If you had a fever, you would most likely rush to the nearest drug store and buy a ‘Crocin’ or any other brand of paracetamol. But, if you were given a plain pill of paracetamol, without any brand name on it, perhaps you would think twice before taking it. Welcome to the world of ‘generic medicine’, an important building block of a flourishing health care system.
In India, there are several false impressions about the quality of generic medicines, compared to branded ones. Statements such as ‘the more you pay, the better the quality’ are often the basis on which generic medicines are weighed down. But, is that true? Are generic medicines, which are just the same compound as the branded medicine, but sold at a fraction of the cost of branded medicine, really bad in quality?
In an attempt to understand this, researchers from the Institute of Public Health (IPH), Bangalore, with the support of the Alliance for Health Policy and Systems Research of the World Health Organization, have assessed the quality of generic medicine and their branded equivalents in South India. This research is part of a larger study to understand the how to improve equitable access to medicines for patients, generic medicines being an important way to do so.
Using qualitative analysis, the researchers also developed a framework that explains the role of trust in improving access to medicines. “We knew from our previous research that improving the availability of generic medicines was not enough to increase its consumption. We also had to address the trust in medicines and in health services to improve access,” explains Dr. Prashanth N Srinivas from IPH, who is the lead researcher of this study.
In this study, researchers focused on medicines for diabetes and hypertension. “Our public health care system has been able to focus reasonably well on communicable diseases such as tuberculosis, and maternal and child health care. But for chronic non-communicable conditions like diabetes and hypertension, patients tend to rely on relatively expensive care in the private health sector,” says Dr. Prashanth, “This is quite sad since these patients require lifelong, continuous care, and any complications are very expensive to treat,” he adds.
To begin with, the researchers tested the quality of generic and branded medicines available for these two medical conditions. Four of the most prescribed medicines for the management of diabetes and hypertension were shortlisted for the study - metformin hydrochloride and glibenclamide for diabetes, and atenolol and amlodipine besylate for hypertension. The medicines for the quality check were sampled from three places: a government district hospital, a private pharmacy and Janatha Bazaar (JB). The Janatha Bazaar is a people’s market, that sells government supplied medicines at highly subsidized costs.
The results of the quality test showed that the quality of the four generic medicines from all the three medicine stores were identical to the quality of the branded medicines and complied to all the prescribed criteria by statutory standards set by the Indian Pharmacopoeia Commission (IPC). The IPC is an autonomous body of the Indian Ministry of Health and Family Welfare, that sets standards of quality for drugs in the country.
If so, what makes the branded medicines expensive? “The huge price difference between generic and branded medicines is likely due to costs involved with fancy packaging, as well as the costs of marketing and promotion of the medicine,” highlights Dr. Prashanth. “Objectively we could not find any difference in quality, but subjectively people, including doctors and health workers themselves, seem to think there is.”
To further compare the differences in the objective versus subjective quality of these medications, the researchers conducted focus group discussions with patients, health care workers and private pharmacists in Tumkur district of Karnataka. The interviews mainly focused on community perceptions of medicines and care, and on health care delivery.
The conclusions of these discussions indicated that trust was a major underlying element in the choice of medicine or health care provider. Various interrelated themes associated with trust, like confidence in the health care providers and medicines, loyalty to the provider, expectations from the providers, patient experience, doctor-patient communication, and competence of the doctor, emerged during the discussions.
In addition, the study found that it was not just the patients who did not trust the quality and efficacy of the generic medicines, but even the doctors and other health care providers. One of the reasons for this could be the prevalence of kickbacks, wherein doctors take commissions from pharma companies to increase prescriptions of expensive branded medicines. “Pharma companies push their branded medicines on doctors based on certain claims regarding their quality. As our study clearly shows, these claims are not always true,” says Dr. Prashanth. Patients who put their trust in these doctors could cultivate similar negative perceptions about generic medicines.
The findings of this study have new lessons for the health care sector. “It is not enough just to increase the availability and access to generic medicines, but also important to build trust regarding the efficacy of these medicines,” explains Dr. Prashanth. The researchers have already taken the first step by using their findings to educate the people of Tumkur about the myths and realities of generic and branded medicines through a series of posters. They are also disseminating this information to district officers, policy makers and policy implementers through regular workshops.