collusive behaviour in healthcare and impact on consumers: evidences from assam and chhattisgarh...
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Collusive behaviour in Healthcare and impact on consumers: evidences from Assam and Chhattisgarh
Rijit SenguptaCUTS International
COHED National Policy Forum24th May 2011
Outline of Presentation
Introduction CUTS study findings COHED project Findings of the First Stage Findings of the Second Stage Conclusions & Way forward
I. INTRODUCTIONMamoni Das visits a public hospital in Guwahati, expecting quality treatment at affordable cost
She is seen by a doctor and given a prescription containing a list of medicines
Approaches public pharmacy, for free medicines
Mamoni is informed that medicines written in the prescription are not available and has to get them from the private chemist, outside
She buys the medicines with whatever little money she had come to the hospital with…
What did we find?
49% of the medicines that Mamoni Das and some of the other patients had to buy from private sources after visiting the public hospital were present in the Hospital Stock Register
9% of the medicines that were absent in the Hospital Stock Register had substitutes, that were present in the Stock
WHY DID MAMONI HAVE TO BUY MEDICINES FROM PRIVATE CHEMISTS?
Possible Reasons?
Docs did not know the status of the medicines in the Hospital Stock Register, and suggested that ‘good quality/effective’ medicines be bought from outside
Mamoni Das was a victim of ‘collusive arrangements’ between various entities inside and outside the public hospital
What is Collusion/Collusive Practice?
Collusion refers to combinations, conspiracies or agreements among sellers to raise or fix prices and to reduce output/supplies in order to increase profits (OECD, 2002)
DID THE PLAYERS (in the public hospital Mamoni visited) ENTER INTO AGREEMENTS TO REDUCE SUPPLY OF MEDICINES through the public distribution channel?
A Grim Picture!
Competition Act 2002 of IndiaThe Competition Act 2002 of India prohibits ‘………enterprises or associations of enterprises (or persons or association of persons) from entering into any agreement in respect of production, supply, distribution, storage……..which has an appreciable adverse effect on competition’. Agreements having such effects on competition result in - determining purchase or sale prices; limiting or controlling production/supply/marketing/development/provision of services; geographical allocation of markets; and collusive bidding.
Competition Commission of India is sufficiently empowered and should investigate if supply and distribution of medicines in these public hospitals have been restricted due to collusive agreements between various players
II.COHED ProjectGoal: Gather evidence of collusive practices and assess if
some of them infringed the provisions of the India Competition Act 2002, or could be addressed through other regulatory instruments
Objectives To identify market malpractices in healthcare in 2 states To assess scope and effectiveness of the present
regulatory system to deal with malpractices/collusion To make recommendations for better regulatory
outcomes To spread awareness about these recommendations
and lay the ground for their implementation
II.COHED Project (Contd.)
Research based Advocacy States: Assam & Chhattisgarh Partnership with local NGOs Field-work and Data Analysis 2-stage Survey
- First Stage: Consumer Survey- Second Stage: Prescription analysis
III. FIRST STAGE: C onsumer Survey
3 towns in each state Public Hospitals Consumer information - household expenditure on
healthcare, behaviour of heathcare providers, availability of healthcare services, prices of such services, etc.
Findings:- Tendency of choosing private healthcare service (often to suit convenience and save time, etc.) existed - Common belief: simple correlation exists between cost of healthcare & its quality
III. FIRST STAGE: C onsumer Survey (Contd.)
- In addition to greater consumer awareness, there is also a need for change in consumer’s attitude towards healthcare
- Private healthcare suffers from high degree of variation and there is hardly any regulation to maintain a minimum standard
- An extremely high frequency of referrals (to diagnostic clinics) combined with the prevalence of ‘cuts’ for referring doctors was noted
- In spite of having received medical treatment at a public hospital, many consumers bought medicines from private sources
WE DECIDED TO DIG DEEPER……….
IV. SECOND STAGE: Prescription Analysis
Same towns as the first stage Prescriptions collected to assess cost of
medicines, availability of medicines in public hospital, etc.
Common Findings- large number of respondents bought medicines from private sources- Non-availability of drugs in public hospital is not uncommon- Insistence by docs to buy drugs from outside- High degree of prevalence of ‘incompleteness of diagnosis’
Cost to Consumers & Availability of Medicines
Procurement of Medicines from Private Sources
28
0
28
4559
0
69
198 3 3
35
5
97
0 10
30
60
90
120
Dr AmbedkarHospital,Raipur
DistrictHospital,Pandri
DistrictHospital,
Durg
CIMS,Bilaspur
Hospitals in Chhattisgarh
Per
cen
tag
e Always
Often
Seldom
Never
Procurement of Medicines from Private Sources
35
6
39.5
13
38
6
33.5
70
27
18
26
17
0
70
1 0
0
10
20
30
40
50
60
70
80
Civil Hospital,Nagaon
Urban HealthCentre, Nagaon
Guwahati MedicalColleage & Hospital
Public HealthInstitutions,Bongaigaon
Hospitals in Assam
Pe
rce
nta
ge Always
Often
Seldom
Never
Cost of Medicines vis-a-vis Source
382
0
115
163
92.5
1.5
33
99
0
50
100
150
200
250
300
350
400
450
DrAmbedkarHospital,Raipur
DistrictHospital,Pandri
DistrictHospital,
Durg
CIMS,Bilaspur
Hospitals in Chhattisgarh
Co
st o
f M
edic
ine
(Rs)
0
20
40
60
80
100
120
Med
icin
e o
bta
ined
fro
m P
riva
te
sou
rces
(%)
Avg Cost ofPrescription(Rs.)Private Sourceof Medicines (%)
Cost of Medicines vis-a-vis Source
140
0
374
66
94
6
98
66
0
50
100
150
200
250
300
350
400
Civil Hospital,Nagaon
Urban HealthCentre,Nagaon
GuwahatiMedical
Colleage &Hospital
Public HealthInstitutions,Bongaigaon
Hsopitals in Assam
Co
st o
f M
edic
ine
(Rs)
0
20
40
60
80
100
120
Med
icin
es o
bta
ined
fro
m P
riva
te
So
urc
es (
%)
Avg Cost of Prescription (Rs.)
Private Source of Medicines(%)
Completeness of Diagnosis
8
92
0010
90
55
45
0
30
60
90
120
Pe
rce
nta
ge
Civil Hospital,Nagaon
Urban HealthCentre,Nagaon
GuwahatiMedical
Colleage &Hospital
Public HealthInstitutions,Bongaigaon
Hospitals in Assam
Completeness of Diagnosis
Incomplete
Complete
42
58
59
41
51
49
68
32
0%
30%
60%
90%
120%
Per
cen
tag
e
DrAmbedkarHospital,Raipur
DistrictHospital,Pandri
DistrictHospital,
Durg
CIMS,Bilaspur
Hospitals in Chhattisgarh
Completeness of Diagnosis
Incomplete
Complete
IV. SECOND STAGE: Account of Medical Representatives
Three types of malpractices:- Reminders- Inducements- Cash payments and bribes
Innovative ways of ‘keeping track of sales’, for cash reimbursements
V. Conclusions & Way forward
Issues for Policy- Procurement and Distribution of medicines- Public display of hospital stock- Periodic scrutiny of Prescriptions- Identify and adopt state level good practices’- Greater attention towards patients- Adoption of Clinical Establishment Act, 2010 in states
Conclusions & Way forward
Issues for Consumer Action- More careful in choosing provider(s)- Approach consumer forum for redressal- Raise demand for generic drugs- Demand discounts
CUTS IS GOING TO TAKE THESE FORWARD IN THE STATES………..
Ending thoughts
Endeavour to make Mamoni Das’s future visits to the public hospitals more pleasant and less costly!!
