P2G2': Fix all the links in the healthcare chain

The Narendra Modi government has a new mantra. Like all mantras of this government, it is flying on the wings of a memorable acronym — “pro-poor good governance”, or P2G2. What could this mean in a country where over 63 million people are pushed into poverty every year due to healthcare costs alone?

One telling piece of P2G2 was revealed to us the other day by the Prime Minister himself. Inaugurating a charitable hospital in Surat, Mr Modi said the Central government was thinking of a legal framework that would make it mandatory for doctors to prescribe only generic medicines. Generics, as most people are aware, are cheaper than the equivalent branded drugs. Mr Modi also reminded us that his government had brought in a new health policy, capped the price of many medicines as well as coronary stents, even if this meant angering the pharma companies.

What could be more P2, or pro-poor, than pushing for affordable medicines in a country where most people pay for medical treatment out of their pocket, and where the biggest chunk of out-of-pocket health expenses goes towards buying medicines?

However, there is a complication, notably the second part of the mantra — G2, or good governance. While the intention of ending the practice of greedy doctors prescribing only expensive drugs is a noble one, there is also the issue of logistics.

Ensuring safe, affordable medicines involves more than just two parties — the doctor and the patient. It means there has to be a sufficient supply of low-cost generic medicines. Then, they have to be distributed effectively. Quality checks are critical and there is a need for much greater awareness among the public about generic drugs.

Arguably, it is tough to really debate the proposed law when we don’t have details. It is also true that in a country like India, it is next to impossible to do anything without hundreds of people telling you immediately that it can’t be done.

That the Modi government is actively thinking of how to make healthcare more affordable is welcome. But a law to force all doctors in the country to prescribe generic medicines by itself may not lead to the desired outcome.

Here is why.

The idea of promoting generic drugs is not new. Last year, the Medical Council of India issued directives to doctors to prescribe medicines using only their generic names and to write legibly. In 2008, the ministry of chemicals and fertilisers had launched “Jan Aushadhi” — with the idea of making quality generic drugs available at affordable prices. Nearly a decade later, the Jan Aushadhi report card is a mixed bag.  The Centre’s ambitious scheme to sell unbranded generic medicines at prices that ordinary people can afford did not quite take off in many places. A 2016 news report suggests that in Madhya Pradesh, for example, the scheme was not a great success due to lack of supply in the Jan Aushadhi stores. The state government-run stores did not get the full stock of essential drugs they were meant to have.

Which brings to one of the key bottlenecks. Even if doctors are made to prescribe generic medicines, what guarantee that the patient will get them? How do we ensure that the end-user, the patient, gets a good deal, specially when many can’t even read or write?

Many health experts fear that the move could end up empowering the chemist rather than the patient. The chemist typically sells the medicine which gives him the maximum profit. What incentive is there for him to sell low-cost medicines? Even if a doctor writes a generic name of a drug on the prescription, how does one ensure that India’s 800,000-odd chemists do not sell the medicines which are most profitable to them? We don’t know what the government proposes to do to tackle this problem.

The Jan Aushadhi scheme was launched with great fanfare but thereafter little was done to really spread awareness about its benefits, or about low-cost generic drugs among the lay public. Over the years, a perception has emerged among many people that low-cost generic drugs are not quite as good as the branded ones. This has been bolstered by the fact that some commonly-used medicines have failed quality audits. But it is useful to remember that there are vested interests who would want to tar the entire generic industry in the country because a few have been found at fault. The answer lies in not being in a state of denial but rigorously enforcing quality. That brings us to regulatory frameworks. India has a chronic shortage of drug inspectors necessary to ensure production and distribution of safe, high-quality medicines. That needs to be corrected urgently.

The cost of drugs and the cost of healthcare have to be brought down. Some steps have already been taken. Last year, the National Pharmaceutical Pricing Authority slapped a price cut of up to 55 per cent for 54 essential drugs, including those for cancer (brain and breast), hypertension, diabetes, antibiotics and other heart disorders.  Recently, the government stepped forward to cap the price of coronary stents. But this does not cover everything.

What can be done?

One oft-cited good practice is the Tamil Nadu Medical Services Corporation (TNMSC) model of centralised tendering and purchasing to improve drug accessibility. This demonstrably reduces the financial burden on the state as well as individuals. The TNMSC was set up in the wake of a massive drug scam in Tamil Nadu. This led to many reforms and a streamlined system of drug purchase, storage and distribution through the medical services corporation in 1994. However, such a centralised system of drug procurement requires trained personnel, streamlined processes, infrastru-cture and IT-enablement so that huge quantities of drugs can be procured, stored and distributed to various user institutions with the least delay. Tamil Nadu spends the most on medicines among Indian states. It also boasts of a robust public healthcare system and a high literacy rate.

The bottom line: It is important to ensure that doctors prescribe generic drugs as much as possible. But wielding a stick alone may not yield the desired results. All the other links in the pharma chain must be fixed for it to be truly P2G2.