The need to take up 'free medicine programme'

Providing healthcare is the responsibility of the state. As a part of providing healthcare, few states like Tamil Nadu, Kerala and Rajasthan have initiated the ‘free medicine programme’. It is time to examine the condition of free medicines in other states too.

Making medicines available free in government health centres is important. It prevents people from sinking into debt, improves the quality of life and increases longevity.

Several reports of the Planning Commission (2011 and 2012) have stressed the need to move towards ensuring free essential medicines, as otherwise, ‘Out-Of-Pocket Expenditure (OOPE)’  on healthcare will be a major cause for economic catastrophes in the families. The number of families that are reduced to penury by the cost of healthcare is shocking. In 2011, nearly 60 million people were impoverished due to high OOPE on healthcare. Of these, nearly 70 per cent of the cases were due to the expenditure on medicines.

The non-availability of free drugs has resulted in low utility of the government health services in India. Increasing the access to free essential medicines will reduce the OOPE burden for the populations and thereby increase the financial protection for the household expenditures. The credibility of public health systems and utilisation by the needy people will depend on the availability of free medicines. In Tamil Nadu, after the introduction of an efficient drug procurement and distribution system to ensure availability of free essential medicines, saw the total number of people accessing public health facilities go up from 20 to 40 per cent.

It is in response to OOPE that states like Tamil Nadu and others have already initiated a free medicine policy which is a great boon for the people. Curiosity makes one wonder as to what is the policy on free medicines in Karnataka. According to the Karnataka government, there is a free medicine policy in place but not ‘really’ implemented in spirit. A recent study in August 2013  by WHO, titled “Karnataka, India Pharmaceuticals in Health Care Delivery,” which has specifically examined in detail the availability (or to be more precise, the non-availability) of free medicines at government health centres across the state throws light on this important public health issue.

The report highlights that stock-out of medicines is a huge problem in many health centres. It reports that “stock-out status of the Karnataka Drug Logistics and Warehousing Society (KDLWS) revealed a significant number of stock-outs on that day. Overall, 24 per cent of items were out of stock in 80 per cent or more of the warehouses and only 23 per cent of items were available in all warehouses. A number of community members and other stakeholders stated that stock-outs were a problem”.

The studies and reports say the state government has set up few ‘Generic Medicines Outlets’ which are mostly situated in the very buildings of government health centres where medicines are sold at an affordable price and are not free. If the ‘free medicine programme’, was in place like it is being falsely claimed by Karnataka health authorities, then one wonders as to why medicines are being sold! It is indeed a huge, unexplainable paradox!     

The non-availability of medicines is being constantly denied by most top level bureaucrats and also the politicians who are at the helm of this. This seems to be a perfect example of an ostrich-like attitude.

Why this shortage?

The Karnataka State Drugs Logistics and Warehousing Society (KDLWS) was planned on the lines of Tamil Nadu Medical Science Centre (TNMSC). But it differs from TNMSC because of the lack of staff in general and the lack of regular staff dedicated specifically to the KDLWS. The two warehouses visited were piled high to the ceiling with drugs and there was lack of information on stock levels at facilities.

“Were the KDLWS to be a medical services corporation, it would have greater autonomy to hire staff.” mentions the WHO report. In addition to a shortage of staff, standard methods for quantification and common electronic management information system (MIS) operating at district warehouses and facilities are unlikely along with the late procurement process such stock-outs.

At the outset, the bureaucrats and the ministers responsible for implementing the free medicine programme for Karnataka will need to accept the fact that the  programme is not in place and that there needs to be changes brought in both, systematically and scientifically. Changing the mindset will be the achievement of the first major milestone coupled with the political will to achieve the same.

The WHO document has suggested several important guidelines. Currently, there are no mechanisms that will truly reflect the medicine requirements at the health centres and so drugs are distributed not on need basis but just on ad hoc. So, the KDLWS needs to produce annual report on consumption comparison of medicines at every district level.

There is an urgent need to bring in transparency in procuring medicines and this should be based strongly on the WHO concept of Essential Drug List (EDL). This list needs to be published in the form of a booklet and distributed to all health facilities and medical colleges. Medical doctors and specifically those in government service at every level need to be sensitised by providing them with pre-service and in-service ongoing training about the use of EDL. A high level committee should monitor that the concept of EDL is in place at every level.

There is a need to obtain a feedback from the exiting patient and interview them to see the number of outside prescriptions that are given. All medical college hospitals should develop evidence-based formulary lists. There is a way forward but all it needs is a political will to serve the needy!

(The writer is president, Drug Action Forum – Karnataka)