The Rajasthan, India Experience Anita Kotwani,

2. The Rajasthan, India Experience Anita Kotwani, Department of Pharmacology, Maulana Azad Medical College,New Delhi, India & DSPRUD

3. Introduction • The study was carried out on a methodology described in the Manual - The Prices of Medicines: A new approach to measurement (WHO - HAI, 2003). • Survey was conducted from April through June 2003. • Study conducted by Delhi Society for Promotion of Rational Use of Drugs(DSPRUD) • Presentation includes the study done, problems encountered and tips for a smooth survey.

4. 28 States and 7 UT Population 1,027,015,247 This is where a large graphic or chart can go. % of people below Poverty line 23.33 Per Capita Income Rs. 10754($225)

5. Area Selected • Rajasthan is the state chosen as it has urban, semi-urban and rural areas. EDL available, made in 2000, contains 311 drugs, for public sector only. • Medicines are not given free to all citizens, but only to BPL card holders, widow, senior citizen, Ex-service men. • No central procurement system, but centralized rate approval, with preference to state government pharmaceutical undertaking, next PSU and for remaining open tender.

6. Sampling • 4 Geographical areas – main urban centre, Jaipur and 3 other administrative areas- Ajmer, Bikaner and Kota • Survey measures prices of medicines in 3 sectors : Public sector Private Sector “Other” sector – Co-operative • In each area, 1 main public health facility and 4 other public health facilities, hence, 5 public health facilities, 5 private pharmacies and 5 from “other” sector. • A total of 20 public facilities, 20 private pharmacies and 20 outlets from other sector were surveyed.

7. Selecting Medicines • Core List – Out of 30, strength for 3 medicines not available. Artesunate, Diclofenac and Fluconazole. So core Drugs – 27. • Supplementary List - Diclofenac (50mg) and Fluconazole (150mg) added to supplementary list. Total drugs in supplementary list – 15. For 6 medicines MSH price not available so 9 supplementary medicines were analysed.

8. Finalizing the MPDC Form • For each medicine, there are 3 Rows and 9 columns. • Row 1 – Innovator Brand • Row 2 – Most Sold Generic • Row 3 – Lowest Priced Generic • Confirmation of Innovator Brand • Survey for Most Sold Generic equivalent • Training of Data Collectors and Pilot study done.

9. Component of Medicine Price & Affordability • Meeting and discussion with officials of pricing authority and other government and other officials. • Pay of lowest paid unskilled government worker Rs. 4900 p.m ( $102.5 )

10. Results • Data entry done in the especially designed computerized WHO/HAI Medicine Pricing Workbook. • Work book automatically generates summary tables. • Exchange rate is entered on the first day of data collection on the international medicine reference price data page. • The MSH reference prices have been selected for comparing 27 core drugs and 9 supplementary drugs.

11. Government of Rajasthan is purchasing medicines at a reasonable price for poor patients. • In the private sector almost half the medicines surveyed are priced less than twice the IRP. • In private sector, prices of the lowest priced medicines available are nearly the same as most sold medicines. • Availability in the public sector is low. • Availability of drugs for HIV/AIDS is poor in private sector as well. • The cost of drug treatment for pneumonia (amoxycillin) for 7 days is half a day salary for the lowest paid government worker.

12. Problems encountered • Confirmation of innovator brand and manufacturing company. Merging up of various pharmaceutical companies in India led to some confusion, brand names for a few medicines were different; inquired from NPPA and other officials in the country. Finally the go ahead was obtained from the technical advisor of the project. • Difficulty in finding the “MSG”. A survey was conducted to find out the MSG.

13. Supplementary list and Reference price. Data was collected for 15 medicines in the supplementary list. But the MSH price for 6 medicines was not available, so results for 9 supplementary drugs have been analysed. • Timing of the survey. Survey was conducted in peak summer.It was difficult for data collectors to travel and collect data, survey took more time to complete. I had to make visits in extremely hot temperatures.

14. Points to be kept in mind before conducting the survey • Read the manual thoroughly and carefully at least twice and before actually conducting any component of methodology, recheck from the manual. • Do not undertake the survey in the extremes of weather or when there are many public holidays. • Before starting the survey, gather baseline information on drug policy and medicine distribution in the respective country. • Identify clearly the three sectors, public, private and ‘other’ sector.

15. Before conducting the survey, four geographical areas and three sectors should be clearly defined. • Finalizing the Medicine Price Data Collection Form is very important and should be made with utmost care. • For the core list of drugs, strength and dosage form should be the same as mentioned in the manual. • Select the supplementary medicines to be surveyed whose MSH/Reference price is available. • Confirm the innovator brand and manufacturing company in your country.

16. Find out the MSG from an authentic source otherwise conduct a survey. Fill the name and company manufacturing it before giving the forms to data collectors. • Select data collectors with either previous experience or such personnel who can approach various pharmacies. • Field supervisor/Principal investigator to check the completeness of the forms. • Identify the government officials from whom information on price regulation can be taken. • Data entry, reentry to be done carefully.