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Free for all

The bigger ills


Most government hospitals are in areas which are out of reach for the rural poor. Till this is rectified, free drugs will not change anything for the needy

A recent proposal by the Planning Commission to provide free generic drugs to patients at all government hospitals over the next Plan period seems to have captured the imagination of the media and public alike. This wellintentioned plan could be a step forward in ensuring a universal healthcare.

However, the important question that seems to have been overlooked is how will the government address the actual issue of lack of access to quality healthcare for twothirds of India's population? This may be a good beginning but needs to be supported with a holistic approach that goes well beyond medicines.

The number of children who die before their fifth birthday of preventable diseases such as malaria and diarrhoea stands at 66 per 1, 000. This is in comparison to 19 in China and 21 in Brazil.

Why are our health parameters poor? India sadly is at the bottom of the pile when it comes to what the country spends on health as a percentage of GDP with even Sri Lanka and Thailand spending more. It is indeed a poor reflection on us as a nation to know that according to OECD there are only seven governments in the world that spend less on health than India!

A recent KPMG report listed dual disease burden and lack of adequate infrastructure and manpower as the two big challenges impeding the expansion of the healthcare sector in India. At six doctors per 10, 000 people, the number of qualified doctors in the country is not sufficient for the growing requirements of Indian healthcare. As recently as 2011, the Deputy Chairman of the Planning Commission was quoted as saying: "We can't produce enough doctors and nurses even if we build a lot of clinics. "

Around 74 per cent of India's graduate doctors work in urban areas which account for only about onefourth of the population. Most government hospitals are in urban areas and out of reach for the rural poor.

Merely making medicines available for free is not good enough. Proper diagnosis is a prerequisite to assess patients and prescribe appropriate medicines. To improve our nation's health we need trained doctors and health workers, we need hospitals and labs, we need reliable distribution channels, and only then can free medicines be appropriately utilised.

An interesting model cited by the Planning Commission is the Tamil Nadu Medical Services Corporation (TNMSC), which procures specified drugs and provides them free to those who go to any government medical centre. But there is a difference - the model in Tamil Nadu has not confined itself to free drugs but has looked at the other challenges of healthcare as well - that of infrastructure and of employing enough qualified doctors at the primary healthcare level.

Interestingly, TNMSC has been in operation since 1995. It took 17 years for anyone, the media and government included, to recognise the initiative and to seek to replicate it. The total pharmaceutical market in India is valued at Rs 60, 000 crore. The Planning Commission proposes that the government spend Rs 27, 000 crore over four years, making it an average of around Rs 7, 000 crore per year which is around 12 per cent of the total market size.

This may be a good beginning but not enough to address the healthcare needs of two-thirds of the population that have no access to quality healthcare. The poor in India will suffer needlessly until and unless healthcare is holistically addressed.
The government has taken various initiatives both at the central and the state level in this direction but much more still needs to be done even in areas where infrastructure exists. Healthcare delivery needs to be improved so that the poor do not have to go to private facilities to address their healthcare needs. Statistics show that "stock out" days in some government facilities are as high as 50+ days at times!

India needs to open 600 medical colleges with 100 seats per college and 1, 500 nursing colleges if we are to meet the global average of doctors and nurses. The purchase of medicines by the government needs to be regulated through transparent procurement systems to promote efficiency and avoid waste and leakage. Public private partnerships need to be espoused to a much greater extent, and will open opportunities to extend access through tele-medicine and other innovative models.

Finally, free drugs should aim at diseases that are prevalent and endemic and not just at providing symptomatic relief. The cost of disease burden based on factors such as misdiagnosis and self-medication are significant. It is important therefore to look at epidemiology, which varies from state to state. A detailed understanding is called for before moving to provision of drugs.

(The author is vice-chairman and managing director, Novartis India and the president of OPPI)

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