India is widely recognised as the pharmacy of the developing world thanks to its generic drugs manufacturing sector. Yet, ironically, it often fails to provide necessary drugs to its own population. Several States across India have been reporting that essential HIV drugs, especially nevirapine, have gone out of stock. This is deplorable considering we supply affordable HIV drugs globally and save millions of lives but have somehow managed a stock-out at home.
Drug shortages are common in India and rarely make news. A stock-out of essential HIV drugs, however, is nothing short of a crisis; it is one that has parallels in previous stock-outs and raises many questions. What causes drug stock-outs? Who is responsible and accountable for them? Where do the poor go when they need these drugs? Finally, what are the implications of these stock-outs on the control of infectious diseases such as HIV and TB?A culture of neglect
Let’s consider how stock-outs happen. Contrary to popular perception, the government is designed to be a competent machinery with detailed systems in place to avoid such crisis. Drug stocks in the public health system are meant to be regularly monitored and the suppliers should be kept in the loop about future requirements. Hence all drug stock-outs are created — either out of neglect or out of self-interest. No drug stock-out is ever an unanticipated one. Who then is responsible for these stock-outs? It’s rarely an individual but usually a result of actions (or inactions) by a group or the entire system. A drug stock-out requires some negligence, compliance and efforts by all actors. For one, it requires the purposeful ignoring of well-structured systems of reporting on drug stocks. It also demands continued delays in forecasting and planning. Finally, there must be extensive procrastination or delay in procurements.
This points to several systemic weaknesses that are difficult but essential to address. There is a culture of neglect where the health establishment is geared for minimal action to disturb the status quo. There is also a deeply ingrained mindset of mutual protection. Despite a looming crisis, people within the system rarely raise an alarm. The matter only reaches a head when word gets out to the media or someone senior calls for explanations. Until then the system protects itself while poor patients wait for the health system to deliver.
Where then do the poor go when they do not receive drugs? They have two options — they can wait and suffer or they go to the private sector. Truthfully, this is not really a choice. It’s well-known that a large number of patients seek care in the private sector only due to the overburdened and patient-unfriendly nature of the public sector. So, those who seek care in the public sector either cannot afford to go to the private sector or have already been exploited by it.
This raises the critical question of the government’s role as the primary provider of drugs and services to the poorest. This extensive power seems to come with little accountability. The issue also has legal and ethical implications: how can the state put lives of patients with HIV at risk by not making essential drugs available? Patients suffering from TB and HIV also suffer extensive physical, psychological, social and economic consequences of these diseases. These diseases impact income, raise expenses and often push families into debt. By not providing appropriate and timely treatment, the government is further acerbating their suffering and also limiting their ability to build constructive lives.Implications for disease control
A stock-out also has significant implications for disease control. Unplanned HIV treatment interruptions lead to increased risk resistance to HIV drugs, failure of treatment, and death. Similarly, a TB patient without drugs can become drug-resistant and infectious. Imagine a TB patient in a crowded slum — coughing and transmitting the disease. Stock-outs also significantly reduce the patient’s trust in the system and makes retention of patients more difficult. Undoubtedly, these stock-outs represent a lack of appropriate governance and accountability within the health system. With new leadership in the Health Ministry, addressing stock-outs should be a top priority. This should be followed by immediate remedial action to ensure that these crises do not recur in any form in the future.
At the same time, it’s also important that we as a people seek accountability for our right to free quality health services. Despite political posturing, the idea of Universal Health Coverage remains elusive and continues to lack political commitment and resources. Neglect by successive governments has resulted in the growth of an unregulated and exploitative private sector which has become the primary provider of health services to Indians. It is ethically and morally untenable that the state can renege on its duty to provide the poor and vulnerable health care, particularly medicines under the public sector. It violates human rights and all notions of justice and empathy. Access to essential medicines in the public health system cannot be a service that the state voluntarily undertakes; it must be considered an undeniable right of every Indian.