Healthy Skepticism International News
January 2006
What can be done in India?
Abstract:
Anant Phadke’s suggestions for reform in India were used as a background paper for the Drug Action meeting in Mumbai in 2003.
Standardization of Medical Care
If people are to get the right kind of drugs at affordable prices, a rational drug policy is a must. In addition, the overall health-policy also has to be rational, because the quality of prescribing cannot be separated from the quality of health-care in general. Health care in India has a chaotic, mosaic pattern from faith heaters in the remote villages to five-star corporate hospitals in metropolitan cities. In the public sector, health-care delivery ranges from Anganwadi workers, ‘malaria doctors’ to super-specialists in teaching hospitals. There is neither standardization of medical care nor proper linkages between different types of health-services. A large part of the precious resources of the people are therefore squandered on irrational medical care. Patients are helpless in putting pressure on doctors to prescribe rationally. Medical science is vast and complicated and despite heightened consumer education, it is impossible for an average consumer in India to find out whether the treatment given by the doctor is rational or not.
Secondly, the doctor-patient relationship has its inherent politics. Doctors can legitimately explore all corners of patients’ body and mind and people seek the doctor’s services when they are unwell. It is more in the nature of seeking help than buying a service. When a patient is cured or relieved of the suffering due to the doctor’s treatment, there is a sense of gratitude in the patient’s mind. This is different from the ‘thank you’ given to say a mechanic who repairs your TV or your vehicle. These two factors make the patient quite vulnerable vis a vis the doctor. Hence it is difficult for patients to look critically at what doctors do and prescribe. Somebody else has to do the watch-dog work in the interest of the patients. Self regulation by professional organizations of doctors is one way out. In India, such a tradition hardly exists. A beginning has to be made by laying down minimum standards and by evolving consensus standard treatment guidelines under local conditions. This may pick up under the threat of the Consumer Protection Act because if a doctor follows standard guidelines, and yet a mishap occurs, the doctor is not morally and legally liable. Preparation and enforcement of standard treatment guidelines as decided by local professional organisations in view of local conditions would not infringe upon doctors clinical freedom, it would be in the interest of both doctors and patients.
Towards universal Health Insurance
The second step to serve the interests of both the doctors and patients is to have third party payment systems. If patients are insured and the insurance agency pays for the doctor’s bill, then doctor’s advice and prescription can be critically examined by a medical expert employed by the insurance agency to find out whether it deviates from standard guidelines. If the doctor has a valid justification for any deviation, that can also be accepted by the insurance agency. However, the private insurance companies would reach out to only the well to do. Even in the US more than 30% people have no health insurance cover. Moreover, multiple private insurance agencies have increased the administrative cost of health insurance in the US. In Canada and Australia on the other hand, there is a far more economical and yet universally available universal health insurance in which every citizen is by birth under health insurance. Patients go to the private practitioner but the government pays for most of the expenses at predetermined rates. Thus nobody is deprived of medical care on account of lack of purchasing power. But at the same time, there is scope for private practice. This system avoids the bureaucratism when doctors become paid employees of the state and also leaves scope for private initiatives. Bureaucratism is quite inimical in a sensitive and personalized service like medical care. The system of universal health insurance also avoids the problems of commercial competition amongst doctors; in the absence of commercial competition, doctors would get back the professional satisfaction of concentrating on proper diagnosis and treatment of patients to relieve his/her suffering.
It may be asked, whether India has the resources today to give health care insurance to everybody. The answer -is yes. We are already spending about 6% of our Gross Domestic Product (GDP) on health-care. But the state’s share is only 21% of this expenditure. This share is lower than that seen even in Bangladesh (33%) and Pakistan (53%). In most developed capitalist countries, this share is 70 to 80% and even in the U.S. - the supposed heaven of private medical care, the state’s share in total health-expenditure is 44%. (Sengupta, Amit 1994, table 1). To actualize the Alma Ata Declaration of ‘Health for All by 2000 A.D.’ the WHO has recommended that the 5% of GNP should be spent on health-care. When even the governments in Sri Lanka, Bangladesh, Pakistan can spend a higher proportion for health-care than private health-expenditure, why can’t the Indian government do this ? The people are already paying 4.5% of GDP in the private sector, if the government spends 5% of GDP on health-care by almost quadrupling its current health-expenses, then an additional special health-tax proportional to income, to meet the extra needs for a Universal Health insurance can be justified. Instead of paying directly to the often exploitative private sector as is done today, people would be wilting to pay a health-tax to the local government who could in turn pay the private practitioners as per negotiated, rational rate-structure. Thus without people having to pay more on health-care than what they are paying today, India can provide for expenses for a universal Health insurance of up to 9.5% of GDP. This much expense should suffice. Though higher in absolute terms, the health-expenditure in Japan, Germany, Canada, France is in the range of 4.5 to 9.5% of the GDP. What is needed in India is intensive public pressure on the Indian government to divert more resources towards health-care.
In terms of human-power, by the year 2000 A.D., as mentioned earlier, we should have had one MBBS doctor per 2000 population and one graduate doctor of some pathy per 1000 population. If this human power was rationally organized and the village Health workers and other paramedics were properly trained and supported, we would have enough trained human power to make health-care of fair quality accessible to all.
Rational Drug Policy
Regulation of medical care through Universal Health insurance would create a favourable framework for proper use of drugs. However, specific additional measures would be required to see that the right kind of drug are available and used in the right way. Let us deal with these measures briefly. These measures have been suggested in the various meetings of the All India Drug Action Network (AIDAN. AIDAN has been the coordinating agency of various groups in India lobbying for a rational drug policy, for the last 15 years).
1) Assessing Drug Needs - There is a need to conduct systematic studies in different parts of India of the extent of various health-problems in the community. The existing studies are too inadequate in scope and are mostly clinic based. Comprehensive studies that record prevalence of all common health problems at the community level would form the basis of estimating the drug-needs in India.
2) Ban on irrational drugs - Only those drugs recommended by standard medical text books or by other such standard sources should be allowed to be marked. All others should be banned.
3) Essential Drugs List - This would be the single most important measure to make the right kind of drugs available at affordable prices to all Indians. Amongst rational drugs, Essential Drugs should have a priority. The list of Essential Drugs and other drugs registered in India should be reviewed every 3-5 years so that obsolete drugs can be replaced with better drugs and other such changes can be made.
As mentioned earlier, the consensus Essential Drugs List for India has been prepared in April 1995 by a team of experts from NGOS. It is a graded list of which drugs are essential at what level of health-care - village Health worker, Primary Health Centre, District Hospital and Tertiary, Super-Speciality level hospital. The Government of India should adopt this list with whatever modifications its experts may suggest and see that resources must be spent on a priority basis to make these drugs adequately available at all times in all government health at various levels.
4) No Unnecessary Syrups - With the exception of antacids which are preferably used in liquid form, for all other drugs, liquid oral preparations should be allowed only for paediatric formulations since children cannot swallow tablets or capsules easily. Syrup-preparations for adults mean unnecessary costly preparations.
5) Only Generic Names - Drugs should be available only under generic name. The manufacturer’s name may be put in brackets after this generic name.
6) Drug Company’s Promotional Activities should be regulated. A permanent committee of experts should be formed to review the ‘educational’ material, which should conform to WHO’S Ethical criteria for drug-promotion. AS Health Action Internationial (HAI) has put it - All promotional literature for pharmaceuticals must be accurate, factual, balanced and up-to- date. It must conform to legal requirements and to standards of good taste. It should be provided in a language readily understandable to the person who will use it. It must not mislead, either directly or by implication, by omission of information or by un-verifiable statements. Promotional material should be screened and be allowed to be published only after approval.
The HAI has also demanded that routine provision of samples of prescription or non-prescription drugs to health-workers, health-institutions or to the general public should not be allowed. This is because such gift of drug-samples has no role in rational therapeutics, but is a mere indirect bribe to promote sales.
Samples of drugs for controlled, approved clinical trials or other research should be allowed.
7) Sponsorship of Symposia and Other Scientific Meetings - Here again, the guidelines laid down by the Health Action international are appropriate.
(i) The organization by pharmaceutical manufacturers or distributors of symposia and other scientific meetings should only be permitted if approval for such a meeting has been granted by the relevant national or international health worker association, health institution or government department; an independent panel of scientists and/or health workers has been set up to review the content of the meeting and full disclosure of the sponsorship is stated in all communications related to the meeting, and at the meeting itself.
(ii) Partial sponsorship of such meetings may be permitted if such sponsorship is requested by the organizers, subject to the full disclosure of the sponsorship.
One would add that the drug company should not have any say in the scientific content of the meeting, selection of the topic or of the speaker.
Thus overall, sponsorship of scientific or professional meetings by drug-companies should be seen as drug industry’s contribution towards continuing Medical Education and not as a direct promotional activity.
8) Proper Labeling - Labeling of drugs should enable lay-people to use drugs properly. It should also mention most common side-effects and should mention danger signals to enable patients to contact the doctor immediately. Special precautions in case of children, pregnant and lactating mothers and old people, should be mentioned clearly. The labeling should be printed in adequately bold size.
9) Over the Counter Drugs - Some drugs like antacid for temporary relief from burning sensation in stomach; mild laxative for constipation, paracetamol for body-aches and simple fever, oral rehydration salt for diarrhoea; antiseptic for wounds, pain-balms for aches and sprains….. can be safely used by lay-people without doctors’ prescription. A list of such drugs should be made and only these drugs be allowed to be sold O.T.C. All other existing “irrational O.T.C. drugs” should of course be banned.
The labeling in case of O.T.C. drugs should be more detailed, giving all -indications, contra-indications, common side-effects and danger-signals. The labeling should be made in English, Hindi and a regional language. It should accompany every pack of 10 tablets.
Information about scientific treatment at home, of minor ailments, with the help of O.T.C. drugs should be widely and repeatedly publicized by the state media. Advertisements of O.T.C. drugs should be reviwed by an expert committee before release. This committee should have a consumer’s representative on it to put forward consumers’ viewpoint about the impact of these advertisements.
10) A limit on Cross-Practice - AS has been argued earlier, non-allopaths should not be allowed to prescribe allopathic drugs beyond a short list of drugs for which they should be given appropriate training. Similarly allopaths should not be allowed to use non-allopathic drugs unless they have been trained to use some of these drugs by a recognized training institute.
11) Compulsory continuing Medical Education of Doctors - As pointed out earlier, this is a must, in today’s fast changing world. Doctors have to renew their registration with the state Medical council every five years. All that is needed today for this is to pay Rs. 50/- towards renewal charges, instead, renewal should be given subject to proof of undergoing minimum CME. The Medical Council should run magazines for CME for general practitioners. Today, there is no specific magazine for CME of general practitioners, whereas professional organizations of specialists have their own magazines.
An open book examination containing multiple choice questions should be conducted every five years to ensure that doctors read these educational magazines. Satisfactory performance in these exams should form a pre-condition for renewal of registration of doctors.
Similar measures will have to be taken for non-allopathic doctors and paramedics using drugs.
12) Improvement in Medical Education - Medical students should be taught the basics of political economy of health and the drug-industry; about the history of drug-regulation in India and ethical issues in promotion of drugs. Such education would enable the doctors to deal with ethical issues in drug-promotion and in a better way.
13) Research on Non-allopathic Drugs should be encouraged with funds, facilities and prestige.
Thus to ensure that resources spent on drugs are properly utilized so that the right kind of drug is used in the correct way, many changes will have to be made in what is allowed to be produced, how it is promoted, how issues concerning drugs are taught and how they are used by health-professionals and the lay-people. All these changes indicated above are simple to make, provided there is political will or pressure to do so.
The above measures cannot be separated from measures to protect and promote the well-earned reliance of the Indian drug industry, from being squandered through the New Economic Policy and the signing of the New Patent Regime of the World Trade Organization. We have not dealt with this aspect because this topic has been well covered by other authors. We reiterate that the steps towards self-reliance are no less important than the above measures towards bringing rationality into this field.
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