Project Report

Private Sector Public Sector

Principal Investigator: Dr. Anita Kotwani, Associate Professor, Department of Pharmacology Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110007, INDIA

December 20118 Medicine prices, availability, affordability and medicine price

components in NCT, Delhi : WHO/HAI methodology

Funding: World Health Organization

Medicine prices, availability, affordability and medicine price components in NCT, Delhi:

WHO/HAI methodology

PROJECT REPORT December 2011

Project Funded by World Health Organization

SEARO, New Delhi

Principal Investigator Dr. Anita Kotwani

Associate Professor Department of Pharmacology

Vallabhbhai Patel Chest Institute University of Delhi, Delhi 110007

anitakotwani@gmail.com

CONTENTS

Page No.

List of Tables i-ii List of Figures iii List of Abbreviations iv Acknowledgements v EXECUTIVE SUMMARY 1 INTRODUCTION 6 1.1 Background 6 1.2 Background: NCT, Delhi and Healthcare 6 1.3 Objectives 8 1.4 Advisory group 8 METHODOLOGY 10 2.1 State background 10 2.2 Sectors surveyed 11 2.3 Survey areas and facilities 11 2.4 Medicines surveyed 12 2.5 Various versions of each medicine collected and Medicine Price

Data Collection Form 14 2.6 Data collection 16 2.7 Affordability 17 2.8 International reference price and median price ratios 17 2.9 Data entry and analysis 18 PRICE COMPONENTS SURVEY 19 3.1 Medicines surveyed 19 3.2 Medicine marketing and supply chain 19 3.3 Stages of price components as described by WHO/HAI methodology 20 3.4 Sector surveyed 20 3.5 Data entry and analysis 21 FINDINGS 22 4.1 Public sector 22 4.1.1 Procurement price 22 4.1.2 Availability of surveyed medicines in public sector 24

4.2 Private sector 32 4.2.1 Medicines prices to patients in private sector 32 4.2.2 Availability of medicines in private sector 35 4.3 Affordability 38 4.4 Price components 39 DISCUSSION 45 5.1 Public sector 46 5.1.1 Variation in procurement price by different public sector agencies 46 5.1.2 Poor availability of surveyed medicines 47 5.2 Private sector 49 5.2.1 Availability and price 49 5.3 Affordability 51 5.4 Price components 52 CONCLUSIONS: SALIENT FINDINGS AND POLICY OPTIONS 57 6.1 Public sector 57 6.2 Private sector 57 6.3 Price components 58 6.4 Policy options to improve access to essential medicines 58 REFERENCES 59 ANNEXURES 61 Annexure 1: List of medicines surveyed 61 Annexure 2: Availability of individual medicine by therapeutic class in

various public sectors 63 Annexure 3: Availability of medicine surveyed in different versions in

private sector 65 Annexure 4: Treatment affordability 67

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LIST OF TABLES

Table No. Titles Page No. Table 1: Number of facilities in each survey area under public and private

sector 12 Table 2: List of medicines surveyed 13 Table 3: List of medicines surveyed for price component survey 19 Table 4: Summary of median price ratios (MPRs) in various public

sectors in Delhi 23 Table 5: Variation in procurement price (INR) by different public sector

agencies for few medicines 23 Table 6: Medicines with 81-100% availability in facilities under GNCT,

Delhi 25 Table 7: Availability of surveyed pediatric antibiotics and medicines on

the day of data collection at tertiary care facilities surveyed in GNCT, Delhi 31

Table 8: Availability of surveyed high-end antibiotics at secondary care and tertiary care public facilities and at private sector facilities 31

Table 9: Summary of medicine prices in the private sector 32 Table 10: Comparison of median MPRs of medicines in public and

private sector 32 Table 11: Comparing the paired data analysis in the private sector 33 Table 12: Mean availability of surveyed medicines in the private sector 35 Table 13: Availability of inhalation medicines for asthma in the private

sector 36 Table 14: Percent availability of surveyed antibiotics in the private

sector 36 Table 15: Percent availability of surveyed pediatric antibiotics and other

medicines surveyed in the private sector 37 Table 16: Median price in INR for surveyed high-end antibiotics in

public and private sector 38 Table 17: Percent contribution of each stage of the supply chain to final

patient price in the private sector: Ceftriaxone 1 gm injection 41

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Table No. Titles Page No. Table 18: Percent contribution of each stage of the supply chain to final

patient price in the private sector: Amoxicillin+clavulanic acid 500 mg +125 mg 42

Table 19: Percent contribution of each stage of the supply chain to final patient price in the private sector: Omeprazole 20 mg 42

Table 20: Percent contribution of each stage of the supply chain to final patient price in the private sector: Amlodipine 5 mg 43

Table 21: Percent contribution of each stage of the supply chain to final patient price in the private sector: Diclofenac 50 mg 43

Table 22: Percent contribution of each stage of the supply chain to final patient price in the private sector: Ranitidine 150 mg 44

Table 23: Percent contribution of each stage of the supply chain to final patient price in the private sector: Erythromycin suspension 125 mg/5 ml 44

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LIST OF FIGURES

Figure No. Titles Page No. Figure 1: Median MPRs for procurement prices of different public sector

agencies 22

Figure 2: Mean availability of surveyed medicines in various public sectors 24

Figure 3: Percent availability of medicines in public sector 25

Figure 4: Mean availability of surveyed medicines at various level of healthcare in public sectors 26

Figure 5: Availability of antihypertensive medicines in public sector 26

Figure 6: Availability of anti-diabetic medicines in public sector 27

Figure 7: Availability of inhalers for asthma in public sector 27

Figure 8: Percent availability of surveyed antibiotics in primary and secondary care facilities, GNCT, Delhi 28

Figure 9: Percent availability of surveyed antibiotics in primary and secondary care facilities, MCD 28

Figure 10: Percent availability of surveyed pediatrics antibiotics & medicines, GNCT Delhi 30

Figure 11: Percent availability of surveyed pediatrics antibiotics and medicines, MCD 30

Figure 12: Price variation for few medicines in public and private sector 33

Figure 13: Price variation for a few medicines in highest and lowest priced generics available at private sector 34

Figure 14: Price variation for a few medicines for brand, highest, and lowest priced generics available at private sector 34

Figure 15: Percent availability of hypolipidemic agents surveyed in private sector 35

Figure 16: Treatment affordability for depression, hypertension, acute respiratory infection and asthma treatment 38

Figure 17: Percent contribution of each stage of the supply chain to final patient price Ceftriaxone 1gm injection 41

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LIST OF ABBREVIATIONS

AMR Antimicrobial Resistance C&FA Carrying and Forwarding Agent CPA Central Procurement Agency DoP Department of Pharmaceuticals DHA Directorate Health Administration DHS Directorate of Health Services DPCO Drug Price Control Order EML Essential Medicine List GNCT, Delhi Government of NCT, Delhi HAI Health Action International HR Hindu Rao Hospital HPG Highest Priced Generic INR Indian Rupee IRP International Reference Price LH Lady Hardinge Medical College and Associated Hospitals LN Lok Nayak Hospital LPG Lowest Priced Generic MSH Management Sciences for Health MPR Maximum Retail Price MSO Medical Store Organisation MPDC Form Medicine Price Data Collection Form MPR Medicine Price Ratio MRP Maximum Retail Price MoC&F Ministry of Chemicals and Fertilizers MoH&FW Ministry of Health and Family Welfare MCD Municipal Corporation of Delhi NCT, Delhi National Capital Territory of Delhi NPPA National Pharmaceutical Pricing Authority NDMC New Delhi Municipal Corporation NGO Non Governmental Organization OB Originator Brand RML Ram Manohar Lohia Hospital SH Safdurjung Hospitals $ US Dollar VAT Value Added Tax WHO World Health Organization WHO/HAI World Health Organization and Health Action International

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ACKNOWLEDGEMENTS

Satisfaction that an investigator has in the successful completion of any research project would be incomplete without the mention of people who made it possible and whose constant support and encouragement served as inspiration and crowned the effort with success. This survey would not have possible without the help of the members on advisory group. I sincerely thank all my members on the advisory group for their support. • Prof. Ranjit Roy Chaudhury – Chairman, National Professor of Pharmacology • Prof. S. N. Gaur – Director, V. P. Chest Institute • Dr. Kathleen Holloway – Regional Adviser, WHO (SEARO) • Dr. N. V. Kamat – DHS, GNCT, Delhi • Dr. M. M. S. Brijwal – Additional DHA (Medical), MCD • Dr. S. Basu, CAMO, MCD • Dr. G. R. Marwah – MSO, MoH&FW • Mr. P. K. Jaggi – ADC, Drugs Control Dept., Delhi • Mr. Ashwani Kumar – President, Pharma Solutions • Mr. Rajiv Sahdev – Director, Pharma Solutions Acknowledgements are due to many government officials for extending help for smooth conduct of the survey. In particular I would like to thank government officials in the Director General Health Services, MoH&FW who cooperated in getting timely permissions; Medical Superintendents and procurement officers and staff of Lady Hardinge Medical College, Safdurjung Hospital and R. M. L. Hospital; Dr. Marwah, MSO office; Dr. Kamat, Dr. Mohonty, Dr. Vijoy Kumar, all zonal-in-charge, doctors, and staff at the Directorate of Health Services, Government of National Capital Territory of Delhi; Medical Superintendents and procurement officers and staff for the all the hospitals from where data was collected under Government of NCT, Delhi; and DHA (Medical), Additional DHA (Medical), the Medical Superintendents, doctors, staff and procurement officers for the Municipal Corporation of Delhi. I wish to thank Mr. P. K. Jaggi and Mr. Ashwani Kumar for getting cooperation from private retail chain pharmacies and retail pharmacies. I express my thankfulness to my excellent and diligent data collectors, Ms. Chanchal Sharma, Mr. Gokran Yadav, and Mr. Amit Kumar, whose sincerity was critical for the success of this project. I wish to thank all the pharmacists who gave their precious time to provide data. I also thank the wholesalers who provided with valuable data for the survey. Special appreciation is due to Ms. Margaret Ewen, Coordinator, Global Projects (Pricing), Health Action International, Global, Amsterdam, for providing expanded Workbook for the survey and for the technical advice and expert opinion. Finally, this study would not have been possible without the financial support of the World Health Organization, SEARO. Conflict of Interest Statement Principal Investigator of the survey or anyone who had cooperated on the conduct, analysis or interpretation of the results have no competing financial or other interests.

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EXECUTIVE SUMMARY

Background: Access to health care is a fundamental right recognized by governments throughout the world. The Indian Government is responsible for providing health care to its citizens, however, out-of-pocket payments account for up to 80% of health financing in India. Medicines account for more than 70% on health spending for outpatient treatment in India, making medicines the largest family expenditure after food. According to the health budget, Government spending on pharmaceuticals is second only to salary for hospital staff. Understandably, the procurement price and availability of essential medicines in the public and private sector are key components in determining access to effective treatment for patients. Therefore, the first step would be to measure the price and availability of essential medicines in public and private sectors in order to develop policies and strategies for improving the access to essential medicines.

World Health Organization (WHO) with Health Action International (HAI) developed a standardized, reliable, and validated methodology for collecting and analyzing medicine price, availability, affordability and medicine price component data across health care sectors and regions in a country. Using this methodology a detailed survey was conducted (July-October 2011) in National Capital territory (NCT) of Delhi.

Methodology: The survey was conducted in both public and private sector facilities covering all eight districts of NCT, Delhi. Three predominant public health providers, Government of NCT, Delhi (GNCT, Delhi), Municipal Corporation of Delhi (MCD), and Central Government (CG) were included for the survey. Private sector sites included traditional private retail pharmacies and retail chain pharmacies of one particular corporate house. In each district, five randomly selected public facilities of GNCT, Delhi and MCD, five retail pharmacies and five retail chain pharmacies located near the public facilities were sampled. For central government, three tertiary care facilities of Delhi were included. Thus, a total of 83 public facilities and 80 private facilities were surveyed. Medicine price and availability data was collected for a basket of 50 medicines specified in dosage form and strength that includes 30 core medicines and 20 supplementary medicines added according to local needs and objective of the survey (Annexure 1). WHO/HAI methodology has identified 30 core medicines – 14 essential medicines from global burden of diseases and 16 are specific for South East Asian region. Supplementary list of medicines (20) were mainly antimicrobial agents. For each core medicine, three versions of medicine were surveyed: originator brand (specified by WHO/HAI, Originator brand is the first brand on the market internationally), highest-priced generic (HPG), and lowest-priced generic (LPG) available. For 20 supplementary medicines, two versions – highest-priced and lowest-priced generic were identified.

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In the public sector, procurement price data was collected from three central agencies for the GNCT, Delhi (Delhi government), MCD, and the CG. Three tertiary care facilities under the CG – Lady Hardinge Medical College and associated hospitals, Ram Manohar Lohia (RML) Hospital, and Safdurjung Hospital also undertake independent medicine procurement to augment the supply from the stock procured by the central agency. RML Hospital and Safdurjung Hospital have a common tender. Procurement price data was also collected from these hospitals.

Seven medicines were selected to study price components, which represented different dosage forms, medicines for acute and chronic diseases, medicines with huge price variation, and one price control medicine. The medicines were: amlodipine, amoxicillin+clavulanic acid, ceftriaxone injection, diclofenac, erythromycin syrup, omeprazole, and ranitidine. As per the methodology, back calculations from the final price (patient price) were done to find the tax, retailer mark up or profit, and wholesaler mark up.

Trained data collectors visited enrolled facilities and recorded medicine availability and price using a standardized form. Several validation and data checking steps during and after collection were used to establish data quality control. Data were entered into a programmed Excel spreadsheet by two data entry personnel using a double entry technique. To facilitate international comparisons, medicine prices were expressed as median price ratio (MPR) or the ratio of a medicine’s median price across outlets to an international reference price, which is taken from Management Sciences for Health (MSH). Affordability was calculated as the number of days the lowest paid unskilled government worker must work to purchase standard treatment regimen for common clinical conditions.

Findings: The salient findings of the survey are mentioned below.

Price and Availability Public sector - The procurement price for the surveyed medicines measured as median MPR for all the three central agencies, Delhi government, MCD, and Central Government was 0.61, 0.59, and 0.53 This indicates that the procurement price was reasonable as compared to international reference price. We found that the central government procurement agency was procuring only 12 out of the 50 medicines surveyed. The procurement prices of tertiary care facilities were higher (0.69 and 0.82) than the central agencies. For few medicines, like atenolol, ceftriaxone injection, erythromycin stearate, metformin, and phenytoin, huge price variation was seen amongst all five agencies.

The mean availability of surveyed medicines at all facilities under Delhi government and MCD was 41.3% and 23.2%. The mean availability of surveyed medicines at tertiary care facility was - 60% for Delhi Government tertiary care hospital; 28% for MCD; and 40%, 42% and

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66% for three tertiary care hospitals under CG. Overall availability of two anti hypertensive agents, amlodipine and atenolol was more than 85% at public facilities under Delhi government and MCD. However, availability of certain pediatric preparations, asthma inhalation medicines, hypolipidemic and antipsychotic medicines was very poor; zinc dispersible tablets were not available in any of the facilities. Newer and second and third generation antibiotics, like amoxicillin+clavulanic acid, cefuroxime axetil, cefixime were available at dispensaries of MCD. Similarly, amoxicillin+clavulanic acid, cefuroxime axetil, cefixime, and roxithromycin were available at dispensaries of Delhi government.

Private sector - Medicines in India are known as “branded” and “branded-generics” but both refer to generic drugs. Until 2005, the Indian regulatory system used a system of process patent and therefore in real sense only generic version of all medicines is manufactured in India. Branded medicines are manufactured by a multi-national or reputed Indian pharmaceutical company. They are marketed by the manufacturer’s medical representatives to prescribers. Branded medicines are more popular, more costly and also the most sold medicines in India. Originator Brands (OBs) are also pooled with branded medicines and do not have any additional recognition as originator brand. “Branded-generics” more closely resemble what are globally referred to as ‘generics’ – though not truly generics since they have a trade name and the cost is not significantly lower than the branded product. Branded-generic medicines have less name recognition, and they depend on the retail pharmacy to promote their brand.

Availability of medicines in the private retail pharmacies was consistently higher than public sector pharmacies. The mean availability of OB, HPG, and LPG was 29.3%, 34.6%, and 68.8%. Similar to the public sector, zinc sulphate dispersible tablets were not available in private sector. Median MPR for OB, HPG, and LPG was 4.71, 5.38, and 2.83. The pair data analysis (including those medicines where data for both products was available) showed OBs were marginally less expensive than HPG (4.71 vs.5.09), OBs were more expensive than LPG (4.41 vs. 3.74), and of course the HPG were more expensive than LPG (5.38 vs. 3.17). The range for median MPR for medicines was 0.56 – 16.51. Surprisingly, off-patent medicines like diazepam, diclofenac, and doxycycline had the highest MPRs, indicating that these medicines are very expensive as compared to international reference price. Findings at chain pharmacies for availability and prices of medicines were similar to retail pharmacies shops.

For certain medicines large price differences were observed for procurement and retail price, for instance, the lowest priced generics at retail pharmacies for amlodipine, atenolol, atorvastatin, diazepam, diclofenac, enalapril, glibenclamide, and omeprazole were 12-28 times expensive compared to mean procurement price for public sector. Diazepam was found to be 28 times and glibenclamide was 12 times expensive in the private sector as compared

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to public procurement price. Certain medicines had huge price difference in highest priced and lowest priced generic e.g., amitriptyline, amlodipine, diclofenac, ciprofloxacin, simvastatin, amoxicillin+clavulanic acid, doxycycline, cefixime, cefuroxime, and ofloxacin.

Affordability - The salary of the lowest paid regular government worker was Rs. 247 per day. For seven-day treatment with highest-priced generic of amoxicillin+clavulanic acid (500mg+125 mg, twice a day) would cost 2.3 days' salary to the lowest paid unskilled government worker. For treatment of asthma, purchase of one budesonide inhaler would cost 1.0 day salary and purchase of salbutamol inhaler would cost 0.4 days’ salary to the lowest paid unskilled government worker. Only a small proportion of the population is employed in the government sector, and wages are much lower in the unorganized sector. Thus, the affordability of medicines for a large subset of the population, including the unemployed, is a daunting challenge.

Price components – Public sector: Government agencies pay 5% VAT (value added tax) on the procurement rate. No other taxes are added on the rate determined by the procurement agencies.

Private sector – In the private sector, trade schemes were found between manufacturer, wholesaler and retailer: these schemes chiefly benefit the manufacturer and the retailer; savings are not passed on to patients. Trade schemes take the form of “buy 10 get 2 free” (a 16.67% discount) or “buy 6 get 1 free” (a 14.28% discount). These schemes/discounts were available for three medicines (ceftriaxone, amoxicillin+clavulanic acid tablet, and omeprazole) out of seven medicines surveyed. These schemes run for extended periods of time. For the six non-scheduled medicines (not under price control) surveyed, the manufacturer reaped a majority of the profit (54%-74%) for branded medicines and the retailer made a similar profit in case of branded-generic (generic) medicines. Therefore, the main profit is for the actor who is pushing and responsible for promoting the sale of medicine. Margin or mark up for wholesaler is usually between 7-11% for branded medicines and for branded-generic medicines the wholesaler’s margin is less, giving most of the margin to retailer to push and sell these medicines. For branded medicines retailer margin was found to be 11-24%. Retailer is also enjoying the benefit of trade schemes offered by the manufacturer. The scheduled medicine surveyed was ranitidine and the originator brand, branded or branded-generic had almost the same final price to the patient. Government levies 5% VAT on medications – a cost that is borne by patients.

Conclusions and Recommendations: This survey revealed the procurement prices of essential medicines at various public sector agencies; poor availability of surveyed medicines at public facilities; newer antibiotics, like amoxicillin+clavulanic acid, cefuroxime axetil, cefixime, roxithromycin available at dispensaries; prices and availability of branded and

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branded generic versions of medicines in the private sector. Many medicines had only one version of the product available which was usually the costly or branded medicine but patient has no choice but to buy that product and that becomes the lowest priced generic available. The presence of trade schemes suggests that prices for these products could be lowered. Significant mark-ups for branded-generic medicines determined by this study imply that the very purpose of generic drugs has been undermined. The wide range of prices for generic equivalents and the proliferation of trade schemes indicate that there is still a large profit margin for the manufacturer.

The following policy options are recommended based on above findings to improve access to essential medicines –

• Procurement agencies to share medicine prices and other related details with each other • Delhi government and MCD to work together for updating the essential medicines list • Develop policies for development of treatment guidelines and antibiotics use • Supplier performance to be monitored by the procurement agencies at regular basis • Discontinuation of VAT levied by the Government • The Government should take measures to increase the drug budget • Government to increase transparency in manufacturer set maximum retail price (MRP) • Government to review the drafted drug pricing policy carefully to decrease prices of

essential medicines • Develop policies that encourage doctors and pharmacists to prescribe/recommend

generic brands • Increase consumer awareness on medicine prices and affordable generic equivalents

through various media • Providing adequate training for doctors to improve prescribing practices around cost

effective generics

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INTRODUCTION

1.1. Background Access to essential medicines has been viewed as an integral component of the right to health, which is a basic human right [1]. India pledged to attain ‘Health for All by the year 2000’ with other WHO Member States at Alma-Ata in 1978. Unfortunately, the situation is far from ideal and a lot has to be done to achieve the goal.

In recent years there has been considerable concern that high prices make medicines beyond the reach of millions of people in developing countries. The price and availability of medicines are key components in determining access to effective treatment that leads to better health of citizens of a nation [2]. Unlike developed countries, in the low income countries household meet their drug and other health care costs “out-of-pocket”. This means from income, domestic savings, borrowing, or the sale of assets. Over 80% of India’s health financing is in this form [3]. In India, individuals have to bear the full cost of their medicines since medicines are not subsidized through social insurance. So the price of essential medicines really does matter – not only to patients, but to governments who are charged with the responsibility to provide healthcare for their citizens.

High prices and low availability are major barriers to the use of medicines and better health, yet little is known about the prices that people pay for medicines and availability of essential medicines in public and private sector. A robust methodology is developed by World Health Organization (WHO) with Health Action International (HAI) that measures medicine prices, availability and affordability in a region or country and comparison between different surveys can be done [4,5] . Findings from these surveys suggest the policy options to increase access to essential medicines. Seven surveys in different states of India were conducted in 2003-2004 utilizing the standardized methodology developed by WHO/HAI [6 - 8]. These surveys have shown that availability of medicines in the public sector was very poor and there was difference in procurement prices of medicines by different state governments. In 2008, 2nd edition of methodology was published that included adjustments to methodology whereby survey is conducted on 50 medicines, 30 pre-determined by WHO/HAI to enable international comparisons (14 global list medicines and 16 regional list medicines) and 20 selected nationally for local importance, which gives the method adaptability to a region and flexibility to choose up to 20 medicines they want to survey in their region [4].

1.2 Background: NCT, Delhi and Healthcare Delhi, officially called National Capital Territory of Delhi (NCT, Delhi), is the largest metropolis by area and the second-largest by population in India, next to Mumbai. The population of the

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Delhi reported with 16,753,265 inhabitants in the Territory at the 2011 Census. Although technically a federally administered union territory, the political administration of the NCT of Delhi today more closely resembles that of a state of India with its own legislature, high court and an executive council of ministers headed by a Chief Minister.

In all public sector facilities, medicines are provided for free. According to the WHO in India, only about 20% of the population access healthcare through the public sector (3). There is a small NGO sector, comprised mostly of faith-based facilities. The remaining 80% of the Indian health care system is characterized by high out-of-pocket payments by patients and their families.

Public sector health care in NCT Delhi is delivered by four entities: the Central Government under the Ministry of Health and Family Welfare (MoH&FW), the Directorate of Health Services (DHS) in the Government of NCT Delhi and two public sector providers in Delhi city – the Municipal Corporation of Delhi (MCD) and New Delhi Municipal Corporation (NDMC). Healthcare to only New Delhi area is provided by NDMC and this area has facilities of Central Government and Government of NCT (GNCT), Delhi as well.

All these public sectors in Delhi have different procurement systems and they procure medicines at different rates. An earlier study conducted in NCT, Delhi (9) revealed that the essential medicine list (EML) or procurement list of all these four agencies is different, Central government generic list of medicines is based on National list of Essential medicines; Delhi government has their own list of essential medicines and they procure medicines according to the EML of GNCT, Delhi; MCD and NDMC have their own special committee that finalize the procurement list based on the drug use pattern in their respective facilities and recommendations from their facilities. Procurement prices for medicines and the availability of essential medicines may vary in the facilities under different public providers of health to the citizens of Delhi. Of course the availability of medicines in facilities run by different public sector will be different. Therefore, it is important to survey the procurement prices and availability of essential medicines in facilities under different public sector agencies to get a complete picture of procurement prices and availability of medicines in public sector.

Since the private sector is an important source of drugs for the population, private outlets covering the entire NCT, Delhi were surveyed. Recently, chain pharmacies have entered the Indian retail sector. This is an important new development which deserves to be examined. Therefore, both types of retail pharmacies were included in the survey, the traditional private retail pharmacies, called chemist shops in Delhi and the chain pharmacies of a leading corporate house.

We also need to study the price and availability of antibiotics in detail in both public and private sector in our country as a first step to rationalize the use of antibiotics. The current

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worldwide increase in antimicrobial resistance (AMR) is a result of many factors, but the foremost cause is the overall volume of antibiotic consumption and use (mis) of antibiotics in the community. With collaboration with WHO, a pilot (Phase I) study was conducted in Delhi, 2003-04, that established the methodology for surveillance of antimicrobial drug use and resistance in the community [10, 11]. The results of the Phase I study clearly demonstrated high use of antibiotics and high resistance level in the community, with newer members from each class of antibiotics being used more than the older members of the same class [12]. The second phase of the study expanded the methodology and surveillance was conducted in 2007-08 in both public and private sector in Delhi. Results of the survey demonstrated high use of antibiotics in both sectors and high use of newer antibiotics in dispensaries of NCT, Delhi [13]. Hence, there is need to study the price and availability of antibiotics listed in essential medicines list meant for dispensaries, hospitals and newer antibiotics available in the country. Therefore, for supplementary medicines various antibiotics for adult and children were included for the survey.

1.3 Objectives The main objectives of the survey were to answer the following questions - 1. What price do people pay for a selection of essential medicines in Delhi? 2. Do the prices of these medicines vary in different sectors e.g., public and private? 3. Do the prices and availability of these medicines vary in different regions of Delhi? 4. What is the difference in prices of originator brand (OB), highest priced generic (HPG)

and lowest priced generic equivalent (LPG) medicines? 5. How do the prices of medicines in Delhi/India compare with international reference

prices? 6. What is the availability of the medicines in the different sectors? 7. What is the availability of medicines, especially antibiotics in primary care, secondary care

and tertiary care facilities? 8. What is the variation in procurement price and availability of medicines in different public

sectors of Delhi? 9. What are the various mark ups in the supply chain for branded and generic medicines? 10. How affordable are medicines for ordinary people?

1.4 Advisory group An advisory group was formed with members who are expert on the healthcare systems and few key persons from public and private sector were included. Before conducting the survey a meeting was held with the advisory group and necessary permission were obtained from each sector. In addition to supporting the principal investigator in planning and conducting the

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survey, the advisory group will help in dissemination of survey findings. A letter of Introduction from WHO SEARO was obtained.

Members of the advisory group:

• Prof. Ranjit Roy Chaudhury – Chairman, National Professor of Pharmacology • Prof. S. N. Gaur – Director, V. P. Chest Institute, University of Delhi • Dr. Kathleen Holloway – Regional Adviser, WHO (SEARO) • Dr. N. V. Kamat – DHS, Government of NCT, Delhi • Dr. M. M. S. Brijwal – Additional DHA (Medical), MCD • Dr. S. Basu, CAMO, MCD • Dr. G. R. Marwah – MSO, MH&FW, Government of India • Mr. P. K. Jaggi – ADC, Drugs Control Dept., GNCT, Delhi • Mr. Ashwani Kumar – President, Pharma Solutions • Mr. Rajiv Sahdev – Director, Pharma Solutions

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METHODOLOGY

This survey of medicine prices and availability was conducted in National Capital of Territory of Delhi (NCT, Delhi) using a standardized methodology which is developed by the World Health Organization (WHO) and Health Action International (HAI) from July-October 2011.

2.1 State background Delhi is the capital of India and has its own elected government and a status between a state and a union territory. Delhi has the political status of a federally-administered union territory known as the National Capital Territory of Delhi (NCT Delhi). The NCT Delhi is divided into eight districts and has three towns viz. Municipal Corporation of Delhi (MCD), New Delhi Municipal Committee (NDMC) and Delhi Cantonment Board (DCB).

Map showing eight districts of National Capital Territory of Delhi

Public sector health care in NCT Delhi is delivered by four entities: The central government has 3 tertiary care hospitals, 1 specialist children’s hospital, and approximately 90 dispensaries (primary health care centers) in Delhi. The Central Government Health Scheme (CGHS) dispensaries serve only central government employees (current and retired). All citizens benefit from services at the tertiary care hospitals of central government. At the state level, the Government of NCT

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(GNCT) Delhi has two tertiary care hospitals, 2 specialist hospitals, around 14 secondary care hospitals and approximately 211 dispensaries (primary health care centers); all citizens can use their services. The two additional public sector providers: the Municipal Corporation of Delhi (MCD) runs 1 tertiary care, 4 secondary care hospitals and around 75 dispensaries and polyclinics; New Delhi Municipal Corporation (NDMC) runs 1 secondary-care hospital, 1 maternity hospital and 12 dispensaries. All citizens can visit and avail the services in these facilities. Since NDMC serves a small area and the same area has facilities of central government and government of Delhi so NDMC facilities were not recruited for the survey.

WHO/HAI methodology has been designed to collect data, analyze and interpret the results in a standardized way. Methodology requires survey to be conducted in six regions of a country or state, in public, private and any other sector responsible for providing healthcare/medicine in the particular country and recommend data collection from five facilities in each region for each sector. This survey was conducted in all 8 districts of Delhi, covering the entire Delhi state.

2.2 Sectors surveyed

Public sector

Central procurement prices were collected from all the three public sector procurement agencies/department viz. Government of NCT Delhi (GNCT, Delhi), Central government, and Municipal Corporation of Delhi (MCD). Tertiary care facilities under central government also undertake independent medicine procurement to augment the supply from the stock procured by the central government procurement agency. Procurement prices were also collected from these tertiary care facilities.

Medicines are provided for free in all public facilities hence only medicine availability was collected from the various public facilities that were surveyed.

Private sector

Data for private sector for availability and prices patients pay for medicines purchased from private retail pharmacies called “Chemist Shops’ and retail chain pharmacies owned by one of a leading corporate houses.

2.3 Survey areas and facilities

Public Sector

Government of National Capital Territory of Delhi (GNCT, Delhi) - A list of public facilities indicating the level of health care provided was obtained from health department of Government of Delhi. All eight districts were included for the survey to cover the entire NCT,

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Delhi. From each district one secondary care and four primary care facilities (dispensaries) were randomly selected. In one of the districts, instead of secondary care, one teaching care (tertiary care) hospital was enrolled for the survey (Table 1).

Central Government – All three tertiary care hospitals, Safdurjung Hospital (SH), Ram Manohar Lohia (R.M.L.) Hospital and Lady Hardinge Hospital (Sucheta Kriplani Hospital) were enrolled and surveyed.

Municipal Corporation of Delhi (MCD) – Five facilities under all eight districts were randomly selected. In one district, the tertiary care hospital and wherever secondary care facility was available were enrolled in addition to dispensaries.

Private Sector

All the eight districts of NCT, Delhi were included for the survey. Five private retail pharmacies and five retail pharmacies in one chain located near the public facilities in all eight districts were selected and surveyed (Table 1).

Table 1: Number of facilities in each survey area under public and private sector S.No. Survey Area Public Sector Private Sector

District National Capital Territory of Delhi

Central Government

Municipal Corporation of

Delhi Retail

Pharmacy Retail Chain

Pharmacy

1 Central 5 2 5 5 5 2 South 5 1 5 5 5 3 East 5 5 5 5 4 North 5 5 5 5 5 North East 5 5 5 5 6 North West 5 5 5 5 7 South West 5 5 5 5 8 West 5 5 5 5

Total 40 3 40 40 40 83 80

2.4 Medicines surveyed

A total of 50 medicines were surveyed. All selected medicines are registered in our country and available as multi-source (generics) products. WHO/HAI methodology has identified 30 core medicines – 14 essential medicines from global burden of diseases and 16 are specific for a particular region. Apart from these core medicines a supplementary list of medicines (20) were added and these were mainly antimicrobial agents plus two inhalers and dispersible zinc sulphate tablet (Table 2).

13

Selection criteria

1. 14 medicines from a global core list recommended by WHO/HAI were included, to enable international comparisons on a global level;

2. 16 medicines from a WHO-SEARO regional core list were included, to allow for comparisons across neighbouring countries in the region;

3. 20 medicines supplementary medicines were selected because one of the objectives of the survey was to find out the availability and price of first generation and newer antibiotics in public and private sector. Two inhalers, budesonide and combination of budesonide and formoterol were included as budesonide inhaler is on Delhi state EML and to check the availability of popular inhalers in combination. Dispersible tablet of zinc sulphate is recommended by WHO for diarrhea in children and in India the burden of diarrhea in children and management is still a concern. Therefore, this medicine was included in supplementary list of medicines.

Table 2: List of medicines surveyed List of Global and WHO-SEARO Regional List (30) Amitriptyline 25 mg cap/tab Global Amlodipine 5mg cap/tab Regional Amoxicillin 500 mg cap/tab Global Amoxicillin suspension 25 mg/ml milliliter Regional Atenolol 50 mg cap/tab Global Atorvastatin 10 mg cap/tab Regional Beclomethasone inhaler 200 mcg/dose dose Regional Captopril 25 mg cap/tab Global Ceftriaxone injection 1 g/vial vial Global Ciprofloxacin 500 mg cap/tab Global Clotrimazole topical cream 1% gram Regional Co-trimoxazole suspension 8+40 mg/ml milliliter Global Diazepam 5 mg cap/tab Global Diclofenac 50 mg cap/tab Global Diethylcarbamazine citrate 50 mg cap/tab Regional Doxycycline 100 mg cap/tab Regional Enalapril 5mg cap/tab Regional Fluoxetine 20 mg cap/tab Regional Gentamicin eye drops 0.30% milliliter Regional Glibenclamide 5 mg cap/tab Global Gliclazide 80 mg cap/tab Regional Ibuprofen 400 mg cap/tab Regional Metformin 500 mg cap/tab Regional Metronidazole 400 mg cap/tab Regional Omeprazole 20 mg cap/tab Global Paracetamol suspension 24 mg/ml milliliter Global Phenytoin 100 mg cap/tab Regional Ranitidine 150 mg cap/tab Regional Salbutamol inhaler 100 mcg/dose dose Global Simvastatin 20mg cap/tab Global

14

Supplementary list of medicines (20) Amoxicillin+clavulanic acid 500mg+125mg cap/tab Supplementary Amoxicillin 250 250mg Tab/cap Supplementary Amoxicillin+clavulanic acid Syrup 200mg+28.5mg/5ml milliliter Supplementary Ampicillin Suspension 125mg/5ml milliliter Supplementary Azithromycin 500mg Tab/cap Supplementary Benzathine Penicillin Powder 2.4MU/vial inj Supplementary Budesonide inhaler 100mcg/dose dose Supplementary Budesonide+Formoterol inhaler 100mcg+6mcg/dose dose Supplementary Cefixime 200mg Tab/cap Supplementary Cefuroxime axetil 250mg Tab/cap Supplementary Cefuroxime Suspension 125mg/5ml milliliter Supplementary Cephalexin 500mg Tab/cap Supplementary Cephalexin Syrup 250mg/5ml milliliter Supplementary Erythromycin powder for suspension 125mg/5ml milliliter Supplementary Erythromycin stearate 250mg Tab/cap Supplementary Gentamicin injection 40mg/ml inj Supplementary Norfloxacin 400mg Tab/cap Supplementary Ofloxacin 200mg Tab/cap Supplementary Roxithromycin 50mg Tab/cap Supplementary Zinc sulphate dispersible 20mg Tab/cap Supplementary

Additional list of high-end antibiotics surveyed (8) 1. Meropenem 500mg inj 2. Imipenem+cilastatin 500mg+500mg inj 3. Colistin inj 10,00,000 units/vial 4. Vancomycin 500mg inj 5. Ceftazidime 1g vial 6. Cefepime 1 g inj 7. Gemifloxacin 320 mg 8. Moxifloxacin 400 mg

2.5 Various versions of each medicine collected and Medicine Price Data Collection Form

Public sector: Public sector had one version of each medicine so only lowest priced generic (LPG) were collected for both price and availability.

Private sector: Methodology suggests collecting data for innovator/originator brand and the lowest priced generic for each medicine.

Until 2005, the Indian regulatory system used a system of process patents which encouraged the growth of India’s generics industry. In real sense we have only generic versions for all medicines that are manufactured in India. Medicines in India are known as “branded” and

15

“branded-generics” but both describe generic medicines. Because all companies want to generate name recognition for their product, all products carry a brand (trade) name. So called branded medicines are manufactured by a multinational or a reputed Indian manufacturer. They are marketed by the manufacturer’s medical representatives to prescribers, often by means of incentives. Branded medicines are more popular and are the most-sold medicines in India. “Branded-generics” more closely resemble what are globally referred to as ‘generics’. Though not truly generics as they have a trade name and the cost is not significantly lower than the branded product. Branded-generic medicines have less name recognition, and it falls on the retail pharmacy to promote the medicine.

Originator brands (OBs) in India are also pooled with branded medicines and as such do not have any additional recognition as originator brand. Many-a-times OBs are not available but the same molecules are manufactured by other companies with different trade names and are popular trade name and are recognized as branded product.

Methodology suggests to measure prices and availability for originator brand and the lowest priced generic (LPG). Name and manufacturer of OBs are known and are mentioned in the methodology, LPGs are identified by visiting each facility. In India for many products OBs are not available but other manufacturers are manufacturing the same product and sometimes branded product could be higher priced than OB. Therefore, for this survey, a third version, highest priced generic was added to find out the price and availability of highest priced version available at each facility.

For global and regional lists of medicines (30) three versions of each medicines were surveyed

• Originator brand • Highest priced generic • Lowest priced generic

For supplementary list of medicines (20) two versions were surveyed

• Highest priced generic • Lowest priced generic

Medicine Price Data Collection (MPDC) form was finalized with 50 medicines with three rows for three versions for each core medicine and two rows for two versions of supplementary medicines. Originator brand were identified and confirmed for their manufacturer in India and entered in the form. The highest priced and lowest priced versions were identified at each facility.

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2.6 Data collection

Training and pilot survey A detailed training for data collectors and area supervisor including a pilot survey was conducted before starting the actual data collection. Data collectors had diploma in pharmacy and were well versed with different generic versions of various medicines available in the market. Area/field supervisor was responsible for data checking on the day of data collections and validation in 20% of the facilities.

Medicine price and availability information collected

Public sector: Procurement price including VAT paid by the government was collected from the following agencies

1. Government of NCT, (GNCT) Delhi – Procurement of medicines is done by a central agency of GNCT, Delhi, called Central Procurement Agency (CPA). Data was collected from the office of CPA.

2. Municipal Corporation of Delhi (MCD) – Procurement of medicines is done centrally and the data was collected from the Directorate Health Administration office.

3. Central Government – For three tertiary care hospitals of Delhi, a central agency called Medical Store Organisation (MSO) does procurement of medicines. Data on procurement of medicines was collected from MSO.

4. Lady Hardinge Medical College and associated Hospitals – One of the three tertiary care hospitals of central government for whom MSO is supposed to purchase medicines, also does procurement by inviting quotations for medicines for its associated hospitals. Data was collected from the procurement office.

5. Safdurjung Hospital and R.M.L. Hospital – The other two tertiary care hospitals of central government for whom MSO is supposed to do procurement, float common tenders for both the hospitals for procurement of medicines. Data on procurement of medicines was collected from the procurement office of R.M.L. Hospital.

Data on availability of medicines was collected by visiting each of the facilities randomly selected for GNCT, Delhi (Delhi government), MCD, and three tertiary care hospitals under CG.

Private sector: Data collectors visited each of the forty facilities of private retail pharmacies called Chemist Shops in Delhi and forty retail chain pharmacies owned by one big corporate.

At facility level, for each medicine, prices and availability was collected for either three or two products:

• originator brand (for global and regional list of medicines) • the highest priced generic (branded or branded generic) for all 50 medicines • the lowest price generic (branded or branded generic) equivalent for all 50 medicines

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The actual products were identified at individual medicine outlets at the time of data collection. Originator brand was always be in the OB row as its name is identified; if this product was available the details were noted down. If more than one product for the same medicines were available, the highest and lowest were identified and entered in the MPDC form, If only one product was available that was entered for the lowest priced generic.

2.7 Affordability In order to quantify the prices of medicines for ordinary citizens, the methodology incorporates an affordability indicator. The affordability indicator is based on the daily wage of the lowest paid unskilled government worker. Thus, the affordability is a measure of the number of days an unskilled government worker needs to work to purchase standard treatment regimens for a selection of conditions using the medicine price data collected. The cost of treatment and affordability for ten pre-selected clinical conditions was calculated in the private sector. These conditions include acute and chronic diseases such as diabetes, hypertension, adult respiratory infection, pediatric respiratory infection, gonorrhea, arthritis, depression, asthma, and peptic ulcer.

The daily wage of the lowest paid unskilled government worker in Delhi is INR 247. As with other states only a minority of the population are government employees. In India, as with many developing countries, a large proportion of the population earns less than the lowest paid government worker.

2.8 International reference price and median price ratios The prices obtained in the survey are compared to international reference prices (IRP) to facilitate national and international comparisons. The reference price serves as an external standard for evaluating local prices. WHO and HAI recommend using the Management Sciences for Health (MSH) International Drug Price Indicator Guide (http://erc.msh.org/) as the reference source. The reference prices for the medicines in this study were taken from the 2010 Price Indicator Guide (14). The MSH prices are net prices from predominantly not-for-profit suppliers to developing countries and NGOs in large quantities. The median unit supplier (procurement) price was used. Where a supplier price was not available, the agency (tender) price was used. Thus, the prices tend to be low. However, they offer a very useful standard against which locally available medicines can be compared.

Median Price Ratios – prices are expressed as a “median price ratio” or MPR. The MPR is the median unit price across the facilities surveyed in a sector (in local currency) divided by the international reference price (also in local currency).

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To obtain the MPR for a medicine in a particular sector, we entered the actual unit price obtained in each facility in the Excel Workbook that accompanies the manual. The workbook calculates the median unit price and then divides this amount by the median IRP (in local currency). The MPR indicates how expensive or cheap the local price is when compared to the external standard price. Hence, the MPR is a unit of measurement of price that ensures a standard approach for comparisons – the higher the MPR, the higher the price.

Workbook also calculates the median price in local currency, i.e., Indian rupee (INR) to facilitate the local comparison and understanding.

2.9 Data entry and analysis

Data were entered in the Excel Workbook that accompanies the WHO/HAI manual and is available on the HAI website. The expanded Workbook to enter three products for each medicine for this survey was provided by the Coordinator, Global Projects (Pricing), HAI Global, Amsterdam. The workbook has different pages for public sector and private sector for entering price and availability. The international reference price of MSH 2010 was entered for all the medicines. Dollar exchange rate for the first day of data collection was entered so that international reference price is converted to local price for comparison and calculating the ratio. Crosschecking was done by double data entry, and use of the workbook’s automated data checker. Workbook has facility to double enter the data for crosschecking of errors and it generates automated data checker. After checking and double entry of data, and data cleaning, analysis was performed using the standardized WHO/HAI Excel Workbook. The Workbook conducts calculations and summary results. In addition a detailed analysis for each public sector, for dispensaries, and tertiary care facilities was carried out.

Affordability of standard treatments for important clinical conditions in the private sector for which price data were collected was also analyzed.

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PRICE COMPONENTS SURVEY

The second part of the survey was to find out the various components that make the final price to patient in private sector or to the government in public sector. The price paid for a medicine is made up of a number of price components, including the manufacturer’s selling price and all costs for freight, tariffs and taxes, wholesale and retail markups, and storage and distribution. Price components are a concern for all those involved in public health and access to medicines, whether the government, nongovernmental organizations (NGO), a social insurance plan, the prescribers or the patients.

3.1 Medicines surveyed

WHO/HAI methodology was used to collect price components for this survey. Seven medicines were chosen for price components study. The medicines chosen were those found to have huge variation in public and private sector, huge price variation in the private sector, medicines in different dosage form, medicines for acute and chronic conditions, and medicine under drug price control or scheduled medicine and non scheduled medicines.

Table 3: List of medicines surveyed for price component survey Medicine, form Strength Scheduled

(Price control)

Therapeutic class

Chronic disease

Price variation

Amlodipine, tab 50 mg, tab Antihypertensive Yes Yes Erythromycin Suspension

125mg/5ml Antibiotic; pediatric

Amoxicillin+clavulanic acid tab

500mg+ 125 mg, tab

antibiotic Yes

Ceftriaxone inj 1 gm vial Antibiotic Diclofenac tab 50 mg, tab Analgesic anti-

inflammatory Yes Public/

Private Omeprazole, tab 20mg, tab Anti ulcer Yes Ranitidine, tab 150 mg, tab Yes Anti ulcer Yes

3.2 Medicine marketing and supply chain

There are two different routes that a medicine can take as it moves from the manufacturer along the supply chain; the route is determined by how the medicine is marketed. If a manufacturer chooses to market the medicine itself as in case of branded medicines, the medicine moves from the manufacturer to a carrying and forwarding (C&F) agent. The C&F agent holds a license to sell the medicines in the name of the manufacturer; and handle

20

distribution of medicines to wholesalers. The manufacturer handles the marketing, which usually entails employing a number of medical representatives who promote the medicine – with doctors, pharmacists, etc. It is agreed by Department of pharmaceuticals (DoP) that for medicines whose price is controlled (scheduled medicines), 8% and 16% are mark ups for wholesaler and retailer and medicines whose prices are not controlled by DoP wholesaler has 10% and retailers have 20% mark ups.

If the manufacturer chooses not to market the medicine itself as in case of branded generic medicines, the medicine moves from manufacturer to a “super-stockist”/wholesaler. This is a distributor who also does marketing to promote the medicine or sells the medicines on to retailers who must promote the medicines in the community. The marks up in this supply chain are not known.

The direct link between the manufacturer and the trade is the carrying and forwarding agent (C&FA). He is the representative of the company and hold stocks on behalf of the company. The C&F agent holds a license to sell the medicines in the name of the manufacturer; they have their own depots and handle distribution of medicines to wholesalers. He typically deals with about half a dozen companies and hold stocks of 4-8 weeks. He supplies to the stockists, depending on the distance, once or twice a month. The CFA typically gets a margin of 2-4% depending on the quantum of business he handles.

3.3 Stages of price components as described by WHO/HAI methodology

• Stage 1: MSP / CIF (manufacturer selling price cost, insurance and freight) • Stage 2: Landed price – port charges (mainly for imported medicines) • Stage 3: Wholesale / Central Medical Store price – wholesaler mark up and if any

transport charges for public sector from central medical store • Stage 4: Retail price – retailer mark up • Stage 5: Dispensed price – if dispensing fee applicable/VAT/sales tax

3.4 Sector surveyed Public sector Details were found from all procurement agencies about any cost added to the rate fixed by the agency with the pharmaceutical company for supplying the medicines.

In public sector no transport charges either from the manufacturer or from central medical stores were found in various public sectors of NCT, Delhi. Manufacturers supply medicines directly either to central medical store or to the facility without adding any cost to the rate approved. A 5% VAT (value added tax) was added to the rate fixed for the procurement.

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Private sector

Seven medicines were surveyed and for each medicine, 2-3 ‘branded’ and 2-3 ‘branded generic’ versions were surveyed for price components. As per the methodology, backward calculations from the final price (patient price) were done to find the tax, retailer margin or profit and wholesaler margin. For branded medicines, data collectors visited retail pharmacies (chemist shops), found the price to patient, VAT applicable, price-to-retailer. Wholesalers who supplied these branded medicines to the retailers were found and price-to-wholesaler and the price-to-retailer were found. We could not interview C&F agents but the margins of C&F agents are 2-4% as informed by informants in the trade.

For branded generic (generic) medicines, we found the retail pharmacy shops who usually stock these medicines. Data was collected from these pharmacy shops and the data from the wholesaler who supplies these branded generic (generic) medicines.

3.5 Data entry and analysis

The methodology has an Excel Workbook designed for entering data for price components survey. Data for all the surveyed medicines for all their branded and branded generic products from private sector was entered. Data was analysed as per the stages described by the methodology.

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FINDINGS

The key measures were

• Medicine availability: per cent (%) availability of individual medicines; mean (%) availability across a group of medicines; and variations between product types ( brand vs generic; highest priced vs. Lowest priced), ;

• Medicine prices: median prices of individual medicines; ratios of median local price to international reference price (median price ratio or MPR); median MPR across a group of medicines;

• Treatment affordability: in relation to the daily wage of the lowest-paid unskilled government worker

• Price components: mark ups for branded and branded generic medicines

4.1 Public sector 4.1.1 Procurement price The median price ratio for the medicines purchased by different agencies is shown in the figure 1. Number of medicines each procurement agency is buying (out of 50 medicines surveyed) is mentioned in the bracket below each bar diagram.

0.61 0.590.53

0.82

0.69

00.10.20.30.40.50.60.70.80.9

NCT (Delhi) (n=37) MCD(Delhi) (n=31) MSO(Central Govt) (n=12)

Lady Harding (n=32) RML/SH (n=27)

Med

ian

MPR

s

Procurement prices of surveyed medicines in various public sectors

Figure 1: Median MPRs for procurement prices of different public sector agencies

23

Only one version that is generics or lowest priced were purchased by the public procurement agencies. The details analysis like median MPR with inter-quartile ranges for the 25th and 75th percentile, minimum MPR and maximum MPR for each procurement agency is mentioned in the Table 4

Table 4: Summary of median price ratios (MPRs) in various public sectors in Delhi GNCT, Delhi

(n=37) MCD (n=31)

MSO (n=12)

LH (n=32)

RML/SH (n=27)

Median MPR 0.61 0.59 0.53 0.82 0.69 25%ile MPR 0.42 0.37 0.30 0.61 0.48 75%ile MPR 0.76 0.76 0.64 1.10 0.87 Minimum MPR

0.07 (Amlodipine)

0.07 (Amlodipine)

0.10 (Amlodipine)

0.34 (Ranitidine)

0.08 (Amlodipine)

Maximum MPR

1.22 (Amoxicillin 500 mg)

1.22 (Amoxicillin 500 mg)

1.03 (Erythromycin

tab) 6.38

(Fluoxetine tab)

1.48 (Erythromycin

tab) GNCT, Delhi – Delhi state government, MCD – Municipal Corporation of Delhi, MSO – Procurement agency for Central government, LH – a tertiary care facility of central government procurement, RML – tertiary care facility under central government that does procurement for two hospitals Note: LH - MPR of Amlodipine was 0.42; MPR of Erythromycin tab in GNCT, Delhi – 0.61, MCD -0.96, LH – 1.21 ; MPR of Fluoxetine in GNCT, Delhi was 0.50 and was not procured by MCD, MSO, RML/SH Few medicines were found to have variation in procurement price by different agencies and the data for procurement price for some of the medicines is shown in Table 5. Table 5: Variation in procurement price (INR) by different public sector

agencies for few medicines S.No. Medicine Name Medicine

Type Unit Price GNCT, Delhi

Unit Price MCD

Unit Price MSO

Unit Price Lady

Hardinge

Unit Price RML

1 Amoxicillin+clavulanic acid Syrup Lowest Price 1.16 0.69

2 Atenolol Lowest Price 0.13 0.14 0.14 0.57 0.14 3 Ceftriaxone injection Lowest Price 8.51 18.28 14.99 15.50 16.46 4 Diazepam Lowest Price 0.21 0.08 0.11 0.08 5 Diclofenac Lowest Price 0.08 0.15 0.11 6 Enalapril Lowest Price 0.19 0.15 0.11 0.39 0.18 7 Erythromycin Stearate Lowest Price 0.85 1.32 1.43 1.68 2.04 8 Fluoxetine Lowest Price 0.27 3.48 9 Metformin Lowest Price 0.17 0.23 0.52 0.22 10 Phenytoin Lowest Price 0.32 0.16 0.16 1.19

Note: GNCT, Delhi – Delhi state government, MCD – Municipal Corporation of Delhi, MSO – Procurement agency for Central government, LH – a tertiary care facility of central government procurement, RML – tertiary care facility under central government that does procurement for two hospitals

24

4.1.2 Availability of surveyed medicines in public sector

In the public sector, one version of each medicine was available. No originator brands were available. Annexure 2 provides the details of availability of all 50 medicines surveyed in all public sector facilities.

Mean availability of surveyed medicines: The mean availability of surveyed medicines in all surveyed facilities under GNCT, Delhi, and MCD are depicted in Figure 2. This figure also shows the availability of surveyed medicines in three tertiary care hospitals under central government, one tertiary care hospital each under GNCT, Delhi and MCD.

Government of NCT, Delhi has essential medicine list (EML) and procurement is made according to the EML. At the time of survey EML 2007 was in place and the procurement was made according to 2007 list. Out of 50 medicines, 40 medicines were on the Delhi state EML. Mean availability of surveyed 50 medicines was 41.3% and mean availability of 40 medicines of EML was 48.8%. Other public sectors do not have their EML but they have their procurement list.

Figure 2: Mean availability of surveyed medicines in various public sectors Overall percent availability of surveyed medicines: The overall percent availability of medicines in facilities under GNCT, Delhi and MCD is shown in Figure 3. Five medicines that have 0% availability in GNCT, Delhi, were not on their EML, they were beclomethasone inhaler, budesonide+formoterol inhaler, captopril, gliclazide, and dispersible zinc sulphate. MCD had 15 medicines with 0% availability, out of these four medicines had procurement price indicating these four to be on their list, these were ceftriaxone injection, diethylcarbamazine citrate, erythromycin stearate, and gentamicin injection.

25

Table 6 shows nine medicines with availability in the range of 81-100% in facilities under GNCT, Delhi. In MCD facilities only three medicines have availability of this range, amlodipine 90%, atenolol 90%, and omeprazole 85%.

Table 6: Medicines with 81-100% availability in facilities under GNCT, Delhi NCT, Delhi

S. No. Medicine Name % Availability 1 Amlodipine 92.5% 2 Amoxicillin 250mg 82.5% 3 Atenolol 85% 4 Ibuprofen 92.5% 5 Norfloxacin 82.5% 6 Omeprazole 85% 7 Paracetamol Suspension 97.5% 8 Ranitidine 85% 9 Salbutamol Inhaler 85%

Figure 3: Percent availability of medicines in public sector Mean availability at dispensaries, secondary care and tertiary care hospitals: Medicines in injection dosage forms are not available at dispensaries and we do not expect all medicines to be available at dispensaries. Therefore, mean availability of surveyed medicines at dispensaries, secondary care and tertiary care hospitals were analyzed and the results are depicted in Figure 4. The mean availability of surveyed medicines was 41.3%, 51.7%, and 60.0% at dispensaries, secondary care, and tertiary care hospital under GNCT, Delhi. The mean availability did not change much in facilities under MCD (Figure 4).

26

41.3 38.3

51.760

23.2 22.930.7 28

0

10

20

30

40

50

60

70

Over All Availability Dispensaries Secondary Care Tertiary Care

% Av

ailab

ility

Mean Availability of Surveyed Medicines at Various Levels of Health Care

GNCT, Delhi

MCD

Figure 4: Mean availability of surveyed medicines at various level of healthcare

in public sectors Availability of surveyed medicines according to therapeutic class in GNCT, Delhi and MCD

Availability of antihypertensive agents: Overall the availability of antihypertensive agents was good (> 85%) in both the public sectors (Figure 5). Captopril was not available as this medicine was not on the EML and in our country enalapril is used from this class of antihypertensive agents.

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Amlodipine Atenolol Captopril Enalapril

in pe

rcent

ages

Name of the Medicines

Availabilty of Anti-Hypertensive Medicines

NCT(Delhi)MCD

Figure 5: Availability of antihypertensive medicines in public sector

27

Availability of anti-diabetic agents: Mean availability of anti-diabetic agents were better in facilities under GNCT, Delhi as compared to MCD (Figure 6).

0.00%10.00%20.00%

30.00%40.00%

50.00%60.00%70.00%

80.00%90.00%

Glibenclamide Gliclazide Metformin

In Pe

rcent

age

Availability of Anti-Diabetic Medicine

NCT(Delhi)MCD

Figure 6: Availability of anti-diabetic medicines in public sector Availability of inhalers for asthma: Essential medicines for asthma surveyed had poor availability in public sector. GNCT, Delhi has two inhalers on the EML list – budesonide and salbutamol but availability of budesonide inhaler was very poor. MCD does not buy any surveyed inhalers.

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

Beclometasone inhaler

Budesonide inhaler

Budesonide Formeterol

inhaler

Salbutamol inhaler

in pe

rcent

age

Inhalers

NCT(Delhi)MCD

Figure 7: Availability of inhalers for asthma in public sector

28

Availability of surveyed antibiotics in primary and secondary care facilities: Figure 8 shows the percent availability of surveyed antibiotics in dispensaries and secondary care hospitals.

Figure 8: Percent availability of surveyed antibiotics in primary and secondary

care facilities, GNCT, Delhi

Figure 9: Percent availability of surveyed antibiotics in primary and secondary

care facilities, MCD

29

At dispensaries of GNCT, Delhi the percent availability of surveyed antibiotics in descending order was norfloxacin, amoxicillin, doxycyclin, cefuroxime axetil, cephalexin, erythromycin stearate, roxithromycin, ciprofloxacin, ofloxacin, cefixime, amoxicillin+clavulanic acid. Many second and third generation antibiotics were available in dispensaries under GNCT, Delhi. In dispensaries under MCD the percent availability in descending order (Figure 9) was found as, ciprofloxacin, doxycycline, amoxicillin+clavulanic acid, ofloxacin, cefuroxime axetil, cefixime, amoxicillin, and cephalexin.

Availability of surveyed antibiotics in tertiary care hospitals: We expect good availability of surveyed antibiotics in tertiary care. The availability of antibiotics on the day of data collection was: ciprofloxacin was available at all facilities; ofloxacin was available at all except Safdarjung Hospital (SH); amoxicillin+clavulanic acid was available at all except Ram Manohar Lohia (RML) Hospital; ceftriaxone was available at all except Hindu Rao (HR); erythromycin and gentamicin inj was available at all except Hindu Rao.

Non availability of surveyed antibiotics in tertiary care facilities:

• LN - Azithromycin, Cefixime, Cefuroxime, Cephalexin, Doxycycline, Norfloxacin • Hindu Rao – Azithromycin, Benzathine penicillin, Ceftriaxone inj, Cefuroxime, Cephalexin,

Erythromycin, Gentamicin inj, Norfloxacin, Roxithromycin • LH – Benzathine penicillin, Cefixime, Cefuroxime, Cephalexin, Roxithromycin, • RML – Amoxicillin+clavulanic acid, Amoxicillin, Azithromycin, Cefixime, Cefuroxime,

Doxycycline, Roxithromycin • SH – Amoxicillin, Azithromycin, Cefixime, Cefuroxime, Cephalexin, Doxycycline, Ofloxacin,

Roxithromycin

Availability of surveyed pediatrics antibiotics and medicines: In facilities under GNCT Delhi, availability of paracetamol suspension was good but zinc sulphate dispersible tablets were not found (Figure 10).

In facilities under MCD, availability of antibiotics and other medicines were less as compared to GNCT, Delhi. Paracetamol suspension was 100% in secondary care but 72% at dispensaries. Like, GNCT, Delhi, zinc sulphate dispersible tablets were not available. The main antibiotics available at dispensaries were amoxicillin+clavulanic acid, co-trimoxazole suspension, and amoxicillin tab but the availability of these antibiotics were also poor (Figure 11).

30

81.3

62.5

31.3

25

0

53.1

40.6

40.6

96.9

0

85.7

100

14.3

0

28.6

14.3

14.3

42.9

100

0

0 20 40 60 80 100 120

Amoxi 250

Amoxi Susp

Amoxi+clav Syp

Ampicillin Susp

Cefuroxime Susp

Cephalexin Syp

Co-trimox Susp

Erythro Susp

Paracetamol susp

Zinc Sulphate Dispersible

% Availability

Mean availability of surveyed paediatirc Prepartions GNCT,Delhi

Sec.CarePr. Care

Figure 10: Percent availability of surveyed pediatrics antibiotics & medicines, GNCT Delhi

30.65.6

58.32.8

08.3

33.30

72.2

0

66.70

66.70

00

00

100

0

0 50 100 150

Amoxi 250

Amoxi SuspAmoxi+clav Syp

Ampicillin SuspCefuroxime Susp

Cephalexin SypCo-trimox Susp

Erythro Susp

Paracetamol SuspZinc sulphate dispersible

% Availability

Mean availability of surveyed paediatric prepartions in MCD

Sec. CarePr. Care

Figure 11: Percent availability of surveyed pediatrics antibiotics and medicines, MCD

31

Availability of surveyed pediatrics antibiotics and medicines at tertiary care facilities: Table 7 shows the availability of surveyed antibiotics and other medicines for children at five tertiary care facilities surveyed in NCT, Delhi.

Table 7: Availability of surveyed pediatric antibiotics and medicines on the day of data collection at tertiary care facilities surveyed in GNCT, Delhi

Medicine Lady Hardinge

RML Hospital

Safdarjung Lok Nayak

Hindu Rao

Amoxicillin 250 Available Available Available Available N.A Amoxicillin suspension Available N.A N.A Available N.A Amoxicillin+clavulanic syrup N.A N.A N.A Available Available

Ampicillin suspension N.A N.A N.A Available N.A Cefuroxime suspension N.A N.A N.A N.A N.A Cephalexin syrup Available N.A N.A Available N.A Co-trimoxazole suspension Available Available N.A N.A N.A Paracetamol suspension Available Available Available Available Available Zinc sulphate dispersible tablet N.A N.A N.A N.A N.A Availability of surveyed high-end antibiotics at tertiary and secondary care facilities: The availability of eight reserve antibiotics is listed in the Table 8. The availability pattern indicates that none of the facilities were procuring colistin, gemifloxacin, and moxifloxacin; ceftazidime was found at 11 hospitals out of 15.

Table 8: Availability of surveyed high-end antibiotics at secondary care and tertiary care public facilities and at private sector facilities

Antibiotic Name Public Sector (n=15)

Retail Pharmacies (n=40)

Chain Pharmacies (n=40)

Cefepime 20.0% 0.0% 10.0% Ceftazidime 73.3% 5.0% 20.0% Colistin 0.0% 0.0% 2.5% Gemifloxacin 0.0% 37.5% 50.0% Imipenem+cilastatin 13.3% 0.0% 22.5% Meropenem 53.3% 32.5% 52.5% Moxifloxacin 0.0% 40.0% 72.5% Vancomycin 53.3% 5.0% 7.5%

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4.2 Private sector

4.2.1 Medicines prices to patients in private sector In private sector ,for 30 global and regional lists of medicines data was collected for all three versions, originator brand (IB), highest-priced generic (HPG) and lowest-priced generics (LPG). For supplementary 20 medicines data was collected for two versions, highest-priced and lowest-priced generics at each facility. Two types of private sector were surveyed, one was traditional retail pharmacy shops, commonly called ‘Chemist Shops’ in Delhi, and second was retail chain pharmacies under one corporate house.

Median MPR for surveyed medicines: The median MPR for all versions, inter-percentile range, minimum MPR, and maximum MPR found is depicted in Table 9.

Table 9: Summary of medicine prices in the private sector Private Chain Pharmacies

Brand (n=16)

Highest Priced (n=28)

Lowest Priced (n=43)

Brand (n=17)

Highest Priced (n=29)

Lowest Priced (n=43)

Median MPR 4.71 5.38 2.83 4.41 4.79 3.12 25%ile MPR 2.59 2.76 1.74 2.21 2.53 1,79 75%ile MPR 7.42 6.84 5.20 7.18 6.78 4.94 Minimum MPR 0.57 0.57 0.56 0.57 0.57 0.56 Maximum MPR 16.51 9.30 9.73 16.51 11.26 9.73

Note: Minimum MPR was for ranitidine for all three versions. Maximum MPR for brand medicine was diclofenac, for highest-priced was for doxycycline, and for the lowest-priced generic was for diazepam. The results were same for chain pharmacies Median MPRs for surveyed medicines in public and private sector: Table 10 shows the comparison of median MPRs for the three versions of surveyed medicines that were found in public and private sector (note: public sector is procurement prices)

Table 10: Comparison of median MPRs of medicines in public (procurement prices) and private sector (patient prices) Version of Medicines

Public Sector Procurement

price

Retail Pharmacies Patient price

Retail Chain Pharmacies Patient price

Lowest priced 0.61 (n=37) 2.83 (n=43) 3.12 (n=43) Highest Priced - 5.38 (n=28) 4.79 (n=29) Brand - 4.71 (n=16) 4.41 (n=17)

Pair-data analysis: Pair data analysis was done as this is a more robust way of comparing prices. It compares only those medicines found for both types, thus avoiding the problem of comparing different baskets of medicines. The analysis shows that if pair wise data is analyzed for OB and

33

HPG (n=8), HPG was found to be more expensive than OB (MPR 5.09 vs. 4.71), OB was more expensive than LPG (4.41 vs 3.74 in retail shops and 4.22 vs 3.43 at chain pharmacies). When the price of HPG and LPG (n= 28) is compared, LPG was found to be 41% and 35% less expensive than the HPG at retail shops and chain pharmacies (Table 11).

Table 11: Comparing the paired data analysis in the private sector Brand Highest

Priced Difference brand to highest priced

Brand Lowest Priced

Difference brand to lowest priced

Highest Priced

Lowest Priced

Difference highest

to lowest priced

Private 4.71 (8)

5.09 (8) -7.5% 4.41

(15) 3.74 (15) 17.9% 5.38

(28) 3.17 (28) 69.7%

Chain Pharmacies

4.71 (8)

5.09 (8) -7.5% 4.22

(16) 3.43 (16) 23.0% 4.79

(29) 3.12 (29) 53.5%

Price variations for few medicines in public and private sector: We expect medicines to be more costly in private sector than procurement price. For few medicines the price variations was astonishingly high as depicted in Figure 12. It was found that median MPR of LPG in private sector for diazepam, amlodipine, atenolol, enalapril, diclofenac, and glibenclamide was 28, 23, 22, 16, 14 and 11 times higher than the median procurement price of these medicines in public sector. All these medicines are used in chronic conditions. Few pediatric antibiotics were also found to expensive in private sector compared to public sector, e.g., cefuroxime suspension, and cephalexin syrup were 7 times costly. Some of the medicines have little price difference in both the sectors as shown for budesonide inhaler, co-trimoxazole suspension, erythromycin, gentamicin injection, and salbutamol inhaler (Figure 12).

0

2

4

6

8

10

12 Comparison of public and private sector MPR

Public sector MPR

Private sector MPR

Figure 12: Price variation for few medicines in public (procurement price) and private sector (patient price)

34

Price variation between brand, highest and lowest generic: For certain medicines huge price variation was observed for brand, highest-priced and lowest-priced generic available on the surveyed facilities (Figure 13 and 14).

Figure 13: Price variation for a few medicines in highest and lowest priced

generics available at private sector

Figure 14: Price variation for a few medicines for brand, highest, and lowest

priced generics available at private sector

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4.2.2 Availability of medicines in the private sector

Originator brand was surveyed and identified for 30 medicines for international comparison. During survey, if two or more than two versions of medicines were available, the highest priced was entered into HPG and the lowest –priced generic was found and entered. If only one version was available then that medicine’s name and price became the lowest-priced generic available.

Annexure 3 gives the detail availability of all surveyed medicines in private sector.

Mean availability in the private sector: Table 12 shows the mean availability of different versions of medicines surveyed.

Table 12: Mean availability of surveyed medicines in the private sector Version of Medicine Retail

Pharmacies Retail Chain Pharmacies

Originator Brand 29.3% 31.2% Highest Priced Generic 34.6% 38.0% Lowest Priced Generic 68.8% 70.5%

Note: Originator brand was surveyed for 30 core medicines and mean availability is for those 30 medicines. Highest priced and lowest priced mean availability is for all 50 medicines surveyed.

Availability of hypolipidemic agents: Two agents, atorvastatin and simvastatin were surveyed in the private sector. Percent availability is shown in Figure 15.

12.530

87.5 8597.5 95

42.5 42.5

2.5 0

40 35

0

20

40

60

80

100

120

Retai

l Pha

rmac

ies

Chain

Phar

macie

s

Priva

te

Chain

Phar

macie

s

Priva

te

Chain

Phar

macie

s

Brand Highest-priced Lowest-priced

% Avai

labilit

y

Availability of Hypo-Cholestrol Medicines in Private retail and Chain pharmacies

AtorvastatinSimvastatin

Figure 15: Percent availability of hypolipidemic agents surveyed in private sector

36

Availability of asthma inhalers: Availability of asthma inhalers surveyed is shown in Table 13. In the private sector, availability of budesonide and salbutamol inhalers was good unlike public sector.

Table 13: Availability of inhalation medicines for asthma in the private sector Inhalers

Brand Highest Priced Lowest Priced Medicines Name Medicine list Private

(n=40) Chain

Pharmacies (n=40)

Private (n=40)

Chain Pharmacies

(n=40) Private (n=40)

Chain Pharmacies

(n=40 ) Beclomethasone inhaler Regional 5.0% 0.0% 0.0% 0.0% 35.0% 37.5% Budesonide inhaler Supplementary 0.0% 0.0% 7.5% 10.0% 62.5% 82.5% Budesonide+Formoterol inhaler Supplementary 0.0% 0.0% 0.0% 0.0% 42.5% 27.5% Salbutamol inhaler Global 52.5% 45.0% 7.5% 7.5% 92.5% 95.0% Availability of surveyed antibiotics: Various antibiotics were surveyed and it was found that availability of few antibiotics, like ceftriaxone injection and gentamicin injection was poor which is expected because injections are not commonly prescribed and benzathine penicillin was not available. For certain antibiotics only one version was available therefore patient has no choice but to buy that particular ‘brand’. This was seen for cefuroxime axetil, cephalexin, doxycycline, erythromycin, norfloxacin, and roxithromycin (Table 14).

Table 14: Percent availability of surveyed antibiotics in the private sector Highest Priced Lowest Priced Medicines Name Medicine list Private

(n=40) Chain

Pharmacies (n=40)

Private (n=40)

Chain Pharmacies

(n=40 ) Amoxicillin+Cla vulanic acid Supplementary 95.0% 100.0% 100.0% 100.0%

Amoxicillin 500 Supplementary 95% 92.5% 97.5% 100.0% Azithromycin Supplementary 95.0% 97.5% 100.0% 100.0% Benzathine Penicillin Supplementary 0.0% 0.0% 0.0% 0.0% Cefixime Supplementary 80.0% 95.0% 97.5% 100.0% Ceftriaxone injection Global 2.5% 5.0% 47.5% 42.5% Cefuroxime axetil Supplementary 55.0% 60.0% 90.0% 100.0% Cephalexin Supplementary 32.5% 30.0% 65.0% 80.0% Ciprofloxacin Global 85.0% 92.5% 100.0% 100.0% Doxycycline Regional 55.0% 60.0% 97.5% 95.0% Erythromycin Supplementary 35.0% 25.0% 82.5% 85.0% Gentamicin injection Supplementary 15.0% 17.5% 57.5% 50.0% Norfloxacin Supplementary 5.0% 0.0% 95.0% 97.5% Ofloxacin Supplementary 92.5% 97.5% 97.5% 100.0% Roxithromycin Supplementary 17.5% 25.0% 92.5% 97.5%

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Availability of pediatric antibiotics and pediatric medicines surveyed: In the private sector, zinc dispersible tablets were not available (though found at one chain pharmacy) and the availability of ampicillin suspension was very poor. Availability of cefuroxime suspension, cephalexin suspension, and co-trimoxazole suspension was also not good (Table 15).

Table 15: Percent availability of surveyed pediatric antibiotics and other medicines surveyed in the private sector

Brand Highest Priced Lowest Priced Medicines Name

Medicine list Private (n=40)

Chain Pharmacies

(n=40) Privat

e (n=40)

Chain Pharmacies

(n=40) Privat

e (n=40)

Chain Pharmacies

(n=40 ) Amoxicillin suspension Regional 0.0% 0.0% 57.5% 70.0% 95.0% 92.5%

Amoxicillin+ Clav Syrup Supplementary 62.5% 90.0% 92.5% 92.5%

Ampicillin Suspension Supplementary 2.5% 0.0% 2.5% 0.0%

Cefuroxime Suspension Supplementary 2.5% 0.0% 55.0% 50.0%

Cephalexin Syrup Supplementary 22.5% 22.5% 50.0% 40.0%

Co-trimoxa suspension Global 5.0% 10.0% 0.0% 0.0% 77.5% 67.5%

Paracetamol suspension Global 62.5% 65.0% 20.0% 17.5% 90.0% 97.5%

Zinc sulphate dispersible

Supplementary 0.0% 0.0% 0.0% 2.5%

Availability and price of surveyed high-end antibiotics: Eight high-end antibiotics surveyed for availability and price at both private retail shops and retail chain pharmacies. The availability of these high-end antibiotics was better at chain pharmacies (Table 8). At private retail shops, gemifloxacin (37.5%), moxifloxacin (40.0%), and meropenem (32.5%) were available. The availability at retail chain pharmacies were: moxifloxacin, 72.5%, meropenem, 52.5%, gemifloxacin, 50.0%, Imipenem+colistin, 22.5%, ceftazidime, 20.0%, cefepime, 10.0%, vancomycin, 7.5%, and colistin, 2.5%.

The price for these surveyed antibiotics is shown in Table 16. At private retail chain pharmacies more than one version of moxifloxacin were available and the median MPR for highest priced was 83.60 vs 69.55 for lowest priced generic.

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Table 16: Median price in INR for surveyed high-end antibiotics in public and private sector

Antibiotic Name Public Sector (Procurement Price)

Private Sector (Retail Pharmacies)

Private Sector (Chain Pharmacies)

Cefepime 80.22 - 145.00 Ceftazidime 31.29 - 416.70 Colistin - - - Gemifloxacin - 14.90 14.90 Imipenem+cilastin 467.78 - 1200.00 Meropenem 866.25 1347.00 1347.00 Moxifloxacin - 69.55 83.60 & 69.55 Vancomycin 60.59 - -

4.3 Affordability A list of the 11 conditions for which the affordability of treatment was measured for the private sector is included in Annexure 4. Affordability was calculated on the basis of the daily wage of an unskilled government worker. The salary of the lowest paid regular government worker was Rs. 247 per day. The cost of treatment and affordability of four conditions is shown in Figure 16.

0.4

1

1.2

1

0.8

2.3

0.4

0.4

1

0.8

0.7

0.3

0.7

0 0.5 1 1.5 2 2.5

Salbutamol Inhaler

Budesonide Inhaler

Amoxicillin

Amoxi+clav acid

Amlodipine

Amitriptyline

No. of days' wages

Treatment affordability

Lowest priceHighest priceBrand

Figure 16: Treatment affordability for depression, hypertension, acute respiratory

infection and asthma treatment in private medicine outlets

39

The prices of treatments in the private retail shop and chain pharmacies were almost equal; hence the affordability in terms of number of days’ wages a lowest paid government worker has to pay for the treatment of a particular disease is the same. Treatment affordability is calculated for one month for chronic diseases and acute infection for the course of therapy. Wages in private sector or in unorganized sector is much less so accordingly the total number of days for the cost can be calculated. In addition, these costs only include the medicine costs. Doctors' consultation fees and diagnostic tests will likely mean that the total cost to the patient may be considerably higher.

4.4 Price components Public sector

For public sector procurement agencies fix the price of medicine (rate control) with pharmaceutical company. It is the responsibility of manufacturer to supply the medicines either to the medical store or to the facility without any extra charge. Government agencies pay 5% VAT on the rate fixed. Therefore, for public sector only stage 5, VAT is applicable.

Private sector

Medicine prices in the private sector are determined by trade relationships between: manufacturer and wholesaler, manufacturer and super-stockist, and wholesaler and retailer.

Trade schemes run between manufacturer, wholesaler and retailer. They take the form of “buy 10 get 1 free” (9.09% discount) or “buy 7 get 3 free” (30% discount); trade schemes were found for 3 out of the 7 medicines surveyed: ceftriaxone injection, amoxicillin+clavulanic acid, and omeprazole. These schemes in India run for extended periods of time.

Examples of trade schemes

# buy # receive “free”

Equivalent % discount

10 1 9.09% 19 1 5.00% 20 1 4.76% 7 3 30.00% 2 1 33.33% 10 2 16.67% 4 1 20.00%

Trade schemes benefit the retailer with larger profit margins, as the medicines that they get free on schemes represent pure profit. There is a benefit to the wholesaler as well, as they have increased volume of sales for those products with trade schemes (Tables 17, 18, 19). There is no evidence that patients benefit from trade schemes: retailers do not discount the medicines for patients.

40

Detailed analysis on price components is shown below (Table 17-23) for seven medicines surveyed for branded and branded generic versions.

All the strips and containers of medicines are printed and labeled with MRP (Maximum Retail Price) by the manufacturer in India. Printing of MRP is mandatory and dispensing pharmacists cannot charge a price exceeding the MRP printed on the medicine’s pack, as per the provision under paragraph 16 of the Drug Price Control Order (DPCO). For the scheduled medicines the DPCO of 2005 established margins for wholesalers of 8% and for retailers of 16%. This should be true whether the medicine is branded or branded-generic. Ranitidine is one such medicine which is scheduled medicine or whose price is fixed under DPCO. The MRP of ranitidine was found to be reasonable and consistent irrespective of branded and branded-generics. The mark-up for wholesaler and retailer was almost the same as established but mark-up were little higher than established for branded-generics (Table 22).

For the non-scheduled medicines or for all other medicines whose price is not fixed by the government there is an agreement between manufacturer and distributors that there should be a 10% margin for wholesalers and a 20% margin for retailers. The other six medicines surveyed belonged to this category and the findings revealed that there was no consistency in the final price to patient for various versions available in the market. The difference between originator brand and other brand is sometimes very high as seen for amlodipine and diclofenac (Table 20, 21); there was no difference in OB and other branded for amoxicillin+clavulanic acid and OB and one other branded product was offering 10+2 scheme (Table18). In case of erythromycin suspension the price of OB was less as compared to other branded product which was most popular and was usually available with chemist shops (Table 23). As far as the MRP of branded and branded-generic is concerned either there was no difference in the final price to patient as found for few versions of amoxicillin+clavulanic acid, amlodipine, diclofenac; or branded generic price was less as seen for omeprazole (Table 19); or the price for branded generic was very high as seen for ceftriaxone injection (Table 17).

For all non scheduled medicines surveyed, the manufacturer collect a majority of the profit (54-74%) for branded medicines and the retailer made a similar profit in case of branded-generic (generic) medicines. For each medicine margin of C&F agent could not be found but it is in the range of 2-4% that we have included in manufacturer or stage 1.

Margins for wholesalers for branded product was usually between 7- 11%, and for branded-generic medicines usually it was much less. One interesting finding was seen for a product, amoxicillin+clavulanic acid manufactured by Cipla in two forms, branded and branded-generic. The MRP for both the product is almost same but the market strategy is different for each version, the one so called branded has wholesaler margin as 26% and for the branded-generic the retailer margin was 59%.

Margins for retailer for branded product was generally between 13-19% but for branded-generic the range observed was between 70 – 78%. Of course the margin or profit for retailer

41

increases if the manufacturer is offering trade schemes as was observed for ceftriaxone injection, amoxicillin+clavulanic acid, and omeprazole.

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

B B B G G G

72.16% 73.23%65.94%

17.23% 20.43% 16.56%

7.22% 7.84%11.18%

3.71%4.60%

2.80%

15.87% 14.17% 18.11%

74.30% 70.21% 75.88%

4.76% 4.76% 4.76% 4.76% 4.76% 4.76%

Stage 5Stage 4Stage 3Stage 2Stage 1-MSP+C&F

Note: Stage 1: MSP (manufacturer selling price) and C&F (carrying and forwarding agents); Stage 2: Landed price – port charges (mainly for imported medicines) not applicable; Stage 3: Wholesaler mark up; Stage 4: Retailer mark up; Stage 5: VAT; B: Branded medicine; G: Branded generic medicine Figure 17: Percent contribution of each stage of the supply chain to final

patient price Ceftriaxone 1gm injection Table 17: Percent contribution of each stage of the supply chain to final patient

price in the private sector Ceftriaxone 1gm injection Manufacturer Ranbaxy Alkem Aristo Wochardt Alembic Nicholas Product Type Branded Branded Branded Branded –

generic Branded –

generic Branded- generic

MSP/CIF including C&F agent mark up (Stage 1)

72.16% 73.23% 65.94% 17.23% 20.43% 16.56%

Stage 2 (not applicable) _ _ _ _ _ _ Wholesaler mark up (Stage 3) 7.22% 7.84% 11.18% 3.71% 4.60% 2.80% Retailer (Stage 4) 15.87% 14.17% 18.11% 74.30% 70.21% 75.88% VAT (Stage 5) 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% Final unit Price (INR) 64.39 49.46 69.01 132.33 107.67 128.01 Scheme# (Purchase Qty.+Free Qty.)

10+2 _ 10+2 _ _ _

# Scheme by manufacturer of buy 10 and get 2 free is given to retailer; this extra 16.67% is the additional profit for retailer.

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Table 18: Percent contribution of each stage of the supply chain to final patient price in the private sector

Amoxicillin+clavulanic acid (500mg+125mg) Manufacturer Ranbaxy Cipla GSK Elder

Pharma Cipla Intas

Product type Branded Branded Originator Brand*

Branded-generic

Branded-generic

Branded-generic

MSP/CIF including C&F agent mark up (Stage 1)

72.16% 53.64% 72.16% 19.80% 32.22% 15.19%

Stage 2 (not applicable) _ _ _ _ _ _ Wholesaler mark up (Stage 3) 7.21% 25.73% 7.22% 2.88% 4.00% 1.84% Retailer mark up (Stage 4) 15.87% 15.87% 15.87% 72.56% 59.01% 78.21% VAT(Stage 5) 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% Final price (unit price in INR)

402.96 40.29

107.99 18.00

241.17 40.19

252.03 42.00

120.41 20.07

275.22 45.87

Scheme # (Purchase Qty.+ Free Qty.)

10+2 _ 10+2 _ _ _

# Scheme by manufacturer of buy 10 and get 2 free is given to retailer; this extra 16.67% is the additional profit for retailer.

Table 19: Percent contribution of each stage of the supply chain to final patient

price in the private sector Omeprazole 20 mg Manufacturer Torrent Dr. Reddy Zydus Alkem Ranbaxy Cipla Product type Branded Branded Branded Branded –

generic Branded –generic

Branded –generic

MSP/CIF including C&F agent mark up (Stage 1)

59.57% 71.98% 62.02% 16.32% 22.18% 16.05%

Stage 2 (not applicable) _ _ _ _ _ _ Wholesaler mark up (Stage 3) 10.32% 8.01% 18.69% 2.42% 4.23% 2.34% Retailer mark up (Stage 4) 25.35% 15.25% 14.52% 76.50% 68.83% 76.84% VAT (Stage 5) 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% Final price (Unit price in INR)

82.31 (5.487)

81.61 (5.441)

87.63 (5.842)

62.50 (4.1666)

22.00 (2.200)

36.70 (3.670)

Scheme# (Purchase Qty.+ Free Qty.)

_ _ 6+1 6+1 _ _

# Scheme by manufacturer of buy 6 and get 1 free is given to retailer; this extra 14.28% is the additional profit for retailer.

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Table 20: Percent contribution of each stage of the supply chain to final patient price in the private sector

Amlodipine 5mg Manufacturer Pfizer Mankind Zydus Cadila Cipla Alembic Product type Originator

Brand* Branded Branded Branded Branded –

generic Branded –generic

MSP/CIF including C&F agent mark up (Stage 1)

74.11% 67.57% 70.61% 73.62% 16.97% 18.30%

Stage 2 (not applicable) _ _ _ _ _ _

Wholesaler mark up (Stage 3)

7.92% 8.68% 8.23% 7.16% 2.96% 2.00%

Retailer mark up (Stage 4) 13.21% 18.99% 16.40% 14.46% 75.31% 74.54%

VAT (Stage 5) 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% Final price (Unit price in INR)

82.50 (8.25)

9.90 (0.990)

27.80 (2.780)

38.86 (2.59)

27.70 (2.770)

26.50 (2.650)

* Originator brand is also a type of branded medicine.

Table 21: Percent contribution of each stage of the supply chain to final patient price in the private sector

Diclofenac 50mg Manufacturer Biochem German

Remedies Systopic Novartis Blue cross Cipla

Product type Branded Branded Branded Originator Brand*

Branded-generic

Branded-generic

MSP/CIF including C&F agent mark up (Stage 1)

72.21% 68.88% 72.46% 70.91% 22.73% 19.75%

Stage 2 (not applicable) _ _ _ _ _ _

Wholesaler mark up Stage 3)

7.25% 10.29% 6.51% 5.29% 11.82% 3.69%

Retailer mark up (Stage 4) 15.78% 16.06% 16.26% 19.04% 60.69% 71.80%

VAT (Stage 5) 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% Final price (Unit price in INR)

7.04 (0.704)

8.84 (0.884)

15.50 (1.550)

47.59 (3.172)

8.80 (0.880)

19.50 (1.950)

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Table 22: Percent contribution of each stage of the supply chain to final patient price in the private sector

Ranitidine 150mg Manufacturer Cadila J.B. chemical GSK Cyber

Pharma Panm

Pharma Product type Branded Branded Originator

Brand* Branded –

generic Branded –

generic MSP/CIF including C&F agent mark up (Stage 1)

72.12% 72.17% 71.03% 54.53% 39.32%

Stage 2 (not applicable) _ _ _ _ _

Wholesaler mark up (Stage 3)

7.26% 7.22% 9.36% 11.09% 10.80%

Retailer mark up (Stage 4) 15.85% 15.84% 14.85% 29.62% 45.12%

VAT (Stage 5) 4.76% 4.76% 4.76% 4.76% 4.76% Final price (Unit price in INR)

7.57 (0.504)

10.10 (0.505)

15.29 (0.51)

5.50 (0.550)

15.00 (0.500)

* Originator brand is also a type of branded medicine.

Table 23: Percent contribution of each stage of the supply chain to final patient price in the private sector

Erythromycin Suspension 125mg/5ml Manufacturer IPCA Abbott Alembic Biochem Product type Branded Originator

Brand* Branded Branded –

generic MSP/CIF including C&F agent mark up (Stage 1) 72.01% 77.28% 77.23% 58.02%

Stage 2 (not applicable) _ _ _ _ Wholesaler mark up (Stage 3) 6.37% 8.25% 6.74% 8.44%

Retailer mark up (Stage 4) 16.86% 9.70% 11.26% 28.77%

VAT (Stage 5) 4.76% 4.76% 4.76% 4.76% Final price (unit price in INR)

22.30 (0.3716)

20.10 (0.3352)

30.10 (0.5017)

21.20 (0.3333)

* Originator brand is also a type of branded medicine. Note for Table 17-23: Medicines in India are known as “branded” and “branded-generics” but both describe generic medicines. All products carry a brand (trade) name. Branded medicines are manufactured by reputed companies and are marketed by the manufacturer’s medical representatives to prescribers, are more popular and are the most-sold medicines. “Branded-generics” more closely resemble what are globally referred to as ‘generics’. Branded-generic medicines have less name recognition, and it falls on the retail pharmacy to promote the medicine.

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DISCUSSION

The present study is perhaps the only study that compares the procurement prices and availability of a basket of essential medicine for three health care providers of public sector in single state of India. The study also surveyed the medicine price and availability in the private sector, from the traditional retail pharmacy shops and recently introduced chain pharmacies. The WHO/HAI survey methodology used is a well established standardized methodology (5-7). The common list of core medicines with specified dosage forms and strengths allows for more reliable international comparisons, whereas supplementary medicines identified at the local/country level ensures local relevance. For the present survey one of the objectives was to measure the availability and price of various antibiotics in public and private sector, therefore out of 20 supplementary medicines, 17 were antibiotics for adults and children. Two inhalers, budesonide and budesonide+formoterol were included to the two inhalers (beclomethasone and salbutamol) already mentioned in the core medicines. An earlier study reported that in India consumption and use of budesonide inhaler is relatively more than beclomethasone inhaler and consumption of fixed dose combination of budesonide with formoterol is increasing over the years (8). Rational treatment of acute diarrhoea in children is still a matter of concern in India. WHO recommends and listed zinc sulphate dispersible tablet as one of the essential medicines for treatment of acute diarrhoea in children, thus, this medicine was added in the supplementary list of medicines.

Despite its strengths, the WHO/HAI methodology has few limitations. First, availability and price are determined for a specific list of survey medicines, and do not account for alternate dosage forms of these medicines or therapeutic alternates. However, for few medicines the alternative therapeutic medicine or dose strength can be added in supplementary list of medicines. Second, differences in quality across products, and differences in patent status between countries are not accounted for. In India, till 2005, product patent was not applicable under TRIPS agreement, only process patent was applicable. Thus, in India, pharmaceutical companies could manufacture the patent product or originator brand just by respecting the process patent. In real sense, all the medicines available in India are generics. For each product, there are multiple manufacturers and every pharmaceutical company give a brand (trade) name to their product. In India, medicines are known as “branded” and “branded-generics” but both describe generic medicines. Branded medicines are manufactured by a multinational or an Indian manufacturer. Branded medicines are more popular and are the most-sold medicines in India. Many-a-times, popular branded medicines in India are more costly than the internationally recognized originator brand and sometimes originator brand is not available but the product is manufactured by other companies. The methodology suggests collecting data for two versions of each medicines, originator brand, recognized internationally,

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already identified and the lowest-priced generic to be identified at each facility. For this survey, because of the situation mentioned above, a third version for each medicine, highest-priced generic was introduced apart from the two versions suggested by the methodology. For 30 core medicines, all three versions were surveyed, originator brand, highest-priced generic, and lowest-priced generic. It was found that the availability of OB was poor; the highest-priced generics are the so called branded products in India are more popular, sometimes more expensive than the OB. For 20 supplementary medicines, highest-priced and lowest-priced generics were surveyed. The highest-priced survey version could have the so called originator brand included for these 20 medicines.

Availability data only refer to the day of data collection at each facility and might not indicate average availability of medicines over time. However, since survey is done in several facilities over a period of time (2-3 months), the data provide a reasonable estimate of the overall situation and are indicative of the real-life situation faced by the patients on a daily basis.

Delhi spans a relatively small geographical area as compared to other Indian states. Therefore, a more detailed study that samples a larger percentage of public and private facilities was possible. Since Delhi is the capital of the country, meetings and rapid dissemination of results to regulatory agencies and policy makers is possible. Required interventions can be planned for different stakeholders to increase access to essential medicines and regulate availability of essential antibiotics for different level of health care facilities.

The survey revealed several important findings that deserve more consideration.

5.1 Public sector

5.1.1 Variation in procurement price by different public sector agencies: All the three central procurement agencies, CPA (GNCT, Delhi), MCD, and MSO (central government) have two-stage tender system, a technical qualification precedes the rate fixed with the company with lowest priced. The median procurement MPR for all the agencies was reasonable as compare to international reference price. However, for certain medicines like ceftriaxone injection, diazepam, and amoxicillin+clavulanic acid the price variation was huge in these three different procurement agencies. The central procurement agency for central government was procuring only 12 medicines out of 50 surveyed. It was found since the number of medicines procured by MSO is less therefore all the three tertiary care facilities under central government make their own parallel procurement. One teaching facility, Lady Hardinge (LH) medical college and associated hospitals has its own tender system and the other two hospitals, Safdurjung Hospital (SH) and R.M.L. Hospital floats a combined tender. Invariably the procurement price of surveyed medicines was higher for these two agencies

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than the central procurement agencies. For quite a few of medicines, like, atenolol, diclofenac, enalapril, fluoxetine, metformin, and phenytoin the procurement price of LH was much higher than other agencies. One of the important reasons could be the quantity of medicines purchased for single facility would be less than for two facilities or combined requirement of facilities of Delhi state or facilities under MCD. The median MPR for three central procurement agencies was between 0.53 - 0.61, the median MPR for local tenders for tertiary care hospitals was 0.69 and 0.82. This finding clearly shows the impact of pooled procurement. It is well established that pooled procurement decreases the medicines prices. Earlier six surveys conducted simultaneously in 2004 in five states of India using WHO/HAI methodology showed median MPR in the range of 0.27 – 0.48 for core medicines (6). The median MPR for core medicines in this study for GNCT Delhi was found to be 0.48. It appears that prices of medicines have increased in India compared to international reference price over the years.

Policy options: The procurement agencies should keep each other advised on their system and the rate list. A common list of “white-company” could be one possibility. The central procurement agency of Central Government, MSO can be more efficient to procure good number of medicines for its facilities. The three facilities under central government can combine their requirement of medicines, making a list on the basis of national essential medicines list, and opt for pooled procurement. These three tertiary care facilities can check the rate list of other public sector agencies of Delhi like, CPA and MCD before finalizing their rate. Government of NCT Delhi and MCD can have a common list of essential medicines for dispensaries, secondary care and tertiary care facilities which can decrease the replication of work.

Governments are also in strong positions to use their powers to exempt themselves from VAT that is paid on procurement price fixed by the government agencies. This can save not only paper work, manpower but money that can be used to buy more essential medicines.

5.1.2. Poor availability of surveyed medicines: In all public facilities lowest price generics were available and medicines are provided free to all patients who visit and have prescription from the facility. The situation of availability of surveyed medicines in all the public sector was poor. The overall mean availability in facilities run by GNCT was 41% and for MCD it was 23%. The mean availability for essential medicines listed by GNCT, Delhi was 49% whereas for MCD the mean availability of medicines for which they had rate control was 34%. The availability scenario at tertiary care facilities for GNCT, MCD, and central government was also not good; though the mean availability was little better than primary health care (dispensaries).

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The positive finding is that two medicines for hypertension, amlodipine and atenolol availability was good in all public facilities. Availability of medicines for other chronic diseases, like asthma, antipsychotic agents, and hyperlipidemia was very poor. Budesonide and salbutamol inhalers are on EML of GNCT, Delhi but they are not in the procurement list of other agencies. Earlier surveys conducted in six states of India have shown that except for Rajasthan, none of the other states like Haryana, Karnataka, Maharashtra, Tamil Nadu, and West Bengal had any inhalers on their procurement list in the survey year 2004 (8). Antipsychotic agents studied, amitriptyline and fluoxetine are on Delhi state EML but not on the procurement list of MCD. Earlier surveys conducted in various states of India have also shown poor availability of medicines in public sector (6, 7).

Mean availability of paracetamol suspension was good in all public facilities, though at MCD it was 75%. Other important finding was that dispersible tablet for zinc sulphate was not procured by any agency though WHO recommends this medicine for treatment of acute diarrhoea in children.

Many antibiotics were available at dispensaries of GNCT Delhi. The availability for antibiotics that are listed in EML for dispensaries was norfloxacin (84%), amoxicillin (72%), and doxycycline (50%), erythromycin (44%), cephalexin (44%), and ciprofloxacin (38%). Other second or third generation antibiotics which are not listed in the EML for dispensaries but were found at dispensaries, cefuroxime axetil (44%), roxithromycin (41%), ofloxacin (38%), cefixime (22%), and amoxicillin+clavulanic acid (22%). In dispensaries run by MCD, availability of newer antibiotics was better compared to some older antibiotics, the availability pattern was ciprofloxacin (72%), doxycycline (69%), amoxicillin+clavulanic acid (53%), cefuroxime axetil (47%), ofloxacin (47%), cefixime (25%), cephalexin (19%), amoxicillin (19%), roxithromycin (8%), norfloxacin (3%), and erythromycin (0%). These findings clearly show that essential medicine list for dispensaries and hospitals need to be developed and implemented too. Findings support the need to develop standard treatment guidelines and promote antibiotic use according to the treatment guidelines. For Delhi government dispensaries there is EML for dispensaries and that does not list many of the antibiotics that were found at dispensaries. As regard the antibiotics for children are concerned, at GNCT Delhi run dispensaries, amoxicillin 250 mg (81%), amoxicillin suspension (62%), cephalexin syrup (53%), co-trimoxazole suspension (41%), erythromycin suspension (41%), and amoxicillin+clavulanic acid (31%) were available. At dispensaries run by MCD, the availability pattern was amoxicillin+clavulanic acid (58%), co-trimoxazole suspension (33%), and amoxicillin 250 mg (31%). This pattern of availability stressed the need for improving availability of first generation antibiotics for children.

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Policy options: There are likely to be various causes for low availability of medicines in public sector. One of the important reasons is governments may be under-budgeting and not providing enough funds to meet the demand. So one of the options is that government or policy makers to take measures to increase the budget for procuring medicines. The other important policy options to improve the situation are, having essential medicine list, revising the list at regular intervals with criteria laid down by WHO, having a separate EML for dispensaries and hospitals. Purchasing medicines on the basis of EML and strictly adhering to EML for dispensaries and hospitals for distribution of medicines. Development and use of standard treatment guidelines will ensure rational use of medicines and the stock outs for newer antibiotic/medicines will decrease. A good quantification method, good supply and distribution system will enhance availability of medicines. Regular workshops and seminars should be conducted for pharmacists, purchase officers, stores-in charge, and dispensaries-in charge for quantification of drug requirements, ability to forecast accurately, and for medicine supply chain management. Regular training programs including workshops and seminars for doctors should be conducted on the use of cost effective medicines, adhering to standard treatment guidelines and appropriate antibiotics use.

5.2 Private sector

Data was collected from traditional private retail pharmacies, generally called chemist shops in Delhi and recently introduced chain pharmacies. Findings revealed that availability of originator brand, branded and branded-generics and price of these medicines were similar at both the types of pharmacies. Therefore, retail pharmacy shops have a good competition from the chain pharmacies.

5.2.1 Availability and price: Availability of medicines in the private sector was consistently higher, though the higher prices of medicines could hinder the access. Generics were more widely available than originator brands. As mentioned earlier, in India, branded medicines are more popular and originator brands (OBs) are not recognized as the brand. Originator brands if available are in the same league as the branded products manufactured and pushed by reputed companies. In fact, this survey has shown OB to be slightly cheaper than the highest-priced generics (branded products). Highest-priced generics or branded medicines were expensive than the lowest-priced generics available at the retail outlets. But for many medicines, only one version of the product was available that may be the costly or branded medicines therefore, patient has no choice but to buy that particular costly branded medicine. This was commonly observed for medicines like ceftriaxone injection, cefuroxime axetil, diclofenac, doxycycline, norfloxacin, and roxithromycin. This indicates that doctors are prescribing mainly the branded medicines that are pushed by the companies through their representatives. Pharmacists will stock those medicines for which they usually get prescriptions. Though for these same

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medicines other generic versions are available and are comparatively cheaper but those versions (branded-generics) are usually not stocked by pharmacies.

A huge price variation between various products for the same molecule was seen for amlodipine, amitriptyline, amoxicillin+clavulanic acid syrup, ciprofloxacin, diclofenac, doxycycline, and ofloxacin. Regulators have kept the free market for a good competition that should bring down the prices but the results of the survey clearly show that this logic is not applying to medicines like it is for electronic market.

Over the years, it appears that medicine prices have gone up as the surveys conducted in 2004 showed that the median MPR for core medicines was below 2, whereas this survey in 2011 shows median MPR to be 4.71, 5.72, and 3.11 for OB, HPG, and LPG for core medicines. For example, if we compare the median MPR for certain medicines in private sector during 2003 for Rajasthan survey ( 7) compared to 2011 Delhi survey, almost all the medicines have a higher median MPR, e.g., amitriptyline (OB and LPG) 5.35 and 4.27 vs. 9,84 and 5.48; amoxicillin (HPG and LPG) 4.65 and 4.55 vs. 7.45 and 7.21; atenolol (OB, HPG, LPG) 5.74, 4.57, 4.53 vs. 8.13, 7.83, 7.07; ceftriaxone inj. 0.38 vs. 2.24; diclofenac (OB, HPG, LPG) 4.92, 4.18, 4.18 vs. 16.51, 9.17, 8.07; fluoxetine (HPG, LPG) 2.20, 2.05 vs. 8.90, 6.99; glibenclamide (OB) 2.82 vs. 7.18. These trends clearly show that medicine prices have increased in India in comparison to international reference price over the years.

Huge price differences were observed for a few medicines between public and private sector: We expect a price difference between public procurement price and medicine price at retail pharmacies. Overall, the median MPR for 41 medicines procured by all the five public sector agencies was 0.59 and for the same medicines the median MPR for lowest-priced generic in the private retail shops and chain pharmacies was 2.83 and 3.12. We found that overall medicines in the private sector to be five time the cost of public procurement, which seems unexpectedly high. However, for certain medicines like diazepam, amlodipine, atenolol, enalapril, diclofenac, glibenclamide the price at private retail pharmacies was 28, 23, 22, 16, 14, and 12 times higher than the median procurement price of these medicines by all the five public sector agencies. A similar finding for diazepam and diclofenac was observed for earlier surveys in 2003 and 2004 at six different states of India (6, 7). These findings give a clue that in the supply chain from manufacturer to retailer, one actor or all have huge mark-ups. Interestingly and unfortunately all those medicines that have shown huge price difference are used for various chronic diseases. In India, incidence of chronic diseases is increasing, indicating an epidemiological transition (15). Patients require long term therapy with medicines for control of chronic diseases. As the expenditure on medicines is out of pocket, patients on treatment for chronic diseases find it difficult to afford the medicines. Increase

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emphasis should be placed by government and policy makers on reducing the cost of these medicines.

Findings for high-end or reserve antibiotics showed that these antibiotics were frequently available at retail chain pharmacies. Two oral preparations, moxifloxacin and gemifloxacin and injection meropenem was also available at retail pharmacy shops. The shops who had stocked these antibiotics were not near to any big public or private hospital but were mostly in the peri-urban areas. The price of gemifloxacin and moxiflocain is not very high as compared to other usually prescribed antibiotics by doctors like amoxicillin+clavulanic acid and cefuroxime. Therefore, regulators should implement the suggested recommendations laid down in the national policy for containment of antimicrobial resistance (16) to dispense third generation antibiotics or high-end antibiotics on prescription of a specialist or on a prescription from a tertiary care hospital.

Policy options: Several policy options are available for regulators, prescribers and patients that can improve access to essential medicines. Policy options related to mark-ups will be dealt in the price component section. Availability of only one version of the medicines at retail pharmacies indicate that probably prescribers are prescribing that particular ‘brand’ or there is incentive for the pharmacist to sell that particular brand. Therefore, there is need to conduct quality of branded-generics or generics and publish it widely in scientific journals and newspaper, and publicize in other media. Government and academic institutes can be engaged to do quality testing and awareness program. Awareness program and workshops for doctors in the medical colleges and for their associations should be conducted where evidence for cost-effective medicines, results of survey showing price difference between various versions of medicines, quality of generics, affordability for treatment of chronic diseases must be addressed. In addition to increasing the confidence of doctors in generic medicines, awareness of pharmacists and patients must be addressed. Internet-based price lists, or prices with pharmaceutical company’s name should be published regularly in important newspaper or announced on television that will raise public awareness and empower people. Consumer awareness about medicine prices will be useful in bringing down the overall prices of medicines. Regulators to implement the rules for newer or high-end antibiotics strictly on prescription will decrease the misuse of antibiotics and will be helpful for containment of antimicrobial resistance.

5.3 Affordability

Government is supposed to provide health care to all citizens, however, in India 80% of population spends out-of-pocket for their health care including medicines. This survey has shown poor availability of surveyed essential medicines in the public sector facilities. So even if patients visit public facility they end up buying medicines from private retail pharmacies.

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The daily wage of the lowest-paid government worker was used as a measure to estimate treatment affordability as this is universally available, reliable, and can be used to make international comparison. The daily wage was found to be INR 247 or $5.5. However, a large proportion of population in India earns less than this amount. Wages in unorganized sector are much less than the government sector. According to World Bank Report, the Gross National Income per capita in India is $1330/annum or $3.6 per day (17). It is reported that about 320 million people in India are working in unorganized sector and around 300 million people are unemployed (18).

With the lowest daily wage of government worker, treatments were not so affordable, e.g., adult respiratory pneumonia if treated with amoxicillin will cost 0.8 days salary and if treated with amoxicillin+clavulanic acid will cost 2.3 days of salary with highest-priced generic. Purchasing one inhaler each of budesonide and salbutamol costs 1.4 days of salary to the lowest paid government worker. However, the lowest paid government worker is substantially higher paid than majority of population. Further, the need for other mandatory expenditure like food, housing, and other family members living on this salary will change the affordability estimate. Affordability can be severely affected by multiple illnesses in the family or if the earning member is one to fall ill. Therefore, the information on affordability is to be interpreted with caution and should not impact on the potential for taking policy decision for medicine prices in India.

5.4 Price components

Survey on price components has given an insight into the entire supply chain and how all the actors in the chain are benefited without any consideration for the patient. A clear picture how final price is made was determined by collecting data for both branded medicines for which pharmaceutical company plays an active role to push its sales and for branded-generic (generic) medicines which are mainly sold in peri -urban and rural areas and are pushed or marketed by the retailer themselves. Many-a-times branded-generic medicines are given by dispensing doctors, unqualified doctors or by pharmacists themselves. There are few wholesalers who mainly deal with only branded-generic (generic) medicines. Data was collected from one of such wholesaler to get a complete picture of supply chain and strategies of pharmaceutical companies. Data was collected for different dosage forms, including injection, tablet/capsule, suspension, medicines for acute and chronic diseases and for medicines whose price is controlled under DPCO (Drug Price Control Order) and medicines whose price is not fixed or control by the government. Medicine prices are set in one of two ways. The Drug Price Control Order 1995 (DPCO) (19) identifies active pharmaceutical ingredients (APIs) for which a pricing formula is used to set the Maximum Retail Price (MRP). The medicines whose prices are set with this

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formula are called “scheduled medicines”. DPCO has 74 molecules as schedule medicines but include a few essential medicines. The National Pharmaceutical Pricing Authority (NPPA) under the Department of Pharmaceuticals (DoP) is tasked with monitoring that prices are consistent with the formula.

For all other medicines – called “non-scheduled medicines” – the manufacturer sets the price and registers that price with the NPPA. In theory, market forces should control the prices of non-scheduled medicines; with over 20,000 generic manufacturers in India, there should be sufficient competition to keep prices down. The NPPA monitors the prices of non-scheduled medicines do not rise more than the allowed 10% in one year.

For scheduled medicines, the NPPA pricing formula sets the minimum mark-ups for wholesalers – 8% – and retailers – 16%. For non-scheduled medicines, these minimum markups are not set, but several informants reported that for branded medicines they average around 10% and 20% for wholesalers and retailers respectively.

The C&F agent receives a margin of 2-4% depending on the quantum of business he/she handles.

All products in India are printed with the MRP which is inclusive of 5% VAT. Medicines are almost always given at MRP rates, sometimes retail chemist shops near big hospitals offer 5% discount.

Trade schemes in the private sector

Trade schemes run between manufacturer, wholesaler and retailer. They take the form of “buy 10 get 1 free” (9.09% discount) or “buy 7 get 3 free” (30% discount); trade schemes were found for 4 of the 8 medicines surveyed: amoxicillin, ciprofloxacin, ceftriaxone, and omeprazole in 2007 (9) and three out of seven ceftriaxone, amoxicillin+clavulanic acid tablet, and omeprazole in 2011. These schemes in India run for extended periods of time

Scheduled medicine

The scheduled medicine surveyed was ranitidine and the originator brand, branded or branded-generic had almost the same MRP, not much price variation was seen. The margins for wholesaler and retailer were almost the same as established for branded products. For branded-generic version of ranitidine the retailer margin was higher than the branded but not as high as for non-scheduled medicine for which MRP is fixed by the pharmaceutical company. Ciprofloxacin is a scheduled medicine but this survey and earlier surveys (6,7) have shown that this scheduled medicine has huge price variation in MRP. The earlier price component study conducted in Delhi (9) had shown huge mark ups for branded generic version of ciprofloxacin and trade schemes were available for ciprofloxacin.

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Non-scheduled medicines

In India few essential medicines are under price control, for most of the medicines government does not fix the price. It is the manufacturer who decides the final price or prints the MRP and decides the price-to-wholesaler, price-to-retailer, and offer trade schemes. For all non scheduled medicines surveyed, the major portion of mark-up was for manufacturer for branded medicines and almost the same percentage of mark-up was for retailer in case of branded-generic (generic) medicines. Therefore, the main profit is for the actor who is pushing and responsible for promoting the sale of medicine, in case of branded product, it is the responsibility of pharmaceutical company and for branded-generic it is the retailer’s responsibility. Margin for wholesaler is usually between 7-11% for branded medicines and for branded-generic medicines the wholesaler’s margin is less, giving most of the margin to retailer to push and sell these medicines. Retailer is also enjoying the benefit of trade schemes offered by the manufacturer. In India, where pharmacist is often the prescriber and dispenser, he/she can easily choose which particular product to be sold to the patient. Moreover, sometimes by offering 5% discount on very high profit product to patient he can win the faith of patient.

Price variations in the manufacturer’s selling price between branded and branded-generic equivalents suggest that some branded medicines are priced well above their true manufacturing cost; instead prices are set at what the market will bear.

Price components for ceftriaxone injection revealed very interesting finding that the most popular branded medicine that is usually available on retail shops is offering 10+2 scheme and the mark-up for wholesaler was also comparatively more (11% vs. 7%) than the other branded product manufactured by another reputed company which was also offering 10+2 scheme. The particular branded version of ceftriaxone for which the margins for wholesaler and retailers were more, was usually found on the pharmacy shops. Another surprising finding for ceftriaxone injection was that the branded-generic product was printed with a higher MRP than the branded product. This finding we had observed in our previous study in 2007 (9). In 2007 study, the difference in MRP for branded and branded-generic was more than the present study and the scheme prevalent for branded was more lucrative, 2+1. The probable reason for generic injections to be costly is that these medicines are usually prescribed for inpatients or for critically ill patients and the pharmacies near big hospitals can easily sell these products to their relatives. These high priced branded-generic are generally stored by pharmacies near tertiary care hospitals. These pharmacies offer 5-10% discount to patients on MRP printed on such products and themselves make enormous profits. As such branded-generics have huge margins for retailers and if the medicine is expensive then the actual profit for retailer is enormous.

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Another important finding was that one company was manufacturing two versions of the product, amoxicillin+clavulanic acid with almost similar MRP or price to patient. However, the marketing strategy was different for both the products, one was like branded product but with huge margin to wholesaler (25%) and the other was branded-generic with good amount of margin (59%) to retailer. We have earlier reported (20) that the same company is manufacturing two versions for cetirizine, lansoprazole, and alprazolam and for these products the retailer margin was 1016%, 201%, and 415%. In India, many other pharmaceutical companies manufacture two versions of the same medicines with different price structure (20).

Patients buying medicines in the private sector do not benefit from cost-effective medicines available. Doctors prescribe by trade name, whether branded or branded-generic medicine and substitution is legally not allowed. None of the stakeholders is bothered for the cost of therapy or affordability for the end consumer or patient. Patient awareness and doctor awareness about different versions and their corresponding price is minimal. The lack of a generic substitution policy means that brand name medicines control the market. Doctors prescribe the brand name medicine that give them the most benefit; pharmacists sell what the doctor prescribed; pharmacists on their own give the particular medicine that gives maximum profit to them; and patients are forced to buy the medicine regardless of price, even when lower-priced equivalents are available. The fragmentation of the market by brand name means that prices do not reach a natural equilibrium.

The model of medicine distribution or sale is changing in India. Many big corporate houses are coming into the market and opening their chain pharmacies. The result of the survey showed not much difference in the price and availability of medicines stocked in traditional retail pharmacy shops and the chain pharmacies. But these chain pharmacies are offering discounts in other forms by making a card for the customers and giving reward points for every purchase to be redeemed later. Moreover, the chain pharmacy is neatly stacked with medicines and the staff is courteous. The chain pharmacies are growing in number. These chain pharmacies may be a threat to the current private sector distribution system in more than one way. First, independent retail pharmacies will find it hard to compete with large companies such as Apollo, Ranbaxy and Reliance, especially in terms of price negotiation and trade terms. Second, the wholesalers will also feel themselves squeezed out, as major manufacturers supply direct to the chain pharmacies, leaving the wholesaler handling small quantities of less expensive branded-generic medicines.

Medicines are also subject to a 5% VAT at all stages of the distribution line. Each level of VAT refunds the previous level, with the exception of the final point of sale – at the pharmacy when sold to the patient or when the public sector procurement office buys for their health

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units. This finding again supports that the customer is the only one penalized; these tariffs (including all duties on the raw material or excise duty) increase the revenue to the government. In fact, patients are also penalized in the public sector, as the VAT reduces the purchasing power of the public sector entity.

Policy options

The findings of the survey clearly show that the market competition does not seem to be driving medicine prices as low as possible. Presence of trade schemes also revealed that there is scope to decrease price of medicines. Findings revealed there is no transparency in fixing the MRP by the manufacturer. Manufacturer decides the mark-ups for wholesaler and retailers. Ministry of chemicals & fertilizer (MoC&F) and its department, Department of Pharmaceuticals (DoP) needs to bring about the transparency in the supply chain mark-ups. As the competition is not working for the prices of medicine market so the rules of free market needs to bend for pharmaceutical sector. Government to increase transparency in manufacturer set MRP. All the changes in distribution lines require re-evaluation of pricing structures and strict monitoring of medicine prices at the point of delivery.

Government need to develop policies that allow for generic substitution and generic prescribing. Regular training workshops should be conducted for the doctors, pharmacists and patients in generic substitution or for awareness about the cost-effective medicines for the same therapeutic class and for the same molecule. Increase consumer awareness of the wide range of quality-controlled generic equivalents and the benefits of generic substitution.

In order to achieve the lowest possible price for essential medicines, the current suggested formula for the new drug policy draft will not bring the prices of essential medicine down. May be the best option is to link it with the lowest procurement price of the same medicines in the public sector and keeping the price in the private sector fixed at 2 to 3 times the lowest procurement price in the country. In order to achieve this, greater collaboration and communication between the MoH&FW, researchers, civil society, and the MoC&F might be required.

Applying value added tax (VAT) or any other tax to the medicines essentially a tax on the sick. Government can easily removes these taxes on medicines to make medicines more affordable.

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CONCLUSIONS: SALIENT FINDINGS AND POLICY OPTIONS

A survey on measuring medicine prices, availability, affordability, and price components was conducted in National Capital Territory (NCT) of Delhi using a well established methodology of WHO/HAI. Data was collected for 50 medicines (30 core list of essential medicines listed by WHO/HAI and 20 supplementary medicines) from all eight districts of Delhi for both public and private sector from July-October 2011. For public sector data on procurement price and availability was collected from three main providers in NCT, Delhi: Government of NCT, Delhi (n=40), Municipal Corporation of Delhi (n=40) and tertiary care facilities of Central Government (n=3). For private sector data was collected from private retail pharmacies (n=40) and retail chain pharmacies (n=40). Prices were compared to an international reference benchmark and expressed as median price ratio (MPR).

6.1 Public sector

• Procurement prices were reasonable as compared to international reference price for all public sector agencies but variation in procurement price amongst agencies

• Generally local tenders of tertiary care facilities had higher prices than pooled procurement

• Availability of essential medicines was poor in all public sector facilities • Availability for certain pediatric preparations, asthma medicines, hypolipidemic and

antipsychotic was very poor and zinc tablet in dispersible form was not available • Newer, second and third generation antibiotics were available at dispensaries • Unreliable delivery from suppliers in public sector probably one of the important factors

leading to poor availability

6.2 Private sector

• In private sector, median MPR for surveyed medicines was in the range of 2.83 - 5.38 • The range for median MPR for medicines was from 0.56 – 16.51 • Highest MPRs for were found for off-patented medicines like diazepam, diclofenac,

doxycycline • For certain medicines huge price difference was observed for procurement and retail price,

e.g., the lowest priced generics at retail pharmacies for amlodipine was 23 times, atenolol 22, atorvastatin 14, diazepam 28, diclofenac 14, enalapril 16, glibenclamide 12, and omeprazole was 12 times higher priced compared to mean procurement priced for public sector

• For certain medicines huge price difference in highest priced and lowest priced generic was observed, viz, amitriptyline, amlodipine, diclofenac, simvastatin, amoxicillin+ clavulanic acid, doxycycline, cefixime, cefuroxime, and ofloxacin.

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6.3 Price components

• Government agencies pay 5% VAT and in the final price to patients in the private sector 5% VAT is included

• Margins for retailer were higher than established markups • For branded generics retailer markups were very high • Trade schemed ‘side step’ pharmaceutical pricing and extra margins for retailers • Wholesaler margins were almost at established markups • Actual profits for certain branded medicines were high • Trade schemes illustrate large manufacturer margins • High levels of competition for non-scheduled medicines does not guarantee lower prices • Brand loyalty, marketing strategies does not allow ‘real’ competition in the market

6.4 Policy options to improve access to essential medicines

• Procurement agencies to share procurement price and other related details with each other

• Public sector agencies like GNCT Delhi and MCD to work together for a common essential medicines list

• Training for quantification for pharmacists and drug store in-charge regarding amount of drugs for their facilities

• Developing and implement standard treatment guidelines for various levels of healthcare • Promote antibiotic use according to standard treatment guidelines • Checks and rules for reliable delivery from suppliers • Procurement agencies and facilities to monitor supplier performance closely • Government to remove VAT • Government to increase transparency in manufacturer set MRP • Include all essential medicines under the price control but with a good formula, may be

linking with lowest procurement price in the public sector • Establish a working group (from MoH & FW, DCGI, MoC&F, private sector, academics

and NGOs) to improve access to essential medicines • Government to review the draft pricing policy carefully to decrease prices of essential

medicines • High-end antibiotics or reserve antibiotics to be dispensed with prescription of a specialist

doctor of a tertiary care hospital • Increase consumer awareness regarding medicine prices and affordable generic equivalents • Train doctors, pharmacists and patients in generic substitution and cost effective generics

59

REFERENCES

1. Hogerzeil H. Access to essential medicines as a human right. Essential drug monitor 2003; 33:25-26.

2. Everard M. Access to medicines in low-income countries. In: Dukes M.N.G, Haaijer-Ruskamp, Joncheere, Rietveld,eds., Drugs and Money. The Netherlands : IOS Press Ohmsha (Published on behalf of WHO Regional office Europe), 2003.

3. Creese A, Kotwani A, Kutzin J, Pillay A. Evaluating pharmaceuticals for health policy in low- and middle-income country settings. In: Freemantle N, Hill S edrs. Evaluating pharmaceuticals for health policy and reimbursement. Massachusetts, U.S.A: Blackwell Publishing (in collaboration with WHO, Geneva), 2004.

4. Measuring medicine prices, availability, affordability and price components. World Health Organization and Health Action International. 2nd edition, Switzerland, 2008. Available from: www.haiweb.org/medicineprices.

5. Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet 2009; 373: 240-249.

6. Kotwani A, Ewen M, Dey D et al. Medicine prices and availability at six sites in India: using the WHO-HAI methodology. Indian Journal of Medical Research 2007; 125: 645-654.

7. Kotwani A, Gurbani N, Sharma S, Chaudhury R. Insights for policymakers from a medicine price survey in Rajasthan. Indian Journal of Medical Research 2009; 129: 451-454.

8. Kotwani A. Availability, price, and affordability of asthma medicines in five Indian states. International Journal of Tuberculosis and Lung Diseases 2009; 13: 574-579.

9. Kotwani Anita, Levison Libby. Price components and access to medicines in Delhi, India. (Project Report) Available at: http://www.dfidhealthrc.org/publications/access_medicines. html

10. World Health Organization. 2009. Community-based surveillance of antimicrobial use and resistance in resource-constrained settings. Report on five pilot projects. http://www.who.int/medicines/publications/who_emp_2009.2/en/index.html

60

11. Kotwani A, Holloway K, Roy Chaudhury R. Methodology for surveillance of antimicrobials use among out-patient in Delhi. Indian Journal of Medical Research 2009; 129: 555-60.

12. Wattal C, Raveendran R, Kotwani A, Sharma A, Bhandari SK, Sorensen TL, Holloway K. Establishing a new methodology for monitoring of antimicrobial resistance and use in the community in a resource poor-setting. Journal of Applied Therapeutic Research 2009; 7: 37-45.

13. Kotwani A, Holloway K. trends in antibiotic use in New Delhi, India. BMC Infectious Diseases 2011;11:(20 April 2011) http://www.biomedcentral.com/1471-2334/11/99

14. International Drug Price Indicator Guide. Cambridge, MA: Management Sciences for Health. http://erc.msh.org/dmpguide/index.cfm?search_cat=yes&display=yes&module=dmp&language=english&year=2010 Accessed July 13, 2011

15. Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366:1744-1749.

16. National Policy for containment of antimicrobial resistance. Ministry of Health and Family Welfare, Government of India. 2011. Available at http://www.ncdc.nic.in/ncdc_new/ab_policy.pdf

17. The world bank: GNI per capita, Atlas method (current US$). Available at http://data.worldbank.org/indicator/NY.GNP.PCAP.CD?display=default accessed on January 12, 2012

18. India Watch - i watch. Available at http://www.wakeupcall.org/administration_in_india/ poverty_line.php. Accessed on January 12, 2012

19. Drugs (Price Control) Order, 1995, Ministry of Chemicals and Fertilizers, Department of chemicals and petrochemicals, Government of India. 1995 Available at http://nppaindia.nic.in/drug_price95/txt1.html Accessed January 26, 2012

20. Singal G, Nanda A, Kotwani A. A comparative evaluation of price and quality of some branded versus branded-generic medicines of the same manufacturer in India. Indian Journal of Pharmacology 2011; 43: 131-136.

61

ANNEXURE 1

List of medicines surveyed

S. No. Medicine Name Medicine Strength Dosage Form

Medicine list

1 Amitriptyline 25 mg cap/tab Global 2 Amlodipine 5mg cap/tab Regional 3 Amoxicillin+clavulanic acid 500mg+125mg cap/tab Supplementary 4 Amoxicillin 500 mg cap/tab Global 5 Amoxicillin 250 250mg Tab/cap Supplementary 6 Amoxicillin suspension 25 mg/ml mililitre Regional 7 Amoxicillin+clavulanic acid Syrup 200mg+28.5mg/5ml mililitre Supplementary 8 Ampicillin Suspension 125mg/5ml mililitre Supplementary 9 Atenolol 50 mg cap/tab Global 10 Atorvastatin 10 mg cap/tab Regional 11 Azithromycin 500mg Tab/cap Supplementary 12 Beclomethasone inhaler 250 mcg/dose dose Regional 13 Benzathine Penicillin Powder 2.4MU/vial inj Supplementary 14 Budesonide inhaler 100mcg/dose dose Supplementary 15 Budesonide+Formoterol inhaler 100mcg+6mcg/dose dose Supplementary 16 Captopril 25 mg cap/tab Global 17 Cefixime 200mg Tab/cap Supplementary 18 Ceftriaxone injection 1 g/vial vial Global 19 Cefuroxime axetil 250mg Tab/cap Supplementary 20 Cefuroxime Suspension 125mg/5ml mililitre Supplementary 21 Cephalexin 500mg Tab/cap Supplementary 22 Cephalexin Syrup 250mg/5ml mililitre Supplementary 23 Ciprofloxacin 500 mg cap/tab Global 24 Clotrimazole topical cream 1% gram Regional 25 Co-trimoxazole suspension 8+40 mg/ml mililitre Global 26 Diazepam 5 mg cap/tab Global 27 Diclofenac 50 mg cap/tab Global 28 Diethylcarbamazine citrate 50 mg cap/tab Regional 29 Doxycycline 100 mg cap/tab Regional 30 Enalapril 5mg cap/tab Regional

62

S. No. Medicine Name Medicine Strength Dosage Form

Medicine list

31 Erythromycin powder for suspension

125mg/5ml mililitre Supplementary

32 Erythromycin Stearate 250mg Tab/cap Supplementary 33 Fluoxetine 20 mg cap/tab Regional 34 Gentamicin eye drops 0.3% mililitre Regional 35 Gentamicin injection 40mg/ml amp Supplementary 36 Glibenclamide 5 mg cap/tab Global 37 Gliclazide 80 mg cap/tab Regional 38 Ibuprofen 400 mg cap/tab Regional 39 Metformin 500 mg cap/tab Regional 40 Metronidazole 400 mg cap/tab Regional 41 Norfloxacin 400mg Tab/cap Supplementary 42 Ofloxacin 200mg Tab/cap Supplementary 43 Omeprazole 20 mg cap/tab Global 44 Paracetamol suspension 24 mg/ml mililitre Global 45 Phenytoin 100 mg cap/tab Regional 46 Ranitidine 150 mg cap/tab Regional 47 Roxithromycin 50mg Tab/cap Supplementary 48 Salbutamol inhaler 100 mcg/dose dose Global 49 Simvastatin 20mg cap/tab Global 50 Zinc sulphate dispersible 20mg Tab/cap Supplementary

63

ANNEXURE 2

Availability of individual medicine by therapeutic class in various public sectors

Psychotherapeutic Medicines Medicines GNCT

Delhi (n=40)

MCD (n=40)

CGH (n=3)

LH RML SJH LNH HR

Amitriptyline 10.0% 0.0% 33.3% 100.0% 0.0% 0.0% 0.0% 0.0% Fluoxetine 2.5% 0.0% 66.7% 100.0% 0.0% 100.0% 0.0% 0.0% Anti-hypertensive Medicines Amlodipine 92.5% 90.0% 66.7% 100.0% 0.0% 100.0% 100.0% 100.0% Atenolol 85.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Captopril 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Enalapril 42.5% 47.5% 66.7% 100.0% 100.0% 0.0% 100.0% 0.0% Antimicrobial Medicines Amoxicillin+clavulanic acid 27.5% 52.5% 66.7% 100.0% 0.0% 100.0% 100.0% 100.0% Amoxicillin 250 82.5% 32.5% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% Amoxicillin 500 70.0% 20.0% 33.3% 100.0% 0.0% 0.0% 100.0% 100.0% Amoxicillin suspension 70.0% 5.0% 33.3% 100.0% 0.0% 0.0% 100.0% 0.0% Amoxicillin+clavulanic acid Syrup 30.0% 60.0% 0.0% 0.0% 0.0% 0.0% 100.0% 100.0% Ampicillin suspension 22.5% 2.5% 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% Azithromycin 2.5% 2.5% 33.3% 100.0% 0.0% 0.0% 0.0% 0.0% Benzathine Penicillin Powder 2.5% 0.0% 66.7% 0.0% 100.0% 100.0% 100.0% 0.0% Cefixime 20.0% 27.5% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% Ceftriaxone injection 12.5% 0.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% Cefuroxime axetil 50.0% 47.5% 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% Cefuroxime suspension 5.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Cephalexin 47.5% 20.0% 33.3% 0.0% 100.0% 0.0% 0.0% 0.0% Cephalexin syrup 47.5% 7.5% 33.3% 100.0% 0.0% 0.0% 100.0% 0.0% Ciprofloxacin 50.0% 72.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Co-trimoxazole suspension 35.0% 30.0% 66.7% 100.0% 100.0% 0.0% 0.0% 0.0% Doxycycline 52.5% 70.0% 33.3% 100.0% 0.0% 0.0% 0.0% 100.0% Erythromycin powder for suspension 40.0% 0.0% 66.7% 100.0% 100.0% 0.0% 0.0% 0.0% Erythromycin stearate 47.5% 0.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% Gentamicin injection 10.0% 0.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% Norfloxacin 82.5% 2.5% 100.0% 100.0% 100.0% 100.0% 0.0% 0.0% Ofloxacin 45.0% 47.5% 66.7% 100.0% 100.0% 0.0% 100.0% 100.0% Roxithromycin 47.5% 7.5% 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% Hypo-cholestrol Medicines Atorvastatin 27.5% 2.5% 33.3% 100.0% 0.0% 0.0% 100.0% 100.0% Simvastatin 2.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

64

Medicines GNCT Delhi (n=40)

MCD (n=40)

CGH (n=3) LH RML SJH LNH HR

Inhalers Beclomethasone inhaler 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Budesonide inhaler 22.5% 5.0% 33.3% 100.0% 0.0% 0.0% 100.0% 0.0% Budesonide+Formoterol inhaler 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Salbutamol inhaler 85.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% Anti-Fungal Medicines Clotrimazole topical cream 62.5% 2.5% 33.3% 0.0% 0.0% 100.0% 100.0% 0.0% Sedative Medicines Diazepam 10.0% 5.0% 100.0% 100.0% 100.0% 100.0% 0.0% 0.0% Anti-Filarial Medicines Diethylcarbamazine citrate 2.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Analgesics Medicines Diclofenac 35.0% 7.5% 66.7% 100.0% 100.0% 0.0% 100.0% 0.0% Ibuprofen 92.5% 15.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% Paracetamol suspension 97.5% 75.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Anti-Diabetic Medicines Glibenclamide 77.5% 42.5% 33.3% 100.0% 0.0% 0.0% 0.0% 0.0% Gliclazide 0.0% 35.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Metformin 60.0% 70.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Ophthalmological Medicine Gentamicin eye drops 62.5% 12.5% 66.7% 100.0% 0.0% 100.0% 100.0% 0.0% Anti-Protozoal Medicine Metronidazole 57.5% 32.5% 66.7% 100.0% 0.0% 100.0% 0.0% 0.0% Anti-Ulcer Medicines Ranitidine 85.0% 17.5% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% Omeprazole 85.0% 85.0% 66.7% 100.0% 0.0% 100.0% 100.0% 100.0% Anti-Epileptic Medicine Phenytoin 60.0% 15.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Pediatric preparation Amoxicillin suspension 70.0% 5.0% 33.3% 100.0% 0.0% 0.0% 100.0% 0.0% Amoxicillin+clavulanic acid Syrup 30.0% 60.0% 0.0% 0.0% 0.0% 0.0% 100.0% 100.0% Ampicillin suspension 22.5% 2.5% 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% Cefuroxime suspension 5.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Cephalexin Syrup 47.5% 7.5% 33.3% 100.0% 0.0% 0.0% 100.0% 0.0% Co-trimoxazole suspension 35.0% 30.0% 66.7% 100.0% 100.0% 0.0% 0.0% 0.0% Paracetamol suspension 97.5% 75.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Zinc sulphate dispersible 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% GNCT Delhi: Government of NCT Delhi; MCD: Municipal Corporation of Delhi; CGH: Central Government Hospitals; LH: Lady Hardinge Medical College and Hospital; RML: Ram Manohar Lohia Hospital; SJH: Safdarjung Hospital; LNH: Lok Nayak Hospital; HR: Hindu Rao Hospital

65

ANNEXURE 3

Availability of medicine surveyed in different versions in private sector

OB HPG LPG Medicine Name Medicine list Retail*

(n=40) Chain# (n=40)

Retail (n=40)

Chain (n=40)

Retail (n=40)

Chain (n=40)

Amitriptyline Global 65.0% 80.0% 2.5% 0.0% 12.5% 12.5% Amlodipine Regional 52.5% 60.0% 82.5% 90.0% 95.0% 100.0% Amoxicillin+clavulanic acid Supplementary NS** NS 95.0% 100.0% 100.0% 100.0% Amoxicillin Global 0.0% 0.0% 95.0% 92.5% 97.5% 100.0% Amoxicillin 250 Supplementary NS NS 72.5% 97.5% 92.5% 100.0% Amoxicillin suspension Regional 0.0% 0.0% 57.5% 70.0% 95.0% 92.5% Amoxicillin+clavulanic acid Syrup Supplementary NS NS 62.5% 90.0% 92.5% 92.5% Ampicillin Suspension Supplementary NS NS 2.5% 0.0% 2.5% 0.0% Atenolol Global 45.0% 45.0% 67.5% 92.5% 97.5% 100.0% Atorvastatin Regional 12.5% 30.0% 87.5% 85.0% 97.5% 95.0% Azithromycin Supplementary NS NS 95.0% 97.5% 100.0% 100.0% Beclometasone inhaler Regional 5.0% 0.0% 0.0% 0.0% 35.0% 37.5% Benzathine Penicillin Powder Supplementary NS NS 0.0% 0.0% 0.0% 0.0% Budesonide inhaler Supplementary NS NS 7.5% 10.0% 62.5% 82.5% Budesonide+Formeterol inhaler Supplementary NS NS 0.0% 0.0% 42.5% 27.5% Captopril Global 0.0% 0.0% 0.0% 0.0% 10.0% 10.0% Cefixime Supplementary NS NS 80.0% 95.0% 97.5% 100.0% Cefriaxone injection Global 0.0% 0.0% 2.5% 5.0% 47.5% 42.5% Cefuroxime axetil Supplementary NS NS 55.0% 60.0% 90.0% 100.0% Cefuroxime Suspension Supplementary NS NS 2.5% 0.0% 55.0% 50.0% Cephalexin Supplementary NS NS 32.5% 30.0% 65.0% 80.0% Cephalexin Syrup Supplementary NS NS 22.5% 22.5% 50.0% 40.0% Ciprofloxacin Global 0.0% 0.0% 85.0% 92.5% 100.0% 100.0% Clotrimazole topical cream Regional 50.0% 55.0% 10.0% 17.5% 50.0% 67.5% Co-trimoxazole suspension Global 5.0% 10.0% 0.0% 0.0% 77.5% 67.5% Diazepam Global 35.0% 52.5% 5.0% 2.5% 37.5% 57.5% Diclofenac Global 97.5% 97.5% 10.0% 12.5% 65.0% 82.5% Diethylcarbamazine citrate Regional 12.5% 10.0% 0.0% 0.0% 10.0% 10.0% Doxycycline Regional 0.0% 0.0% 55.0% 60.0% 97.5% 95.0% Enalapril Regional 0.0% 0.0% 42.5% 32.5% 92.5% 97.5% Erythromycin powder for suspension Supplementary NS NS 15.0% 15.0% 55.0% 55.0% Erythromycin Stearate Supplementary NS NS 35.0% 25.0% 82.5% 85.0% Fluoxetine Regional 0.0% 0.0% 42.5% 62.5% 80.0% 92.5%

66

OB HPG LPG Medicine Name Medicine list Retail*

(n=40) Chain# (n=40)

Retail (n=40)

Chain (n=40)

Retail (n=40)

Chain (n=40)

Gentamicin eye drops Regional 5.0% 2.5% 2.5% 0.0% 65.0% 50.0% Gentamicin injection Supplementary NS NS 15.0% 17.5% 57.5% 50.0% Glibenclamide Global 65.0% 72.5% 0.0% 0.0% 5.0% 7.5% Gliclazide Regional 0.0% 2.5% 55.0% 67.5% 95.0% 97.5% Ibuprofen Regional 95.0% 82.5% 0.0% 0.0% 45.0% 40.0% Metformin Regional 0.0% 0.0% 82.5% 80.0% 97.5% 95.0% Metronidazole Regional 45.0% 52.5% 2.5% 5.0% 92.5% 95.0% Norfloxacin Supplementary NS NS 5.0% 0.0% 95.0% 97.5% Ofloxacin Supplementary NS NS 92.5% 97.5% 97.5% 100.0% Omeprazole Global 0.0% 0.0% 87.5% 95.0% 100.0% 100.0% Paracetamol suspension Global 62.5% 65.0% 20.0% 17.5% 90.0% 97.5% Phenytoin Regional 37.5% 45.0% 32.5% 40.0% 90.0% 95.0% Ranitidine Regional 95.0% 85.0% 82.5% 87.5% 97.5% 95.0% Roxithromycin Supplementary NS NS 17.5% 25.0% 92.5% 97.5% Salbutamol inhaler Global 52.5% 45.0% 7.5% 7.5% 92.5% 95.0% Simvastatin Global 42.5% 42.5% 2.5% 0.0% 40.0% 35.0% Zinc sulphate dispersible Supplementary NS NS 0.0% 0.0% 0.0% 2.5%

*Retail indicates the retail pharmacies shops and #Chain indicates retail chain pharmacies. OB – Originator Brand HPG – Highest priced generic LPG – Lowest priced generic **NS – Not surveyed

67

ANNEXURE 4

Treatment affordability

Daily wage of lowest paid government worker (in local currency): INR 247 Asthma Private Retail Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Salbutamol inhaler 100 mcg/dose as needed 200 Brand 98.00 0.4 HPG LPG 102.74 0.4 Diabetes Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Glibenclamide 5 mg Tab 30 60 Brand 65.43 0.3 HPG LPG Hypertension Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Atenolol 50 mg Tab 30 30 Brand 103.50 0.4 HPG 99.60 0.4 LPG 90.00 0.4 Hypertension Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Captopril 25 mg Tab 30 60 Brand HPG LPG 270.00 1.1 Hypercholesterolaemia Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Simvastatin 20mg Cap 30 30 Brand 540.00 2.2 HPG LPG 145.20 0.6

68

Depression Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Amitriptyline 25 mg Tab 30 90 Brand 300.60 1.2 HPG LPG 167.40 0.7 Adult respiratory infection Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Ciprofloxacin 500 mg Tab 7 14 Brand HPG 129.78 0.5 LPG 67.90 0.3 Paediatric respiratory infection Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Co-trimoxazole suspension 8+40 mg/ml 7 70 Brand HPG LPG 16.97 0.1 Adult respiratory infection Private Sector

Select Medicine Name Medicine Strength Treatment Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Amoxicillin 500 mg Tab/Cap 7 21 Brand HPG 202.65 0.8 LPG 195.93 0.8

Adult respiratory infection Private Sector

Select Medicine Name Medicine Strength Treatment Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Cefriaxone injection 1 g/vial 1 1 Brand HPG LPG 69.00 0.3

69

Anxiety Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Diazepam 5 mg Tab 7 7 Brand 19.25 0.1 HPG LPG 18.55 0.1 Arthritis Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Diclofenac 50 mg Tab 30 60 Brand 190.20 0.8 HPG 105.60 0.4 LPG 93.00 0.4 Pain/inflammation Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Paracetamol suspension 24 mg/ml 3 45 Brand 22.20 0.1 HPG 22.20 0.1 LPG 22.20 0.1 Ulcer Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Omeprazole 20 mg Tab/Cap 30 30 Brand HPG 174.60 0.7 LPG 125.00 0.5 Acute Respiratory Infection Private Sector Select Medicine Name Medicine Strength Treatment

Duration (in Days)

Total # of Units per Treatment

Product Type

Median Treatment Price

Days' Wages

Amoxicillin+clavulanic acid 500mg+125mg Tab/Cap 7 14 Brand HPG 562.33 2.3 LPG 167.86 0.7