Sakthivel Selvaraj, Habib Hasan Public Health Foundation of India, India 1

Background Provision of safe and effective medicines to patients is one of the central goals of a public health system. However, inefficiencies in public procurement and distribution of pharmaceuticals due to poor governance and lack of transparency impede the process of access at every stage, from procurement and distribution to the dispensing of drugs. This may be seen in developing countries in general and India in particular. 2

Background India’s government health care system is diverse, given the diversity of practices, strategies and policies pursued in the health care system by various states in India. The heterogeneity in drug procurement and distribution models in various states of India reflects this phenomenon. This has implication for availability and stock-outs of essential drugs in frontline public health facilities. 3

Background In order to generate evidence on availability and stock- outs of essential medicines in public health facilities and also on effectiveness and efficiency of two diverse government drug procurement and distribution systems this research was conducted in India. 4

Objective To examine the availability and stock-outs of essential drugs in public health facilities in the state of Bihar and Tamil Nadu, India. 5

Methodology Design: Cross-sectional analytic study. Setting: The study was conducted across 60 public health facilities. Study Population: The public health facilities were selected through a stratified random sampling procedure which accounted for regional and economic diversity in each state. Sampling: The selected health facilities are first level referral units (called as Referral Hospitals in Bihar and Upgraded PHCs in the state of Tamil Nadu) and are essentially 30-beded hospitals which cater to about 100,000 populations. 6

Methodology Sampling: Of the total 38 districts in Bihar, 30 health facilities located in 17 districts (roughly 45 %) were visited for primary data collection. Similarly, in Tamil Nadu 30 health facilities, located across 18 districts, accounting for 60% of the total number of districts, were visited. Data Sources: Data on drug availability on the day of the survey, medicine stock-out position for the last 6 months and other indicators were collected during the facility survey through a structured questionnaire. Outcome Measure(s): Availability/unavailability of essential medicines on the day of survey, stock-outs during previous 6 months and average duration of stock-outs. 7

Results 8

9

10

Results 11

12

Results Our findings reveal that the mean availability of “basket of drugs” for Bihar was about 43% as against roughly 88% for Tamil Nadu. Also, in terms of the stock-outs, Bihar’s health facilities registered an average of about 42% stock-outs of drugs with a mean duration of 105 days in the previous 6 months of the survey period. The proportion of stock-out for Tamil Nadu stood at around 17% with a mean duration of 50 days. Also, the availability of the most important class of drugs, namely, Antibiotic’s and Antipyretic’s was low at 40% in Bihar. However, the evidence from Tamil Nadu suggests that almost all the broad therapeutic categories had more than 80% availability. 13

Conclusions The key to improving access to medicines depends not only on high public expenditure on medicines but also on robust procurement and distribution system. Best practices should be learned from Tamil Nadu’s procurement and distribution system and should be replicated in Bihar to improve its drug supply system and enhance access to medicines across the facilities. 14

Conclusions Tamil Nadu follows centralized procurement and decentralized distribution system whereas Bihar follows decentralized procurement with ‘cash and carry’ model. 15

Funding Support: This work would not have been possible without the financial support from Results for Development Institute (R4D), Washington, under the Transparency and Accountability Program, Their constant encouragement and support to this study are highly appreciated. Institutional Affiliation Disclaimer: This research report is based on a study conducted by researchers based at Public Health Foundation of India, New Delhi. The views expressed in this report do not reflect the views of the institution. Any errors and omissions are those of the researchers themselves. 16