Summary Report of A Study of Supply and Use of Pharmaceuticals in Satara District

Item

Title
Summary Report of
A Study of
Supply and Use of Pharmaceuticals
in Satara District
extracted text
Summary Report of

A Study of
Supply and Use of Pharmaceuticals
in Satara District

Dr. Anant Phadke
Audrey Fernandes
L. Sharda
Dr. Amar Jesani

o

Foundation for Research in Community Health
84-A, R.G. Thadani Marg,
Wodi, Bombay - 400 018
April 1995

p~eiG

A STUDY OF SUPPLY AND
USE OF
PHARMACEUTICALS IN
SATARA DISTRICT
(Summary)
In India, about Rs. 7000/- crores of drugs are consumed every
year. It is acknowledged that substantial part of these drugs are irrational
combinations which are also wrongly used. In the Government sector,
there is a great deal of shortages of drugs. The current study tries to go
into the details of the supply and use of drugs in an average district in
Maharashtra. No such district level study has been done so far in India.

Parti

SUPPLY OF PHARMACEUTICALS
IN SATARA DISTRICT
1.

Objectives

To study the amount and the pattern of drug supply to the public
and private sector in Satara district, the shortages in the public sector.

2.

Methodology

Based on socio-economic indicators of development, (CMIE
index), drug supply and OPD attendance in public health facilities, Satara
district was chosen as an average district in Maharashtra. Based on
socio-economic considerations, the talukas in Satara district were divided
into developed, average and drought-prone zones. Three PHCs and one
Rural Hospital from each zone (9 out of 69 PHCs and 3 out of 10 RHs),
one Cottage Hospital (out of two) and the district Civil Hospital were
selected to study the amount of each drug indented and supplied to the
Government health facilities, shortages, if any, and the dynamics of supply,
utilization and shortages. The total number of drugs and their formulations
supplied, were recorded in physical terms as well as their prices to arrive

1

at the drug-expenditure. All these data were re-arranged as per the
categories of the WHO Essential Drug List.
To study the regularity of availability of drugs, the date of supply
and'the date of nil stock were recorded for each drugs. Depending upon
the availability in days, of different drugs, they were grouped into six
categories - i> Always Available ii> Regularly Available iii> Irregular
iv> Very Irregular v> Effectively Not Available vi> Never Available.
An estimate of the total sale of drugs in the private sector was
mace on the basis of informal yet very reliable sources of information.

3.

Results

3.1 - Total Drug Supply
Our findings of representative sample of PHCs and Rural
Hospitals if extrapolated to the district level, give the cost of all category
of drugs (excluding Leprosy, Contraceptives and vaccines under the
immunization programmes) supplied to the public sector as follows.

Average cost of supply/unit
(1991-92)

No. of
Units

Total

PHC

Rs. 39,495.80

69

2725210.20

R1

Rs. 95,697.49

10

956974.90

Cottage

Rs. 2,15,080.00

1

215080.00

Civil

Rs. 17,26,029.00

1

1726029.00

5622862.80

Total

The total supply to the public sector in 1991-92 was
Rs.5622862.80 i.e. around 56 lakhs while the lowest estimate we had for
the private sector for 1991-92 was 21.28 crores (Rs. 87 per capita).

.

3.2 - Range of Drugs Supplied
The nine PHCs were supplied on an average of 42 generic drugs
each (range - 27 to 50) in 171 formulations and dosage forms like

2

Table 1

Availability of Drugs at 9 PHCs
and 3 Rural Hospitals in Satara District (1990-92)
PHCs
As % of
total no.
of drugs

RHs
No. of As % of
Drugs total no.
of drugs

Sr.
No.

Type of Availability

No. of
Drugs

1.

AA - Always Available

0

0

2

1.25%

2.

R - Regular (available
76 to 99% of days)

4

2.68%

18

11.32%

3.

I - Irregular (available
51 to 75% of days)

10

6.71%

26

16.35%

VI - Very Irregular
(available 25 to 49% of
days)

45

30.02%

60

37.73%

EN - Effectively Not
available (available 1
to 25% of days)

81

54.36%

51

32.07%

NA - Not Available
through the year

9

6.04%

2

1.25%

159

100%

4.

5.

6.

Total

149

100%

Note : The Data excludes anti-TB drugs and very marginal supplies.
combination drugs, tablets, syrups, injections in various dosages. The
corresponding average figures for the three Rural Hospitals were - 35
generic drugs in 189 formulations. The Cottage and Civil Hospital were
supplied with 129 and 151 generic drugs respectively in a large number
of formulations.

3.3 - Regularity of Availability
The above figures denote only the total number of drugs supplied
over a period of one year. It is also quite important to study the availability

3

of drugs on a day to day basis. It was found that in those nine PHCs, only
14 out of 149 formulations (9.4%) were available for more than half the
days of the year. In case of the three Rural Hospitals, 46 out of 159
formulations (29%) were available for more than half the days. Thus
there'are continuous, gross shortages at PHCs and RHs of even these
Essential Drugs. Some of the details of availability are given in table
No.l.

4.

Conclusion

The drug supply to the Public Health Facilities in Satara District
is too less, less than 3 percent of the drug-supply to Ute private sector.
There are continuous, gross shortages of even commonly required
medicines in the PHCs and Rural Hospitals.



4

PART 11

USE OF PHARMACEUTICALS IN
SATARA DISTRICT

Objectives
The overall aim of this second phase of this study was to study
the use of pharmaceuticals in Satara district. In pursuance of this overall
aim, the following specific objectives were delineated.

A)
To study the prescriptions of doctors in public and private
sector in order to assess their rationality ; the extent of the use of
unnecessary, irrational, hazardous drugs and unnecessary injections. To
correlate these aspects of prescriptions with the educational status of
doctors, and the relevant socio-economic factors.
B)
To study the factors affecting prescription behaviour of
doctors, viz the Continuing Medical Education of doctors, the extent of
competition amongst doctors; the marketing practices of the drug­
companies and drug-stores etc.

C)
To assess the knowledge status of - nurses in PHCs about
the drugs they commonly use and thereby to study indirectly the use of
drugs by such nurses.
D)
To study the extent and nature of sale of prescription­
drugs (schedule drugs) which arc sold over the counter (OTC) without
prescription.

E)
To estimate the wastage in both public and private sector
on account of use of irrational drugs by doctors.

F)
To study the extent of expenses incurred by patients on
account of “private - prescriptions” given by doctors in the Public Health
Facilities. (PHFs).
*

G)
To study the morbidity pattern in PHC-OPD (Out-Patient
-Department) and to estimate the average drug requirement and drug

5

budget of PHCs if all the cases coming to the PHC-OPD were to be
adequately and rationally treated. To compare this need with the actual
supply of drugs to PHCs.

Methodology
The methodology for each of the sub-components of this study
was tailored according to Ute objectives and has been described at the
beginning of each of the corresponding subsection of this report. The
overall sampling frame has been described in the section-A i.e.
Prescription-Analysis. The specific methodologies as given in different
sections are to be seen in the context of this sample frame.

A

PRESCRIPTION - ANALYSIS

It is widely believed by critics that doctors’ prescriptions in India
are irrational to a large extent, leading to a lot of financial wastage.
However, barring one exception, there are no systematic studies in India
which have analysed a representative sample of doctors’ prescriptions in
relation to the diseases for which they are given. The current study has
conducted such an analysis of 1944 prescriptions collected in 59 visits to
Out - Patient Clinics of 30 public health facilities and of 1638 prescriptions
from 62 visits to 19 private clinics from different parts of Satara district.

A -1 : Objectives
To study the prescriptions of doctors in Satara district in public
and private sectors, in order to assess the rationality of these prescriptions
and the extent of use of unnecessary, irrational, hazardous drugs, and
unnecessary injections.
To co-relale these aspects of prescription-behaviour with the
’ educational status of doctors, their being in the private or public sector
and the geographic situation of prescribing doctors (urban or rural area,
• developed or backward area).

6

A-2. : Materials and Methods
A-2.1 : Selection of Public Health Facilities
To get a representative sample, the Satara district was divided into
three zones - backward, average and developed zone as in the first part of
the study. Atleast five Primary Health Centres and one Rural Hospital
from each of these zones, (25 out of 69 PHCs in 1991-92 and 3 out of 10
RHs in the district,) the only functioning Cottage Hospital (out of two)
and the District Civil Hospital were selected for the study through
purposive sampling, a total of 30 Public Health Facilities (PHFs).

A-2.2 : Selection of Private Clinics
For the study of private sector, doctors from each of the following
educational backgrounds were chosen from each of the three zones. Post­
graduate, MBBS, non-allopathic degree (Ayurvedic or Homeopathic both types as a rule prescribe allopathic medicines) and Registered Medical
Practitioner (who doesn’t have any recognised degree as such).
Private Practitioners were generally selected from the same village
or town from where doctors from public sector were chosen so that
comparison between the two becomes more meaningful.

A-2.3 : Prospective Data Gathering
To record all drugs given to the patient, the data were collected
prospectively by posting pharmacist- investigators for a day in each of
Hie clinics to record both types of drugs - those given in the dispensary
and those prescribed for buying from a medical shop for first 30-35
cases.

A-2.4 : Rationality Indicators
Selection of appropriate indicators for assessing rationality of
prescriptions is an important issue. We chose the following rationality/ •
irrational! ty/i ndic ators.

7

A-2.4.1

Average number of drugs prescribed and percentage of
prescriptions containing more than 3 drugs.

A-2.4.2 Percentage of prescriptions Containing -

*

a) irrational drug/s
b) unnecessary drug/s
c) hazardous drug/s
d) unnecessary injection/s

A-2.4.3 Scores Obtained by Prescriptions The above indicators study only specific aspects of prescriptions.
An indicator is necessary which would study the prescription as a whole.
Such an indicator viz. - marks obtained by each prescription as compared
to a possible maximum of 30 assigned marks per prescription, was
developed for this study. For this purpose, Standard Drug Treatment
Regimens (SDTRs) for all the 92 commonly found diseases in these
prescriptions and 16 Prescription Analysis Guidelines (PAGs) divided
into 4 categories were developed. Marks were given to each prescription
on the basis of these SDTRs and PAGs. Prescriptions were grouped in
three slots - rational (25 to 30 marks), semi-rational (15 to 24 marks),
irrational (upto 14 marks).

A-3 : Results
A-3.1 : Rationality-Indicators
The data were inputted and analysed with the help of the LOTUS
system. 2 sample t test, chi-square test and F tests were carried out to test
statistical significance. The important, summarized results of prescription
analysis are as follows - (For details, please see Table No.2 and 3). In
general, the level of rationality of prescriptions in Satara district is quite
low.
1> The average score per prescription is very low -

The proportion of Rational Prescriptions is low and of irrational
prescriptions high in all types of doctors in spite of liberal guidelines used

8

Table no. 2

Prescription Analysts of Doctors in Satara District
Sector-wise and Area-wise Comparison
No.
No. of
of
presc­
visits
riptions
to
Clinics

Sector

No. of Prescriptions containing

No.of
drugs
per
RX

More
than
3
Drugs

Irra­
tional
Drug

Hazar­
dous
Drug

Unne­
cessary
Injec­
tion

Unncessary
Drug

Grading of prescriptions
Rational

Semirational

Irra­
tional

(R)

(S)

(D

Avg
Score
per RX
(out
of
30)

Total Sector
(%)

121

35S2
(100)

28

1767
(49.3)

680
(19)

376
(105)

851
(23.8)

1698
(47.4)

651
(18.2)

1327
07.0)

1604
(44.8)

1422

Total Public Sector
(%)

59

1944
(100)

28

871
(44.8)

107
(55)

129
(6.6)

485
(24.9)

828
(426)

424
(21.8)

752
08.7)

768
095)

16.14

Rural Public
(%)

40

1234
(100)

26

521
(422)

73
(5-9)

69
(5.6)

262
(21.4)

456
07)

264
(21.4)

476
08.6)

494
(40.0)

1622

Urbar

*c

7

271
(100)

28

141
(52)

6
(22)

11
(4.1)

67
(24.7)

133
(49.1)

86
01.7)

108
09.9)

77
08.4)

1634

Small Towns
(%)

12

439
(100)

3.0

209
(47.6)

28
(6-4)

49
(112)

156
(355)

239
(54.4)

74
(16.9)

168
08.3)

197
(44.9)

15.76

Total Private Sector
(%)

62

1638
(100)

3.0

896
(54.7)

573
05)

247
(15.1)

366
(22.3)

870
(53.1)

227
(13.85)

575
05.10)

836
(51)

1252

Rurai Private
(%)

14

371
(100)

29

186
(50.1)

103
(27.8)

44
(115)

80
(21.6)

148
09.9)

56
(15.1)

138
072)

177
(47.7)

14.42

Urban Private
(%)

27

726
(100)

29

437
(60.2)

265
(36.5)

109
(15)

116
(16)

411

94
(129)

256
05.3)

376
(51.8)

1255

r l

Small Towns
(%)

21

541
(100)

3.3

273
(150.5)

205
(37.9)

94
(17.4)

170
(31.4)

311
(57.5)

77
(14.2)

181
.
035)

283 ,
(523)

1136

9

I able no. 3
Prescription Analysis of Doctors in Satara District
Education-wise Comparison
No.
No. of
of
pres­
visits
criptions
to
Clinics

Sector

No.of
drugs
per
RX

No. of Prescriptions containing
More
than
3
Drugs

Irra­
tional
Drug

1767
(49.3)

680

Hazar­
dous
Drug

Unne­
cessary
Injec­
tion

Unncessary
Drug

Grading of prescriptions
Rational

Semirational

irra­
tional

(R)

(S)

(b

Avg
Score
perRX
(out
of
30)

376
(10.5)

851
(23.8)

651
(18.2)

1327
(37.0)

1604
(44.8)

1422

(47.4)

166
029)

25
(5.0)

29
(5.8)

252
(50)

126
(25.0)

209
(41.5)

169
03.5)

15.64

67
(16.5)

4
(2.8)

6
(42)

15
(10.4)

59
(41)

60
(41.7)

55
(38.2)

29
(20.1)

19.65

3.0

223
(61.9)

162
(45)

19
(53)

14
(3.9)

193
(53.6)

68
(18.9)

152
(422)

140
08.9)

14.71

2238
(100)

3

1055
(47.1)

266
(11.9)

176

572
(25.6)

1029
(46)

437
(195)

851
(38.0)

950
(425)

15.34

0-9)

51

1624
(100)

27

737
(45.4)

91
(5.6)

101
(62)

415
(25.6)

694
(427)

342
(21.0)

638
093)

644
09.7)

1630

21

614
(100)

3.0

318
(51-8)

175
(28.5)

75
(122)

157
(25.6)

335
(54.6)

95
(15.5)

213
04.7)

306
(49.8)

13.03

All Non-Allopaths
(%)

28

719
(100)

3.1

355
(49.4)

214
09.8)

138
(192)

199
(27.7)

355
(19.4)

77
(10.7)

224
(31.2)

418
(58.1)

1128

All RMPs
(%)

5

121
(100)

22

67
(55.4)

34
(28.1)

37
(30.6)

51
(421)

62
(512)

11
(9.1)

43
05.5)

67
(55.4)

10.09

Total Sector
(%)

121

All Consultants
(%)

Public

3582
(100)

2.8

16

501
(100)

3.1

290
(575)

3

144
(100)

3

13

360
(100)

A11MBBS
(%)

72

Public

(%)
Private

(%)

(%)
Private

(%)

10

<j98

for analysis. The proportion of rational prescriptions and the average
score per prescription rises with the educational qualification of the
doctor. Though the overall score of consultants (post graduate doctors)
is slightly better, they tend to use more unnecessary drugs.
2> A very high proportion of prescriptions of all types of doctors contain
irrational/unnecessary/hazardous drugs or unnecessary injections or
more than 3 drugs.
3> Public sector prescriptions are more rational than private
prescriptions. However, proportion of irrational injections in the public
sector is slightly higher than in the private sector.

Most of the differences in performance of different types of doctors
in the level of rationality as assessed by different rationality indicators,
were statistically significant.

A-3.2 : Other Observations
A-3.2.1 : Average score for Most Common Diseases :
Fourteen most common diseases who’s combined share in the
total morbidity is more than 60% (61.05%) were listed. The grading of
prescriptions for these 14 diseases was as follows :

Rational - (25 to 30 marks) - Nil
Semirational (15 to 24 marks) - 6 diseases
Irrational (upto 14 marks) - 8 diseases

A-3.2.2.: Diseases with Irrational Prescriptions :
Diseases whos share in the morbidity load at OPD is more than
1 % and who have received less than 15 marks; i.e. whos prescriptions are
irrational have also been listed. Obviously special attentions will have to
be given to the drug-treatment of these disease in Continuing Medical
Education of doctors.

05001

A-3.2.3. : Grossly Irrational Prescriptions
We came across many prescriptions which were grossly irrational.
They "contained either a totally wrong selection of the main drug or use of
contraindicated drug or two or three analgesics or haematinics etc. We
have reproduced 25 such grossly irrational prescriptions encountered the
collection of prescriptions during Winter 1993. This is only an illustrative
list. Many more such examples were found.
Surprisingly, ?11 types of doctors from RMPs in a small village
to post-graduate doctors in large town were found to be writing grossly
irrational prescriptions.

B
FACTORS INFLUENCING
PRESCRIPTION BEHAVIOUR OF DOCTORS
Different factors other than the needs of rational therapeutics
influence doctors’ prescriptions - level of Continuing Medical Education
(CME) of doctors, the marketing strategy of the drug companies, extent
and type of competition amongst doctors, availability of medicines, socio­
economic background of patients etc. In this exploratory exercise, we
studied some of the factors that in their own perception, influence doctor’s
prescriptions in Satara district.

B-l Materials and Methods
This study is in two parts. In Part-I, we explored the gambit of
factors that contribute to doctors’ iirational prescribing. In Part II, we
used the results of analysis of doctors’ prescriptions (from section A of
the study), to compare their rationality score with the socio-economic
factors influencing their prescriptions.

1st part - Structured questionnaire plus focussed interview
As an entry point, we administered a small two page pretested
structured questionnaire which sought information regarding qualifications
of the doctor, his/her sources of continuing medical education, the number

12

of medical representatives that visited him in a w \,k, his/her views on
patients expectations, his/her opinions on drugs available in Ute open
market.
Focussed interviews were conducted with those doctors who were
willing to give information beyond this questionnaire. The guidelines to
the focussed interview included various probes for the investigators to
find out more about the sources that public and private doctors had to
Continuing Medical Education marketing practices of drug-companies
and drug-stores, availability of drugs, extent of competition.

find part - Questionnaire
To correlate the rationality score of doctors with certain socio­
economic factors, we used a revised version of the earlier questionnaire
which we first pretested. This questionnaire was brief in asking the doctors’
opinions about medical companies and their practices on field, additional
qualifications of the prescribers (in terms of even practical knowledge
such as hospital training etc), number of medical stores in the area, number
of medical representatives that visited, tire peer pressure on the doctors,
number of patients etc.

Sampling
We randomly picked five Primary Health Centres (PHCs) in the
each of the three zones as in the rest of this study. One medical Officer
each from these 15 PHCs and one or two private doctors operating in the
same village or nearby villages were interviewed.

B-2 : Results
In Part II study, we had proposed to compare rationality scores
with the socio-economic surroundings of the doctor. The rationality scores
however revealed that very little co-relation was possible as majority of
doctors in our sub-sample had a very low rationality score.

The Qualitative Results were as follows -

B-2.1> CME in the private sector is almost entirely left to the discretion
of the individual doctors and only 12.6% actually subscribed to periodicals

13

other than those published by drug companies.
In the public sector, the department of health services conducted
trainings at frequent intervals for Medical Officers, though these mainly
stressed and centered around the implementation of National Programmes.

B-2.2>. The drug company propaganda, through its printed literature
(i.e. pamphlets and periodicals), and Medical Representatives forms the
most important source of ‘Continuing Medical Education’ for doctors.
Though this is promotional literature and therefore biased, it receives Ute
sanction of more than 68.1% of private and 50% of public doctors as
being a source of education.

B-2.3> Cost influenced prescribing patterns in a significant way. Rising
costs of drugs have resulted in doctors changing the manner in which
they dispense drugs. Though prescribing an expensive drug carries with
it a higher status; doctors are cautious that the cost of the drug is not out
of the purview of the patient as it may work negatively in Ute case of a
poor patient.
Rising costs of drugs was also making it difficult for a doctor to
dispense drugs as well as charge a fee. Some doctors therefore resorted to
dispensing less and prescribing more.

B-2.4> Low availability of drugs at the PHC meant that MOs were
compelled to prescribe drugs from the open market. However, MOs also
looked at the socio-economic profile of the patient prescribing ‘outside’
drugs for ‘important’ patients etc.
B-2.5> Increased crowding of doctors has led to private doctors seeking
ways to draw and keep patients leading to a change in prescribing habits.
Administration of placebos, in the form of unnecessary injections, drugs,
the prescribing of more expensive drugs to appease the patients’ notion
that the more expensive medicine the better it is: are all strategies to keep
the clientele with them.



14

C

KNOWLEDGE OF PHC NURSES
ABOUT COMMON DRUGS

Answers given by 24 nurses in 9 PHCs and their sub-centres to
a questionnaire about 10 drugs they use, were evaluated by assigning
marks to answers, by comparing the answers with the standard answers
prepared for this purpose. The average number of marks scored by these
nurses was 49.88%. The breakdown was as follows - marks for
indications of drugs 68.17%, dose 75.19%, precautions 28.96%. This shows
that nurses in PHCs, need continuing education about the drugs they use,
especially as regards precautions to be taken while using drugs.

D

ILLEGAL SALE OF OTC DRUGS

In the study of sale of drugs in a day in a drug-shop in Satara, it
was found that all types of drugs were available OTC without doctor’s
prescription. OTC sales in a day (Rs.497.99) accounted for 11.23% of
the total drug sales (Rs.4436) in a day in that shop.

E

FINANCIAL WASTAGE DUE
TO IRRATIONAL PRESCRIPTIONS

In part A of this study, we confirmed the earlier
impressions of many critical observers that a substantial proportion of
doctors’ prescriptions contained irrational and/or unnecessary drugs. Such
irrational prescriptions means unnecessary additional expenses on drug­
treatment for the patient or the payer of the drug-bills. We are unaware
of any systematic published Indian study which calculates this financial
wastage due to irrational prescriptions. We therefore, decided to estimate
the financial wastage/loss to the patients due to irrational prescriptions.
Out of the 1080 and 810 prescriptions collected in summer 1993
from public and private sector respectively, 10% sub-sample was picked.
up by systematic random sampling.
This sub-sample was subjected to cost-analysis. Per day cost of
drug treatment as per those prescriptions by doctors, minus the per day'
cost as per Standard Drug Treatment Regimens (SDTRs) gave us tlie

15

financial loss to the patients due to irrational prescriptions per day of
diug treatment. It will be seen from the table E-l that due to irrational
prescriptions, a whopping 63.6% of money spent on drugs is
isle!
The proportion is much higher in case of private sector ((>9.2 /< > as
compared to that in the public sector (55.4%). Based on available
estimates of rate of morbidity in India, in tire community, and the 1991 -92
OPD attendance data in PHFs in Satara district, this wastage of Rs.
4.76 and Rs. 2.08 in private and public sector respectively per day, per
prescription, if projected at Satara district population, (1991) amounts to
Rs. 17.70 crores. This startling finding buttresses the argument that in
India today, people do not get adequate drug treatment, not so much
because we are poor, but mainly because a lot of money is wasted on
irrational prescriptions.

Table no. F.-1
Monetary Wastage Due to
Irrational Prescriptions

Sr.
No.

Private

Public

Total

1.

No. of Prescriptions

68

84

152

2.

Cost of doctors’prescriptions
per day (in Rs.)
467.62

315.67

783.3

Cost as per S.D.T.R per
day (in Rs.)

144.09

140.82

284.91

Wastage due to irrational
prescriptions per day (in Rs.)323.53
(Sr. no. 2 minus Sr. no. 3)

174.85

498.38

Wastage as % age of money
spent by the patient
(Sr. No. 4/2x100)
69.19

55.39

63.63

Wastage per prescription
per day. (Rs.) (Sr. No. 4/1)

2.08

3.28

3.

4.

5.

6.

4.76

16

F

PROPORTION OF PRIVATE
PRESCRIPTIONS IN PUBLIC
HEALTH FACILITIES

Patients visiting Public Health Facilities (PHFs) should get all
the drugs required for die treatment of their ailments, free of charge from
the PHFs. But there is a common complaint, as well as our own
observation during this study, that doctors in PHFs ask patients to buy
some of the medicines by giving them “outside - prescriptions”. This is
because of chronic shortage of medicines in PHFs. We decided to estimate
the amount spent by patients on such “outside - prescriptions” in a sub­
sample of prescriptions in our study. To our knowledge, there are no
published estimates about such “outside - prescriptions” given in PHFs
in India.

F-l : Materials and Methods
Out of the 561 prescriptions copied from PHFs during winter
1993, a 20% sub-sample was selected by systematic random sampling.
In case of the 145 prescriptions thus selected, the drugs prescribed through
the “outside - prescriptions” and the “dispensed drugs” were listed
separately. The cost of both types of drugs (prescribed and dispensed)
was calculated as per retail prices as given in the 1992-93 edition of
Indian Pharmaceutical Guide (IPG).
In the same way cost-analysis was also done separately for
prescriptions of 7 PHFs located in cities and small towns (as listed in the
District Census 1981) out of total of 19 PHFs studied in winter 1993.
These urban places have one or more drug-stores and hence doctors in
PHFs in these places tend to write outside-prescription more often.

F-2 : Results
The cost of ‘private prescriptions’ in Public Health Facilities in
case of these 145 randomly selected O.P.D. cases in Satara district in a
day in winter 1993, was 15.43% of the cost of drugs dispensed from -

17

these 19 clinics to these 145 patients. In absolute terms, the cost of
these privately prescribed drugs if distributed over all these 145 patients,
comes to only Rs.0.82 per patient (It may be noted that out of these 145
patients, many were not given any private prescription).
In the bigger and small towns also, the cost of privately purchased
drugs as a proportion of cost of dispensed drugs on an average was 15.64%.
It ranges a great deal from zero to 221.5%. The average cost of privately
purchased drug, per prescription in these 7 PHFs was found to be Rs.
7.97, which is much higher than that found for all centres, (urban and
rural together).
It appears that the overall proportion of privately prescribed drugs
in PHFs in Satara district is not high but is sizeable. In some Public
Health Facilities in big and small towns, where it ranges considerably,
from zero to a very high of 221.5%.
Patients coming to PHFs should get all the drugs needed for their
ailments and they should not be required to buy medicines at ah. The
present average of 15% of drugs required to be bought by patients is not
high but certainly undesirable and should be zero.

G

NEED VERSUS SUPPLY OF DRUGS

There arc no systematic estimates available of drug-needs of PH Cs
and the total drug-needs of a district. Since such estimate is required for
any rational drug-planning, we made such estimate on the basis of available
data in Satara and morbidity rates in India. This drug-need has been
compared with the drug-supply to Satara-district

G-l

Materials and Methods

G-l.l Drug-need of Patients Coming to PHC
Out of the 9 PHCs chosen in Part I of our study for study of
Supply of drugs, a representative sample of six PHCs was selected to
estimate the drug needs so that these drug-needs could be compared
with the actual supply to these six PHCs.
A five percent systematic random sample of OPD case papers

18

from these six PHCs was taken to find out the frequencies of various
diseases reported. These frequencies were multiplied by the drug-cost
of treatment per disease, as per SDTR as worked out in Annexure A-I.
This gave the drug-costs for patients coming to these PHC-OPDs for
curative/symptomafic care. This was compared with the drug-supply to
these six PHCs.

G.1.2 : Drug-Need of All Citizens in Satara District
Patients coming to PHC-OPD are only a small fraction of the
total ill-persons in the community. We therefore estimated the drug-need
of all ill-persons in the community and further drug-needs for preventive
care for all needy persons in Satara district.

G.1.2.1 : Drug-Need for Curative Care at OPD level
The community based comprehensive morbidity data required
for this estimation are not available for Satara district. We therefore used
the available estimates of rate of morbidity for Indian community to arrive
at a total morbidity load in Satara district, under the assumption that rate
of morbidity in Satara district (an average district in Maharashtra) would
not be much different than the All-India average. This morbidity load
multiplied by the average drug-cost per case (Rs. 11.74) as per SDTR,
gave the total drug need for OPD level-care.
In the exercise G. 1.1, we had excluded drug-cost of treatment of
leprosy and tuberculosis, since the routine case-paper records at PHCs
exclude TB and leprosy cases. (These data are maintained separately).
For estimating the total drug-needs of the Satara district, we therefore
had to add the estimated total drug-cost for all TB and leprosy patients in
Satara. For this purpose, we had to again use estimated rate of morbidity
for India/Maharashtra for these two diseases. This morbidity load was
multiplied by cost per case as per SDTR for TB and leprosy to get total
drug-cost for all TB and leprosy cases.

G: 1.2.2 : Drug-needs for All Indoor Cases
The drug-expenditure for indoor cases in Civil and Cottage

19

Hospital accounts for most of the indoor drug expenditure in the public
sector. We made a liberal assumption that the indoor-drug-expenditure
in the private sector is ten times die indoor drug expenditure in these two
hospitals, as given in the Performance Budget (1993-94) of Govt, of
Maharashtra, and on that basis estimated the drug-cost of all indoor cases
in Satara district.

Gl.2.5 : Drug Needs for Preventive Care
These needs are mostly for vaccination of children and for Ante
Natal Cases (tetanus immunization plus iron-calcium supplementation)
in short, drug-cost for total coverage in MCH-programmes. Since the
age-wise break-up of Satara-population is not available, we again used
lite All-India figures for percentage-wise share of various age-groups to
get total number of children in age-groups - 0 to 1 yr, 1 to 2 yrs, 2 to 3
yrs, and 5 to 6 yrs and of pregnant women in Satara district. This number,
multiplied by the cost of preventive medication per person as per prices
of Haffkine BPCL (the public sector concern, which supplies vaccines to
Maharashtra Govt.) gave us the total cost of preventive medication in
Satara district.

G-2 : Results
G-2.1: The drug-need for OPD-level curative/symptomatic care
for the six PHCs under study, was an average of Rs. 67660 per PHC,
Rs. 11.74 per case. (This excludes TB and leprosy cases). The drug­
supply for curative, symptomatic care for these six PHCs, as found in
part-I of this study was Rs. 37134 per PHC. Thus there was a short fall
of Rs. 30526 per PHC, which is 8.41% of the recurring annual expenditure
of Rs. 0.363 million per PHC in 1991-92. Thus, if the recurring annual
expenditure for PHCs is increased by a mere 8.41% to increase drug
supply to PHCs, and if all the drug-supply is used rationally, all patients
coming to PHC-OPD can be adequately treated.

G.2.2 : Total Drug Needs of Satara District
As revealed by the exercise outlined in section G1.2, the total

20

drug-needs of Satara district in 1991-92 would be as follows :
i.

For curative care for all patients at OPD
level excluding TB and Leprosy

Rs. 151.70 m.

ii. For all cases of TB and Leprosy

Rs. 29.73 m.

iii. For all indoor cases

Rs. 17.82 m.

iv. For total coverage in preventive
medication in MCH Programme

Rs.

6.86 m.

Rs.206.11 m.

Total

The total drug-supply in Satara district was a minimum of Rs.
212.8 m. in private sector and Rs. 5.6 m. in public sector. Thus, this
supply is more than sufficient to meet all the drug-needs of the Sataradistrict. Thus, the drug-needs of Satara-district are not being met today,
not because of lack of resources, but because of wastage tlirough irrational
use.

CONCLUSIONS

The overall conclusions of this study are:

1>
The drug-supply to the public sector in Satara District was a
mere Rs.5.6 million, as compared to the most minimum, reliable estimate
of a drug sale of Rs.212.8 m. in the private sector during 1991-92. The
drug supply especially to PHCs and RHs suffers from chronic gross shortages and haphazardousness.
2>
The overall quality of prescriptions of doctors both in public and
private sector is low. There is very high proportion of use of unnecessary,
irrational, hazardous drugs and unnecessary injections especially in the
private sector. Public Sector prescriptions are more rational titan private

sector prescriptions. Proportion of rational prescriptions increases with
educational qualification.
3> ' There is very little of proper Continuing Medical Education of
doctors. This along with the influence of the Medical Representatives,
increasing prices drugs and competition amongst doctors influence the
prescriptions of doctors in the private sector, whereas in the public sector,
Ute chronic shortage of drugs affects prescriptions, apart from lack of
proper CME.

4>
Knowledge of PHC - nurses about the drugs they use is
satisfactory as regards indications and dosage but quite unsatisfactory
as regards precautions and side-effects.
5>
Due to irrational prescriptions,69% and 55% of the money spent
on prescriptions in the private and public sector, respectively, is a waste,
with an average of 63%. Projected to the Satara-district level, this wastage
amounts to Rs. 17.7 crores out of the total drug supply of Rs.22 crores.
6>
Patients visiting government clinics in Satara district have to buy
15% of the drugs prescribed to them, instead of getting all drugs free.

7>
If all the patients coming to the six PHC under study, were to be
adequately and rationally treated, there would be a drug-short fall of Rs.
30525.92 per PHC. This shortfall can be met by a mere 8.41% increase
in the annual recurring expenditure of Rs. 0.363 million per PHC.

8>
If all the patients in Satara district were to be adequate and
rationally treated and if all children and women were to be fully covered
in the MCH Programme in 1991-92. the drug-expenditure would have
been Rs.20.61 crores, compared to the total drug expenditure of Rs.21.84
crores in Satara district. It is thus, not lack of resources, but its irrational,
wasteful use, wliich is responsible for the unmet drug needs of the Satara
district.

The overall drug situation in Satara district is that of ‘Poverty
Amidst Plenty’ - poor drug supply to the public sector, poor quality of

22

prescriptions, a lot of wastage of the adequate drug-expenditure incurred
by the people in Satara district.

The full report - ' A Study of Supply and Use of
Pharmaceuticals in Satara District' (168 pages, A-4 size), is
available with the Promotion Officer, FRCH, 3-4 Trimiti 'B',
Apts., 85, Anand Park, Aundh, Pune-411 007, INDIA.

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of Rs. 10/- towards the bank commission charges. Please draw
the chequc/DD in favour of 'The Foundation for Research in
Community Health' payable at Bombay, but mail it to our Pune
office address as our publications unit is based in Pune.

23

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24

This is the summary of 'he report of 'A Study of Supply and Use
of Pharmaceuticals in Satara District', Maharashtra State. The overall
conclusions of this study are :
*
The drug-supply to the public sector in Satara District was a mere
Rs.5.6 million, as compared to the most minimum, reliable estimate of a drug
sale. e£Rs.212.8 m. in the private sector during 1991-92. The drug supply
especially to PHCs and RHs suffers from chronic gross shortages and
haphazardousness.
*
The overall quality of prescriptions of doctors both in public and
private sector is low. There is very high proportion of use of unnecessary,
irrational, hazardous drugs and unnecessary injections especially in the private
sector. Public Sector prescriptions arc more rational than private sector
prescriptions. Proportion of rational prescriptions increases with educational
qualification.
*
There is very little of proper Continuing Medical Education of
doctors. This along with the influence of the Medical Representatives,
increasing prices drugs and competition amongst doctors influence the
prescriptions of doctors in the private sector, whereas in the public sector,
the chronic shortage of drugs affects prescriptions, apart from lack of proper
CME
*
Knowledge of PHC - nurses about the drugs they use is satisfactory
as regards indications and dosage but quite unsatisfactory as regards
precautions and side-effects.
*
Due to irrational prescriptions,69% and 55% of the money spent on
prescriptions in the private and public sector, respectively, is a waste, with
an average of 63%. Projected to the Satara-district level, this wastage
amounts to Rs. 17.7 crores out of the total drug supply of Rs.22 crores.
*
Patients visiting government clinics in Satara district have to buy 15%
of the drugs prescribed to them, instead of getting all drugs fr?e.
If all the patients coining to the six PHC under study, were to be
adequately and rationally treated, there would be a drug-short fall of Rs.
30525.92 per PHC. This shortfall can be met by a mere 8.41% increase in
the annual recurring expenditure of Rs. 0.363 million per PHC.
*
If all (he patients in Satara district were to be adequate and rationally
^treated and if all children and women were to be fully covered in the MCH
Programme in 1991-92, the drug-expenditure would have been Rs.20.61
crores, compared to the total drug expenditure of Rs.21.84 crores in Satara
-■^district. It is thus, not lack of resources, but its irrational, wasteful use, which
is responsible for the unmet drug needs of the Satara district.
The overall drug situation in Satara district is that of ‘Poverty Amidst
Plenty'.

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