A study of pricing and availability of Children’s medicine in Orissa state
Trupti rekha Swain, Rath B, Dehury S, Samal S, Tarai A, Nayak H , Jena J
Dept. of Pharmacology,SCB Medical College, Cuttack, Orissa, India,E mail: drtruptiswain@yahoo.com
Problem Statement: More than 50% of the population of Orissa depends on public health sector for their health care needs.
The state has very poor health indicators with infant mortality rates of 65 per 1000 live births. The essential drugs list of 2009
had very few children’s formulations on the list. The Better Medicines for Children Project in India was initiated in Orissa to
improve availability and access to safe, child-specific medicines for all children of Orissa. Objectives: To assess the
availability and pricing of a list of essential children’s medicines in public and private sectors of Orissa. This was the initial
step necessary to improve access to essential medicines for children Design: Cross sectional study was conducted for
duration of six months in the year 2010. Setting: Community based survey in the rural and urban areas of six geographically
different districts of Orissa - Cuttack, Ganjam, Sambalpur, Kalahandi, Kandhamal and Balasore. Study population:
Information on availability was collected from a total of 28 outlets from each district. 14 were from public sector, twelve
from private sector and two outlets from other sectors such as non-governmental organizations (NGO) and mission sector.
Data were collected from all different levels of health care facilities including 10 primary, 3 secondary and one tertiary health
care level. Twelve outlets were surveyed from private sector including one each of doctor associated clinic and nursing home
associated clinic. Two outlets from NGO/Mission sectors were also included which constituted as other sectors. Policy(ies):
34 essential children’s medicines based on the disease profile of Orissa State was chosen for the survey using standard WHOHAI methodology for pricing and availability surveys. Outcome Measure(s): Intervention(s): The availability of these 34
medicines in the public, private and other sectors as well as the prices of medicines, affordability of standard treatment
regimens by the lowest paid government worker and the price components. Results: mean availability of medicines in
Public, and other sectors were17.0 ± 26.1, & 21.8 ± 30.7 respectively. In the private sector, the mean availability of highest
priced medicines and lowest priced medicines was 10.8% and 38.5% respectively Only 3-6 health care facilities in the public
sector (n=82) had medicines such as injections penicillin, phenobarbitone, gentamicin and beclomethasone inhaler. A few
essential medicines like diazepam rectal gel, chloramphenicol injection, benzyl benzoate lotion, carbamazepine chewable
tablets and zinc dispersible tablets were not available even in the private sector. Life saving medicines like
amoxicillin+clavulanic acid and artemether+lumefantrine combination was not available in the public sector. They showed
very high variation in price, (private sector) i.e., Indian rupees 1.45 - 7.94, and 8.50 - 25.66 respectively making treatment
regimens unaffordable for poor patients. Private sector prices to patients were, on average, 244.2% higher compared to the
lowest price equivalents. In treating common conditions (fever & diarrhea) lowest paid government worker in Orissa would
need between 0.1 (fever, diarrhea) to 0.7 days’ wages (respiratory infection) Intervention: Not applicable Conclusions:
Availability of pediatric essential medicines is poor in Orissa State in all sectors. Unavailability of many of the essential
Background
• Orissa Government procures medicine centrally which is
made available in Govt. outlets free of cost.
•Price of any medicine in India is governed by Central Ministry
through an independent body, National Pharmaceutical
Pricing Authority.
• Orissa like few other states of India has introduced a system
of levying tax on MRP at a single point i.e. first sale in the state.
• Price is subjected to VAT on the basis of MRP.
• Complicated role of different stake holders in controlling
medicines price, the money actually paid by patients, varies in
different situation
Study Objectives/ Questions
• What is the percentage availability of child specific medicines
in different health sectors of Orissa ?
• What is the % availability of lowest priced and highest priced
medicines in private and other sector?
• What is the difference in price between highest priced and
lowest priced branded products of important child medicines
and their generic equivalents?
• What different charges get added on to the price of medicines
as they proceed from manufacturer to patient?
• How do the prices of medicines in Orissa, a resources poor
state compare to those in other countries?
Methods
Survey conducted in six randomly selected Districts
(regions)
Data on 34 essential medicines in the public, private
and NGO/Mission sectors of each district, collected
in medicine outlets using a validated sampling
frame. ( 14 facilities each)
Highest-priced and lowest-priced medicine available
on the day of visit to that facility noted.
Data was also collected on government procurement
prices.
Medicine prices expressed (median price ratio or
MPR) (as ratios relative to MSH reference prices
2010).
Data entered to Excel workbook
Affordability calculated as the number of days'
wages lowest-paid unskilled government worker,
needs to purchase standard treatments.
Method ( Price component)
 Price components survey conducted to
identify the add-on costs in the supply
chain contributing to final patient prices.
 Data collection on central policies related
to price components, &Tracking specific
medicines through the supply chain
 Medicine tracking conducted in two
districts: Cuttack ( Urban) and Balasore
( rural).
 Six medicines tracked backwards in public
and private sectors to identify add-on costs
Mean percentage availability of Medicines in
different Health Sectors of Orissa
Public sector
(n = 82 outlets)
All medicines
(n = 34 medicines)
Central
Procurement by
Govt.
Mean
Availability 0.0%
(Standard
deviation)
17.0%
26.3%
Private sector
(n = 82 outlets)
NGO/Mission
Sector
(n= 5 Outlets)
All medicines
All medicines
(n = 34 medicines) N=34 medicines
Highestpriced
product
10.8%
17.9%
Lowestpriced
product
38.5%
31.6%
Highest- Lowestpriced
priced
product product
0.0%
21.8%
30.9%
Percentage availability of antibiotics in
the public and private sectors
Ofloxacin tablet
Co-trimoxazole suspension
Amoxicillin suspension
Gentamycin injection
Benzylpenicillin injection
Procaine penicillin injection
Chloramphenicol powder for injection
Amoxicillin dispersible scored tablet
Azithromycin dispersible tablet
Amoxicillin + clavulanic acid tab
Amoxicillin + clavulanic acid dry syrup
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
Private (n=79) Public (n=79)
Essential Paediatric medicines with low
availability (< 25%) in all three sector:
•
•
•
•
•
•
•
•
•
•
•
•
Chloramphenicol powder for injection
Diazepam rectal solution
Beclomethasone inhaler
Benzyl Benzoate lotion
Zinc dispersible tablet
Ferrous sulfate suspension
Benzyl penicillin G injection
Isoniazid + rifampicin + pyrazinamide dispersible tab
Phenobarbital injection
Procaine penicillin G injection
Carbamazepine chewable tab
Carbamazepine suspension
Comparison of Govt. procurement price
and private sector price
Public sector
Product type
Lowest price
generic
(n = 14
medicines)
Median
MPR
0.52
Private sector
25th
75th
percenti percent
le
ile
0.39
0.74
Product
type
Median
MPR
25 %ile
75
%ile
Highestpriced
(n = 9 )
1.83
1.57
2.67
1.46
1.06
2.29
Lowest
price
generic
(n = 23)
Price (Private Sector )
• Out of 34 no’s of medicines, 23 medicines are lowest priced compared to
MSH price Final patient prices for highest price and lowest priced
medicines in the Private sector are about 1.83 and 1.46 times than their
international reference prices, respectively
• Lowest paid government worker requires 0.1 days’ wages (fever) & 0.3
days’ wages (Falciparum malaria) to purchase medicines from the private
sector whether highest-priced or lowest price generics are used.
• However, many people in Orissa earn much less that the lowest
government wage; even treatments which appear affordable are too
costly for the poorest segments of the population.
• Given that 42% - 47% ( rural India) of the population are living below
the international poverty line of less than $1/day, even treatments which
appear affordable are financially out-of-reach for a substantial number of
people.
Medicines showing large price variations
across outlets (Private Sector)
Medicine Name
Ofloxacin tab
Azithromycin dispersible tablet
Phenobarbital injection
Albendazole suspension
Amoxicillin suspension
Amoxicillin + clavulanic acid tab
Amoxicillin + clavulanic acid tab
Medicine
Type
Lowestpriced
Lowestpriced
Lowestpriced
Lowestpriced
Lowestpriced
Highestpriced
Lowestpriced
Median
Price
Ratio
(MPR)
25%
75%
ile
ile
%
difference,
25%ile vs.
75%ile
2.15
1.89
2.83
50
1.47
1.20
1.86
55
2.67
1.70
2.71
60
1.27
1.27
2.41
91
3.83
2.26
4.52
100
0.94
0.79
1.88
139
1.29
0.65
1.75
170
Comparison of percentage contribution of
price component to final price of Paracetamol
Percentage contribution of price com ponents to final
price
Percentage contribution of price com ponents to final
price
Originator brand
Branded generic
4%
4%
19%
31%
8%
65%
4%
Manufacturer's selling price
Stage 2: Landed price
Stage 3: Wholesale
Stage 4: Retail
Stage 5: Dispensed price
2%
2%
61%
Manufacturer's selling price
Stage 2: Landed price
Stage 3: Wholesale
Stage 4: Retail
Stage 5: Dispensed price
Summary
• Mean availability of essential pediatric medicines in the public sector
of Orissa is only 17.0%.
• In Private sector, the mean availability of highest price and lowest
priced medicines is 10.8 % and 38.5%, respectively.
• Availability of Children’s medicine is 21.8% in Other sectors
• Out of 34 no’s of medicines, 23 medicines constituted lowest price
compared to that of MSH price and only 9 No’s were found from high
priced medicine
• Final patient prices for highest price and lowest priced medicines in the
private sector are about 1.83 and 1.46 times than their international
reference prices, respectively
• In treating common conditions using standard regimens, the lowest paid
government worker would need between 0.1(fever) and 0.3
(Falciparum malaria) days’ wages to purchase medicines from the
private sector
• Cumulative % mark-ups for individual medicines ranged from 9.78 %
to 326% for different child specific medicines available in Orissa. In
private sector, price variation was 53% to 326%
• In public sector, Govt. procurement price vary between 9.78 % to
11.09 % only. But in other sectors cumulative mark up was 22.25 22.59 %.
Implications & Conclusion
• Government of Orissa should procure children’s medicine on a
priority basis looking at the very high childhood morbidity and
mortality. The procurement of medicines should be from prepared
Essential Medicines List for children (EMLC 2011)
• Regulatory authorities should import more child specific
formulations for the state.
• It should be made mandatory to keep essential life saving medicines
for children in every private shop.
• The cost of medicines in private sector should be lowered by
regulatory authorities through specific policy change.
The results of the survey proves that availability,
price and affordability of child specific medicines in Orissa state
should be improved for ensuring equity in access for basic medical
treatments. This requires multi-faceted interventions including
review / refocusing of policies and regulations for essential
lifesaving drugs for children .
Thankfully Acknowledge support of
MKCG Medical
College, Berhampur
Dr Dhaneswari Jena
Dr Abinash Panda
Dr Ayaskant Sahoo,
Dr Ajitesh Sahu,
SCB Medical
College, Cuttack
Prof. B. Mohapatra
Prof. S Mohanty
Dr Priti Das
Dr Rajashree Samal
Dr Gaurav Kumar
Dr Sansita Parida
VSS Medical College,
Burla
Dr Debasish Bisoi
Dr Santwana Mahar,
Dr Monalisa Jena,
Dr Ramachandra Giri
Dr Himanshu S. Sahu,
Dr Sudhira Ku Parida,