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Building access to healthcare in rural India: possibility and feasibility of low-cost medicine
Yashavantha Dongre and B. Mahadevappa
Department of Studies in Commerce, University of Mysore, Hassan, India, and

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R. Rohini
Institute of Clinical Research India, Bangalore, India
Abstract
Purpose The purpose of this paper is to evaluate the possibility of marketing specic low-cost drugs across segmented markets in India. Design/methodology/approach The study is empirical in nature, based on the primary data gathered through actual eld survey. The study analyzes the attitudes, perceptions and experiences of ve stockists, 50 physicians and 100 patients drawn from 20 healthcare organizations from different parts of the State of Karnataka in India. Findings The survey ndings revealed that patients would be happy and would have better access to medicine if the same is offered at a lower price. Doctors are willing to prescribe generic drugs. Generic drug market has good economic feasibility. At present, the consumption of generic drugs to branded drugs in hospitals is found to be in the ratio 2:3 while for the stockist it is in the ratio 1:2. The study also revealed the fact that patients prefer to take generic medicines mostly on the basis of physicians advice. They do consider cost but generally go by the prescriptions of the doctors. Practical implications Prescribing generic drugs would denitely contribute to greater use of medicine by the rural poor and thus better health conditions in rural areas. Low-cost medicine is an opportunity for pharmaceutical companies because consumers of healthcare are increasingly concerned with the quality and the cost of drugs that they buy. This research enhances sales and marketing management in terms of creating awareness of the importance of doctors perceptions. Healthcare providers would benet from the ndings of this paper. Originality/value As the generic drug market encompasses a variety of healthcare professionals and users, this paper establishes a practical methodology to have an understanding about the attitudes, perceptions and experiences of stockists, physicians and patients regarding the usage of such low-cost drugs. Keywords India, Drugs, Generics, Rural areas, Medical care Paper type Case study

International Journal of Pharmaceutical and Healthcare Marketing Vol. 4 No. 4, 2010 pp. 396-407 q Emerald Group Publishing Limited 1750-6123 DOI 10.1108/17506121011095218

Introduction Over the years, India has made signicant strides in the advancement of healthcare and the quality of life. Recently in India, the life expectancy of a person is 64.4 years, a notable increase compared to the situation in the early 1990s. However, the WHO estimated in 1999 that the percentage of the Indian population having sustainable access to essential drugs was within the 0-49 range, resulting in India being categorized as a country with a low-level access to healthcare (Basak, 2005). It is often held that the main obstacles preventing consumer access to medicine are economic constraints, particularly as a majority of Indians reside in rural areas. Recently, drug costs are among the main drivers of the overall healthcare cost ination along with more aggressive contract

bargaining by doctors, hospitals and new medical technology. Within this scenario, there is a need to ensure that economically weaker sections of the population in rural India (who exhibit higher rates of disease proneness, higher infant mortality, higher malnutrition and lesser life expectancy) have better access to medicine. One of the remedies in tackling the problem of the escalating cost of healthcare in general and that of the drugs in particular has been the use of generic drugs. Generic drugs are expected to play an important social role in making life-saving drugs available at lower prices. That is why governments of several countries including the USA are encouraging generic manufacturing. Recently, the world generics market has grown to a level of $50 billion. In all countries, generics are far lower priced than their branded equivalents. That is the very objective of the generics option. Almost 15 percent of the formulation market in India is generics of anti-invectives, analgesics, anti-diarroheals and cough and cold preparations. Large portions of these products go to bulk users like hospitals, nursing homes and medical practitioners. The composition of the Indian pharmaceutical market is a mixed one with 57 percent formulations, 15 percent bulk and 28 percent exports. Exports form a vital component of the growth strategy of most Indian pharmaceutical companies and the growth over the last ve years has been more than 20 percent. The USA is the largest export market for Indian pharmaceuticals. A major share of Indian pharmaceutical exports is destined to highly regulated markets such as that of the USA, Germany, UK and The Netherlands. The Indian generic drug manufacturing has seen a substantial rise over the last few years and is expected to be the main growth driver in the future. During the period 2002-2005, the market for generic drugs exceeded US$55 billion. India, with its technology, R&D facilities and trained human resources can capture a signicant part of this market. With new drugs slated to be introduced in the Indian market, the share of patented drugs is expected to rise. Patent expirations would contribute to the growth of the generics market. Advanced countries like the USA are publicising increased consumption of generic drugs especially by the xed income older generation. This is expected to further bolster the generic drug production market in India. Domestic market in India itself is estimated to be worth US$12 billion by 2010 (Department of Chemicals and Petrochemicals, 2008). The Indian pharmaceutical industry has shown tremendous progress with reference to infrastructure development, technology base creation and the development of production. The pharmaceutical industry produces bulk drugs belonging to major therapy groups. India ranks fourth worldwide accounting for 8 percent of the worlds production in terms of volume and 13 in terms of value. The industry has developed good manufacturing practices facilities for the production of different dosage forms. The pharmaceutical industry exports drugs and pharmaceuticals worth over $3.8 billion. It ranks 17th in terms of export value of bulk actives and dosage. Indian exports cover more than 200 countries including the highly regulated markets of the USA, Europe, Japan and Australia (Department of Chemicals and Petrochemicals, 2008). Therefore, the opportunities for the Indian pharmaceutical industries are scope for generic drug production market, contract research, lean manufacturing, clinical research and trials, signicant export potential and supply of generic drugs to developed markets. The fact that Karnataka High Court and subsequently the Indian Supreme Court stayed the implementation of pharmaceutical policy 2002 questioning the stand of government over the exclusion of many essential drugs under the gambit of price control reveals the importance of price-controlled essential drugs in India.

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Literature review Considerable research has focused on generic drug issues. Topics such as labeling, information disclosure (Morris and Kanouse, 1981; Morris et al., 1992) and direct-to-consumer advertising of prescription drugs (Masson and Rubin, 1985; Morris et al., 1989; Roth, 1996; Sheffet and Kopp, 1990) have been extensively studied. Creyer et al. (2001) explored how consumers healthcare behaviours may change as switch drugs become increasingly available. The ability to self-medicate, using medicine once available by prescription only, is one of the most attractive features of switch drugs (Oster et al., 1990). In fact, many drugs that were switched from Rx to over the counter (OTC) status outsell traditional OTC brands in their product categories (Hoy, 1994; Kavanoor et al., 1997). Over the past several years, the worldwide market for generic drugs has grown at a faster rate than the pharmaceutical industry as a whole. This is largely due to strong efforts to contain drug costs by government agencies, as well as growing condence in generic quality by both health professionals and consumers (Suh, 1999). Many issues need to be taken into account when an innovator product is replaced with a generic alternative. These issues vary widely depending on the people associated with the generic drugs, viz., physicians, pharmacists and patients. Physician attitudes towards generic substitution is most often related to their general prescribing behaviour, perception of therapeutic efciency, beliefs about generic drugs and previous experience with using generic alternatives, including any negative effects (Banahan and Kolassa, 1997). Perceived risk on the part of the GP is a signicant determinant of generic drug adoption and that the desire to simplify work load decisions is also important (Turnbull and Parsons, 1993). Intervention methods should be chosen to change physicians prescribing behaviour, through education of rational drug prescription, to improve the quality of prescribing practice of GPs (Gholamreza and Meimandi, 2005). A study by Stern (2002) analyses the contrasts and overlaps between the perceptions of healthcare managers and actual prescribing behaviour. While there are aspects of prescribing behaviour which are well understood, there are a number of areas where perceptions differ markedly from the patterns found in practice. The managerial implications of these differences are discussed. Pharmacists usually consider regulatory issues, drug class, cost and bioequivalence information when dispensing generic products along with patients medical and medication history and their comfort with a brand change (Suh, 1999). For patients, the main issues of concern in taking generic drugs include ease of consumption, changes in therapeutic effects, side effects, practical use (e.g. size, shape and appearance), willingness to take medication and concern about managing their health condition (Kjoenniksen et al., 2006). The cost dimension is the other factor that makes use of drugs more attractive in the regions such as rural India. Hence, there is a strong case for popularizing generic medicines. Generic drugs are generally about a third to one-half cheaper than the identical brand drug. It is, therefore pertinent to examine the possibility and feasibility of low-cost medicine in rural areas. Objectives of the study The present study pursues the following objectives: (1) to analyze the perceptions of the distributors, physicians and consumers (patients) regarding the distribution/prescription and consumption of low-cost drugs;

(2) to examine the relationship between cost and consumption of medicine so as to suggest ways of better access to medicine in rural India; and (3) to identify common medicines which attract a low-cost option. Methodology The study is empirical in nature, based on the primary data gathered through actual eld survey. The data were collected from a sample of ve stockists of Bangalore/Mysore; 20 hospitals from Bangalore, Bellary, Chamarajagar, Dharaward, Dakshina Kannada, Mysore, Shimoga, Uttara Kannada and Udupi districts; and 100 patients randomly selected from sample hospitals. The sample of hospitals is presented in Table I and the main healthcare services offered by them are reported in Table II. For the patients perception analysis, data were collected from 100 individual respondents. The demographic details of the respondents are presented in Table III. For the physicians perception analysis, data were collected from 50 individual respondents. The demographic details of the respondents are presented in Table IV. Three separate structured questionnaires were designed and administered to hospitals/stockists, doctors and patients. Respondents were asked to mark their awareness and perceptions about the generic drugs on a continuous ve-point Likert scale as strongly agree, agree, unsure, disagree and strongly disagree. The questions were focused both on the issue of possibility of marketing (stockists), possibility of prescribing (doctors) and possibility of consumption (patients). Reliability was tested using the Cronbach alpha coefcient. Extrapolation method was used to quantify the data and to make projections of demand. Approximations were made in terms of retail price per unit of each drug, so as to arrive at an average trend.
Type Charity hospitals NGO hospitals Co-operative hospital Private hospitals Quasi-government hospital Total n 11 5 1 2 1 20 % 55 25 5 10 5 100 Size Small Medium Large Total N 11 7 2 20 % 55 35 10 100 Region Urban Rural n 11 9 % 55 45

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Total

20

100

Table I. Sample of hospitals

Community services 1. Health education 2. Health screenings 3. Disease prevention programme 4. Medical camps 5. Any other mobile clinic HIV AIDS education and awareness patient counseling

% In-patient services % Out-patient services 60 55 45 50 30 1. Medical 2. Surgical 3. Obstetrics and gynecology 4. Cardiology 5. Orthopedic 6. Neurology/ neurosurgery 7. Nephrology/ urology 8. Oncology 80 1. Diagnostic care 65 2. Therapeutic care 60 3. Ambulatory surgeries 4. Casualty and emergency services 5 40 5. Any other direct absorbed 15 treatment under RNTCP 15 20

% 90 80 25 45 15 Table II. Main healthcare services offered by hospitals

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Statistical software, SPSS (v 9.05) was used to tabulate and analyze the data. The results of reliability analysis are presented in Table V. Finding and discussion Patients awareness and perception about generic drugs The mean values and standard deviations of the patients awareness and perceptions about generic drugs are presented in Table VI. From Table VI, it is evident that patients have immense faith in the physicians knowledge and prescription and are willing to take generic medicines if and only if a physician prescribes the same (mean 4.36). Even though the majority of the patients are from poor backgrounds, they are aware of the existence of generic drugs and the difference between generic drugs and their branded versions (mean 4.10 and 4.03, respectively). However, the patients strongly disagree to buy or take generic medicines even if recommended and supplied by a well-known chemist/druggist (mean 1.84).

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Profession Physician Surgeons Administrator Physician cum Administrator Surgeon cum Administrator Pharmacist Total Note: n 50

n 34 9 1 2 2 2 50

% 68 18 2 4 4 4 100

Gender Male Female

n 36 14

% 72 28

Experience (years) ,5 5-10 10-15 . 15

n 9 9 7 25

% 18 18 14 50

Table III. Demographics of respondents by profession, gender and experience

Total

50

100

Total

50

100

Gender Male Female Table IV. Demographics of patients by gender, age, education and income

n 53 47

Age (years)

n 17 30 25 28

% 17 30 25 28

Education Below SSLC Graduation Post graduation Any other

n 65 12 17 6

% 65 12 17 6

Income (Rs. per month)

53 . 15 to ,30 47 . 30 to ,45 . 45 to ,60 . 60

Total

100 100 Total

100 100 Total

,5,000 5,000-10,000 10,000-20,000 20,000-30,000 .30,000 100 100 Total

65 65 9 9 13 13 6 6 7 7 100 100

Note: n 100

Table V. Results of reliability analysis of patients perception about generic drugs

Dimensions Awareness about generic drugs Perception about generic drugs

No. of items 5 5

Cronbacha 0.6731 0.5614

Question Awareness about generic drugs Q1. I am aware that there are many generic versions of medications available Q2. I know very well the difference between a branded drug and a generic drug Q4. I do not think that the generic version of the drugs is as effective as the branded version Q5. I do not think that the generic version of the drugs is as safe as the branded version Q7. The generic forms of drugs must pass the government testing to show that they contain the same contents as that of the branded ones. I am aware of this before I took this questionnaire Perception about generic drugs Q3. Generally I am comfortable in taking the generic form of medication Q6. I am willing to take the generic drug as it is cheaper than the branded drug Q8. I am aware of the fact that my physician has enough knowledge of the generic versions of the branded drugs Q9. I am ready to buy the generic drugs if they are manufactured by a well-known company Q10. I am ready to buy the generic drugs if they are supplied from a reputed chemist/druggist Notes: A agree; SA strongly agree

Percentage response of strongly agree and agree

Mean SD

Healthcare in rural India

75 79 34 37

4.10 4.03 2.86 2.90

1.24 1.12 1.11 1.01

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65 34 56 96 54 16

3.58 3.18 3.15 4.36 3.15 1.84

1.07 0.80 1.16 0.72 1.27 1.11 Table VI. The average scores of patients awareness and perceptions about generic drugs

Patients awareness and knowledge about generic drugs Among the surveyed respondents, the majority (75 percent) were aware that there are many generic versions of drugs available in the market and about 79 percent knew that generic drugs differ from their branded versions. However, 48 percent of patients doubted the effectiveness and safety of the generic drugs when compared to that of branded ones. About 65 percent of the respondents, even from the economically poor background, knew that the generic substitutes of drugs must pass through the government testing to show that they contain the same contents as those of their branded versions. Patients perceptions and knowledge about generic drugs Among the patients, only 34 percent were comfortable in taking the generic form of drugs. More than half of the respondents (56 percent) were willing to take generic substitutes as they are cheaper than the branded drugs. The patients (96 percent) were fully aware that their physicians have sufcient knowledge about the generic drugs while prescribing the same to them. About 54 percent agreed to buy them if manufactured by a well-known company and only 16 percent were willing to buy if drugs are supplied from a reputed chemist/druggist. As per the cost and access to medicine criteria, the majority of the patients (85 percent) felt that cost of medicine inuences their intake of medicine. Furthermore,

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they often worry about diseases more because of the expenses they have to incur than due to the possible damage it might cause to their body and mind. There was total unanimity as to the need for low-cost drugs to improve their health standards. Since cost of drugs is an important factor but the patients generally go by the advice of the doctors, the study examined the perceptions of doctors towards low-cost options in medicine.

Physicians perception about generic drugs The main ndings of the physicians perception about generic drugs are listed below. The perceptions indirectly lead us to the possible trends of prescribing such drugs by the doctors: . Knowledge of bioequivalence. Most of the physicians/surgeons (82 percent) felt that they require more information on how bioequivalent tests are conducted for generic drugs. About 54 percent of the physicians agreed that all generic products of a particular medicine that are rated as generic equivalents are therapeutically equivalent to the innovator brand product. Only 50 percent of the physicians believed that all generic products of a particular medicine that are rated as generic equivalents are therapeutically equivalent to each other, while 26 percent of the doctors have no say in this regard. About 40 percent of the respondents were not sure of the bioequivalence of a generic drug to that of the brand-name drug. While 36 percent strongly agreed that a generic drug is bioequivalent to a brand-name drug, 24 percent of the doctors disagreed. . Dosage. About 70 percent of the respondents strongly agreed with the fact that generic medicines must contain the same dose as the brand-name drugs. About 86 percent preferred to have the generic medicines in the same form (tablets, capsules, etc.) as the brand-name drugs to satisfy the needs and expectation of the patients. . Quality of generic drugs. About 60 percent of the respondents felt that generic medicines are not of inferior quality when compared to branded drugs. Only 12 percent felt that generic medicines are of inferior quality when compared to branded drugs. . Safety and efcacy of generic drugs. About 66 percent of the doctors disagreed that the generic medicines are less effective than branded medicines. About 80 percent of the respondents needed more information on the issues pertaining to the safety and efcacy of generic drugs. About 42 percent felt that brand-name drugs are required to meet higher safety standards than generic drugs, while 14 percent were of the view that same standards are followed in both the cases. . Prescription pattern. Regarding prescribing habits, 52 percent had branded drugs as their rst choice, while 60 percent preferred to prescribe generic drugs. About 82 percent respondents agreed that cost has been an important factor for the prescription of generic drugs. About 72 percent felt that using generic name is easier to recall than a brand name. About 60 percent are condent in prescribing generic drugs without focusing on brand name.

Cost. The majority (94 percent) strongly agreed that generic drugs are less expensive than branded drugs. If generic drugs are slightly cheaper than branded drugs, 50 percent preferred generic drugs. Assessment of quality of generic drugs. About 60 percent assess quality of generic drugs by improvement in patients condition; 22 percent by potency of the drug, 18 percent by cost, 18 percent by companys name and 8 percent expressed other views, i.e. generic drugs should also undergo standard lab tests. The quality of generic drugs were assessed monthly (30 percent), quarterly (48 percent), half-yearly (14 percent) and annually (4 percent) in hospitals. Before receiving the generic drugs, the doctors said they check the storage conditions, supply conditions, place from which the drugs are being supplied (86 percent). Buying habits. About 58 percent of the respondents said that they buy generic drugs according to budget allocation, while 28 percent procure drugs by committee decision/management pressure. Side effects. The majority (84 percent) of doctors are of the opinion that generic medicines will not have more side effects than brand-name medicines. Whenever any side effect is observed by the use of generic drug, 24 percent doctors said they temporarily stop the usage, 22 percent stop the purchase permanently, but 58 percent would inform the concerned manufacturers. Free distribution of generic drugs. For free distribution of generic drugs, the doctors considered cost only (6 percent), cost and quality (76 percent), patients economic condition (44 percent) and availability of drugs (18 percent). Market potential for generic drugs. About 48 percent of the doctors felt that there is high market potential for generic drugs, while 46 percent of them felt the potential is medium (average).

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The study established that the patients look for low-cost drugs and will happily take generic drugs provided the doctors prescribe them. Further, the doctors are generally willing to prescribe such low-cost drugs with some check on quality. It is now important to see whether such drugs can bring in adequate prots for distributors/stockists so that there is also a market potential for such drugs. Annual consumption of drugs The annual consumption of drugs per hospital and per stockiest in terms of quantity and cost is presented in Tables VII and VIII, respectively. The consumption of generic drugs and branded drugs in the hospitals is found to be in the ratio of 2:3, while for the stockist it is at a ratio of 1:2. This shows that the stockists see higher potential for selling generic drugs. Obviously, they are distributing such drugs to institutions other than hospitals also. In most cases such generic/low-cost drugs nd way to special medical camps, mass treatment melas and free distribution of medicine by NGOs/charitable organizations, especially at the rural areas. The annual consumption of drugs per hospital was about 92,858 strips/bottles or about Rs 221,650. In terms of quantity, antacid drugs were consumed more in hospitals, followed by haematinics. Anti-depressant drugs and cough syrup were the least consumed drugs in the hospitals surveyed. Stockiest procured more quantity of

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Type of drugs Analgesics Anti-inammatory drugs Antipyretic drugs Antacids Antibiotic drugs Cough syrup Anti-depressant drugs High blood pressure drugs Antihistamines Haematinics Vitamins Anti-diabetic drugs Total

Quantity Strips/bottles 1,226,500 317,852 163,500 189,000 258,000 101,600 61,800 105,572 34,000 104,667 151,077 219,000 2,932,568

Cost % 41.82 10.84 5.56 6.44 8.80 3.46 2.11 3.60 1.16 3.57 5.15 7.47 100 Rupees 3,812,000 2,094,560 1,308,000 1,494,000 10,320,000 6,848,000 2,472,000 3,666,000 788,000 3,508,000 3,420,000 8,652,000 48,382,560 % 7.88 4.33 2.70 3.09 21.33 14.15 5.11 7.58 1.63 7.25 7.07 17.88 100

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Table VII. Annual consumption of drugs per hospital

Type of drugs Analgesics Anti-inammatory drugs Antipyretic drugs Antacids Antibiotic drugs Cough syrup Anti-depressant drugs High blood pressure drugs Antihistamines Haematinics Vitamins Anti-diabetic drugs Total

Quantity Strips/bottles 1,146 2,995 15,917 21,372 15,826 112 60 1,324 455 20,136 12,915 600 92,858

Cost % 1.23 3.23 17.14 23.02 17.04 0.12 0.06 1.42 0.49 21.69 13.91 0.65 100 Rupees 7,640 2,244 25,758 24,004 87,169 1,920 300 3,602 6,740 44,837 16,236 1,200 221,650 % 3.45 1.01 11.62 10.83 39.33 0.87 0.14 1.62 3.04 20.23 7.32 0.54 100

Table VIII. Annual procurement of drugs by stockists

analgesics, and anti-inammatory drugs followed by antibiotics. Antihistamines were procured least by the stockiest. Cost seems to be the primary driving force in procuring either branded or generic drugs (50 percent) followed by feedback by physicians (15 percent) and the companys name (15 percent). About 60 percent of the hospitals were buying generic drugs by budget allocation and 30 percent by committee decision/management pressure, while the remaining 5 percent were buying because of physician pressure. About 85 percent of the hospitals felt that generic medicines would be bought by charitable organizations, 60 percent felt that hospitals run by non-governmental organizations and 25 percent felt that hospitals run by co-operatives would most likely buy generic/low-cost drugs. About 50 percent opined that government organizations in rural area could be potential customers for such drugs.

Managerial implications This research enhances sales and marketing management in terms of creating awareness of the importance of doctors perceptions. It has been claimed that perceptions are equally important, if not more important, than actual communication (Gross and Guerrero, 2000). Further, studies can be done to note if this difference in perception translates towards difference in prescription of drugs. So far, very few of the pharmaceutical companies in India have collected data of perceptions of doctors towards generic drugs as well as factors that affect doctors prescribing decisions. This research provides useful information that is relevant to strategize sales and marketing plans for pharmaceutical drugs in India. Management of hospitals, the Ministry of Health and pharmaceutical companies can make good use of all the ndings drawn from the research. Better understanding of doctors perceptions towards branded drugs and generic drugs is of great competitive advantage to both sales and marketing departments of pharmaceutical companies. It also will help the Ministry of Health in detailing and disseminating its policies on generic and branded drugs. A good understanding of the factors that doctors consider before prescribing is important for those responsible for managing health budgets whether at the local or national level. Low-cost medicine is an opportunity for pharmaceutical companies because consumers of healthcare are increasingly concerned with the quality and the cost of the drugs that they buy. Thus, healthcare providers would benet from the ndings of this study. Conclusion Our study reveals that the cost of medicine is a signicant factor inuencing the patients attitude towards consumption of medicine. Generally, the patients do not discontinue the medicine or keep off from taking medicine because of high prices. However, the majority of them were of the opinion that the reduced cost of drugs would certainly motivate them to consult a doctor and take medicine on a more regular basis. During the course of the discussion with the doctors, hospital administrators, stockist and other informed individuals, it was felt that there are quite a few external factors inuencing the prescription of specic drugs. These may not be the basic determinants but would certainly have an impact on the market potential of any drug. The awareness about the generic/low-cost drugs is not satisfactory. Doctors on their part are generally willing to prescribe such drugs, if they are convinced of their need and quality. This establishes a case for methods of educating/informing the doctors about the need for such drugs. Many times the choice of the patient has a say in prescription. Many doctors felt that once they prescribe a branded drug and if the patient nds that it had positive effect, the patient would next time insist on getting the same prescription or many a times venture to simply buy same drug directly from the retailer (wherever possible). The economic status of the patient inuences the prescription to a signicant extent. Doctors clearly make choices of drugs based on the paying capacity of the patient. Geographical area (urban/rural) has a greater inuence than the type of hospital (private/government/charitable) in so far as possibility of prescribing generic/low-cost drugs. Promotional measures initiated by drug manufacturers, especially those found in case of branded ones, do have high to very high inuence on prescriptions. There exists a whole series of complements/gifts and other related incentives that seems to be playing a key role. This issue cannot be overlooked.

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Trust in the respective physician plays an important role in taking medication. If the doctor prescribes, gives proper information and guidance about generic medicines, patients from any background (poor/rich) are willing to take them. To a certain extent patients believe in the generic substitutes manufactured by reputed rms that also manufacture branded drugs, but are not keen to buy the same if they are supplied by a reputed chemist/druggist. This clearly draws ones attention on educating/informing the pharmacists regarding generic drugs so that they can convince the patients to buy those drugs. According to the study, the ratio of generic drug to branded drug is 2:3 and a hospital buys on an average 92,858 strips/bottles per annum. Therefore, the probable market size for low-cost drugs in Karnataka is 9,285,800 strips/bottles for 100 hospitals. In monetary terms, it amounts to about Rs 22,165,000. This is obviously a big enough size for any manufacturer or distributor to produce/distribute low-cost medicine. So the low-cost medicines are economically viable too.
References Banahan, B. and Kolassa, E. (1997), A physicians survey on generic drugs and substitution of critical dose medications, Archives of Internal Medicine, Vol. 157 No. 18, pp. 2080-8. Basak, S.C. (2005), Changes in Indias patent regime and access to medicine, available at: www. pharmabiz.com/article/detnews.asp?Archa&articleid28721&sectionid46 (accessed 1 September 2010). Creyer, E.H., Hrsistodoulakis, I. and Cole, C.A. (2001), Changing a drug from Rx to OTC status: the consumer behavior and public policy implications of switch drugs, Journal of Product & Brand Management, Vol. 10 No. 1, pp. 52-64. Department of Chemicals and Petrochemicals (2008), Pharmaceuticals, available at: http:// chemicals.nic.in/pharma1.htm (accessed 16 September 2010). Gholamreza, S. and Meimandi, M.-S. (2005), The quality of prescribing in general practice in Kerman, Iran, International Journal of Health Care Quality Assurance, Vol. 18 No. 5, pp. 353-60. Gross, M.A. and Guerrero, L.K. (2000), Managing conict appropriately & effectively: an application of the competence model to Rahims organizational conict styles, International Journal of Conict Management, Vol. 11 No. 3, pp. 200-26. ` Hoy, M.G. (1994), Switch drugs vis-a-vis Rx and OTC: policy, marketing, and research considerations, Journal of Public Policy & Marketing, Vol. 13 No. 1, pp. 85-96. Kavanoor, S., Grewal, D. and Blodgett, J. (1997), Ads promoting OTC medications: the effect of ad format and credibility on beliefs, attitudes, and purchase intentions, Journal of Business Research, Vol. 40 No. 3, pp. 219-27. Kjoenniksen, I., Lindback, M. and Granas, A. (2006), Patients attitudes towards and experiences of generic drug substitution in Norway, Pharmacy World & Science, Vol. 28 No. 5, pp. 284-9. Masson, A. and Rubin, P.H. (1985), Matching prescriptions drugs and consumers, New England Journal of Medicine, Vol. 13 No. 8, pp. 513-15. Morris, L.A. and Kanouse, D.A. (1981), Consumer reactions to the tone of written drug information, American Journal of Hospital Pharmacy, Vol. 38 No. 5, pp. 667-71. Morris, L.A., Mazis, M.B. and Brinberg, D. (1989), Risk disclosures in televised Rx drug advertising to consumers, Journal of Public Policy & Marketing, Vol. 8, pp. 64-80.

Morris, L.A., Tabak, E.R. and Olins, N.J. (1992), A segmentation analysis of prescription drug information-seeking motives among the elderly, Journal of Public Policy & Marketing, Vol. 11 No. 2, pp. 115-25. Oster, G., Huse, D.M., Delea, T.E., Colditz, G.A. and Richter, J.M. (1990), The risks and benets of an Rx-to-OTC switch: the case of OTC H2-Blockers, Medical Care, Vol. 28 No. 9, pp. 834-52. Roth, M.S. (1996), Patterns in direct-to-consumer prescription drug print advertising and their public policy implications, Journal of Public Policy & Marketing, Vol. 15 No. 1, pp. 63-75. Sheffet, M.J. and Kopp, S.W. (1990), Advertising Rx drugs to the public: headache or relief?, Journal of Public Policy & Marketing, Vol. 9, pp. 42-61. Stern, P. (2002), How health managers see prescribing, Marketing Intelligence & Planning, Vol. 20 No. 2, pp. 104-12. Suh, D. (1999), Trends of generic substitution in community pharmacies, Pharmacy World & Science, Vol. 21 No. 6, pp. 260-5. Turnbull, P. and Parsons, N.E. (1993), Generic prescribing in general medical practice: an attitudinal study of general practitioners, Marketing Intelligence & Planning, Vol. 11 No. 4, pp. 30-40. About the authors Yashavantha Dongre, PhD, is Professor of Commerce at the Department of Commerce, University of Mysore, Post Graduate Centre, Hemagangotri, Hassan, India. His area of research interest is non-prot sector management. He was a Postdoctoral Research Fellow under Japan Foundation at Japan. He has completed research projects of Ford Foundation, USA and University of Technology, Sydney, Australia and has visited Japan, China, Canada and Southeast Asian countries to present research papers in international conferences. He has published several research papers in national and international journals including Vikalpa. He has 25 years of teaching and research experience. He is also the Coordinator for Third Sector Research Resource Centre, University of Mysore, Mysore, India. B. Mahadevappa, PhD, is a Reader at the Department of Studies in Commerce, University of Mysore, Manasagangotri, Mysore, India. His area of research is TQM and accounting for non-prot organizations. He was a UGC Postdoctoral Research Fellow at the University of Mysore. He has published several research papers in national and international journals and attended international conferences at Bangkok and Taiwan. He has 21 years of teaching experience. R. Rohini, PhD, is Associate Professor at the Institute of Clinical Research India, Bangalore, India. She obtained her Masters in Chemistry from Mysore University and was a Senior Research Associate in Astra Zeneca Pharma, Ltd After obtaining MBA, she pursued her Doctoral studies at the University of Mysore. She has published several research papers and presented papers at national and international conferences. Her area of interest is human resource management and TQM in healthcare services. She is a Life Member for Academy of Hospital Administration, India and Life Member for Indian Society of Hospital Administrators and Member for International Society for Third Sector Research. R. Rohini is the corresponding author and can be contacted at: rohinirangaswamy@gmail.com

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