Indian Journal of Pharmacology Medknow Publications on behalf of Indian Pharmacological Society ISSN: 0253-7613 EISSN: 1998-3751 Vol. 38, Num. 2, 2006, pp. 93-94

Indian Journal of Pharmacology, Vol. 38, No. 2, March-April, 2006, pp. 93-94

Editorial

Implementing rational drug use: A success story

Mathur VS

Formerly Professor of Pharmacology, PGIMER, Chandigarh and formerly Chairman, Department of Pharmacology and Therapeutics, College of Medicine, Arabian Gulf University, Bahrain. E-mail: themathurs@hotmail.com

Code Number: ph06024

For the successful launching of any programme for the betterment of the people three things are warranted: political will, effective administrative support and a dedicated independent organization, preferably non-governmental (NGO).This holds true for providing quality drugs both in the hospitals and dispensaries run by the government and the private sector.

That such a programme can be organized and successfully carried out is best illustrated by the example of the National Capital Region (NCR) of Delhi. In 1994, Dr. Harsha Vardhan, the then Minister of Health and Family Welfare of NCR Delhi, was determined to ensure that the common people had access to quality drugs. Before he took over, as in most states of the country, the availability of good quality drugs was ridden with inefficiency, inefficacy and insufficiency. The citizens of Delhi were often denied a regular supply of drugs, encountered ad-hoc dispensation and were handed over drugs of dubious quality including traditional medicines of questionable efficacy and safety.

The Delhi Model was successful because the three basic principles which I had mentioned earlier were adhered to. There was political will - Dr. Harsh Vardhan was determined to see the program through, there was administrative support - backed by the minister and a dedicated hand picked group of individuals headed by Prof. Ranjit Roy Choudhury who was instrumental in forming the Delhi Society for the Promotion of Rational Use of Drugs (DSPRUD).

The Delhi State Drug Policy document of 1994 aimed at achieving the following goals:

(i) Preparation of essential drug list for the three levels of health care. (ii) Organizing central procurement of medicines. (iii) Establishment of centralized procurement, storage and distribution system. (iv) Preparation of formularies for primary, secondary and tertiary care. (v) Quality assurance of the medicines purchased and stocked. (vi) Training in rational use of drugs-undergraduate students, interns and doctors serving the government dispensaries. (vii) Dissemination of drug information. (viii) Preparation of Standard Treatment Guidelines and distribution to the doctors and medical students. (ix) Promoting research on rational selection and prescribing of drugs. (x) Monitoring and evaluation of the programme.

Prof. Roy Choudhury with his long standing contribution to the WHO Essential Drugs Program was able to receive the active support of the WHO which under the WHO-India Essential Drugs Programme which provided about USD 350,000 to the Society over the last 5 years. In October, 2002 the World Health Organization South East Asia Regional Office (WHO-SEARO) commissioned an external evaluation of the impact of the activities of DSPRUD undertaken in the past 5 years. The five member review committee found that DSPRUD has played an essential role in improving the pharmaceutical situation in the state of Delhi, and in the establishment of EDP in a number of other states in India. The report highlighted the achievements of the DSPRUD and said that the Delhi State Drug Policy has been implemented well and an effective and transparent pooled procurement and distribution system has been established.

In Delhi, 95% of the medicines prescribed are being actually dispensed at all levels of health facilities, primary, secondary and at teaching hospital. centralized pooled procurement of essential drugs results in saving upto 30% of the allocated funds.

Good quality, essential drugs are now almost always available in the public sector. In addition, a number of high quality basic tools have been developed by DSPRUD such as India Essential Drugs Program (IEDP) policy, pooled procurement system, Standard Treatment Guidelines (STG), Essential Drug Lists(EDL), State Formulary etc., These provide excellent models for other states which want to emulate the Delhi model.

A non-government organization has blazed a trail; it has executed a program effectively with minimum bureaucracy but with full support of the state government. I recently met with Dr.Harsh Vardhan at his residence on Friday, April 8, 2006, to tweak his memory of the events that literally changed the way in which drugs were being procured, distributed and used in Delhi.

Some excerpts of the conversation follow:

Prof. Mathur (VSM): Why did you commit yourself to such a programme?
Dr. Harsh Vardhan (HV): Before I became the Health Minister of Delhi in 1993, I had been a medical practitioner for 10 years. As an active student leader in Kanpur Medical College, I had noticed on more than one occasion, that drugs were being stolen, substandard drugs were being provided, transactions were being made under the table. On becoming Health Minister, I used to take rounds in the Delhi hospitals. I would talk to patients as well as hospital employees to study the situation prevailing in hospitals at that time and -whether patients were getting the drugs prescribed to them.

The first impression I got was that many of the drugs were not available in the hospitals despite the fact that crores of rupees were being spent on procurement of drugs. Prescriptions were mainly influenced by the promotional measures of drug companies. I realized that something was seriously wrong with the system and decided to take corrective steps in a professional manner. By that time my polio effort had proved a big success with the result that the medical community had developed some faith in me. I started looking for knowledgeable, honest, committed professionals who could work with me to set up systems and regularize drug supply to Delhi hospitals. In one of my discussions with Professor K.K. Agarwal (formerly Professor of Pharmacology, Maulana Azad Medical College, New Delhi), who later became Medical Superintendent of GTB Hospital, Delhi, suggested the name of Professor Ranjit Roy Chaudhury (formerly, Dean PGI Chandigarh), who he thought could help me in my endeavour. I talked to Prof. Roy Chaudhury on telephone and asked for an appointment to see him. He, however, told me that I need not go to him, rather he would come to my office whenever I needed him. We met in early 1994 and had a long discussion wherein I outlined my desire. I suggested that he could be our advisor with some remuneration. It impressed me a great deal when he said that he would do all we wanted for free and, if we were keen to pay him something, we could pay Re 1 per month. That was how it all started.

VSM: What challenges did you face and how did you overcome them?
HV: I was asked to establish the drug authority in India. When I discussed this with Professor Roy Chaudhury, he drafted the first paper on Drug Policy for the Delhi Government. Every three months I used to call a press conference to tell the press about our forthcoming efforts. At times, I used to provoke the press so as to get adverse comments. This was done to ensure that the medical superintendents of Delhi hospitals did not purchase unnecessary drugs.

One day, I realized that in spite of our best efforts, things were either not moving in the right direction or moving at a slow pace. Even for small amounts of money- sanction from the Finance Minister was awaited. Luckily Professor Roy Chaudhury with his contacts in the WHO enlarged the scope of this endeavour to the India-WHO Essential Drugs Programme. Initially, there was some resistance from the medical community but when they realized that our efforts were unbiased, they started supporting us. The , success of Polio Eradication Programme helped me gain the confidence of the medical community and we started receiving cooperation from all over. With financial support from the WHO and the expertise of Professor Roy Chaudhury, we prepared standard treatment schedules and several other publications, and extended help to other states of India. The Delhi Programme was named the Delhi Model, which has now won national and international recognition.

VSM: Tell us about your initial struggles in implementing the model.
HV: The biggest jolt came when the government changed in Delhi. The new Minister of Health gave a statement in some newspapers that the drug procurement programme was all rubbish and that the drugs available in Delhi government hospitals were of substandard quality. Fortunately for us the Health Minister of Punjab (Mr H.S. Brar who later became the Chief Minister of Punjab), who belonged to the same political party as the new minister of health had shown a great interest in our programme and had introduced this programme in Punjab. He had written a letter to the Chief Secretary of Delhi thanking him for introducing this programme to the state of Punjab. When the new Health Minister of Delhi raised this issue in the Assembly and wanted to stop this programme, I spoke on the floor of the house and asked why he wished to revert to the old system which was so inefficient when they had experienced the success of the Delhi model in Punjab? After this they decided not to make any changes in this programme. We had planned to have a drug authority housed in a building at Karkardooma with a fully computerized procurement system. The construction of this building had started when I was Heath Minister but unfortunately the new government and the new Health Minister did not pursue it further. The Secretary Health and the Drug Controller General changed and the new government did not want the old government′s initiatives to continue. The building was given to the Directorate of Health Services. The WHO, however, continued with its initiative and expanded the programme to other states of India.

VSM: Do you think you had a better insight being a doctor?
HV: Being a doctor certainly helps, but I think the professional and technical guidance and the expertise of a man like Professor Ranjit Roy Chaudhury is important.

VSM : Could you throw some light on the group of people you chose to work with?
HV: The idea was to have people who were strictly professional, had ample experience, a noble vision and whose integrity was beyond doubt. I was looking for the best team that could deliver the goods. I do not think I deliberately avoided people from politics. One of the groups we constituted was the Special Purchase Committee for the procurement of drugs for the Delhi Government. This committee had a huge responsibility of finalizing tender documents, inviting quotations, etc. We wanted people on this committee from the system that was already operating in the government but not anyone who would ultimately decide, they were only ex-officio members. I kept myself totally away from this exercise. I do not remember even a single instance during my term of five years when I ever spoke to any member of the committee regarding which drugs should be purchased and which should not. Also, I do not remember having given an appointment to representatives of any drug company or drug manufacturer.

VSM :Dr Vardhan, are you more interested in quality? Swadeshi or videshi.?
HV: Frankly speaking, I did not promote swadeshi in its traditional form; our major emphasis was on quality. That is why there was a two-envelope system in the tender documents. During an informal discussion, I said that if there is an equally good quality drug of Indian origin, I would definitely prefer to use the Indian drug. In fact, quality was the main concern; we never discussed the companies. During my tenure as the Health Minister of Delhi, I do not remember even a single instance when we discussed any drug with a particular name of a company. In fact, in my prescriptions, the swadeshi concept was always there but as a Minister I do not remember that I had an issue with the name of a company such as IDPL. Even drug companies did not approach me.

Acknowledgments

Copyright 2006 - Indian Journal of Pharmacology