP	KAR	All India
Are the medicines prescribed readily available? Yes No	95 5	99 1	97 3

6.1.4    SUBSTITUTION OF MEDICINES

In the opinion of about 70% patients, chemists suggest substitution of medicine in case the prescribed medicine is not available (see Table 49). But majority of the respondents (i.e., around 78%) at the all India level said that the chemists never inform them about such substitution.

TABLE  49 : SUBSTITUTION OF MEDICINES

Percentage of respondents

Question	Total
	UP	KAR	All India
Does chemist suggest substitute medicine? ·         Always ·         Mostly ·         Sometimes ·         Never	1 28 39 32	0 1 72 27	1 15 55 29
Does chemist give medicine substitutes without informing you? ·         Always ·         Mostly ·         Sometimes ·         Never	0 2 34 64	1 0 7 92	1 1 20 78

6.1.5    PRICES OF MEDICINES

A big majority of the respondents both at the all India level and individual state levels reported that the prices of the medicines are not frequently changed by the manufactures.

TABLE 50: CHANGE IN THE PRICES OF MEDICINES

Percentage of respondents

Question	Total
	UP	KAR	All India
Is there a frequent price change by manufacturers? Yes No	2 98	6 94	4 96

6.1.6    MEDICINE PROCUREMENT PATTERN OF PATIENTS

74% patients replied that medicines are available free of cost at the hospital (see Table 51). The percentage of respondents saying that doctors give them medicines was only 20 at the all India level. There exists, however, substantial difference in this respect at the state levels. While 32% respondents in UP said that doctors give them medicines, only 7% said so in the case of Karnataka. So far as the question of doctors charging prices for the medicine they give, respondents appear divided in their opinion. While at the all India level 57% said that doctors do charge them for the medicines they give, the respective percentages of such respondents for the states of UP and Karnataka are 65 and 50.

TABLE  51: MEDICINE PROCUREMENT BEHAVIOUR OF PATIENTS

Percentage of respondents

Question	Total
	UP	KAR	All India
Are medicines available free of cost at hospital (government or private) where you visit during illness?                                                                                                                                                                                    Yes                                                                                                                                                                                                      No	65 35	83 17	74 26
Does doctor give you medicines? Yes                                                                                                                                                                                                     No	32 68	7 93	20 80
If yes, is it charged or free? ·      Charged ·      Free	65 35	50 50	57 43

6.1.7    AVAILABILITY OF ALTERNATIVE THERAPY

At the all India level, the study shows that although patients also go in for alternative medicine systems like homeopathic and ayurvedic, almost everybody, i.e., 99% of them, go for allopathic medicine system based therapy.

TABLE 52: AVAILABILITY OF ALTERNATIVE MEDICINE SYSTEMS

Percentage of respondents

Question	Total
	UP	KAR	All India
System of medicines prevalent in area : ·            Allopathic ·            Homeopathic ·            Auryvedic ·            Unani ·            Traditional	99 56 27 0 1	100 0 0 0 0	99 28 14 0 1

6.1.8    INSTANCES OF SPURIOUS DRUGS

At the all India level. 93% patients replied that they have never come across any instance of spurious drugs (see Table 53).

TABLE   53: PREVAILING MALPRACTICES IN MEDICINE DELIVERY

Percentage of respondents

Question	Total
	UP	KAR	All India
Any instance of spurious drugs noticed by you? ·          Many a times ·          Sometime ·          Rarely ·          Never	1 4 5 90	1 0 3 96	1 2 4 93

6.2       CHEMISTS’ VIEW POINT

 6.2.1    AVAILABILITY OF MEDICINES

Chemists at the all India level are found to be unequivocal regarding the availability of medicines.  93% replied that the prescribed medicines are always available (see Table 54).

TABLE 54: AVAILABILITY OF PRESCRIBED MEDICINE

Percentage of respondents

Question	Total
	UP	KAR	All India
Required medicine available · Always · Mostly · Sometimes	6 84 10	68 28 4	37 56 7

 6.2.2    CHEMISTS’ CONSULTATION FOR MEDICINES

54% chemists said that patients consult them for medicines many a times or sometimes (see table 55). But the incidence of such consultation differs across the states. While 63% chemists in UP reported that the patients consult them, the incidence of such consultation in the state of Karnataka is found to be 45%.

TABLE 55: CONSULTING CHEMISTS FOR MEDICINES

Percentage of respondents

Question	Total
	UP	KAR	All India
Customer consults chemist for medicines? ·         Many a time ·         Sometimes ·         Rarely ·         Never	16 47 20 17	3 42 44 11	10 44 32 14

6.2.3    CHEMISTS’ AWARENESS ABOUT NPPA

Awareness among the chemists at the all India level is very low, with 76% of them agreeing that they have never heard about the NPPA and its role.

TABLE  56 : AWARENESS ABOUT NPPA

Percentage of respondents

Question	Total
	UP	KAR	All India
Awareness about NPPA? Yes No	4 96	43 57	24 76

 6.2.4    PRICE DIFFERENCES IN PRESCRIBED MEDICINES

Majority of the chemists at the all India level are of the opinion that prices of medicines across different locations do not vary. As many as 81% chemists held this opinion. Furthermore, 73% chemists replied that medicines are sold at MRP (see Table 57).  So far as the question of charging local taxes over MRP is concerned, 57% chemists said local taxes are charged.  But the incidence of such practices differs across the states. While in UP 20% said so, the corresponding percentage figure for the state of Karnataka turns out to be as high as 94%.

TABLE   57: DIFFERENCES IN PRICES OF PRESCRIBED MEDICINES

Percentage of respondents

Questions	--
	UP	KAR.	All India
Price difference at different location. Yes No	16 84	22 78	19 81
Do prices differ for all or some medicines? Some All	82 18	88 12	85 15
At what prices are  medicines sold? ·    At MRP ·    Less than MRP ·    More than MRP	88 6 6	59 0 41	73 3 24
Are local taxes  charged over MRP? Yes No	20 80	94 6	57 43

6.2.5    PRACTICE OF ISSUING CASH MEMOS

There is tendency among the chemists of not issuing the cash memos at the time of sale of the medicines to the customers.  Only 23% chemists at the all India level reported that the cash memos are always issued at the time of sale of medicines (see Table 58). There prevails a substantial difference across the two states in this respect. While only 8% chemists in UP reported that the cash memos are issued in all the cases, 38% chemists subscribed to this view in the case of Karnataka.

TABLE  58 : CASH MEMO ISSUED WITH THE SALE OF MEDICINE

Percentage of respondents

Question	Total
	UP	KAR.	All India
Cash memo issued? ·      All cases ·      Some cases ·      None ·      No response	8 39 39 14	38 43 10 9	23 41 24 12

6.2.6    AWARENESS AMONG THE PATIENTS: CHEMISTS’ VIEWPOINT

85% to 86% of the chemists said that the patients always or mostly are both price and quality conscious, and they do check the price, expiry date and the batch number of medicines purchased (see table 59).

TABLE  59 : PATIENTS’ AWARENESS

Percentage of respondents

Questions	Total
	UP	KAR.	All India
Does customer check MRP? ·      Always ·      Mostly ·      Sometimes ·      Never	37 56 7 0	33 49 18 0	35 53 12 0
Customer checks batch no/expiry date? ·       Always ·       Mostly ·       Sometimes ·       Never	50 39 11 0	32 50 18 0	41 45 14 0

6.3       DOCTORS’ VIEW POINT

6.3.1   PRESCRIBING MEDICINES AS PER PATIENTS’ ECONOMIC CONDITIONS

The conclusion that emerges from this study is that 80% of the doctors prescribe medicines keeping the patients’ economic condition in mind (see table 60).

TABLE 60: MEDICINE AS PER PATIENTS ECONOMIC CONDITION

Percentage of respondents

Question	Total
	UP	KAR	All India
Do you keep  patients’ economic condition while prescribing medicines? Yes              No	65 35	96 4	80 20

6.3.2    DOCTORS’ OPINION ABOUT THE MEDICAL AID

Doctors are of the view that there is in general shortage of government hospital, dispensaries and vans, but the number of private nursing homes, hospitals and private practicing doctors is adequate.

TABLE  61: DOCTORS OPINION ABOUT MEDICAL AID

Percentage of respondents

Questions	Total
	UP	KAR	All India
Opinion about medical aid in area?                                                            Government Hospital Yes No	43 57	63 37	53 47
Government Dispensary Yes No	39 61	52 48	45 55
Government Vans Yes No	13 87	43 57	28 72
Private Hospital Yes No	59 41	76 24	68 32
Nursing Homes Yes No	83 17	96 4	90 10
Private Practitioners Yes No	96 4	99 1	98 2

6.3.3    PRESENCE OF SPURIOUS DRUGS

Doctors are better equipped to identify the availability of spurious drugs and around 43% of them at the all India level agreed that there are incidences of spurious drugs (see Table 62).

TABLE 62: PRESENCE OF SPURIOUS DRUGS

Percentage of respondents

Question	Total
	UP	KAR	All India
Are there any instance spurious drugs marketed in the area? ·      Always ·      Mostly ·      Sometimes ·      Never	2 6 35 57	2 9 33 56	2 7 34 57

 6.3.4    DOCTORS’ AWARENESS

Although the awareness about NPPA is higher among the doctors, but it is still low as compared to the patients and chemists (see Table 63). At the all India level, 36% doctors said that they are aware of NPPA. But the percentages of doctors saying so in the two surveyed states differ substantially. While as many as 57% doctors in Karnataka said that they are aware of NPPA, only 15% said so in the case of UP. But so far as the question of knowledge about the drug prices, about 90% of the doctors at the all India as well as the individual state levels reported that they have idea about the prices of drugs.

TABLE  63: AWARENESS OF DOCTORS

Percentage of respondents

Questions	Total
	UP	KAR	All India
Aware of licensed drug manufacturing unit in local area? Yes No	0 100	24 76	12 88
Aware of NPPA Yes No	15 85	57 43	36 64
Any idea on prices of drugs? Yes No	91 9	87 13	89 11

Chapter 6(b)

SUMMARY OF THE FINDINGS OF ALL INDIA

PATIENTS VIEW POINT

POSITIVE ASPECT

• 97% patients said that the prescribed medicines are available.
• 98% patients said that in case the prescribed medicine is not available chemists give them substitute medicine only after informing them.
• 96% patients said that there is no frequent price change in the medicine by the manufacturer
• 99% patients adopt allopathic system,
• 97% patients said that there is no incidence of spurious drugs.

NEGATIVE ASPECT

• 52% patients visit govt. hospitals during their illness.
• 98% patients are unaware about NPPA and its role.
• 28% adopt homeopathic system and 14% adopt ayurvedic system of therapy.
• 60% patients said that medicines are available at same price at different locations.
• 60% patients found the price of medicine reasonable and affordable.

CHEMISTS VIEW POINT

POSITIVE ASPECT

• 93% chemists said that required medicines are available.
• 100% respondents agreed that medicines are available in the market and there is no problem in the supply of medicine from the manufacturers.
• 81% chemists said that there is no difference in the price of the same medicine at different locations.
• 100% chemists said that there is no price variation in MRP printed on the label for same medicine sold at different locations.
• 73% chemists said that medicines are sold at MRP plus Sales tax.
• 94% chemists said that there had been no instances of spurious drugs.
• 87% chemists said that patients check MRP, batch number and expiry date prior to the purchase of medicine.

NEGATIVE ASPECT

• 54% chemists said that patients consult them for medicine.
• 24% chemists said that medicines are sold at more than MRP plus Sales Tax.
• 15% chemists said that usage of vitamins and 10% said that usages of injectable minerals are irrational.
• 78% chemists said that they are not aware about NPPA
• 65% chemists said that they rarely issue bills or cash memo during the sale of medicine.
• 60% chemists said that they do have substitute of prescribed medicine available with them.

DOCTORS VIEW POINT

POSITIVE ASPECT

• 90% doctors said that there are private nursing homes in their area.
• 98% doctors replied that they use the drugs rationally
• 100% doctors replied that all the prescribed medicines are easily available.
• 94% doctors said that medicines being sold at the same price at different locations.
• 93% doctors said that medicines are sold at MRP.

NEGATIVE ASPECT

• 72% doctors said that government vans are not adequate in their area.
• 43% doctors confirmed the incidence of spurious drugs but refused to divulge any further information.
• 64% doctors are not aware of NPPA.

Chapter 7

CONCLUSION

MAJOR FINDINGS OF THE STUDY:

7.1       AVAILABILITY OF MEDICINES AND ITS SUBSITUTES

7.1.1    Medicines normally required by the patients are “mostly” available and non-availability is temporary as replied by more than 93% Chemists and Patients. But at the block level some shortages of medicines were reported. They are mostly temporary in nature except of few costly life saving drugs like anti-cancer drugs. Most of the chemists said they could not store all the required medicines because of the shortage of funds. They also complained that new drugs are launched in the market frequently and it is not possible for them to store all the medicines. Lack of proper mechanism to exchange the expired drugs and replacement on time by the manufacturers, medical representatives and distributors also aggravates the problem of availability and sale of expired drugs.

7.1.2    Substitutes of prescribed medicines of either same drug or other therapeutic values are available, and they are given to the patients only after properly informing them. A comprehensive list of medicines that are in short supply but for which substitutes are available is given in Table 64(a).

Table: 64 (a) NAME OF MEDICINES WHOSE SUBSTITITE ARE AVAILABLE

S.No	Name of Medicines That Are In Shortage And Whose Substitutes Are Available
1	Ceftum 250
2	Norfloxacin
3	Nimotas – CD
4	Syrup Ossidos – T
5	R – Butol
6	Flugraine
7	PNA
8	Flozen
9	Vidaylin – M Drops
10	Hycal Forte
11	Sormo
12	Monopark
13	Monicor
14	IHD
15	Ciplox
16	Cefadyl
17	Pyrodex
18	Novamox

But there are few medicines whose substitutes are not available. A comprehensive list of medicines that are in short supply but for which substitutes are not available is given in Table 64(b).

Table: 64 (b) NAME OF MEDICINES WHOSE SUBSTITITE ARE NOT AVAILABLE

S.No	Name of Medicines That Are In Shortage And Whose Substitutes Are Not Available
1	Enthro
2	Ranitidine
3	Scoline
4	Helex
5	Adelphane – Esidrex
6	Pyridactil
7	Pantodac – 40
8	Inj. Clexane
9	Angised Tab.
10	Disulfiram

7.2       PRICE OF MEDICINE

7.2.1    Most of the respondents agreed that there is no difference in the price of same medicine at different locations and medicines are sold at MRP. In few places, the difference in price of medicine occurred either due to sales taxes or because of short supply or due to heavy competition. According to the survey price differences were found to be existing in the case of either the medicines meant for T.B and Cancer or Vaccines.  It has also been observed by our field staff/ experts that in the case of several non-controlled drugs, i.e., vitamins, minerals and tonics, the difference between the price charged by the manufacturer to the retailer and the price to the patient is well over 400%. For example:

Drug Name:                Nimesulide

Price to Retailer:        Rs. 6 per 10 tablets

MRP to Patient:         Rs.24.00 per 10 tables

The reputed brands have been found to be charging more and the differences in price of same generic drugs can go upto 500 percent. As observed by our field staff/expert, the name of few drugs where the price difference was found to be very high is shown in the Table 65.  For instance, it can be observed from table that in the case of Ciprofloxacin, Cadila charges Rs. 8/- for Ciplox 500 mg whereas the same generic drug Ciprofloxacin 500 mg is available at Rs. 3/- only.

TABLE-65: PRICE DIFFERENCE OF SAME MEDICINE

Manufacturers Name	Drug Name	Weight	MRP (Rs.)
Cipla	Salbutamol	4mg	0.54 each
Eros Pharma Bangalore	Salbid	4 mg	0.17 each
Cipla	Ciplox	500 mg	8.00 each
Ciprofloxacin (Generics)	–	500 mg	3.00 each
Bluecross	Blumox	–	2.50 each
Amoxycillin (Generics)	–	–	0.50 each
Cadila	Wormin	–	12.00 each
Allindazole  (Generics)	–	–	3.25 each

7.2.2    Only 7% doctors and 24% chemists reported that medicines are sold at more than MRP inclusive of taxes. Few cases of overcharging in the lifesaving medicines like the medicines for TB have also been observed because of short supply.

7.2.3    The survey shows that almost 80% doctors normally prescribe medicines keeping the economic conditions of the patients in mind. Hence, 60% respondents found the price of medicines as being both reasonable and affordable.

7.2.4    100% Chemists, and 96% Patients agreed that there are no incidences of printing different price on the label for same medicines sold at different locations. They also said that there is no frequent substantial price increase in the medicine by the manufacturer.

7.2.5    93% doctors agreed that medicines sold during the course of hospitalization are sold at MRP. But in the case of a few hospitals in Uttar Pradesh our field staff and experts observed that doctors sell the medicines given free of cost to them as samples and charge arbitrary prices from the patients.

7.3  QUALITY OF MEDICINE AND ALTERNATIVE MEDICINE PRACTICES

7.3.1    The study shows that availability and usage of allopathic medicines is much better as compared to that of our traditional forms of medicines. Patients still opt for alternative therapies. Because of high awareness, almost 99% patients adopt allopathic therapy, but it is also seen that among them 28% go for homeopathic and 14% adopt ayurvedic system of therapy.

7.3.2    3% patients, 6% chemists and 43% doctors reported a few instances of spurious drugs in the market. But when probed further, none of them came forward to divulge any information about the shops that were selling those drugs.

7.3.3    As high as 30% chemists in the state of Uttar Pradesh (especially at block level) were found not using refrigerator. They are storing critical medicines and injectables on the selves. Lack of fund, erratic electric supply and non-availability of refrigerator, maintenance staff are some of the main reasons cited for not storing drugs and injectables in the refrigerator.

7.3.4    Drugs are normally used rationally as found in this study. But in the case of vitamins, injections and minerals, their usage is found to be erratic and irrational. Data reported in Tables 66 and 66(a) also are a pointer to the irrational usage of medicines in India. The tables contain information provided by the doctors in response to the questions as to which are the major diseases and which medicines are for such diseases. It was observed by the VOICE experts and also was pointed out explicitly by NPPA in its meeting with VOICE, that most of the medicines prescribed for various diseases are actually not meant for those diseases, thus indicating irrational usage of such medicines.

7.3.5        This study shows that there are no licensed manufacturing units in the surveyed area of Uttar Pradesh, but in Karnataka few respondents said that there are some licensed manufacturing units. But even in the case of latter, the respondents were not aware of the exact names and addresses of such units.

7.3.6        The widely prevalent diseases are Gastroentritis, TB, High and Low Blood Pressures, Malaria, Viral Fever, Diahoerra, Typhoid, Pneumonia and Respiratory Infections. But when asked about the medicines prescribed against these diseases it has been found that wrong medicines are prescribed  (see para 7.3.4 above).

TABLE 66: PREVELANT DISEASES AND THE MEDICINES PRESCRIBED*

S. No.	Endemic Disease		Medicine Prescribed
1.   2. 3. 4.	Gastroenteritis   Gastritis Goitre Filariasis		IV Fluid, Oxytetracycline, Tinidazole, Metrogyl, Ciprofloxacin, Norfloxacin, Tetracycline IV Fluid, Antacid Oral Iodine Hetrazan, Unicarbazan, Banocide forte, Banocide Syrup
5. 6. 7. 8.	Sugar Fractures Liver Pain HBP / LBP	Euglucon, Protamine Zinc Combiflam, Flexon, Protamine Zinc Beptazine-H, Cimetin, Clodex, Tenelol, Timizol
9. 10.	TB Viral Fever	Combutol, Tab. INH, Tab. IHD, Pyrazinamide, Isonex, Isoniazid Amclox, Calpol Syrup, Indomethacin, Ciprofloxacin
11. 12. 13. 14.	Malaria Dysentry Headache Cold/Vomitting	Chloroquine, Metacin, Paracetamol, Quinine Blumox, Metronidazole Amaebecide, Brufen Benadyle, Ceff-250, Siquil
15. 16.	Diarrhoea R.T.I	Metrogyl, Norfloxacin, Ciprofloxacin, Ringerlactate, Electrol Amoxycillin, Cephalexin, Ampicillin, Cloxacillin
17.	Eczema	Betnovate-N
18. 19. 20.	Enchephelities Typhoid Pneumonia	Destrose, Dexona, Monocef Ciprofloxacin, Calpol, Paraxin, Chloramphenicol, Septran, Ofloxacin, Amoxycillin, Ceff-250 / 500, Cetazone, Cephalexin
21.	Amoebiasis	Anti-M, Tinidazole
22.	Conjunctivitis	Ciplox eye drop, Mycin eye drop
23. 24.	Entrocolitis Viral Hepatitis	Tinidazole, Metrogyl, Ciprofloxacin Paracetamol
25. 26.	Stomach Pain Headache	Spasmizol-K Brufen
27.	Migrane	Ibumax, Calpol
28.	Cancer	Vincristine Sulphate, Methotrexate, Bleomycin
29.	Jaundice	Liv 52, Livoerb, Glucose Powder
30.	URTI	Cephalexin
31.	Hydrosyel	Banocide

* The prescribed medicines against the respective disease are as per the views of the respondents. Although on actual checking with some senior doctors it is found that some medicines are wrongly prescribed.

TABLE-66(a):  DOCTORS OPINION: PREVELANT DISEASE OF THE AREA AND THE MEDICINES PRESCRIBED*

Sn.	Endemic Disease	Medicine Prescribed
1.	Gastroenteritis	Tinidazole, Metronidazole, Ciprofloxacin, Ranitidine, Norfloxacin, Taxim-O, Oframax, Meganeg, Tetracycline, Norflox, Metrogyl, Metromidazole, Nalidixic acid, Furoxone, Cotrimoxazole, Gelusil, Lanzol, Rantac
2.	Malaria	Chloroquine, Amalar, Paraquin, Ciprofloxacin, Quinine, Lariago, Reziz, Primodil, Nivaquine, Imol,
3.	Respiratory	Amoxycillin, Penicillin, Analgesic, Vepen, Infections      Sparfloxacin, Roxithromycin, Cotrimoxazole, Ampicillin, Cloxacillin
4.	Entric Fever	Ciprofloxacin, Chloromycetin, Analgin, Ciplox 500mg, Perinorm, Ofloxmacin, Sparfloxacin, Paraxin, Alcipro, Norflox,
5.	Typhoid	Ofloxmacin, Ciprofloxacin, Chloramphenicol, Cepetroxic Sparfloxacin, Paraxin, Paracetamol Ceftrioxane, Cefixime
6.	ARI	Co-Trimoxazole, Ampicillin, Amoxycillin
7.	Viral Fever	Inj. PFT, Dexona, Quintor
8.	TB	Refobacin, INH, Ethanhite, Ethambutol, Pyrazinamide, Isoniazid
9.	Dental Disease	Amoxycillin, Aeromox
10.	Upper Respiratory	Ampidil, Tab Restyl, Paracetamol, Amoxycillin, Tract Infection    Cotrimoxazole
11.	Lower Respiratory	Paracetamol, Amoxycillin, Cephalexin, Tract Infection
12.	Anaemic	Ziferrin-TR, Fezee
13.	Amebic Dysentry	Tinidazole, Ciplox-TZ, Inj.Garamycin, I.V.Dextros
14.	Infection Disease	Ciprofloxacin, Zentamysin
15.	Hepatities	Analiv, Vitamin B.Complex, Tonics, Liv-52
16.	Helmenthis	Albendazole
17.	Acidpeptic Disease	Ranitidine, Omeprazole, Lansoprazole
18.	UTI	Syproxin, Amikacin
19.	Artherities	Doliprane, Ibuprofen, Profentol
20.	Jaundice	Liv-52, Cap.Hepin, Livomyn
21.	Flu	Paracetamol, Crocin, Alcipro
22.	Diarrhoea	Lopamide, Norfloxacin, Flagyl, Ciplox-TZ, Norflox-TZ, Cefuroxime
23.	Bronchopneumonia	Ceftriaxone, Cefuroxime, Amoxycillin
24.	Bronchitis	Roxythromycin, Amoxycillin
25.	Tonsil	Amotid, Novamox

* The prescribed medicines against the respective disease are as per the views of the respondents. Although on actual checking with some senior doctor/experts, it is found that some medicines are wrongly prescribed.

 

Chapter 8

RECOMMENDATIONS

Based on the findings of the study VOICE recommends following measures to be adopted by NPPA and other concerned organizations dealing with healthcare issues for ensuring better availability of medicines at affordable prices.

8.1       AVAILABILITY OF MEDICINES

8.1.1        MAKING FUNDS OR LOANS AVAILABLE TO THE CHEMISTS

Chemists complained that due to lack of resources they are unable to provide quality service to the customers and also minimum infrastructures like equipment for proper storage of medicine are not affordable. Government, banks and other financial institutions should form a task force and conduct a study in this area and then suggest a solution by writing a white paper on how to arrange resources. The focus has to be on raising funds at the most cost-effective price, for chemists to stock and store medicines in the most scientific manner.  Once an effective money lending mechanism is in place, the chemists will have more funds at their disposal and thus they will be able to maintain better inventory of the required medicines. This will also help them to buy and maintain their basic equipments like refrigerators, invertors etc. to store the injections and other sensitive medicines at proper temperatures.

8.1.2        MAKING DISTRIBUTION CHANNELS MORE ACCOUNTABLE

Availability of medicines is also affected by the erratic visits of medical representatives and company distributors and dealers especially in the case of the far-flung block areas. There are also complaints of not properly changing the expired drugs. The pharmaceutical companies need to ensure that their representatives and distributors make regular visits and check the availability of medicines. They should also take note that if expired drugs are not properly and timely removed, the local retailers will try to sell them. The persons from the concerned government departments should also make regular and sudden visits to ensure that quality medicines are timely available to the patients.

8.1.3        DOCTORS SHOULD PRESCRIBE SUBSTITUTE MEDICINES

In the case of non-availability of drugs, patients are totally left at the discretion of chemists and it is he who suggests the substitute medicines. It is, therefore, recommended that the prescription should also mention the names of substitutes in case the prescribed medicine is not available. NPPA with institutions like Indian Medical Association and Indian Medical Council should develop a code of conduct for the medical practitioners of all sciences to prescribe medicines to the patients with atleast two to three alternatives. This would facilitate consumers as in case prescribed medicines are not available then the patients can opt for the prescribed substitutes. This will also help to bridge the mistrust, which is existing today between the doctors and patients.

8.2       PRICE OF MEDICINES

(8.2.1)   PEOPLE BELOW PROVERTY LINE SHOULD GET MEDICAL SERVICES AND MEDICINES FREE OF COST AND AT SUBSIDISED PRICES

Government should control prices of life saving drugs and price lists of such drugs should be prominently displayed at the chemist shops. Medicines should be distributed free or at subsidized prices to the poor consumers living below the poverty line. The mechanism to detect citizens living below the poverty line can be determined through several instruments, which have been suggested by the consumer organizations to the Government at several consultations. One such example is identity cards with photograph of the family and making such documents and names public to check misuse.

(8.2.2)   INFORMING PATIENTS ABOUT MEDICINES AND THEIR COSTS

The study has indicated that there is no information available to the patients (even to the educated citizens) about the medicine availability, prices and other similar information, which the patients should be kept updated. Due to lack of such information, consumers are solely dependent on the local chemists for the information on substitution, cost effectiveness and other parameters for the selection of right drugs. It has also been observed during the study that even whatever little communication that exists with the patients it is not in an understandable language. NPPA along with the drug manufacturers should try to find a solution by publishing the retail prices of essential medicines along with their substitutes and generic forms. It could be done with the help of doctors and paramedical workers verbally for the illiterate and for others in all the leading newspapers or other form of communication like radio, TV and public announcement, to protect the rights of the consumers on price information and choice.

(8.2.3)   PRINTED MRP SHOULD INCLUDE THE SALES TAX

The study shows that due to differing sales tax across the states, patients are confused on the actual price of the medicines. There is a constant mistrust that prevails between the service providers and the users.  NPPA should look into this matter and formulate a strategy to make uniform pricing of the same medicine throughout the country. The printed MRP should include sales taxes so that patient can just look at the medicine pack and pay the price that is printed on it. This will stop the confusion that is created in the mind of patients on actual MRP of medicines and will also go a long way in preventing the retailers from charging extra in the name of sales taxes and build the desired confidence between the retailer and the consumer.

(8.2.4)   KEEPING STRICT VIGILANCE ON THE REASON FOR CHARGING HIGH PRICE 

As observed by our field experts, drugs with same molecule and weight are available at different prices. The reputed brands with better brand image charge more and this price difference sometimes goes upto 500 percent. NPPA needs to explore the possibility of reducing the price difference between the branded and generic formulation of the given medicine, and also take necessary steps to promote the prescription and usage of the generic formulations of the medicines among the doctors and patients.

(8.2.5)   ENSURING PROPER USAGE OF SAMPLED DRUGS BY THE DOCTORS

In the block areas our field staff has observed that doctors do sell the free samples of medicines given to them by the manufacturers and charge arbitrary prices from the patients. Pharmaceutical companies should strictly restrict the number of free samples that is to be given to the doctors and very prominently and legibly display on the labels in local language regarding all the sample packs. Innovative ideas can emerge from consultations between the manufacturers, doctors and the consumer organisations for supply of such sampled medicines to the poor consumers with the help of consumer organizations, hospitals and nursing homes. Companies joining such schemes may be given wide publicity by publicizing their names in the newspapers, TV and also on hoarding, banners and other promotional tools at the hospitals and nursing homes.

8.3       QUALITY OF MEDICINES AND ALTERNATIVE MEDICINE PRACTICES

(8.3.1)   POPULARISING TRADITIONAL MEDICAL TREATMENT           

As expected, the study reflected a strong popularity among patients towards the allopathic therapy. The influence of private sector in the pharmaceutical industry and especially the role of multinational corporations have almost driven away our traditional forms of medicines. There is a great need for the Health Ministry to look into this issue and formulate policies to encourage the growth of our traditional forms of medicines. A comprehensive study needs to be immediately carried out by the consumer organizations to investigate various existing barriers undermining the usage of traditional medical science. It is an immediate priority for all of us to understand the gravity of the situation and encourage the policy makers to bring in large amount of investments in traditional health care areas. The Ministry of Health along with NPPA should formulate incentives for investments in the traditional medicines and farming of medicinal plants. It is also observed that very few students are also opting to study the traditional medical science, as it has not received the adequate recognition from the Government and the community.

(8.3.2)   STRICT VIGILENCE FROM THE CONCERNED DRUG DEPARTMENT

To stop the sale of spurious drugs, surprise checks should be conducted time to time at the chemist shops and strict vigilance should be exercised in the case of smuggling of medicines from one state to another. The concerned State health department should conduct regular checks on whether the doctors who are practicing have a recognized certificate or degree in association with the State Medical Association and consumer organizations. If any doctors are found guilty then strong action should be taken against them. There should also be a similar autonomous agency in every State to keep strict vigilance on the medicines sold in the market. The study shows that patients consult chemists for medication and medicines are sold without any prescription and all rules and regulations concerning the code of conduct to be adopted by chemists are violated without any hesitation. Government should evolve some mechanism to curb such practices. It is also recommended that all the state governments should conduct a survey immediately on all such cases filed in the various courts disposed or pending on all such violations under the DPCO for the last ten years and the reasons for delay and judgment obtained. The survey will throw open a healthy debate within the community on the effectiveness of DPCO and involve the key stakeholders like various institutions and organizations representing doctors, chemists, pharmaceutical companies and consumer organizations to formulate strategies to check the quality of drugs and implement a viable solution.

8.4       OTHER SUGGESTIONS

(8.4.1)   DEVELOPMENT OF QUALITY INFRASTRUCTURE

This study substantiates the regular reports that appear in newspapers and other media on the impotency of drugs made available to the consumers. The study reveals that it is due to lack of infrastructures like cold chain, testing facilities on the quality of medicine, training at various levels dealing with medicine distribution and prescription dissemination. The recent incidences, which were reported in the media regarding the polio infection even after the immunization program, the loss of eyesight due to wrong medicine at the time of eye operations always raised doubts on our existing infrastructure. The competence of medical practitioners and the service providers gets questioned due to such deficiencies and poor infrastructure. The study showed that drugs are not stored in refrigerators in block areas. The regulatory authorities like NPPA should initiate efforts to ensure that all the state level drug regulating and monitoring bodies conduct regular tests, third party surveys and evaluate the available infrastructure for upgrading the technology and the skills of the implementing agencies at the cutting edge. All the state governments must prepare a framework and an action plan to implement effectively the entire existing infrastructure and ensure upgradation of the infrastructure wherever required. The resources required for such activities should be made available on a priority basis by the planning commission or the financial institutions. NPPA should also make the service providers accountable to the citizens in the case of negligence or sub-standard quality of service delivery.

(8.3.5)   BENCHMARKING SERVICE STANDARDS OF PUBLIC SERVICES

One of the key highlights of the study is that the citizens do not have the requisite health care facilities at the block and town levels for immediate as well as subsequent treatments. Government should try to identify the gaps and should either on its own or in collaboration with the private sector try to build the necessary health care facilities in the towns and villages. There is also an immediate need for developing the minimum service standards to be made available to the citizens availing government supported health programmes. NPPA should authorize a State nodal agency to monitor the quality of these services from time to time and ensure accountability of the existing system to the citizens by providing minimum standards defined by NPPA in consultation with the service providers and the consumer organizations.

(8.3.6)  INCREASE AWARNESS AMONG PATIENTS

Educating consumers and service providers regarding the various existing rules and regulations have to become one of the most important components of NPPA by documenting the various violations and its remedies. Till date the citizens are not clear about the redressal mechanisms available in the country. Whatever system exists in the country is not user friendly. Through advertisement and other promotional methods like monthly newsletter in local languages in association with consumer organizations, awareness must be built among the patients on how to examine and differentiate original from duplicate medicines. Education must be given on labeling information and testing facilities should be provided to check quality at random. All these measures will ensure quality products and provide the right choice to the consumers. In backward areas where menace of quacks is very high, concerned health departments should take necessary steps to educate the patients on the dangers of going to quacks. The health department should make public all information on all such quacks who are practicing in rural and urban areas as professional medical practitioners to educate the consumers and seek support from consumer organizations to make all such information more public and protect the consumers from exploitation

(8.3.6)   PUBLICISING THE ROLE OF NPPA AND STRENGTHENING ITS EFFECTIVENESS 

The study reveals that the patients are not aware about the various control and monitoring mechanisms on drug prices and the role of NPPA in making certain essential drugs affordable to the common citizens. There is an absolute need to publicize the role of NPPA in a much larger magnitude throughout the country. The role of the regulators like NPPA has to be strengthened by the Government by making them autonomous and fully insulated from political and Government bureaucracy.

(8.3.7)   REGULAR CONSULTATION WITH CONSUMER ORGANISATIONS

As there is a strong relationship existing between the practicing doctors, chemists and drug manufacturers, there is an equal need to induce a similar relationship between the patients, consumer organizations and the regulatory agencies into this relationship. The consumer organisations also need to take up responsibilities to regularly evaluate the existing systems and the role of the regulators at the state and national levels. They should also from time to time investigate the lapses like ineffective health care delivery system and the infrastructure bottlenecks. The manufacturing costs of essential medicines have to be controlled and if necessary supported by the Government for the poor and disadvantaged sections of the society. Such subsidy should continue till such time the market is matured and the regulators are fully empowered to take strong action against the violators in the interest of the consumers. The consumer organizations also need to seek the services of experts to be able to intellectually intervene on all such subjects. All such activities concerning monitoring of prices and availability of medicines by consumer organizations must be supported by NPPA. NPPA should create a fund either by imposing a cess on the manufacturers’ turnover or by inviting voluntary contributions from industry for financing such activities.