A preliminary assessment of availability and pricing of children's medicines in government hospitals and private retail pharmacies in a district of Andhra Pradesh.

Sir,

Children's access to medicines in suitable pediatric formulations is a matter of global concern today.[1] Medicines prescribed for children are often off-label. Nonavailability of child size medicines encourages the use of adult dosage forms, splitting them into parts before giving to a child. This practice is not scientific and is far from rational, since children are not just miniature adults. Thus many children lack access to essential treatment because no suitable formulation exists, or those that do are either not available or are too expensive.

In the backdrop of paucity of literature addressing this problem in India, this preliminary cross-sectional survey was planned to assess the availability and pricing of some common pediatric medicines in government health facilities vis-à-vis in private retail pharmacies.

The study was conducted during May-June, 2011 in the district of East Godabari in Andhra Pradesh, India.

The data collection form used for this purpose was developed with little modification of the ‘WHO Children's Medicines Survey Form’,[2] customizing to suit our purpose. The availability and pricing of 20 core children's medicines were assessed in the survey. All of these 20 core medicines were in ‘WHO Model List of Essential Medicines for Children, Oct 2007’,[3] and 15 of them were included in National Essential Medicine List of India 2003.[4] For data collection in this survey the WHO/HAI methodology was followed after due modification.[5]

As no patient data were used in this survey, there was no ethical dilemma. However, permission was obtained from local health authority (from Chief Medical Officer of Health of the district) before conducting the survey.

Two of the authors (LR and MB) acted as the data collectors, and visited the 8 public health facilities of different tiers, and 7 retail pharmacies, nearest to the respective public health facilities, during a period of 6 weeks in May-June, 2011. In retail pharmacies, the actual price to the patient of the cheapest brand as available on the day of the survey was documented. In public health facilities, procurement prices for medicines were obtained from State government's Central Drug Stores (CDS) listing.

For all practical purposes, formulations that existed in alternative pediatric dosage form and pack size were regarded as ‘available’. Overall, the availability was at best sub-optimal in all levels of public health facilities - 35% in the teaching hospital pharmacy, 30% in the district hospital, 35% in primary health centers (PHCs) and 30% in community health centers (CHCs). Even availability in retail pharmacies was only 37.85% [Table 1].

Table 1

Availability of the surveyed medicines (in % of the WHO 20 core medicines)

Out of the 20 formulations, only six - amoxicillin oral suspension, amoxicillin-clavulanate oral suspension, injection ceftiaxone, cotrimoxazole oral suspension, ORS sachet, paracetamol syrup - were available in all the public facilities surveyed, as compared to only 5, e.g., amoxicillin oral suspension, injection ceftiaxone, ferrous salt suspension (combined with folic acid), ORS sachet, paracetamol syrup, in all private pharmacies. As high as 13 formulations (acyclovir suspension, artemether-lumefantrine tablet, beclomethasone inhaler, carbamazepine suspension, INH tablet, mebendazole chewable tablet, mebendazole syrup, nevirapine syrup, nystatin drops, rifampin-isoniazid tablet, salbutamol inhaler, vitamin A capsule, zinc dispersible tablet) i.e., 65% of the basket of medicines, were not available in any of the eight public facilities surveyed, while 10 out of the 20 core medicines, e.g., acyclovir suspension, artemether-lumefantrin tablet, beclomethasone inhaler, carbamazepine suspension, INH tablet, nevirapine syrup, nystatin drops, rifampin-isoniazid tablet, vitamin A capsule, zinc dispersible tablet, i.e., 50% were not available in any private pharmacy. The last named 10 medicines were not available in any government facilities either. Availability of anti-infectives was also poor in general. As many as 7 out of 12 (58.33%) antiinfective formulations in the WHO list of 20 core medicines were not available in either government hospitals or in retail pharmacies [Table 1].

The price comparison of medicines was done only for those items that were available in all or most of the government and private facilities. The cost of even the cheapest brand for a given medicine as available in a retail pharmacy was much higher than the procurement price of the same item for government facilities. Barring for one item, amoxicillin suspension, the variation of prices of medicines among different private facilities was not too wide. For amoxicillin suspension, the price range of the cheapest available products in different retail pharmacies was to the tune of Rs 80 – Rs 28 [Table 2].

Table 2

Price of surveyed medicines

This pilot study reveals children's sub-optimal access to core essential medicines in both public facilities and private retail pharmacies in a district of India. This is a matter of serious concern and demands urgent attention. The survey paves the path for a larger and more in-depth study to further assess the magnitude of the problem in a nation-wide perspective, with perhaps a greater focus on affordability.