Article

Access to Quality Medicines: Rajasthan Model

“Reaching the Unreached”
Nirmal Gurbani*
Professor (Pharmaceutical Management), Institute of Health Management Research, IIHMR University, Jaipur and Adviser,
Rajasthan Medical Services Corporation, Jaipur

Under the UN initiative for Universal Healthcare Coverage, a healthcare and beyond the reach of most of the people, there is differential drug
system can serve at its best only with access to quality medicines and health pricing and promotion of non-essential drugs. Analysis of the list of top
products, which can be best ensured by proper selection and use, affordable selling brands in Indian market reveals that many brands which comprise
prices, sustainable financing and reliable supply system. Pharmaceuticals of non-essential drugs that are higher priced alternatives without a clear
(medicinal products, vaccines, contraceptives, diagnostics, devices and therapeutic advantage and many drugs that are unnecessary, irrational
health supplies, etc.) constitute second highest item of expenditure after and even hazardous are being promoted by the industry, permitted by
the manpower in any given health facility. There is an urgent need to put the regulators, prescribed by the doctors and consumed by the patients.
in place advanced and tangible policies that would ensure un-interrupted
supplies of essential medicines, especially in low resource settings. As India: ‘Pharmacy of the Developing World’
pharmaceuticals The access framework India has one of the best developed pharmaceutical industries and
are a link between produces about 20 per cent of the world’s drugs. 376 manufacturing
the p a t i e n t a n d plants in the country have US FDA approval which is second only to US.
health services, Over 1000 companies are WHO GMP approved. India is among the top
their availability or five producers of bulk drugs in the world, 3rd in (10% in global sales)
absence contributes terms of volume and 14th (1.5%) in terms of value (Total Sale Rs 73,000
to the positive or Cr within India and Exports Rs 80,000 Cr as per March 2013 IMS data,
negative impact on with rate of growth over 11%). Patented drugs make up approximately
health. Utilizing these 8% of total market sales in India and 92% of Indian drugs market is out
broad principles, of patent. On account of providing highly significant proportion of cost-
the Rajasthan state effective quality medicines under internationally funded programs in HIV/
have launched on AIDS, Tuberculosis and Malaria and otherwise as well, India is regarded
2 nd October, 2011 as the “Pharmacy of the Developing World”. The irony is that this success
a “Mukhyamantri Nishulk Dawa Yojana (MNDY)” i.e. Chief Minister Free has not been translated into availability or affordability of medicines for
Drug Distribution Scheme (CMFDDS) through an autonomous “Rajasthan all. Pharmaceutical market in general, is free for all players and there is
Medical Services Corporation” (RMSC). 607 medicines, 73 surgical items complete asymmetry about the pricing information. Although Hon’ble
and 77 different kinds of sutures along with 71 products directly supplied Supreme Court had directed the Union Government in 2003 to control
by the Government of India, as prescribed by doctors are made available the prices of all essential medicines, it took 10 years to issue new Drug
free of cost to all kind of patients visiting public health facilities. Under Price Control Order (DPCO) in May 2013. It is not that the actual costs of
this scheme, a population of about 7 crores (70 millions) is being served the medicines are higher in the country, but the promotional activities of
at an annual expenditure of about Rs. 300 Crores. the industry have made the retail prices exorbitantly very high resulting
in not only impeding the access to medicines, but irrational promotion
Background of not needed medicines. Prevailing problems and barriers in access to
As per the UN Charter and the Declaration of Alma-Ata, 1978, “Health medicines are listed in Box 1.
for All”, good quality healthcare is a basic fundamental right of people
It is evident from the Tables 1 to 6 that costs of making medicines in
and should be made available to all. In all advances in medical sciences,
India are not high but overpriced to accommodate irrational promotion.
medicines have remained the core in the healthcare and would continue to
Medicines often become unaffordable to weaker sections of the
be the core; thereby it implies that access to essential medicines is also a
society.
basic human right of the people. Ironically a large section of population is
still deprived not merely because there is any fundamental insufficiency of
Issues of Drug pricing control
resources, but a lack of will to put in place right strategies. As per WHO,
world over about two billion people are unable to have access to essential The Government of India exercises price control over drugs by means
medicines mainly due to their high cost. This deprivation causes immense of Drugs Price Control Order (DPCO) under power conferred under Essential
suffering, pain, fear and loss of life. As a result, thousands of people die Commodities Act, 1955. In 1979, 347 essential drugs were under price
daily, among them the vast majority is children below five years of age. control. Subsequently, drug companies have succeeded in reducing the
As per WHO 65% of the Indian population lacks regular access to essential basket of price controlled drugs to 142 drugs in 1987. In 1995, this came
medicines. In spite of the remarkable success of Indian pharmaceutical down to 76 and until recently only 72 out of over 500 commonly used
industry, the provision of affordable medicines to people remains a great drugs are under statutory price control. In compliance to the directions
task. To meet health expenditure, three-fourth of the total out-of-pocket issued by the Hon’ble Supreme Court of India in 2003, the Government of
expenditure in the country is spent on buying medicines. In general, India has issued a new Drugs (Price Control) Order 2013 effective from
medicines are beyond the reach of most people, expenditure on medicines May 2013. It gives the ceiling prices of specified 348 drugs and their
makes people poor, sickness leads to poverty, medicines are overpriced 600+ dosages forms of the drugs are mainly those covered under the

*E-mail: [email protected]

Pharma Times - Vol. 47 - No. 02 - February 2015 18

National List of Essential Medicines (NLEM). The earlier DPCOs were Addressing “Availability of Quality Generic Medicines” in
based upon the cost incurred in manufacture of the drug (cost based Rajasthan
pricing). The new DPCO brings into ambit more number of drugs but
the calculation of ceiling price is based upon the average market price A. Evolution based on medicines wholesale prices and
of the branded and generic drugs (market based pricing). It touches printed retail prices information
only 18 % of the market of Rs 72000 crores and leaves most fixed dose
Efforts to provide medicines at affordable prices to improve access
combinations FDCs) and other combinations /formulations of NLEM
to medicines in Rajasthan started as a pilot project as early as in 2006
drugs untouched including non-standard dosages (eg. Paracetamol 650
in one of district in Rajasthan named Jhalawar by Dr Samit Sharma, the
mg), chemical analogues (e.g. covers atorvastatin but not rosuvastatin),
then newly appointed IAS officer as SDM. Incidentally, he was a post-
etc. The profit margins, even post May 2013 price control under the
graduate pediatrician turned into an administrator. This was an “Evolution”
new DPCO are anywhere between 100 to 4700 percent (Table 2). The
to establish fair price medicine shops” as the forerunner to free medicines
Government has succumbed to the pressure of the Industry that let
which eventually became consolidated as the “Chittorgarh Model” when
market competitive forces decide the prices of the medicines. Public
he became the District Magistrate into a district level initiative for “Making
health action group allege that the Government has shown priority on
medicines affordable” through Fair Price Medical Shops. This was an
the health of the industry over the health of the people and contend
initiative to devise mechanisms to bring down prices of medicines and
that the market cannot decide medicine prices because pharmaceutical
common surgical items to its minimum, so that even the poor can afford
market is largely profit oriented, brand leader is often also the price
them. Medicines were procured by generic names using transparent
leader (costliest drug is most sold) as most often buyers/patients do
open tender system and dispensed through Cooperative Medical Stores.
not choose the medicines and decision is taken by others (doctors/
It was basically a district wide chain of fair price medicine shops which
retailers) who are often directly or indirectly paid for making such
serve OPDs and Indoor patients of Government Hospitals and also the
decisions. Besides this, unlike most other items, drugs have no
general public. These low cost drug and surgical item sale outlets are not
alternative (one can remain alive without unaffordable onions but not
subsidized, they were self sustainable as they generated enough revenues
without medicines) as the need to buy drugs is immediate, involuntary
and no external aid was required. The purpose of the initiative was to reach
and obligatory and have to make decision usually under distress.
the unreached, i.e. to make medicines affordable to everyone, especially

Box 1: Problems and Barriers in Access to Medicines

Problem 1: Medicines are beyond the reach of our people
• The expenditure on health is the second most common cause for rural indebtedness.
• Over 23% of the sick don’t seek treatment because they are not having enough money to spend.
• Over 40% of hospitalized patients have to borrow money or sell their assets to get them treated
Problem 2: Expenditure on medicines makes people poor
• Expenditure on drug constitutes about 50-80% of the health care cost
• Expenditure: Out of Pocket 79%. State Government 14%, Central Government 4%, Private Investment 2-3%, Private Insurance about 1%
• Expenditure on health is responsible for 3% shift from APL to BPL every year
• A study by World Bank shows that as a result of single hospitalization 24% of people fall below poverty line in India
Problem 3: Medicines are overpriced and beyond the reach of the majority
(Table 1 and 2)
• Tender prices are just fraction of prevailing market prices
Problem 4: Differential Drug Pricing (Table 3)
• Legally the quality standards prescribed for all these products are identical and law does not permit any grading/indexation on quality of the
products. Analysis as per pharmacopeia requirement shows no quality variation. Clearly the huge margin between the stockiest price and
MRPs is promotional incentives to doctors and chemists.
Problem 5: Prescription by brand name (Table 4 and 5)
• There are huge price variations among different brands and patient are left at the mercy of the prescribers or advice of retailers as patients
are not aware of equivalent cheaper/affordable alternatives
Problem 5: Promotion of Non-essential drugs
• Drugs produced are not in alignment with the disease pattern
• Sales of top 300 brands reveals that Only 38% of brands are of the drugs mentioned in the National List of Essential Medicines and other 62%
brands comprise drugs that are higher priced alternatives without a clear therapeutic advantage and many are unnecessary, irrational and
even hazardous
• Piractecam is not marketed in USA. In UK permitted for use in just a single indication, a rare disorder called cortical myoclonus, that too only
as an adjunctive therapy, contraindicated for adolescents under the age of 16 years and in hepatic and renal impairment, during pregnancy and
lactation. In India it has been allowed for intellectual decay, social maladjustment, lack of alertness, change of mood, deterioration in behavior,
learning disabilities in children associated with the written word. The drug is being promoted for use in young children no contraindications;
no need to observe any precautions and no adverse drug reactions.

Pharma Times - Vol. 47 - No. 02 - February 2015 19

 Table 1: Procurement / Tender Price Comparison of Selected few Generic Medicines procured by the Rajasthan
Medical Services Corporation (RMSC) with corresponding few Branded Drugs in 2012
S. Name of Drug Pack Size RMSC Tender Equivalent Popular Brand Pack Size MRP
No Price (in Rs.) (in Rs.)
Analgesic, Antipyretic & Anti-Inflammatory Drugs (pain relievers)
1 Diclofenac Sodium Tablets IP 50 mg 10 Tabs strip Rs 1.24 Voveran(Novartis) 10 Tab Strip 31.73
Dicloran(Lekar) 23.43
Anthelminthics (Medicines for worms infestations)
2 Albendazole Tablets IP 400 mg 10 Tabs Rs. 6.28 Zental (GSK) 10 Tab 175.00
Anti Infective Drugs / Antibiotics (to treat infections)
3 Azithromycin Tablets IP 500 mg 10 Tabs Rs 58.80 Azithral (Alembic) 10 Tabs 308.33
Anti-Neoplastic &Immunosuppressant Drugs + Palliative Care
4 Paclitaxel Injection IP100mg 16.7 ml vial Rs338.66 Mitotax(Dr.Reddy) 16.7 ml vial 4022.00
Innotaxel(Innova) 4500.00
Cardiovascular Drugs (Mediciness for Heart ailments)
5 Atorvastatin Tablets IP 10 mg 10 Tab Blister Rs 2.98 Atrova(Zydus) 10 Tab Blister 103.74
6 Clopidogrel Tablets IP 75 mg 10 Tab strip Rs 6.10 Clopigrel(USV) 10 Tab Strip 215.50
Antidiabetic Drugs
7 Glimepiride Tablets IP 2 mg 10 Tab strip Rs 1.95 Amaryl(Aventis) 10 Tab strip 117.40
Psychotropic Drugs
8 Diazepam Tablets IP 5 mg 10 Tab strip Rs 1.30 Valium(Abbott) 10 Tab strip 30.22
9 Alprazolam Tablets IP 0.5mg 10 Tab Blister Rs 1.47 Anxit (Micro) 10 Tab Blister 25.80
Alprax (Torrent) 25.33

Table 2: Procurement / Tender Price Comparison of Selected few Generic Medicines procured by the Rajasthan
Medical Services Corporation (RMSC) with corresponding few Branded Drugs in 2014
Sr. Name of the Medicine Pack size RMSC Procurement DPCO 2013 MRPs of Selected brands (in Rs.)
No. Price Rs. Ceiling Price Rs
1. Cetirizine Tablets 10 mg 10x10 7.7 192 Cetzine 201.6,  Alerid 190.1,  Zyncet 190.1,
Zyrtec 190
2. Cefixime Tablets 100 mg 10x 10 119.77 818 Zifi 495,  Taxim O 807.5
3. Cefixime Tablets 200 mg 10x 10 225.51 1196 Taxim O 1255.7,  Ziprax  1152.5
4. Diclofenac Sod Tab 50 mg 10x10 9.15 207 Dicloran 204.7,    Reactin 205
5. Ofloxacin Tab. 200 mg 10x10 65.49 521 Oflox 514.5,  Zenflox 375,  Oflomac 514.5
6. Ceftriaxone Injection 1 g 1 Vial 12.13 58.94 Monocef  61.84
7. Amlodipine Tabl. 5 mg 10x10 8.23 301 Amlogard 297,  Amtas 312.9,  Stamlo 297, 
Amlopress 315.6,  Amlopin 297.2
8. Clopidogrel Tab. 75 mg 10x10 47.74 1066 Plavix 1053.1,  Clopigrel 1053.2,  Deplatt  470, 
Clopivas 474.5

9. Atenolol Tablets 50 mg 10x14 17.51 308 Aten 304.22,  Tenolol  305.2,  Atecard  322, 
Tenormin 319.9,  Atenova 299.88

10. Domperidone Tab. 10 mg 10x10 11.15 240 Domstal 237.7,  Motinorm  230,  Domperi  325.5, 
Dodom 237.7, Dom DT 237.3
11. Glibenclamide Tab. 5 mg 10x10 8.44 102 Daonil  100.8,  Euglucon  95
12. Alprazolam Tab 0.5 mg 10x10 9.14 214 Anxit 211, Trika  211, Alprax 211
13. Losartan Tablets 50 mg 10x10 30.2 457 Losar 479.9, Tozar  451.5,  Losacar  480, 
Losium 283.6

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 14. Azithromycin Tab. 500 mg 10x3x3 386.93 1962.9 Azithral 2056.5, Azee  1941.3, Aziwok 1935, 
Zithrox 1938,  Zathrin 1935 (for 90 tablets)
15. Enalapril Tab. 5 mg 10x10 12.08 315 Envas 310.8,  Enace 330.3, 
Enam  296.6, Nuril 310.8 
16. Atorvastatin Tab. 10 mg 10x10 26.1 628 Atorva 659.4, Tor  659.6,  Atorec 620.5, Tonact 
650.6
17. Paclitaxel 260 mg Injection 43.4 ml Vial 646 13900.15 Mitotax 9588,  Cansure 10000
18. Imatinib Tablets 400 mg 10x10 1,911.48 28529 Imatib (Cipla) 29935.6
Veenat (Natco) 26550 ,
 Zealata (Ranbaxy) 28170 
19. Glimepiride 2 mg 10x10 12.9 Not in DPCO Amaryl 1386.6

Table 3: MRPs Comparisons of the 3 Brands of Cetrizine Manufactured by the Same Manufacturer
Drug Brand Name Generic Name Rate for chemist for Printed MRP Rate for chemist for 10 Printed MRP
manufacturing given by 10 Tablets (Stockiest in 2012 Tablets (Stockiest price) after DPCO 2013
company company price) in 2012 after DPCO 2013
Cipla Alerid Cetrizine 10 mg 28.85 37.50 15.80 20.19
Cipla Cetcip Cetrizine 10 mg 1.88 33.65 2.36 19.01
Cipla Okacet Cetrizine 10 mg 1.84 27.50 2.36 19.01

Table 4: Comparison of Wholesale and Retail Prices of Selected few Brands of Injection Amikacin
Name of the Drug Branded Generic Name assigned Generic Stockiest Price per Printed MRP
Manufacturer by the manufacturer Name of the Medicine Injection In Rs. In Rs.
Cadila Amistar 500 Amikacin 500 mg 8.00/- 70/-
German Remedies Amee 500 Amikacin 500 mg 8.00/- 70/-
Wockhardt Zekacin 500 Amikacin 500 mg 9.90/- 70/-
Alembic Amikanex 500 Amikacin 500 mg 8.22/- 64.25/-
Intas Kami 500 Amikacin 500 mg 8.13/- 60/-

Unichem Unimika 500 Amikacin 500 mg 7.80/- 72/-

Ranbaxy Alfakim 500 Amikacin 500 mg 8.50/- 70/-
Cipla Amicip 500 Amikacin 500 mg 7.42/- 72/-

Table 5: MRPs Comparisons of the Different Brands of Imatinib Mesylate 400 mg used in Blood Cancer in 2012
S.N Generic Name Strength Brand Names Company Pack Size MRP in Rs.
1 Imatinib Mesylate 400 mg Gleevec M/s Novartis 3x10 Tab 1,23,000/-
2 Imatinib Mesylate 400 mg Veenat-400 M/s Natco 3x10 Tab 10,560/-
3 Imatinib Mesylate 400 mg Zealata-400 M/s Ranbaxy 3x10 Tab 10,364/-
4 Imatinib Mesylate 400 mg Imatib-400 M/s Cipla 3x10 Tab 9,000/-
5 Imatinib Mesylate 400 mg Mitinab-400 M/s Glenmark 3x10 Tab 9,000/-
6 Imatinib Mesylate 400 mg Imanib-400 M/s Intas 3x10 Tab 7,500/-
the poor, asset less and disadvantaged section of the society, to reduce at Rs. 8 -10 through Cooperative Medical Shops instead of Rs. 70 i.e.
out of pocket expenses of people on health, to increase the accessibility printed MRP. many more patients could afford treatment and many more
of drugs, to decrease expenditure from the state exchequer by bringing lives could be saved). This was facilitated by adopting transparent open
down the government employees health care reimbursement bills and tender system for drug procurement, making available almost all commonly
also the pensioners medical fund expenses and to promote rational use prescribed drugs at low cost, ensuring strict quality control and monitoring,
of drugs by minimizing prescription of unnecessary drugs by adopting establishing district wide chain of low cost shops covering the rural areas
Essential Drugs List and Standard Treatment Guidelines (For example – A to make them accessible to all, convincing doctors amicably to prescribe
pneumonia patient who may not able to purchase injection Amikacin by generic names, checking prescription of unnecessary drugs, which
500 mg as it is sold in the market at about Rs.70 (MRP) whereas its costs a lot and persuading private chemists to offer generic drugs for
wholesale price was about Rs 7 only and this injection could be supplied sale. This innovative approach has been widely applauded under Amir

Pharma Times - Vol. 47 - No. 02 - February 2015 21

Khan’s “Satyamev Jayate”. Thus, medicines and surgical items were are insufficient for minimal batch size, branded drug can be supplied
available at unbelievably low prices; much below the printed market rate at generic prices after hiding MRP.
(MRP) with significant fall in treatment costs, as per illustrative list under 5. While orders for supply are issued centrally by the RMSC, but supplies
Table 6 and 7. are received at District Drug Warehouses (DDW) in “Quarantine Area”
from where supplies are transferred after quality testing to Sub stores
B. Addressing ”Availability through Free Drugs Distribution
of Medical College Hospitals, District Hospitals, Community Health
in Rajasthan through MNDY” through a Policy declaration Centre, Primary Health Centres for onwards issue to Drug Distribution
(Political will) and establishment of Rajasthan Medical Centres (DDC) at OPDs/IPDs, OTs/Wards/Injection room. All DDWs
Services Corporation (RMSC) have well defined storage capacities, including cold storage (walk in
Recognizing the need to address crucial roadblocks on the way to coolers, ILR, deep freezers) etc. with strict compliance to First Expiry
providing affordable, good quality and timely healthcare to people, the First Issue (FEFO).
Government of Rajasthan announced the scheme for providing commonly 6. To ensure ”efficacy of generic medicines a three Step quality checking
used essential generic medicines and general health supplies free of cost system has been adopted, viz. (i) Check at procurement level
to all patients visiting government health facilities. It was launched on (Strict parameters for selection of reputed supplier companies as a
Mahatma Gandhi’s Jayanti i.e 2nd October, 2011 with title “Mukhyamantri prequalification), (ii) Check at supply level – Acceptance of drugs only
Nishulk Dawa Yojana (MNDY)” i.e. Chief Minister Free Drug Distribution with QC passed batch release certificate (COA) -QC passed test report
Scheme (CMFDDS). The benefits under the aegis of MNDY have been of each batch supplied along with the invoices, without which goods
extended to the entire 7 Crore population of the state (irrespective of BPL not accepted in warehouses and (iii) Check at issue level – Pre-release
or APL). Under this scheme constitution of an autonomous centralized quality assurance, i.e. Stock quarantined, Samples sent to QC cell,
procurement agency for transparent procurement of quality health products Retesting of all batches of drugs after masking manufacturers details
was a major initiative. Major components of this scheme are: with coding in Govt. approved empanelled labs for quality parameters

ESSENTIAL COMPONENTS OF FREE MEDICINES SCHEME

TO MAKE DRUGS AVAILABLE IN GOVT HOSPITALS TO CHANGE PRESCRIPTION BEHAVIOUR OF DOCTORS
1. Establishment of autonomous centralized procurement agency: Rajasthan 1. Sensitization and orientation about rational use of drugs
Medical Services Corporation.(RMSC) (RUD).
2. Identification of drugs and health products for free essential drug list (EDL) 2. Write prescription on self carbonated prescription slips
through a “Technical Advisory Committee (TAC) of experts
3. Procurement through a two-bid transparent e-tendering process (Quality and 3. Diagnosis must be written
price)
4. Drug Warehouse at every district 4. Write Generic / Salt names
5. Empanelled laboratories for quality testing 5. Use out of Essential Drug List
6. System for transportation of drugs 6. Follow Standard Treatment Guidelines
7. System for storage and distribution of drugs in all hospitals 7. Constitution of Drug and Therapeutics Committee (DTC).
8. e-Aushadhi Software for Inventory management 8. Prescription Audit
9. Transparent and prompt payment system 9. Computerized drug dispensing up to PHCs
10. Sufficient funds. 10. Patient counselling
1. Establishment of Rajasthan Medical Services Corporation with well of Identity, Purity, Strength and other specified tests whichever is
defined cells for Procurement (e-tender), Supply (purchase orders), applicable as per pharmacopoeias. After receiving the test reports of
Logistics (storage, distribution & transportation), Quality Control coded samples and decoding by QC cell only quality passed stocks
(testing and issue), IT (inventory control) and Finance (payments, etc) are released for distribution of supplies.
under the command of Dr Samit Sharma with proven track record for 7. A total number of 15169 DDC have been equipped with required shelves/
improving affordable access to quality medicines as Managing Director racks, refrigerator, computer with printer, stationary, Pharmacist and
of RMSC. Informatics assistant.
2. Identification of drugs and health products for free essential drug list 8. e-Aushadhi Software for Inventory management is a complete Supply
(EDL) through a “Technical Advisory Committee (TAC) of experts which Chain Management Solution for drugs, surgical items and sutures
has identified Drugs (607), Surgical (73), and Sutures (77) for free which provides inventory management at all DDWs and at sub stores
distribution and Criteria for inclusion are Efficacy, Safety, Suitability / DDCs of Medical College Hospitals, District Hospitals, CHCs and PHCs
and Cost effectiveness. and is implemented across 5139 locations spread across the state.
3. A two-bid open transparent tendering process allows only manufacturer It provides detailed information from the stage of procurement of the
/ Importer to participate provided it has an annual turnover more than drug to its consumption by the end users. Key features of e-Aushadhi
Rs 20 Cr., GMP Certificate, 3 years market standing for the product, facilitates online annual demand submission, online purchase order
and the Firm or product should not be blacklisted/debarred/convicted. generation to suppliers, provision to maintain expiry date/shelf life,
Now e-procurement is mandatory. Information of rate contract (RC), provides details of Quality control, ability to track drug inventory online,
tender conditions, supplier contact details are available on website ability to generate customized reports, facilitates inter-ware house
www.rmsc.nic.in for all visitors. transfer of drugs, alert generation in different colours for expired drugs,
4. Procurement is mainly by generics only. However, if quantities ordered re-order level and maintains daily stock ledger of drugs, etc.

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 Table 6: Comparison of Chittorgarh Cooperative Store Sale Rate with MRP Printed on pack/strip
Generic Name of Drug Unit Chittorgarh MRP Printed on Name of Surgical item Printed Rate to the
Cooperative Store pack/strip (Rs.) MRP Patient
Sale Rate (Rs.)
Albendazole Tab IP 400 mg 1 tablet 1.37 25 Blood Transfusion Set 43 12.3
Alprazolam Tab IP 0.5 mg 10 tablets 1.75 14 I.V.Cannula 18 63 7.48
Arteether 2 ml Inj 1 Injection 11.72 99 I.V. Set 50 6.61
Amlodipine Tab 5 mg 10 tablets 3.12 22 Surgical Gloves 40 7.3
Cetrizine 10 mg 10 tablets 1.5 35
Ceftazidime 1000 mg 1 Injection 64.9 370
Atorvastatin Tab 20 mg 10 tablets 22.59 170
Diclofenac Tab IP 100mg 10 tablets 2.75 25
Diazepam Tab IP 5 mg 10 tablets 1.9 29.4
Amikacin 500 mg 1 Injection 8.67 70

Table 7: Cost difference in treatment common cold (5 days)

When medicines are prescribed by brand name and purchased from chemist When medicines are prescribed by
shop Generic name and purchased from Coop. Store
Qty of medicines Rate per Cost (no. x Rate per Cost (no.
Name of drug No. Name of drug
required 10 tabs rate) 10 tabs x rate)
10 tab Ciprofloxacin 500 60.54/- 60.54/- 10 tab Ciprofloxacin 500 12.85/- 12.85/-
10 tab Nimesulide 25/- 25/- 10 tab Nimesulide 2.12/- 2.12/-
5 Tab. Cetrizine 35/- 17.5/- 5 Tab. Cetrizine 1.50/- 0.75/-
Total 103.04/- Total 15.72/-

9. Transparent and prompt payment system allows payment of all Policy for rational use of medicines and prescribing rational treatment
stakeholders through NEFT/RTGS, internet banking in instant manner is in place and various orders have been issued by the Government
and Supplier payment especially against supplies through e-Aushadhi to all facilities requesting that carbon copy prescriptions be used, one
Software and deposits by any stake holder through CBS of PNB and copy for the patient and one for the facility, diagnosis be written on all
through e-deposit. prescriptions which should be signed by the doctor, drugs be prescribed
10. On an average an annual outlay of Rs 300 Cr. Is sufficient to cater the by generic name from essential drugs with due regard to STGs, Drug and
needs of 7 Cr populations. Therapeutic Committees be established in all large hospitals, prescription
audit be done by the DTCs to ensure appropriate use of medicines, “No to
11. Number of medicines being made available at healthcare institutions
MRs” – avoidance of perverse financial incentives, use of non-essential
is according to level of the healthcare facility, viz. Medical College &
drugs be justified by the concerned doctor, patients be counseled and
attached Hospitals (550-600), District Hospital (350-450), CHC (175-
dispensing be monitored.
250), PHC/Dispensary (75-150), Sub-centre (20-30).
12. Ensuring generic prescribing with compliance to STGs as much as Sensitization and orientation about rational use of drugs
possible using educational, managerial and regulatory interventions. (RUD)
By adopting above initiatives, the price monopoly of drug manufacturers Pursuant to launch of MNDY an initial resistance to change in the
is broken by procuring drugs by tender system with the benefit of the prescribing pattern was felt on behalf of the doctor community deployed
“Economies of Scale” wherein procurement of medicines at lowest rates at public health institutions; therefore seminars,confrences and review
can be ensured due to the bulk central purchase orders. Due to bulk/ meetings were held regularly at state, zonal and district level to sensitize
pooled procurement purchase, easy and quality oriented transparent the doctors towards rational use of drugs. All 33 districts have been
tender procedures, the State government has saved on time and money. covered by a core team of RMSC. To dispel the apprehension of doctors
The Tables 1 and 2 clearly illustrate comparison of the procurement on quality, it was shared that most Big Pharmas are not the original
prices by RMSC and prevailing MRPs of equivalent selected medicines manufacturers, but they source their supplies through contact manufctuing,
at the time of launch of the MNDY scheme and current scenario on few eg. Torrent, Zydus Cadilla, Indico, IPCA, Micro Lab, Mankind, Lupin,
selected medicines. Abott, Wokhardts, Piramal Healthcare, Sun, Cipla, Intas, Sanofi Aventis
gets products manufactured by Akums (with over 800 Cr. turnover) and
Behaviour change of health providers and public education same manufacturing company is RMSC supplier. Therefore, there is no
Change prescription behaviour of doctors compromise on quality issue. Further, the State have developed and
AS per WHO it is not only increasing access but also implementing published guidelines for RUD (Rational Use of Drugs) for rational prescribing
rational use of drugs that makes the access truly holistic. Not only the EML with a provision for Prescription audit. One of the major roles that the Drug
has been implemented well in the state, but there has been education and and Therapeutic Committees have to play is to undertake prescription audit
supervision to ensure that all doctors prescribe EML drugs by generic name. in order to identify prescription errors and undertake corrective action

Pharma Times - Vol. 47 - No. 02 - February 2015 23

at the institution. Prescription audit and feedback consists of analyzing age of 6 years) coming for treatment to Government Hospitals. This will
prescription appropriateness and then giving feedback; involving peers in help improve gender ratio by aiding “Save the girl child” programme.
audit and feedback (peer review) is particularly effective. Prescription audit 5. Savings to Government: After one year of RMSC it was reflected that
is undertaken to see if the treatment of a specific disease is in accordance centralized procurement has resulted in enormous savings to the state
with guidelines – the percentage of prescribing encounters in accordance government as follows -
with standard treatment guideline).The DTCs have to identify the % of
• Amount spent on costly medicines by RMSC- approx. 507 Cr.
prescriptions not in accordance with the STGs, number of cases where
counseling was done and number of case where action has been initiated. • Market price of these medicines – approx. 3000 Cr
The circular issued states that in case of defaulters – • Savings of approx. Rs. 2493 Cr. to the State Government which can
 Step 1- Counselling by Unit head and DTC members has to be done be spent on developmental works or creation of other community
facilities.
 Step 2 -Written advice to the concerned doctor by Controlling officer
with copy to the department 6. Smiling patients & and thousands of lives saved: The MNDY
scheme has succeeded in ensuring that essential generic medicines
 Step 3-Case may be referred to Principal Secretary Medical & Health are available free of cost to patients in all public health facilities.
/Med. Education for disciplinary action Procurement and distribution of medicines are efficiently managed
and EML drugs are prescribed by generic name by all prescribers.
Awareness Generation in Public There remains the challenge of irrational use of essential medicines for
There has been extensive education of the public through IEC which a coordinated approach involving many different stakeholders
interventions such that patients now know that they are entitled to receive is needed.
free medicines from the health facilities. The RMSC has a monitoring
and evaluation unit, which operates a help-line. Patients are free to Challenges of the Journey so far
call this number if they do not get medicines from the facilities. RMSC • Geographical spread of the state 342,239 Sq. Km. and large distances
encouraged NGOs like “Prayas” with technical support of ActionAid with - PHC up to 150 km from district HQ (DDW)
support to organize various meetings/seminars, etc. such as: (i) Two days • Population- 70 million population - longer waiting times (Increase in
state level workshop on Right to Free Treatment and MNDY, Rajasthan, both OPD IPD patients numbers after MNDY/MNJY schemes)
(ii) Development of Monitoring tools and IEC material, (iii) Divisional • Cold chain maintenance (in summer temp rises up to 510C)
Level Workshops on Right to Free Medicine, (iv) Two days district level • High patient load in tertiary care centers and shortage of Doctors/
workshops on right to free treatment, and (v) Public Hearing on MNDY. Pharmacists
• A common myth amongst public that “generic” drugs are less
Impact of Free Drug Scheme (MNDY in Rajasthan) effective.
MNDY has Improved the availability of essential drugs, reduced the • Poor confidence of doctors on generic drugs due to lack of scientific
cost of treatment, occurrence of catastrophic illnesses which require evidence of their quality and efficacy.
hospitalization because large number of patients who do not seek
• Issues related to pilferage, breakage, deterioration, drugs becoming
treatment till it gets very serious for non availability of money will begin
obsolete etc.
availing health care, Save patient from heavy load of unreasonable and
• Lack of checks and control of quality at various levels of supply
unnecessary drugs which are the cause of rising drug resistance and
chain.
other iatrogenic morbidities and money so saved can be used to improve
nutrition and condition of other social determinants of health in the country. • Failure to generate realistic annual demand and non submission of
This ambitious scheme has been lauded not only at the national level timely indent.
but acclaimed recognition at international platforms as well. As a result • Unforeseen epidemics of swine flu, malaria, dengue, Chickengunia,
the Corporation has witnessed visitors from number of states, NGOs as scrub typhus etc
also from the WHO and the World Bank. The impact can be briefly put • Sub optimal storage conditions of drugs at institutions and space
together as – constraint at DDWs in earlier days.
1. Increase in access and equity of the underserved and Reached out • To maintain un-interrupted supplies at all levels due to delays by
to the unreached : After implementation of scheme, number of outdoor Pharmaceutical manufacturers, fluctuation in dollar rupee value and
and indoor patients has increased significantly at government hospitals. alternate supplier for each drug are often not available.
Since the launch of the scheme the total number of beneficiaries - 10.68
Cr. Patients and more than 200,000 patients are being benefitted every
Conclusion
day. Before MNDY patient’s attendance was about 44 lakhs which now Utilization of the available appropriate and accurate pricing information
stands over 80 lakhs per month. supported by technical expertise for pooled procurement of quality
products, strong political support and clear administrative approaches
2. Decrease in out of pocket expenditure: There is huge amount of
coupled with proper educational, managerial and regulatory support can
reduction in out of pocket expenditure in the treatment of common man
successfully bring a positive change towards Enhancing Affordable Access
as all costly medicines are being provided free of cost. Every day more
to Quality Medicines toward Universal Access to Health. In nutshell, RMSC
than 2 Lac patients are being benefited with an average cost per patient
motto is “All Essential Medicines at all Public Health facilities at all times
being around Rs.15. Otherwise the cost of these drugs purchased from
so that no human being dies for want of medicines.
the market would have the cost around Rs.300 to 500.
3. Source of Youth Employment: On implementation of this scheme References
a sizable youth has got employment, e.g. 1345 Pharmacists been 1. Access to affordable essential medicines; http://www.who.int/medicines/mdg/
recruited permanently under this scheme and 3600 Computer Operator MDG08ChapterEMedsEn.pdf
and Information Assistant have been engaged on contract. 2. Roy Chaudhury, Ranjit, Gurbani NK; Enhancing Access to Quality Medicines for
the Under-served, DSPRUD-WHO, 2004 Annamaya Publishers, New Delhi
4. Increase in Numbers of Girl Child treated: After implementation of
the Scheme there is a substantial increase in number of girl child (upto 3. http://rmsc.nic.in/

Pharma Times - Vol. 47 - No. 02 - February 2015 24