Commerce on the issue. His deposition made for a powerful case for providing generic drugs and protecting domestic capacity for manufacturing inexpensive medicines.
These two are among the major recommendations made by the High Level Expert Group (HLEG) on Universal Health Coverage, set up by the Planning Commission in October 2010. The facts presented by Khan are also well documented in many reports and advocacy briefs of civil society groups.
So what is new? It is the manner in which the case was compellingly presented by the actor-director-producer. Public health researchers and advocates love data. People, on the other hand, love stories. Khan bridged this gap well, weaving the facts into a moving narrative in the manner of a master storyteller.
India has the dubious distinction of being in the top tier of countries with very high out-of-pocket expenditure on health (at present, estimated to be 71%). This is because of a very low-level of public financing (1.4%). As a result of high healthcare costs, 40 million Indians are pushed into poverty each year. About 72% of the out-of-pocket expenditure is due to spending on drugs. The supply of free drugs to in-patients in government facilities has come down from 31% in 1987 to 9% in 2004. During the same period, the provision for free drugs came down from 18% to 5% in out-patient care.
In a system of universal healthcare, essential drugs need to be supplied free to those who need them. The list of essential drugs is periodically prepared by the World Health Organisation and at the national level by the health ministry. Efforts should also be made to weed out individual drugs or combinations that have no proven benefit or can even cause harm. Spurious drugs, too, have to be stopped from entering the market.
The advantage of generic drugs lies in their low cost. The process patenting regime introduced in 1970s fostered the growth of the generic drug industry in India. Most of the essential drugs are now available in generic form, for domestic use and export. If governments choose to procure and provide a free supply of these drugs in public facilities, many patients will benefit without draining their pockets or straining public finance.
In August 2011, Spain announced that all drugs will have to be prescribed by their generic names. This policy was expected to provide an annual saving of ¤2.4 billion. In November 2011, Mexico announced that, to achieve universal health coverage, 3.5% of its GDP would be spent on health, of which 30% would be used exclusively for providing free drugs.
In India, the HLEG recommended that essential drugs be procured as generics by the government and distributed free through all healthcare facilities under the programme of universal health coverage. If this supply is initially confined to public facilities, it would cost only an additional 0.1% of the GDP, over present government expenditure. This is easily affordable and should be implemented as one of the early steps for moving towards universal health coverage.
The Tamil Nadu Medical Systems Corporation has developed an excellent model of centralised procurement and decentralised distribution of quality-assured generics through all public healthcare facilities, thereby helping patients and saving costs. Sale of generic drugs through Jan Aushadhi shops has also proved popular in Rajasthan.
Both physicians and the government are responsible for the low use of generic drugs. Doctors have grown used to prescribing brand names. As students of medicine, they are familiar with generic names. When they start their life as interns and practitioners, brand names become imprinted on their minds through regular indoctrination by representatives of drug companies. As they fall into the habit of prescribing by brand, they start rationalising it, to themselves as well as others, as an insistence on quality. Physicians should be restrained from prescribing costly branded forms when equally effective but cheaper generics are available.
Governmental agencies in charge of drug procurement, too, have been reluctant, in many states, to adopt the Tamil Nadu model. Its transparency curtails the opportunity for corruption and kickbacks. The violent deaths of three chief medical officers in Uttar Pradesh is a sad reflection on the state of our drug procurement systems.
Of course, quality matters. All drugs, whether generic or patent protected, must be subject to strict quality assurance. Drug regulation in India has been weak for several years, due to inadequate central staffing, laxity of state-level regulators and limited number of testing laboratories. To ensure the effectiveness and integrity of drug regulation, we need to speedily correct all of these deficiencies.
In the meanwhile, stars like Khan should continue to highlight issues such as access to healthcare and affordable medicines, unfazed by the ire and fire of critics. To grapple with the ground realities of India, kuchh to tare utre zameen par.
K Srinath Reddy is president, Public Health Foundation of India and chair of Planning Commission’s High Level Expert Group on Universal Health Coverage
The views expressed by the author are personal