Improving Governance and Accountability in India

1
Improving Governance and Accountability in
Indias Medicine Supply System

• Sakthivel Selvaraj, Maulik Chokshi, Habib Hasan
  and Preeti Kumar
• Public Health Foundation of India (PHFI)
• New Delhi, India
• Presented at
• Peer Review Workshop of TAP
• Results for Development Institute-World Bank

2
Access to Medicine Framework

• Unreliable Medicine Supply
• Unfair Health Financing mechanisms
• Unaffordable Medicine Prices
• Poor Quality Medicines
• Irrational use of medicines
• Lack of new medicines

3
Objectives of the Study

• Identify gaps institutional challenges that
  impede access to medicine
• Examine budgetary allocation on drugs
  associated inefficiency leakages
• Assess competitiveness of medicine procurement
  price in 2 states
• Generate evidence on availability stock-outs
• Analyse prescription dispensing pattern
• Explore alternate policy options.

4
Methodology

• Sampling
• Two-stage Stratified Sampling
• First Stage Unit - Districts
• 17/18 districts
• diverse geographic economic profile
• Second Stage Unit - Public Health Facilities
• 60 Community Health Centres (CHCs)
• 30 Referral Hospitals - Bihar
• 30 Upgraded PHCs -Tamil Nadu
• Survey Period
• October, 2009 January, 2010.

5
Methodology
Number of First Level Referral Units and Sample
Selected
States Number of Facilities Operational Number of Sample Selected Percentage of Selected Sample
Tamil Nadu (Upgraded PHCs) 220 30 14
Bihar (Referral Units) 70 30 43
Total of Two States 290 60 29
6
Methodology
Selected Sample of Public Health Facilities in
Bihar
District/ Regions Economically Poor Economically Moderate Economically Rich
North 2 3 3
South 2 0 4
East 2 2 2
West 7 1 2
Total 13 6 11
Selected Sample of Public Health Facilities in
Tamil Nadu
District/ Regions Economically Poor Economically Moderate Economically Rich
North 4 2 2
South 0 5 3
East 4 5 1
West 0 0 4
Total 8 12 10
7
Sources of Data

• Budget Documents/Records
• Central and State governments
• Actual expenditure - year 2006-07
• Revised and Budget figures - years 2007-08 and
  2008-09
• Major states accounts 90 total health
  expenditure
• Data/information on public procurement
• Tender Documents
• Rate Contracts
• Bidding process informationtechnical and
  financial bid

8
Geographic Location of Bihar Tamil Nadu
9
Districts of Bihar
10
Districts of Tamil Nadu
11
Description of Survey Instruments

• From health facility, we administered
  questionnaire on broad variables such as
• volume value of drugs procured, stored and
  dispensed at the facility level,
• availability of drugs, adherence to EDL
  (Essential Drug List), stock-outs, price charged
  at the facility, quantity and price of drugs that
  would have to be paid out-of-pocket (OOP) outside
  the public sector outlets, rational prescription
  practices, etc.
• To be specific, at the facility level, we
  examined records of Main Stock and Sub Stock
  Registers.
• In addition, we also obtained photo images of
  prescription slips from patients (roughly about
  30-40 slips from each of the facility).

12
Demographic Profile
S. No. Item Bihar Tamil Nadu India
1 Total population (Census 2001) (in million) 82.9 62.41 1028.61
2 Decadal Growth (Census 2001) () NA 11.72 21.54
3 Crude Birth Rate (SRS 2008) 28.9 16.0 22.8
4 Crude Death Rate (SRS 2008) 7.3 7.4 7.4
5 Total Fertility Rate (SRS 2007) 3.9 1.6 2.7
6 Infant Mortality Rate (SRS 2008) 56 31 53
7 Maternal Mortality Ratio (SRS 2004 - 2006) 312 111 254
8 Sex Ratio (Census 2001) 919 987 933
9 Population below Poverty line () 42.60 21.12 26.10
10 Schedule Caste population (in million) 13.05 11.86 166.64
11 Schedule Tribe population (in million) 0.76 0.65 84.33
12 Female Literacy Rate (Census 2001) () 33.1 64.4 53.7
13
Health Infrastructure of Bihar vs Tamil Nadu
Bihar Bihar Bihar Tamil Nadu Tamil Nadu Tamil Nadu
Item Required In -position Shortfall Required In-position Shortfall
Sub-centre 14959 8858 6101 7057 8706 -
Primary Health Centre 2489 1641 848 1173 1215 -
Community Health Centre 622 70 552 293 206 87
Multipurpose worker (Female)/ANM 10499 9127 1372 9921 10343 -
Health Worker (Male) MPW(M) at Sub Centres 8858 1074 7784 8706 3278 5428
Health Assistant (Female)/LHV at PHCs 1641 479 1162 1215 1362 -
Health Assistant (Male) at PHCs 1641 634 1007 1215 303 912
Doctor at PHCs 1641 1565 76 1215 2260 -
Obstetricians Gynaecologists at CHCs 70 21 49 206 - -
Physicians at CHCs 70 38 32 206 - -
Paediatricians at CHCs 70 17 53 206 - -
Total specialists at CHCs 280 104 176 824 - -
Radiographers 70 15 55 206 - -
Pharmacist 1711 439 1272 1421 1349 72
Laboratory Technicians 1711 135 1576 1421 909 512
Nurse/Midwife 2131 1425 706 2657 - -
14
Procurement models in India

• Centralized procurement for vertical programs
  through procurement agencies
• HLSP, HLFPPT, UNOPS
• Pooled procurement through autonomous agencies
• Tamilnadu (TNMSC), Rajasthan (SPO), Delhi
  (DPSRUD)
• Decentralized procurement
• Chattisgarh
• Rate contract based
• Bihar

15
Competitive Bidding Process

• In Bihar, the number of drugs procured in 2007-08
  was 369, compared to 91 and 89 in previous two
  years. In the year 2006-07, there were 19
  successful bidders, 3 companies lesser than the
  previous year. The number of co submitting
  tender, being successful and number of products
  selected has seen increase over a period of time.
  However, there are considerable numbers of drugs
  without any bid or not procured by the SHS.
• TNMSC floats tender for an EDL of 262 drugs
  annually and have been successful in getting bids
  for most of the EDL. Around 100 companies have
  shown interest in supplying drugs to the state
  through TNMSC during the year 2007-08.

16
Health Expenditure
17
Public Private Expenditure in Health
18
Drug Expenditure by Major States
2006-07 Actuals 2006-07 Actuals 2006-07 Actuals 2007-08 Estimated 2007-08 Estimated 2007-08 Estimated 2008-2009 estimates 2008-2009 estimates 2008-2009 estimates
States Total DE (INR) Millions Total HE (INR) Millions DE as of HE Total DE (INR) Millions Total HE (INR) Millions DE as of HE Total DE (INR) Millions Total HE (INR) Millions DE as of HE
West Bengal 1075.2 17231.3 6.24 1178.8 18620.4 6.33 1364.0 22901.0 5.96
Orissa 146.4 6305.6 2.32 146.2 8740.7 1.67 153.7 10488.5 1.47
Uttar Pradesh 1354.6 43336.5 3.13 1496.3 46364.5 3.23 2079.8 56258.7 3.70
Madhya Pradesh 774.5 11753.8 6.59 632.3 13197.4 4.79 646.3 16289.2 3.97
Gujarat 507.2 11828.5 4.29 416.3 13218.2 3.15 479.1 15446.3 3.10
Chattisgarh 127.2 4273.8 2.98 142.4 6466.8 2.20 206.3 8869.8 2.33
Tamil Nadu 960.4 17834.1 5.39 1303.5 20241.3 6.44 1493.0 21019.4 7.10
Bihar 57.4 12038.4 0.48 155.1 14140.3 1.10 664.4 13315.7 4.99
Karnataka 813.0 11802.9 6.89 1117.7 13854.5 8.07 1204.3 19024.6 6.33
Jharkhand 241.3 10216.7 2.36 246.6 9212.2 2.68 151.5 9970.8 1.52
Rajasthan 903.2 12472.1 7.2 965.4 13614.3 7.1 1066.3 15897.3 6.70
Kerala 1182.4 99992.8 11.83 1171.1 11378.4 10.29 1241.9 14545.6 8.35
Punjab 61.9 7394.7 0.84 217.9 7662.6 2.84 110.1 8578.4 1.28
19
Drug Expenditure by Levels of Care
2008-09 Estimates 2008-09 Estimates 2008-09 Estimates 2008-09 Estimates 2008-09 Estimates
States Total Drug Expenditure (Millions) Tertiary Care Drug Exp (As Total Drug Exp.)  Primary secondary Drug Exp (As Total Drug Exp.) Urban Services Drug Exp (As Total Drug Exp.) Rural services Drug Exp (As Total Drug Exp.)
West Bengal 1364 73.08 26.92 74.2 25.8
Orissa 153.7 95.41 4.59 95.82 4.18
Uttar Pradesh 2079.8 54.5 45.5 55.25 44.75
Madhya Pradesh 646.3 62.71 37.29 68.28 31.72
Gujarat 479.1 84.17 15.83 94.91 5.09
Chattisgarh 206.3 24.34 75.66 87.35 12.65
Tamil Nadu 1493 40.04 59.96 45.23 54.77
Bihar 664.4 56.86 43.14 57.25 42.75
Karnataka 1204.3 46.07 53.93 46.68 53.32
Jharkhand 151.5 43.56 56.44 44.16 55.84
Rajasthan 1066.3 96.4 3.6 96.66 3.34
Punjab 110.1 71.25 28.75 77.84 22.16
Kerala 1214.9 66.51 33.49 72.49 27.51
Figures for 2007-08 estimates
20
District-wise Share of Drug Expenditure
District Drug Exp/Per capita Drug Exp Per Illness episode (OPD visit)
Jamui 4.61 780.35
Katihar 84.53 661.08
Nawada 5.30 623.11
Samastipur 3.84 561.85
Banka 7.14 110.33
Araria 6.68 89.41
Saran 5.29 84.08
State Total 7.16 59.93
Aurangabad 6.76 15.04
Madhepur 3.16 14.70
Gaya 2.66 14.13
Khagaria 6.33 13.65
Vaishali 2.97 12.87
Muzzafarpur 1.89 11.29
Buxar 1.51 7.62
21
Expenditure Pattern of Drugs in Bihar as Per EDL
Rate Contract
Therapeutic Category Drug State Drug Exp. () EDL status Rate Contract Availability ()
Anti-Fungal Fluconazole 23.44 YES YES 60.0
Vaccine A.R.V. 14.94 YES NO 30.0
Antibiotic Azithromycin 5.57 NO NO NA
Respiratory System Cough Expectorant 4.37 YES YES 43.3
Vitamins Vitamin B Complex Syrup 4.00 YES NO 40.0
Antibiotic Ciprofloxacin (E) Tab 3.78 YES YES 46.6
Vitamins B Complex 1.87 NO NO 66.6
Antibiotic Amoxicillin- Cap 1.35 YES YES 46.6
Antibiotic Erythromycin 1.14 YES YES 6.67
Antibiotic Metronidazole 1.06 YES YES 76.6
Anti-pyretic Paracetamol 1.04 NO NO 50.0
22
Availability of Medicines at District Level
Bihar available (survey day) Stock-out (6 mnth) Stock-out (days) Tamil Nadu   drugs available (survey day) Stock-out (6 mnth) Stock-out (days)
Begusarai 52.27 38.63 114.08 Coimbatore 90.91 13.64 25
Darbangha 0 100.0 180 Cuddulore 81.81 21.21 44.52
E-Champaran 31.82 54.54 126.2 Trivillur 83.6 18.18 49.17
Gopalgunj 45.45 38.63 87.7 Erode 90.9 18.18 60.56
Jhanabad 38.63 47.72 82.2 Kanyakumari 90.9 6.818 6.67
Lakhesarai 59.09 31.82 87.86 Nagapattam 77.27 18.18 103.75
madhubani 40.9 34.09 78.7 Namakkal 100 9.09 40.0
Muzafarpur 27.27 100.0 180.0 Nilgiri 86.36 13.64 73.33
Nalanda 45.45 22.73 102.0 Perambur 90.91 18.18 75.0
Patna 25.75 43.9 74.9 Salem 86.36 13.64 35.0
Purunea 60.60 45.45 70.3 Shivganga 90.91 27.27 30.17
Samasthipur 36.36 36.36 91.25 Tanjavore 95.45 29.54 48.25
Saran 50.0 33.33 87.5 Thiruvnamalllai 86.3 13.64 75.0
Siwan 61.36 27.27 131.85 Tirunellveli 81.81 12.12 56.25
Vaishali 63.64 31.82 58.57 Tuticorm 77.27 27.27 72.0
Bhojpur 31.8 18.18 121.2 Villupuram 90.9 22.72 41.25
Katihar 36.36 31.82 111.43 Virudnagar 90.9 2.27 25.0
Vellore 68.1 9.09 42.5
Total 42.64 41.35 105.0 Total 88.8 16.37 50.19
23
Availability of Medicines at Facility Level
24
Comparative Scenario of Drug Availability Bihar
vs Tamil Nadu
( Drugs available on Day of Survey)
25
Stock-Outs at Facilities Bihar vs Tamil Nadu(
Stock-Outs)
26
Duration of Drugs Stock-Out(Stock-out (days) in
preceding 6 months)
27
Availability and Stock-Out Scenario
Bihar Bihar Bihar Tamil Nadu Tamil Nadu Tamil Nadu
Drugs Availability (Survey day) Stock-out (6 mnths) Duration of stock out (6 mnths) Availability (Survey day) Stock-out (6 mnths) Duration of stock out (6 mnths)
Albendazole-400mg 70.00 26.67 78.75 100.00 6.67 35.00
Amoxicillin-250mg 46.67 30.00 94.67 90.00 10.00 51.67
Asprin-75 mg 16.67 3.33 150.00 90.00 36.67 48.64
Chlorpheniramine-4 mg 40.00 60.00 80.83 96.67 6.67 30.00
Ciprofloxacin-500 mg 46.67 46.67 64.86 86.67 40.00 45.00
Cough syrup 43.33 66.67 79.75 73.33 43.33 34.50
Diclofenac Sod-500 mg 40.00 36.67 82.73 93.33 20.00 55.77
Dicyclomine-10mg 56.67 26.67 90.63 90.00 0.00 30.17
Flucanazol-150mg 60.00 26.67 92.75 23.33 0.00 0.00
Getnamycin Eye/ear drop 40.00 26.67 83.63 100.00 0.00 0.00
Metoclopromide 53.33 20.00 73.33 86.67 10.00 25.00
Metronidazole-400mg 76.67 23.33 112.14 93.33 6.67 37.50
Paracetamol 125 mg/ 5 ml 50.00 46.67 71.43 100.00 3.33 10.00
Rantidine-150mg 43.33 56.67 97.94 93.33 36.67 61.82
Salbutamol-4 mg 50.00 26.67 116.25 100.00 10.00 43.33
Vit B Complex Tab 66.67 36.67 45.45 90.00 0.00 0.00
Inj. ARV 30.00 53.33 62.19 93.33 3.33 15.00
Erthromycin Tab 6.67 40.00 84.58 80.00 36.67 80.83
Co-trimoxazole 23.33 36.67 130.00 83.33 10.00 48.33
Tab Ferrous sulphate folic acid 43.33 36.67 68.45 90.00 10.00 53.33
Vit B complex Syp 40.00 40.00 100.00 86.67 10.00 28.33
Calcium Tab 20.00 20.00 120.00 70.00 23.33 85.57
28
Availability of Individual Drugs across Health
Facilities
29
Availability Stock-Out Therapeutic Categories
Bihar Bihar Bihar Tamil Nadu Tamil Nadu Tamil Nadu
Therapeutic Category Availability (Survey day) Stock out (6 mnths) Duration of stock out (6 mnths) Availability (Survey day) Stock out (6 mnths) Duration of stock out (6 mnths)
Antibiotic 40.00 33.89 101.00 88.89 17.22 43.89
Antifungal 60.00 26.67 92.75 23.33 0.00 0.00
Antihelmenthics 70.00 26.67 78.75 100.00 6.67 35.00
Antipyret Analgesic 40.83 28.33 98.70 94.67 13.33 35.91
Antacid Antiemetic 48.33 38.33 85.64 90.00 23.33 43.41
Minerals 31.67 28.33 94.23 80.00 16.67 69.45
Respiratory System 44.44 51.11 92.28 90.00 20.00 35.94
Vaccines 30.00 53.33 62.19 93.33 3.33 15.00
Vitamins 53.33 38.33 72.73 88.33 5.00 14.17
30
Availability of Therapeutic Class of Drugs Bihar
vs Tamil Nadu
31
Summing Up

• Bihar spent inadequate funds on health care on
  drugs in the past, but recent trends in post-NRHM
  years show reversal of that trend and therefore
  availability of drugs has improved considerably.
  
• This evidence is also corroborated from various
  stakeholders themselves during visit to
  facilities other available data.
• Moreover, Bihar is now on its way to replicate
  TNMSC model (Tamil Nadu Model of Procurement and
  Distribution), the benefits of which is expected
  to bear tangible fruit in near future.
• Alongside, acute shortage of health workforce
  pharmacists need attention.

32
Way Forward.

• Scale up public spending 1-3 of GDP.
• A centralized procurement system with a
  well-functioning decentralized distribution model
  appears to usher in competition, transparency,
  value-for-money and ensures availability of
  quality and rational medicines at affordable
  rates to government.
• Therefore, centralized drug procurement
  decentralized medicine distribution system
  appears to be the key to improve governance and
  transparency in medicine supply system in India.