Comparative Availability of Selected Essential Medicines for Selected Chronic Diseases in Bhiwani District, Haryana, India

Article history: Received on: 08/07/2015 Revised on: 01/08/2015 Accepted on: 21/08/2015 Available online: 27/09/2015 Medicines represent a substantial proportion of the economic costs for treating chronic diseases. In low and middle income countries (LMIC), 50–90% of the population have to pay for medicines themselves. Inappropriate access and availability of essential medicines contribute substantially to out-of-budget expense. A significant population of developing countries (upto 90%) purchase medicines through out-of-pocket payments. This research study was conducted to investigate the comparative availability of selected essential medicines for selected chronic diseases in Bhiwani district. Standardized methodology of World Health Organization and Health Action International was employed. The research study was conducted on retail pharmacy outlets of Bhiwani District i.e. residential areas of Bhiwani city and five administrative areas of Bhiwani district. Overall percent availability of the most of the surveyed medicines used in the treatment of chronic diseases was found to be less than 50%. Dissemination of well documented information on availability medicine consumers in all residential areas may enhance consumer demand for lower price medicine and thus may serve to enhance the availability of demanded medicine (lowest priced) in all the areas of Bhiwani district.


INTRODUCTION
Medicines represent a substantial proportion of the economic costs for treating chronic diseases in most of the countries.In Latin America and the Caribbean, medicine costs account upto 44% of the direct medical costs for diabetes (Barcelo et al., 2003).Further, in low and middle-income countries 50-90% of the population have to pay for medicines themselves (Quick et al., 2002).A significant proportion of chronic disease morbidity and mortality can be prevented if medications are made accessible and affordable (WHO, 2008).Several studies have examined the availability of essential medicines; however none have focused specifically on medicines used to treat chronic diseases (Ewen, 2003).Globally, approximately 35 million deaths (60% of all deaths) are attributable to chronic diseases each year, with more than 30 million deaths (52% of all deaths) due to cardiovascular disease (accounting for 30% of all deaths), cancer (13% of all deaths), chronic respiratory disease (7% of all deaths) and diabetes (2% of all deaths) (WHO, 2005).World Health Organization (WHO) estimated that upto 30% of the world's population lack regular access to essential medicines and upto 50% in the poorest countries of Africa and Asia (WHO, 2011).Generic medicines are upto 20-90% cheaper than their innovator brands (Shafie and Hassali, 2008) and "gold standard" and "first line therapy" for many acute and chronic diseases (Sheppard, 2011), promoting generic medicines to improve medicine access both for government and individuals who have to pay out of pocket for medicines (Cameron et al., 2009).A generic medicine is identical to its corresponding innovator medicines in terms of safety, quality, efficacy, dosage form, strength and route of administration and has the same intended use as the innovator medicine (FDA, 2009).Promotion of generic medicines recommended being a part of the national medicine policy (Cameron et al., 2011) to achieve a comprehensive and sustainable health care system in Europe (Godman et al., 2010).The present study is perhaps the only study that compares the availability of generic as well as branded medicines of selected essential medicines for selected chronic diseases in a single district of any state.This research study covers whole of Bhiwani district along with administrative areas serve to document comparative availability of generic as well as branded medicines of selected essential medicines used in the treatment of chronic diseases (Hypertension, Ulcers, Diabetes, Depression) in different geographical areas of Bhiwani district.
The method used in the present study is based on World Health Organization (WHO), Geneva, Switzerland and Health Action International Global (HAI), Amsterdam Netherland Guidelines.A manual of WHO/HAI survey methodology was released in 2003 (WHO andHAI, 2003).Later this WHO/HAI manual was updated in 2008 (WHO andHAI, 2008) to reflect the wealth of practical experience in conducting medicine price and availability survey.

Background
Bhiwani, 21th district of Haryana is located in Northern.Other major administrative areas in district are Charkhi Dadri, Siwani, Loharu, Tosham and Bawanikhera.To investigate the comparative availability of selected essential medicines for selected chronic diseases at retail pharmacy outlets in Bhiwani city and its administrative areas were included in this study.

Sampling
This baseline data collection research study was documented at retail pharmacy outlets in different geographical and administrative areas of Bhiwani district.

Medicines Surveyed
Twenty essential medicines for selected chronic diseases in different dosage forms as shown in (table 1) were selected.To carry out survey, medicines used for the treatment of four chronic diseases (Ulcer, Depression, Hypertension, Diabetes) were selected from the National List of Essential Medicines, India 2011 (NEML, 2011) and hospital formulary of Bhiwani.

Data Collection
This survey had been designed to provide a comprehensive picture of comparative availability of selected essential medicines for selected chronic diseases in a single district of any state.
To carry out the survey WHO/HAI methodology was adopted.It is usually not feasible to Collect data from a large number of health facilities, pharmacies and other medicine outlets, so a small sample of facilities was selected in at least six geographical areas: a country's main urban centre and five other administrative areas (WHO and HAI, 2008) (survey areas) as shown in figure 1 and 2.

Percent availability of selected essential medicines used for the treatment of chronic diseases (Hypertension, Ulcer, Diabetes, Depression) in different geographical areas of Bhiwani city
In this procedure data was collected on the given format i.e. availability of selected essential medicines used for the treatment of chronic diseases in Bhiwani district.Percent availability of each surveyed medicine was calculated in each geographical area of Bhiwani city by dividing the number of retail pharmacy outlets having that medicine by total number of retail pharmacy outlets of that geographical area.

Cumulative percent availability of selected essential medicines used for the treatment of selected chronic diseases in Bhiwani district
In this procedure data was collected on the given format from Bhiwani city and five administrative areas (Dadri, Siwani, Loharu, Tosham, and Bawanikhera).Cumulative percent availability of each medicine was checked and it was divided by total number of retail pharmacy outlets of Bhiwani district.

Percent availability of each brand/generic of selected essential medicines used for the treatment of selected chronic diseases in different geographical areas (BA1, BA2, BA3, BA4, BA5) of Bhiwani city
In this procedure data was collected on the given format from Bhiwani city (BA1, BA2, BA3, BA4, BA5).The percent availability of each brand/generic in each geographical area was calculated by dividing the number of retail pharmacy outlets having that brand/generic by total number of retail pharmacy outlets in that geographical area.

Percent availability of each brand/generic of selected essential medicines used for the treatment of selected chronic diseases in different geographical areas of Bhiwani city and five administrative areas of Bhiwani district
In this procedure data was collected on the given format from Bhiwani city (BA1, BA2, BA3, BA4, BA5) and five administrative areas (Dadri, Siwani, Loharu, Tosham, Bawanikhera) of Bhiwani district.Percent availability of each brand/generic of each surveyed medicine for each geographical  Hydrochlor thiazide 25mg tab/cap and administrative area was calculated separately and also for Bhiwani city.

Cumulative Percent availability of total number of brands/generics of each selected medicine available in Bhiwani district
In this procedure total number of brands/generics available for each surveyed medicine in Bhiwani district was collected on the given format in a specific administrative/ geographical area/main urban centre available in whole Bhiwani district.

Data processing
Percent availability of each selected medicine for selected chronic diseases in Bhiwani district and its administrative areas was analyzed by standard mean error.

Ethical approval
Ethical approval of the research study was obtained from Distt.Drug Controller Officer, Bhiwani and map of Bhiwani city was collected from municipal council, Bhiwani.

Overall percent availability of each surveyed medicine for selected chronic diseases in geographical areas of Bhiwani district
Availability is presented as percentage of the essential medicines used for the treatment of chronic diseases (Hypertension, Ulcer, Diabetes, and Depression) found on retail pharmacy outlets surveyed.Overall percent availability of selected medicine for selected chronic diseases is 39% in Bhiwani district as shown in figure 3.

Percent availability of surveyed medicine in Bhiwani district
Percent availability of each surveyed medicine for selected chronic diseases in Bhiwani city and its administrative areas is shown in the table 2.

Cumulative percent availability of surveyed medicine in Bhiwani district
Cumulative percent availability of each surveyed medicines for selected chronic diseases in Bhiwani district can be summarized as shown in the table 3.

Availability of surveyed medicines and its brands
According to World Health Organization and Health Action International (WHO & HAI) manual 2008; each medicine has originator brand i.e. international originator brand product for the medicine and generic equivalent is all products other than originator brand that contain same active ingredient whether marketed under a brand name or the generic name.Availability of number of brands of selected essential medicines for selected common ailments is shown in table 5.

DISCUSSION
Bhiwani covers a larger geographical area as compare to other districts of Haryana state.Therefore, in order to get more précised results about the percent availability each surveyed

Fig. 3 :
Fig.3: overall percent availability of selected medicine for selected chronic diseases in bhiwani district.

Fig. 4 :
Fig. 4: Overall Percent availability of each surveyed medicine for selected chronic diseases in Bhiwani district.

Fig. 5 :
Fig. 5: Cumulative Percent availability of each surveyed medicine for selected chronic diseases in Bhiwani city.

Table 3 :
Percent availability of each surveyed medicine for selected chronic diseases in different geographical areas of Bhiwani city.

Table 4 :
Cumulative percent availability location/area of each surveyed medicine for selected chronic diseases in Bhiwani District.