The price of health

The high price of essential medicines often make it difficult for senior citizens to afford proper medical care, leading to several other complications. This timely and thought provoking article from Baru explores the problem.

The escalating cost of medicines

Among the several drivers pushing significant drug price rise in India over the last two decades, the following two are fundamentally important:

(a)   the drastic changes with regard to bringing the Indian Patents Law in line with the international agreements on the intellectual property rights (the indigenously produced and cheaper generic drugs yielding the market space to branded drugs from the multinational pharmaceutical companies much more expensively priced under patent protection (1))

(b) allowing the big multinational corporations to acquire (2) ever burgeoning market share in the pharmaceutical industry, thereby providing a clout in deciding prices and influence in shaping up government policies on the drug price control.

As a result of these policy changes, the retail prices of most essential medicines required for diseases spanning routine infections, chronic acquired ones like diabetes, hypertension, cardiovascular problems, and especially those for critical illnesses like cancer and Alzheimer’s disease have shot up appreciably over the past decade or so.

Add to this the other major shift in the health policy, wherein the government is consciously abdicating its role as the primary health service provider and allowing the private players and market forces to determine the availability and the price of the health care in this country.(3,4)

In this scenario, it is not difficult to understand why the proportion of medical expenses that the Indians currently incur using largely their own resources is believed to be unusually high.(5) While the escalating healthcare cost affects majority of the Indians, senior citizens are particularly vulnerable. Though people of any age can be afflicted with cancer, there are empirical evidence and some scientific arguments to suggest that an aging body may be predisposed to the disease (accumulation of mutations in cancer genes over a longer duration, exposure to a variety of carcinogens and progressive inability to repair cell damages, etc).

Facing the trauma of cancer detection and diagnostic follow up is devastating at any age, but for a man at 77 to discover a malignant tumor blocking his esophagus or for a happy grandmother of 65 to find one surreptitiously growing in the breast, can appear as an indescribably cruel caprice of nature shaking their grip on life. Surgical intervention (in operable cases), radiation therapy and chemotherapy (if advised given the advanced age) are all fairly expensive and there is always a fractional certainty of a positive outcome. In failed cases, the palliative care at home or at hospices can endlessly prolong the agony of the patient and test the resilience and the resources of the caregiver. Even if the cancer is thwarted or, hopefully eliminated, the afflicted often continues to suffer some kind of debility, loss and morbidity, requiring additional long term medication and supplements to pull on. There is an estimate (3) that more than 80 per cent of cancer-affected Indians end up with private treatment facilities and of them more than 90 per cent meet the expenditure for such treatment out of their own pocket.

Some form of dementia (primarily associated with memory loss and degradation of other cognitive functions) as an adjunct of the old age may be manageable without much medical attention. However, some of the aggressive forms like the Alzheimer’s disease, show clinical symptoms requiring active intervention involving diagnostic prognostication, highly expensive medication and other management methods. The Alzheimer’s and Related Disorders Society of India (ARDSI) estimated (2010) that there were 3.7 million elderly currently living with dementia in India, each spending Rs. 43,000 per annum on medical care. (6)

Even otherwise, lower immunity and susceptibility to many adventitious infections, preponderance of common lifestyle diseases like diabetes, hypertension, poor lipid profile (acquired midlife) characterize large segments of the elderly populace, many of them graduating into kidney ailments and/or cardiovascular problems often as an almost pre-destined follow up to those chronic maladies. All these require lifelong medication, routine pathological and a range of diagnostic tests, some (like angiography) requiring temporary hospital admission and procedures like dialysis. Partly out of genuine urge to look for more effective remedies and partly under careful manipulation by the pharmaceutical companies, more recent, novel and branded drugs (7) are likely to be prescribed by the doctors. Also sharing a more prevalent aggressive worldview, they would often suggest more detailed investigations, using ever more sophisticated and expensive tools obtained with cutting-edge bio-medical research, looking for an elusive diagnosis, as the prognosis worsens. No wonder that the medical bill of the seniors will be pushed upwards relentlessly.

Being on the margin of the society both in urban and rural India, the old denizens cling desperately to the medicines, therapies prescribed by their doctors for continuing their tenuous toehold on life and thereby fighting off their shrinking sense of well being and autonomy. One obvious financial implication of the escalating medical expenses for many senior citizens is inability to afford appropriate medical treatment using their own meager and devaluating resources and to become woefully dependent on their children or other relatives that could potentially lead to strain in the relationships and other hardships. The net result is a loss in the quality of life and dignity and associated anxiety and depression. For poorer households bordering on penury and destitution, this amounts to neglect, denial or forgoing access to medicines and/or treatment.

Notes and citations

1.   Gleevec, the Novartis (MNC) branded drug for chronic myeloid leukemia can cost up to Rs 1.4 lakh per patient for a month, an equivalent generic drug in India may cost about Rs 9000 for the same dosage; generic donepezil (a staple drug for Alzheimer’s disease) may cost about Rs 1100-1300 (90 tablet pack) in the Indian market, the international branded version ARICEPT could be equivalent to about $840 for the same pack

2. “Are Takeovers Taking Over Indian Pharma?” (knowledge@wharton Today, 24 August 2011 )

3. Selvaraj and Karan, Economic and Political Weekly, 3 October, 2009

4. Montek Singh Ahluwalia, the deputy chairman of the Planning commission, called for a new health policy framework in which government should vacate its role of primary health care provider and allow for greater privatization of the health sector (Times of India report, 8 August 2012)

5. The regional adviser of WHO, Dr. Kathleen A Holloway sounded alarm on the ballooning out-of-pocket (OOP) health expenses of the average Indians and the direct relation of that fact with the progressive/catastrophic pauperization of the Indian population. The planning commission has apparently acknowledged the scenario. (Times of India report, 2 November, 2011)

6. As quoted by Dr. Ennapadam S. Krishnamoorthy in his article “Dementia: a looming threat” (The Hindu, September 29, 2010)

7. A very commonly prescribed low-end TYPE-2 diabetes medicine as a cheap local brand (bare bone generic version : metformin 500 mg + glimepiride 1mg) may be obtained at Rs 19 for a 10 tablet pack, but a more respectable brand like Amaryl from Aventis may cost Rs 124 for the same pack. There is a published report comparing the effectiveness and safety (side effects) vis-à-vis the prices based on an extensive survey of oral drugs used to treat TYPE-2 diabetes and a case can be made out for the overall benefit in favour of many cheaper generics.

Photograph courtesy: Silvertalkies