During my visit to Amritsar (a city located in the northern Indian state of Punjab) and its surrounding rural villages, I spoke with physicians, pharmacists, and the local population about various topics, including their local access to healthcare, expectations of government-subsidized healthcare for patients and government employees, and any existing gaps/healthcare needs. One thing that came up time and time again in my conversations was the issue of over-prescribing. Coming from the mind-set of stream-lining medication lists and the abundance of medication noncompliance, it was surprising to hear that patients wanted (sometimes demanding!) more medications, regardless of whether or not treatment was actually indicated. The rationale being that a pill/IV/injection would be the quick fix for their ailment or disease, and that if a doctor didn’t prescribe them something then they were “incompetent” and patients would likely go elsewhere…somewhere more willing to hand out prescriptions. In my conversations with physicians and pharmacists who work in the government-run community health centers, it was clear that they were frustrated with the culture of prescribing and also the lack of access to medications in smaller rural settings. Though they try their best to explain the rationale behind whether or not a treatment is warranted, it seems that patients are often dissatisfied if they walk away empty handed. They are worried about them resorting to “quacks” or unqualified medical professionals to seek out medical care. As an outsider it’s frustrating to see the vicious cycle of excessive prescribing and I can only imagine how difficult it must be working in the system on a daily basis.
Along with the issue of over-prescribing, there is also the lack of basic medications available in the smaller community health centers that serve the rural communities. Supplies in general are very basic in the local clinics (usually no laboratory/diagnostic testing). I visited two centers, one center which had no medications and the last supply they received was over 6 months ago and the second center was close to running out of medications that were distributed over a month ago. Patients are given medications free of cost when the clinic can provide them, otherwise they must travel to the regional outpatient clinic that is located ~30 km away or pay out of pocket at a local pharmacy (basic meds costing around 1 rupee per day, roughly 50 cents per month). Given that most of the people in these remote areas who use the government centers live at or below the poverty line, it is difficult for them to sacrifice the time and the cost to travel to a distant clinic or pay out of pocket.
These issues raise the question about what can be done to improve access to medicines in lower and middle income countries and who is responsible for this task; is it the government, pharmaceutical companies, NGOs…? With over 2 billion people without access to medications worldwide, it’s a massive undertaking that will require a collaborative approach. I wanted to focus on the role of pharmaceutical companies in the issue. The Bill and Melinda Gates Foundation, as well as the UK and Dutch governments, help fund the Access to Medications Index. The index ranks the top 20 pharmaceutical companies’ efforts to improve access to medications in over 100 lower and middle-income countries through seven measures (strategy, governance, research and development, pricing, licensing, capacity building and donations). Here’s the link to 2016 report cards. While the Index is helpful in promoting large pharma companies involvement in improving accessibility of medications through various means, it’s not clear what the actual impact is on the burden of disease and the local communities involved. I came across this blog post from The Lancet highlighting this issue. Some companies, such as Novartis, have started to address this issue. Novartis has linked up with Boston University to evaluate Novartis Access, an initiative to provide 15 different medications (on- and off-patent) in Kenya for the treatment of non-communicable diseases (CVD, respiratory diseases, DM, breast cancer) for the cost of $1 USD per treatment. Boston University will publish the results on the availability and price of treatments at both public and private institutions in Kenya, as well as changes in prescriber behavior and awareness of treatment availability among patients. While improving access to medicines in lower and middle-income countries is essential, it’s just as necessary to consider how improving access actually impacts local healthcare and patient attitudes.