Better public health, better access in Bihar
New health minister delivers
By Dr. Sanjay Pandey and Gautam Chakroborty
In India’s poorest state, a young Health Minister and new drug procurement model raise hope for better access to medicine and treatment. Even so, the challenges for delivering public health services in Bihar remain huge.
The national picture
First the good news. Bihar’s new Health Minister, Tej Pratap Yadav, a 28 year old school dropout with no administrative experience, is showing surprising fervor in strengthening the state’s inadequate public healthcare system, including access to medicine. This has succeeded in putting to rest earlier controversy over his appointment, which was seen by many as a favour to his powerful political boss father, Laloo Prasad Yadav, who heads the largest party in the ruling coalition government.
Health officials in the state have been pleasantly taken aback at the enthusiasm the young minister has shown for his job after being appointed six months ago. He has made surprise inspections at public hospitals, insisting that life saving drugs be made available in all of them across the state. The officials feel that with the minister taking a personal interest in improving availability of medicine this could reduce the rampant corruption in drug procurement by public health departments. Ironically, the current drive to boost public health care is propelled by a major image makeover by his influential father, who has been in the past charged and convicted in massive corruption scams.
Bihar’s many challenges
Yet despite some optimism, the challenges for access to medicine are enormous in a backward state like Bihar. The statistics are chilling. According to a study by the Public Health Foundation of India (PHFI) last year, drug availability in public health facilities in Bihar ranged from 30-50 percent compared to 80-90 percent in Tamil Nadu. As per the National Sample Survey (NSS) 71st round (2014), the average expenditure on medicines per episode of outpatient visit in Tamil Nadu (TN) is less than Rs.450, in Bihar it is almost Rs. 600. And although the situation has improved over the past decade as per the NSS 60th round (2004), only one percent of the people accessing outpatient care in government hospitals in Bihar received free medicines while the figure was more than 23 percent for Tamil Nadu.
Following Tamil Nadu’s lead
Indeed there is increasing importance given both by the central and state governments to the Tamil Nadu Medical Supplies Corporation (TNMSC) model. Interest centres on its centralised procurement, quality control and payments, but decentralised supply chain which is driven by computerised and automated invoicing and inventory management systems. Hence, under the National Rural Health Mission (NRHM) the central government has encouraged states to constitute autonomous procurement and supply chain management agencies for medical supplies, on the pattern of TNMSC. The NRHM, while promoting health systems reforms in states, has also directly contributed in increasing the public spending on medicines.
In Bihar, the government expenditure on medicines and drugs increased from around Rs.6 per capita in 2007-08 to approximately Rs.25 per capita in 2013-14. Although the increase in state budget on medicine has played a major role in this increase (state drug expenditure rising from 4.5 percent of total state health expenditure in 2007-08 to 7.12 percent in 2012-13), NRHM contributed another 50 percent to the state’s contribution on medicines. Interestingly whereas the household expenditure on medicines per out-patient contact in Tamil Nadu has increased from around Rs.230 in 2004 (NSS 60th round) to Rs.440 in 2014 (NSS 61st round), in Bihar, it remained stable around Rs.600 between 2004 and 2014.
Access limited to basic medicines
The Population Foundation of India conducted focus group research last year, across villages in six districts of the state. They found that the availability of drugs had improved over the last five to six years overall, but this encouraging statistic betrays the fact that since 2014 the situation has started to deteriorate. They found that basic medicines were available in the primary and secondary facilities, but the higher level drugs (mostly antibiotics and injectables) still had to be purchased from private drug stores.
Severe shortages of drugs and medical kits have also been reported by district health officials and public healthcare doctors because of a lack of funds. They say that central funds have not been forthcoming for vaccines, ORS for diarrhoea, etc. At the same time inefficient drug procurement has led to tardy spending of the drugs budget by the state government. Moreover the move by the central government to shift financial resources to the states had led to bureaucratic delays.
Adopting a better procurement model
Although access to health and medicines does not explicitly figure in the current Chief Minister Nitish Kumar’s seven point agenda for Bihar, the state has officially committed to move away from its “Cash-and-Carry” (decentralised indenting, payments and supply chain) system to Bihar Medical Equipment and Drugs System (BMEDS), on the lines of TNMSC. The state has also adopted Essential Drug List (EDL) of 33 items for outpatient care and 112 items for in-patient care at the primary and secondary level government health facilities. However, as mentioned earlier shortages and stock-outs of antibiotics and injectables continue even among EDL items.
The crisis around antibiotics and injectables is also related to the issue of irrational prescription of drugs. The PHFI study mentioned earlier shows that the percent of healthcare encounters where injections were prescribed were three-and-half times higher in Bihar (4.9 percent) as compared to Tamil Nadu (1.4 percent). Bihar also had larger proportion of encounters where antibiotics were prescribed (66 percent, as against 60 percent in TN). Reining in irrational prescriptions and promoting generic drugs are essential steps to tackle the shortages of therapeutic drugs and also reducing healthcare cost.
Policy and pricing are essential for access
Yet important as they are, efforts to provide affordable medicines for the general public, through institutional reforms (corporations), automation in supply chain management, increasing drug budget and promoting rational prescriptions addresses only the public health system. In a state where 72 percent of outpatient visits by rural population and 79 percent by urban population is to private healthcare providers, public health system interventions will have limited success in ensuring people’s access to affordable drugs. This would need additional policy interventions in drug price regulation and promoting generic drugs market. Thus a larger policy and program level interaction with the professional bodies of medical personnel and drugs and pharmaceutical industries is needed, over and above the improvement of government drugs supply systems.
Dr. Sanjay Pande
Dr. Sanjay Pande is Director Programmes, Population Foundation of India is a public health specialist with two decades of experience in reproductive and child health, urban health and community processes. He has worked in international and multinational organizations and has a doctorate in economics.
Gautam Chakroborty is Public Health Economist, Population Foundation of India. Gautam has over 18 years experience in research and advocacy. He specialises in health economics and finance for health systems strengthening.