MANAGEMENT OF THE SICK HEALTHCARE SYSTEM
( By Dr.S.V.Nadkarni, M.S. )

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Supply of Medicines

In the private sector, nothing in free and the patient has to buy his medicines. Food and Drugs Administration keeps a mcontrol on prices and quality of the drugs and within its limited man-power and authority. it is doing a commendable job. I do not propose to discuss this aspect, as it covers a wide field of pharmacentical industry and the drug control by F. D. A. (Medicines includes orals and injectables or skin-application, dressings etc.)

But in order to control wild prescription of costly drugsoften quite unnecessorily - I suggest that the "basic doctors, i. e. general practitioners should be prohibited from prescribing high-cost high-tech investigations, as well as high cost medicines and modern medicines introduced in the last 2 years. F. D. A. could be pursuaded to force the companies to mark these medicines as "To be prescribed by consultants only." The medical council and luckily the pharmaceutical companies are seriously considering a total ban on gifts, presents, conferences or foriegn tours, offered by companies to doctors as in inducement to prescribe such high cost medicines. It is a welcome step. Earlier it is implemented, the better. These two measures would hopefully reduce the unnecessary expenditure on drugs and medicines by the common man.

In the public sector, the state govt. and the municipal corporation buy medicines, through a process of tenders. A tender committee goes through the tenders and accepts the lowest compatible tender, for each particular medicine. As a professor of surgery and later as a Deam, I was a member of the tender committee of Mumbai. Muncipal Corporation and, I feel, the system of selection of drugs was fool-proof. There has never been a complaint about faulty supply of medicines, injectables in the B. M. C. in the last several decades. Despite criticisms, I am inclined to believe that the process is quitegood in the government too. But the compulsion to buy only the lowest quotation, leaves all the doctors in the state with a choice of a single brand of any particular drug. It is advisible to accept upto 3 or 4 different brands, or all those brands which are close competetors in price and leave the option to various health centres to opt for any one of them as per their choice. The state will have a very marginal higher expenditure but the doctors will have some freedom to choose the brand they prefer. It will also reduce the chances of the item, becoming not available due to short supply due to any extraneous causes in the approved company like strike, disputes, mismanagement etc. There will be adequate alternatives available. However, the main difficulty in the supply, apart from lack of budget, is a highly centralized system of the state government. It causes long scrutinies and thus long delays in supplies reaching peripheral hospitals and primary health centres. Once the tenders are approved, the purchase procedure should be decentralised and the districts. if not the talukas–should be authorised to puchase and disburse the drugs wihtin the limits of their budget. The hospital should have the freedom to choose the particular brand from among the approved brands. This way the complaints would be reduced to a minimum.

One great advantage of tender purchase by the state is an extremely low price that companies quote for such bulk purchases. Compared to their market price, medicines and injections are quoted, at least 30 - 40 % lower-sometimes even at half the cost - than the market price. Hence, the patients in the public sector will still benifit a lot, even if they have to buy these medicinesat the public hospital. As stated earlier, the government or the municipal corporation gets these medicines at about 70% of the retail price-or even lower. Hence, selling at 'cost-price' still means 30% reduction in cost for the patient. I have aheady grouped the patients in 3 groups.

  1. These who attend primary health-centres or public dispensaries and are refered to secondary or tertiary hospitals. They have come through proper channels, and therefore are entitled to highly subsidised charges. A fixed charge of Rs. 2 per one day's medicines in villages and Rs. 5/- in towns and secondary hospitals would be chargeable to them. It could he 'free' for all those below poverty line.
  2. Those who attend public hospitals directly or those who are referred from the private sector will pay the 'cost-price' actually incurred by the government or municipality companies can be asked to mark 'govt. price', along with M.R.P. on all supplies to the state.
  3. Private paying class patients will have to pay the market price–M.R.P.. They can be given even 10% concession over the M.R.P., as an incentive to attend public hospitals.

I have also emphasized that the whole section of medical supplies should be under the chief accountant. Thus the chief accountant will be answerable to balance the purchase and sale of drugs. If some patients below the poverty line are totally exempted and others subsidized as mentioned, the accountant will be able to claim this subsidized amount from the government on paper, so that he can balance the expenditure with income. This will greatly reduce chances of pilferage and thefts.

The doctors must be prohibited from prescribing drugs not quoted in the tenders. If required the superintendant is always authorized to make special purchase within some financial limits.

Thus the supply of medicines will be more assured than before. Pilferage, thefts and unnecessary costly prescriptions will be prevented to a large extent and a part of the expense on drugs will also be recovered from hose who can afford to the extend they can afford.

In Summery

  1. High cost medicines and modern medicines introduced during the previous two years should be prescribed by consultants only. Basic doctors should be prohibited from prescribing these drugs in public sector.
  2. Tender committee should approve 3, 4 or more brands, which are reasonably close to the lowest quoted brand. It will ensure supply.
  3. Hospitals should be free to purchase any of the approved brand wihtin its budgetary limits.
  4. The process of purchasing should be decentralised to the district level–if possible even to the taluka level.
  5. Medicines should not be 'free' except for those below poverty line and a fixed charge of Rs. 2/- for village and Rs.5/- for town-dwellers should be charged to all at primary centres and also in hospitals when they are refered properly from primary to secondary to tertiary health care centres.
  6. In hospitals, the patients attending 'out of turn' or refered from private sector should pay 50% of the the 'cost price', which the govt. / corp. has paid. Paying class should pay the market price. but can get 10% discount.
The whole 'Suuply of Medicine' section should work under the chief accountant, so that the expenditure and the sale income is properly tallied. This will help to prevent pilferage and thefts.
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