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Chapter 2 Essential Drugs

Chapter 2 Essential Drugs

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Published by: S.Srinivasan ('Chinu'); Renu Khanna on May 20, 2010
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Chapter 2
 The root causes of ill-health in developing (and underdeveloped) countries like India, are malnutrition, lack of clean water and sanitation, and unemployment. With a population of more than 100 crores, Indiaaccounts for about 16 per cent of the global population. India is a country where 37% of the population stilllive below the poverty line and where the proportion of out-of-pocket expenses out of the total expenditureon health in one of the highest in the world; with only 17% of the expenditure contributed by thegovernment (figures from the National Health Policy 2002). In addition our burden of diseases is among thehighest in the world (see box on Load of Diseases). Also see box
 Anatomy of Health Disaster 
P. Sainath.
Essential Drugs
 Tuberculosis: 1/3 of world's cases: 15 million cases. Largest number of multi-drug resistant cases.
HIV/AIDS. Second highest in the world: 3.5 million persons.
 Acute respiratory diseases: 950,000 deaths per year.
 Acute diarrhea: 19 crores illness episodes per year and an estimated mortality of 1 lakh children per year
Malaria especially falciparum malaria is a public health problem with an estimated 2-3 million cases per year and amortality of 20,000 per year.
Kala-azar is a significant public health problem in certain states and causes.
Parasitic infections include hookworm infections, which contribute in a major way to iron deficiency anemia, andfilariasis.
Hypertension: 20-40% in urban areas, 12-17% in rural areas.
Diabetes mellitus: Largest number of diabetics in the world. 4 % of India's population And cause for 1.1 % of alldeaths.
Cardio-vascular disease: 31.7 % of all deaths in 2000.
Cancer: Estimates of age standardised rates of cancer range from 99.0 to 129.6 per 100,000 in males and 104.4 to154.3 per 100,000 in females. 7 lakh new cases per year and cause for 7.4 % of all deaths in 2000.
Chronic respiratory diseases: 65 million cases and cause for 2.5 % of all deaths in 2000.
 Anemia: Anemia is a major public health problem in women and children with a prevalence of 74.3 %in children of 6-35 months and a prevalence of 49-56% in women (NFHS 1998/99). Anemia contributes to 1/3 of maternalmortaltiy.
(Source: Abdul Ghaffar, K.Srinath Reddy and Monica Singhi: “Burden of Non-Communicable Diseases in South Asia”,
, No 7443, 3 April 2004)
Load of Diseases in India
1. Why We Need Only Essential Drugs?
Nearly 50% of healthcare costs are contributed by expenditure on drugs. NSSO surveys reveal figures of upto 80 percent in rural areas. In a study done for the WHO on treatment costs incurred by patients with TB, it was found that 60% of the costs were contributed by drug costs. With the rise in health care costs the numberof persons who do not seek treatment because of economic reasons has risen in both the urban and rural
areas (NSS 52 round), which is disturbing. According to a World Bank study, as a result of the costs of asingle hospitalization, 35% of people fall below the poverty line.
1.1 Increasing Drug Costs to the User
By P Sainath
 Janreddy's family survived crop failure. But debts of Rs 300,000 to cover health costs have nearly destroyed them. Loans taken to cover health costs have been a major contributor to the debt-suicide cycle in Andhra Pradesh 
 Janreddy sat wracked with pain, a picture of ill health. "Why isn't this man on his way to hospital," we asked theneighbours crowding around his bed. "Well," they said nervously, "we just brought him home from one. He was therefor days. This family has already lost all its money on hospitals." Janreddy died hours after we met him. His daughter-in-law, who became a bonded labourer to keep the family afloat, will remain one till debts of Rs 500,000 are paid off. Over Rs 300,000 of that was incurred on medical costs. His wife, who donated one kidney to her son -- both of his had collapsed -- does any work she can find. The son, Narsi Reddy,confined to the house, has to drink only the purest water in a place where there is none. His medicines cost around Rs1,000 a month. The huge medical bills of this family of six were incurred despite the son getting free operations at the OsmaniaGovernment Hospital in Hyderabad. They had first gone to private hospitals for check-ups, a biopsy and other tasks. As the costs mounted they sold off land and cattle to meet them. That Narsi Reddy had sunk four borewells didn'thelp. All of them failed. Crisis on their four-acre farm in Chelliagudam village of Nalgonda district saw Janreddy'shealth also cave in. "They might just have survived the crop failure," say the neighbours, "but their medical costsdestroyed them."Health spending is amongst the fastest growing components of rural family debt. More so in Andhra Pradesh. Foryears, the state boosted the private sector in health, promoted corporate hospitals and pioneered the 'user fees' systemin government ones."The Chandrababu Naidu government dismantled the public health system," says M Geyanand, a leading doctorfrom Anantapur district. Dr Geyanand is also state president of the Jana Vignyana Vedika (JVV), a body that aims topromote popular science and the scientific temper. "Ninety per cent of patients who go to public hospitals are poor. When that system fails them, they turn to private ones at a huge price. Health costs often count for as much as 20-25%of the total expenditures of such households. And a single medical emergency can ruin them." A common thread running through the farmers' suicides plaguing the state has been very high medical spending. Justfive households affected by such deaths had health costs totalling around Rs 400,000. All of them farming families who held between half-an-acre and three acres of land (some of that mortgaged). Janreddy's family has not seen asuicide. But it fits this profile rather well. As do countless other poor households. Even last year, we ran into a farmer who had attempted suicide in theNallamada mandal of Anantapur district. His friends managed to get him to a hospital just in time.
 Anatomy of a Health Disaster
 The rescued farmer abused his saviours. The reason: The four-day stay and treatment in hospital cost Rs 45,000. "Itried to commit suicide because I could not pay debts of Rs 150,000," he said bitterly. "Now I owe even more."Many of those who succeeded in taking their lives in 2004 had huge medical bills. P Hanumantha Reddy's family inNizamabad district owes Rs 200,000. The survivors of A Narasimhalu in Medak have to rustle up Rs 70,000 plusinterest. The tab for K Shivarajaiah's family in the same district is Rs 50,000. All this was money borrowed at absurdrates of interest."There is a link between the suicides and the crisis of health in Andhra," says Dr Geyanand. "The collapse of thepublic health system is crucial. In any poor village, you can see people dying of diseases that should not kill them.Malaria is just one example. For years now, all their support systems have been slashed. The costs are so high, they runout of money halfway through treatment. Those who fall ill are selling land, gold, cattle and other assets to pay medical bills. They also take loans they can never repay."In the past decade, the little access the poor had to health sharply declined. So Gunala Kumar discovered when he hadto fork out Rs 40,000 in medical costs to private hospitals in Medak. That remains a big chunk in his total debt of overRs 200,000. A debt that caused him to take his own life in Meerdoddi village this month. Like his father whocommitted suicide last year."Maybe it is better to die," says Yekalapu Husein of Shabuddlapur in Nalgonda. "How will we pay the fees they ask usto at these hospitals?” A toddy-tapper who suffered a fall from a tree while at work, Husein has run up huge billshimself. Then came his malnourished wife's illness. His 'medical debt' now stands at Rs 200,000. "Even if we get freecare at Osmania Hospital," he laughs, "we do not have money for the bus fare to Hyderabad and back."In Gedavalli village in the same district, the local rural medical practitioner sold all his land to pay his own treatmentcosts of Rs 400,000 at a corporate hospital in Hyderabad.In the years these dramas unfolded, public hospitals were starved of funds, medicines and drugs. Given Rs 600 croreby the World Bank for public health, the Naidu government spent this mostly on buildings. Very few doctors ornurses were recruited. The buildings now show decay for lack of maintenance. Naidu also authored a government'tie-up' with corporate bodies. Under this, employees of the state went to corporate, not public hospitals. Thegovernment reimbursed their costs. This meant a windfall for those hospitals. It also meant many scams in the shapeof inflated reimbursement bills. Meanwhile, health institutions in the public sphere suffered.“The introduction of 'user fees' made health even less accessible to the poor," says a senior IAS officer. The fees havesince been withdrawn by the new state government. Also dumped was an idea of handing over some super-specialtdepartments of public hospitals to 'private management'. That is, to corporate hospitals. The damage, though, has been done. The medical costs of those who preferred death to debt still plague the living. We pass Janreddy's wife at the bus stand, looking for any 'coolie work' she can find. There are, after all, bills to be paid.
P Sainath is Rural Affairs Editor of 
 The Hindu
. He received the A H Boerma Award, in 2001, for his contributions to the development debate in the Indian media.)This article originally appeared in 
 The Hindu
 , July 1, 2004
 A problem, which has complicated the control and treatment of infectious and communicable diseases inIndia, is the increasing problem of drug resistance in common infections and diseases of public healthimportance. Drug resistance has become increasingly frequent: chloroquine-resistant falciparum malaria,multi-drug resistant TB (new strains resistant to both INH and Rifampicin), new typhoid strains resistantnot only to chloramphenicol but also increasingly to quinolones. The latter results in a dramatic escalation
1.2 Increasing Drug Resistance

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