The patients are usually vulnerable to exploitations and have to bear for irrational treatments and pay for medicines exorbitantly. This is the usual complaints from patient advocacy groups who are constantly asking governments, administrative bodies, WHO and United Nations to have a control over other stake holders of health care provision. The stake holders involve drug industry, doctors, nurses and pharmacists who are self-regulated by their own professional organizations and regulatory councils.
Each organizations and council have framed its own code of ethics and have constitutional patron for smooth running of health care services. Despite having provisions to punish errant members, patients and public are not satisfied with the quality of services provided to them and are expressing their displeasure on various forums and media. The powerful lobby of industry and opposing and neglecting the government and regulators are successful so for in manipulating the business in their favour. The lack of strong political will and rampant corruption have made the government and regulation to streamline the drug administration to control the stake holders. The major complaints by patients and public against all other health care providers are the breach of trust, lack of transparency and accountability by health care provider.
Pondering over history of health care is worthwhile now to understand the complexities and controversies haunting the health care sectors. India systematically adopted the modern medicine system Allopathy and forgot the traditional health care system Ayurveda. In ancient times , Ayurveda, supported by Kings , has established itself as health centric rather drug centric. The practitioners are referred as equivalents to god, by nicknaming as “ Naryano Vaidyo Hari”. The drugs and other requirements of health care were formulated by themselves. There were no pharmaceutical industries to supply medicines. It was not driven by money but by support from the Kings.
The change in times, has led to development of pharmaceutical industries who invested in research and were able to successfully establish and run industries to cater the needs of large populations in the management of the diseases of the patients. The Indian pharma industry has grown into a multibillion activity with projections of $70 billion in 2020 by market pundits. The Indian pharma Industry has successfully conquered markets worldwide and has earned reputation as ‘Poor Men’s Pharmacy of World’, by providing affordable medicines in most of the therapeutic areas.
However greed and failure of self-regulations among stake holders are now ruling the health care sector which is very much dangerous to public health. The Indian Pharma industries is truly cosmopolitan in nature, comprising of small, medium and large scale and also classified as indigenous (IDMA) and MNC (OPPI). All the industries can register their manufacturing by state drugs control department and can market throughout India and abroad. The drugs in India although regulated are available in the open market without prescriptions for self-medication.
The pharma industry are indulging in fierce competition for market share, market development and market expansion. In order to reach the ever increasing target, they indulge in unethical marketing practices and are accused of prescription manipulation by influencing the doctors and pharmacists by offering schemes. Presently In India, there are nearly lakhs of formulations from less than 1000 active pharmaceutical ingredients. Most of these products are me too, irrational combinations with uncertain quality. For e.g., we have thousands of similar formulations sold by variety of brand names. These large number branded medicines with lookalike and sound alike names are confusing the doctors, nurses, pharmacists and patients leading to medication errors. The government of India recently identified the irrational combinations of products and banned them from the Indian market. Recently the Government of India with Consumer forum of India jointly collected variety of formulation to know the ground reality of quality of content across the nation. The preliminary findings are alarming as many formulations of medicines are not up to the label claims content and quality parameters. Presently the quality control and assurance are done in-house, as government and regulators are unable to handle this activity independently.
Allopathic medicines are like double -edged sharp blades. All medicines from Aspirin to Zidovidine carries a risk and are capable of inducing injuries and death endangering patient’s safety. Uncertainty of unknown risks of ADRs has prompted worldwide alert and initiated global pharmacovigilance programs. Drug toxicities and drug injuries are usually the outcomes of irrational use of medicines. There are many drug induced deaths and injuries reported from regulated markets in USA and Europe where documentation is mandatory. As we have failed to establish such systems, we are not sure about the magnitude of dangers by wide spread irrational use of medicines across the country.
Looking at the diversity of socioeconomic distributions of Indian demographics, we can find most of the populations are below poverty line. In India the similar medicines are sold at different prices by different brand names. There are nearly 200 to 300 times differences in prices among same medicine. The companies are able to market the expensive medicines with the hand in glove adjustments with prescribers and retail drug stores. Recently Government of India through various councils has warned the health care providers not to have any trading understanding with particular pharma industry. The MCI has directed the doctors to write the prescriptions of medicines in generic names only.
The Bureau of Pharma PSU of India (BPPI) was established under the Department of Pharmaceuticals to make availabile cost-effective good quality generic medicines throughout India to Indian Public. In India, patients usually pay out of pockets for purchasing the prescribed medicines. The BPPI in order to achieve its objective are revitalizing the pharma public sector units like Indian Drugs and Pharmaceuticals Ltd. , utilizing the facilities for manufacture of generic medicines. The generic medicine retail outlets are initiated under the branded franchises called Jan Aushadhi. The Jan Aushadhi franchises are promoted by the active patronage of government of India as ‘Pradhan Mantri Jan Aushadhi Kendra (PMJAK)’. It is a joint public private partnership to make availabile affordable medicines to Indian patients. In March 2017, the BPPI aims to distribute 1000 formulations in 3000 PMJAK. The PMJAK wants to provide cheap, quality medicines to public in place of expensive branded medicines. The cost of the medicines linked to affordability, play an important role in patient compliance which in turn effects health care delivery.
The Government of India has also introduced several programs to upgrade the quality of health care workers and services by introducing pharmacy practice skills and pharmacy technician jobs. For example, National skill development council of India (NSDC) has introduced programs for hospital assistants and ophthalmic assistants. On similar lines pharmacy assistant/ technician is under consideration of NSDC. The Pharmacy Practice Guidelines 2015 has empowered all registered pharmacists to undertake pharmacy practice as a professional service. As per Pharmacy Practice Regulations, the pharmacist has to undertake the entire responsibility of medicine use, how to manage health, and professional care and concern. They are obliged to instruct and monitor the patients’ health as per the Hand Book of WHO-FIP pharmacy practice 2006.
The patient centric care involves the following principles popularly called as Pickers Principles viz.,
• Respect for patients preferences
• Coordination and Integration of care
• Information and education
• Physical comfort
• Emotional support
• Involvement of family and friends
• Continuity and transition
• Access to care
If we want to take an inventory of above principles in Indian health care sector, we will soon realize the huge gaps in health care services. It is not only expensive but of poor quality and uncertain outcomes. Although there are consumer forums established to help the suffering patients, they seldom challenge the providers regarding quality of services. For example the patient preferences are blatantly neglected, as the system of health care delivery in our country is dominated by provider choices. The patients are kept in the dark and what are the alternative options available are seldom informed. The poor communication among health care providers makes it impossible to have equity among providers. The care usually in isolation is incomplete with very poor outcomes.
The patients’ needs to be educated on matters of drug, diseases and lifestyle modifications by the pharmacists. We find a lack of interest, as it is considered as waste of effort and time. In developed countries, pharmacist are paid extra money for providing patient education and counseling. In these countries, the pharmacist earn money not by selling medicines but by providing patient counseling and education. The government is committed in principle to protect the patients and health consumers by injuries caused by indiscriminate and irrational use of medicines.
If we visit the nursing homes and corporate hospitals we can find wall posts claiming the hospital policies regarding patient care. It is a mirage to expect hospital authorities to show a genuine interest in providing physical comfort and emotional support. The corporate hospitals and private nursing homes claim un-matching bills to the treatments provided. There are no laws to control the medical expenses, it is merely law of demand and supply, putting the patients and families to worry about huge medical bills to be settled before discharge from the hospitals. The health care provision seldom seeks the involvement of family and friends, even in psychiatry and cancer.
The institutional support and palliative care are important areas, which are yet to be developed in India. We find the patients after discharge are left to manage their conditions without any professional assistances. For example a diabetic or hypertensive patients admitted to hospitals with cardiac diseases , are seeking again critical health care facilities, as they do not have an access to continuity of care outside the hospital after discharge. The rural versus urban, rich versus poor, insured versus not insured has created the under privileged demographics deprivation of access to health care.
In reality most of the progressive governments are adopting universal health care policy. Universal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, usually refers to a health care system which provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes. Universal health care is not one-size-fits-all and does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered. It is described by the WHO as a situation where citizens can access health services without incurring financial hardship.
To conclude, the pharmaceuticals are not only the inputs in health care delivery. The product -centric market has done much damage to health of the patients. It is time to change the market to patient -centric care.
(The author is Director, SCS College of Pharmacy, Harapanahalli, Karnataka)