Seeding the Scheme

Rajasthan implements a Free Medicine Scheme

Text by Smriti Parhi
Photographs by Abhniva Sharma

It is uncommon to walk into a government official’s office where toys are strewn across the room, or a child’s wind chime moves in the breeze on the window. But Dr. Samit Sharma is an uncommon man. These toys are not props, they are a reinforcement for his employees to do a good job.

In a bureaucracy where everything appears mundane, Dr. Sharma brings innovative and new ideas to the workplace. As the pioneer of Rajasthan’s Free Medicine Scheme in a health system wrought with challenges, his innovation was not just administrative. “There is no use of discussing a problem for long unless you are looking for a solution.”

Formally called the Mukhyamantri Nishulk Dava Yojana (MNDY), the Chief Minister’s Free Medicine Scheme, this Scheme provides quality, generic drugs at no expense to all and helps to ease the significant out of pocket expenditures on health care that the current national health system demands.

India does not have a universal health care system, leaving it to state governments to work with their citizens on health care policies. The primary source of health care financing in many countries, especially in the developing world, is out of pocket payments. India has one of the highest out of pocket payments for health care, an estimated 65-70 percent of earned income. Less than ten percent of Indian households have health insurance for one member or more. When households have to shift their spending and reduce basic necessity expenses to pay for health care, experts consider it to be “catastrophic”.

In Rajasthan, on average before MNDY, 89.4 percent of household expenditures on health care was spent on medicine. According to the World Health Organization in 2010, 65 percent of patients were unable to access the essential medicines they needed to recover from an illness.

Dr. Sharma developed a model of treatment that integrates generic drug procurement and dispensation to the benefit of patients, medical professionals and tax payers. Tracing the genesis of the program, Dr. Sharma recounts his days as a pediatrician in a private hospital where he was offered a “cut” to prescribe only particular medications from a pharmaceutical company. The medicine sold at 20 INR, had the production cost of 1.70 INR, and he was offered it for 2 INR. This encouraged him to learn more about generic drugs and the cost of production, and he started looking for a way to provide medication at low costs to what he calls the “common man”.

Since his 2005 posting to Jalawar, he had been looking for options to reduce the costs of medications. He spoke to pharmacists and was able to procure medicines for low prices at the hospital pharmacies where he worked. He continued this practice on a small scale as he moved to different assignments within the medical system, including Chittorgarh. A refined idea for the scheme started taking shape as he met civil rights activists working in the area of health and human rights. His work was joined by Dr. Narendra Gupta, the founding member of Prayas, a research and advocacy NGO focused on health as a human right.

In 2009 in Chittorgarh, Dr. Sharma, with the support of Prayas, initiated a low cost medicine scheme as a pilot program. With the results of that program, an advocacy campaign began aimed at convincing Rajasthan state officials to implement a free medicine scheme for the entire state, where costs would be lowered through bulk purchases of generic drugs and all the citizens of the state – and beyond – could benefit.

In 2011, when he was the Managing Director for the Rural Health Mission and also the Project Director for the Rajasthan Health Development Program, he prepared a budget of 300 crores ($45 million) for medicines and with the government of Rajasthan’s support, Dr. Sharma began the Rajasthan Free Medicine Scheme.

Implementing a program offering free medicines in a state of more than 70 million people with diverse geography and needs was met with many challenges.

The Scheme began in stages, with initially 200 types of generic medicines made available. As the process became systematized, more medicines were added to the list, eventually making 612 available, including hospital supplies like sutures and needles as well as free diagnostics.

The public healthcare system in India is divided between Central and State governments, municipal areas, and Panchayats (local governments). The primary level includes village teams, sub-centers (SCs) and Primary Health Centers (PHCs).

The Rajasthan Medical Services Corporation (RMSC) was created and given the responsibility for centralized purchasing, quality control and providing medicines to all health facilities in the state. Generic medicines and this centralized system of procurement allowed the efficient distribution of quality drugs.

RMSC procures the items in generic names by finalizing the rates and supplies through an open tender process. All medicines and surgical needles are procured based on the need and consumption pattern of the items by the state medical institutions. The procurement orders are placed four months out with two months stock likely to be in transit and under quarantine, so stocking is a year round affair. One of the most challenging aspects of this is to be able to predict the needs of the health facilities for any given year. To contend with this, ten percent of the budget is allocated for decentralized purchasing of medicines as needed.

Once the medicines are procured, the suppliers send them directly to the District Drug Warehouses (DDW). The stock of drugs received at each DDW is entered into a stock register and kept in quarantine until sampling and receipt of quality control test reports.

Dr. Kalpana Vyas is the current Head of Logistics at RMSC and has been a part of RMSC since its inception. He said, “All drug warehouses were put with basic infrastructure. We did not have racks, and trolleys; those were put in place. We have 39 DDWs in total. The Drug Distribution Centres (DDCs) were set up for distribution of medicines to the patients. For a patient load of 150, one DDC was considered to be the norm.”

About 1,400 pharmacists were recruited for the new system. In 2013, computer operators were added for the management of and entries into the e-Aushadhi software. E-Aushadhi is the digital system designed to track the supplies. Since its successful implementation in Rajasthan, the application has been replicated by many other states in the country.

The medicines are tracked throughout the supply chain, ensuring that they are transported and used according to need and expiration date. One of the challenges of the decentralized system before the Scheme was that many medicines would expire and either be thrown out or, unfortunately, given to a patient. The RMSC, as well as all parts of the supply chain, is able to keep better track of all medicines to ensure maximum efficiency and little waste.

Despite the difficulty of implementing such a vast, logistical infrastructure and effort across an area the size of Texas, it could be said that the technical pieces were easier to address than the challenge of convincing doctors to prescribe generic medications.

In most countries, having the population warm to generic drugs takes time. Generic drugs are medicines that can be produced by any pharmaceutical company, all using the same ingredients. These are not medicines that are “owned” by any company. Some generic medicines are marketed under their internationally agreed upon name and are called generic generics. There are generics marketed under some branded names that are called branded generics. For brand medication, all versions post its patent period have the same active ingredients. The presence of one or two extra compounds does not ensure that branded drugs have a better effect than generic ones.

Pharmaceutical companies in India often give part of their profits to the doctors that prescribe their medicines, encouraging doctors to develop a “brand loyalty”. Unfortunately for the patient, these brand name medicines are often expensive. Pharmaceutical companies encourage the use of brand name medicines and brand name generics. They sell for a higher price, and people are willing to buy them because of the goodwill and trust they have in the marketplace.

Doctors’ opposition to the Free Medicine Scheme centered around their suspicions about the quality of ‘cheap’ drugs and their skepticism about the inclusion of the necessary or most used and effective drugs, as well as the loss of personal income. Dr. Sharma addressed this by making doctors part of the decision-making process for the Essential Drug List and Standard Drug Protocol, forming an advisory committee for the purchase and updating of the Essential Medicines List, which lists all the medicines available under the Scheme.

Doctors, like patients, are often enamored of the myth that branded drugs have more compounds and are better than their generic counterparts. Dr. Sharma, attuned to this, began a sensitization program to appeal to physicians’ emotional side, showing how the program would alleviate the suffering of people.

His philosophy is “every person has a good person and a bad person inside them. If you nourish the virtues and discourage the vices, a good person comes out.” Dr. Sharma seeks to encourage the good in all.

Doctors are now trained to understand that all versions of the branded medication, post its patent period, have the same active ingredients. The quality of the drugs was a critical component, for the patients and for the doctors, to ensure buy-in to the whole Scheme. To maintain the quality of the medicines, a random sample of products is taken from each batch and then sent to one of six empaneled and impartial labs throughout the country.

At the beginning of the Scheme, RMSC also monitored the prescriptions written by doctors. For this, self-carbonating prescription pads were made available. Once a doctor prescribed a medicine, there were automatically two copies of it made. The patient keeps one, and the other stays with the DDCs. At any given time, the District Project Coordinators (DPCs) could go through the prescriptions and provide feedback to doctors about over prescribing, prescribing rationally, and the Essential Drug List.

Management of the implementation and the staffing of the scheme across 33 districts had to be done carefully and thoughtfully. While Dr. Sharma believes his team was a family that “fell in his lap,” all of his team members shared that they were carefully chosen. His management philosophy focuses on accountability and making all staff take ownership of their work. He made it clear that each person who came to him with a problem also had to come with a list of three solutions. He believes this sense of ownership encouraged his team to align toward a common goal. He also used simple ways of working to maintain open communication, such as the popular messaging mechanism of WhatsApp. And those simple ways worked – he would get over a thousand messages each day from all 33 districts. The sense of connection that he built brought accountability to each person’s actions.

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One of the doctors who was part of the core team that implemented the scheme in the state is Dr. Raghu Raj Singh (right). A man in his late 40s, Dr. Singh is a doctor who believes in the nobility of his profession. Dr. Saab, as most doctors are called in India, sweats through most of Jaipur’s heat. He does not want to bribe the car contractor for a vehicle with an air conditioner. He is not a man who works for money, his compensation is the respect that people give him.

Sharing his experiences as a child, he talks about the trouble in finding the exact same medicine the doctor prescribed. “You could find some at one shop, some at the others, and for still others you had to come in the next day. I did not understand it, and would wonder if the hospital could make the medicine available. When I saw Samit Sir’s plan, it reminded me of that. Ideally, in any set up, medicine should be part of the health care provided and under the scheme, it is in the hospital and also free.”

In addition to the more frequently used drugs such as pencillins, the Scheme also provides medications for rare diseases. Guillain–Barré syndrome (GBS) is a rapid-onset muscle weakness disease. GBS can lead to death as a result of a number of complications: severe infections, blood clots, and cardiac arrest. For many patients, it is diagnosed too late. For others, access to medication had been challenging. The cost of the medical treatment for the disease is about 3.5 lakhs ($5,300). Dhanni Devi Sharma, 55, was quickly diagnosed with the illness and had access to medication under the Free Medicine Scheme. With a family of two sons and their wives and children, the prior cost of the drugs would have set the family back a full year of savings.

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The strength of the scheme is that it is working not just in the major cities but also in the parts of Rajasthan that are remote and had few health care facilities. Prabhu Dayal Khajotia, a daily wage worker, is visiting the Primary Health Center in Renwal, a town about 30 kilometers outside of Jaipur. He brought his daughter, Asha, who is anemic and has had a fever for more than three days. Prabhu was hoping that she would get better on her own, given the changing weather. She did not, and he is missing aday’s work and earnings to get her medicines. He is irked about the loss of pay, but the medications do not burn a hole in his pocket.

Sharda, 37, has been coming to the facility for the last three years. Her family runs a department store. She travels a distance of three kilometers, from another village named Mohabbatpura, to get her medicine. She has been diagnosed with diabetes, and the PHC provides her much needed medicines for free. The money she saves is being kept aside for her daughters’ weddings.

Heeralal Raigar is the Village Representative. This is a man who holds power in the village. He waits with the others in queue, and he uses the opportunity to strike up a conversation. Heeralal has a family of many brothers, their wives, children and children’s families. Today, he has come with his wife and grandson. He comes to the facility “often for any problems that the family has.”

The indoor ward in the Renwal center has no electricity, but the drug distribution counter keeps busy.

With all of these improvements in outreach and access, there is always more to be done. Though just six kilometers away, the PHC at Chittoda is nothing like Renwal. It is housed in two small rooms in an abandoned school. One room functions as the “hospital”, the other as a store house for drugs and broken chairs. There are two ANMs and a doctor who visits erratically. There are no pharmacists, or beds, or electricity. The drug counter is a table with some bottles of Ferrous Sulphate, some Paracetamol and just a few other medications.

Cramped corners, rooms bursting at the seams. The smell of medicine, sweat, urine and blood. Loud noises of people talking, crying, breathing. The air filled with waiting. Maybe there’s one fan, sometimes a window. The out-patient hours in any Indian public health facility are the busiest time of day – they are also the hours that are most emblematic of the challenges India’s health care system faces. Doctor absenteeism, lack of basic amenities at health facilities, and insufficient public funding continue to plague the system across the state. It emphasizes the need for ongoing campaigns by organizations such as Prayas, activists, doctors and the larger community to make health care available to all.

The Rajasthan Free Medicine Scheme cannot solve all of the challenges facing India’s public health care system. But it is one step in easing the burden, especially for those living in poverty, and in creating healthier and more productive communities.

In an evaluation of the Free Medicine Scheme, the World Health Organization and Public Health Foundation of India reported that the combined outpatient and inpatient care visits rose from 3.5 million in July 2010 to 7.8 million in July 2013, more than doubling the access and reach of health care.

People who would otherwise choose to visit para-professionals and uncertified doctors are now coming to the public health care facilities. This remains the greatest achievement for the Scheme. As the number of patients increases and the demands on the system to provide responsible health care grow, the Scheme can be the foundation for building a better health care system in India. At the scheme’s core is the belief in the democratic system of the country -- as long as there are the needs of the people, there will be ways to fulfill them.