Pharmaceutical distribution networks in peri-urban India

: 2.088_NEP Pharmaceutical distribution networks in peri-urban India P. Makhijani, H. Reid, L. Vadlamani, M. Walsh; Stanford University, Stanford, CA, USA Background: The urban poor in India rely upon private general practitioners (GPs), who often have no formal training in modern medicine, in order to access allopathic medications. While prior studies have researched the practices of these GPs, no recent studies have investigated their pharmaceutical distribution networks. Our study fills this gap by documenting this pharmaceutical distribution network and its effects on medical practice in the peri-urban areas of India. Methods: We conducted 132 in-depth qualitative interviews with households, GPs, chemists, distributors, medical representatives and manufacturers in Mumbai and its surrounding areas. We solicited interviewees through in-person visits and phone calls. Findings: The market for drugs in Mumbai is primarily physiciandriven, with very little distinction drawn between allopathic and non-allopathic providers. Most poor households do not use generic drugs even though they are far cheaper. A majority of providers also stock loose drugs dispensed directly to patients, because of patient demand. Through these interviews, we gained information about regulations, pharmaceutical marketing and supply chain practices. We found heterogeneous enforcement of medical regulation. While the Food and Drug Administration (FDA) recently increased enforcement of regulation on chemists’ practices, provider practices remain relatively unencumbered by existing legislation. Medical representatives from pharmaceutical companies provide gifts, invitations to conferences and other special privileges to encourage prescriptions of their medications. Fierce competition among the distributors and wholesalers in the supply chain facilitates lower prices and wide access to medications. Interpretation: While we must consider selection bias, our analysis indicates a shifting medical landscape toward a general practitionerdriven market. The relatively strict medical practice enforcement of chemist compared to GPs has increased the role of GPs in primary care. At the same time, an abundance of wholesalers and distributors has created easily accessible and relatively cheap medications for these GPs to dispense from their clinic. Finally, pharmaceutical company incentives shape the knowledge and practice of these GPs without necessitating regard for consumer welfare. Funding: We were funded through the Policy Implementation Lab, a division of the Freeman Spogli Institute, at Stanford University. Abstract #: 2.089_NEP: 2.089_NEP Investigating the knowledge and impact of dengue and chikungunya in a rural population in Yoro, Honduras Nathaniel Warner, Daniel Olson, Nadia Nasroor, Bako Sanogo, Gonzalo Bearman, Michael Stevens; Internal Medicine, Virginia Commonwealth University, Richmond, VA, School of Medicine, Virginia Commonwealth University, Richmond, VA, Infectious Diseases, Virginia Commonwealth University, Richmond, VA, Virginia Commonwealth University Medical Center, Richmond, VA Background: Dengue and Chikungunya cause significant morbidity in Latin America. While Dengue has been endemic in Honduras for many years, Chikungunya was only recently introduced and has spread rapidly throughout the country with over 50,000 endemic cases thus far in 2015 alone. There is no data on the impact of these diseases in the local populations surrounding La Hicaca, a rural, mountainous region in Yoro, Honduras. Methods: In June of 2015, a fifty-question survey was given to the villagers of La Hicaca and seventeen surrounding villages to investigate the impact and local awareness of Dengue and Chikungunya. Survey was IRB approved and written informed consent was obtained prior to participation. Fifty-eight surveys were completed. Respondents were grouped by relative poverty level and descriptive and comparative analysis was performed. Findings: 62% of respondents reported at least daily mosquito bites and 33% reported having had Dengue in the past. One patient reported having Chikungunya but this was self-diagnosed. 79% of respondents knew Dengue was transmitted by mosquitoes versus only 33% who knew this about Chikungunya (p<0.0001). The poorest respondent group was less likely to know that Dengue is transmitted by mosquitoes (60.0% vs 93.9%, p1⁄40.00168), and less likely to know that mosquitoes lay their eggs in standing water (36.0% vs 81.8%, p1⁄40.0004). There was very little knowledge about Chikungunya and the largest knowledge deficits were seen in the poorest respondents. 58% of respondents emptied standing water around their homes to prevent mosquito bites. Respondents listed poor access to resources and lack of funds as the main barriers to mosquito prevention. Interpretation: Despite Dengue and Chikungunya being endemic in the region, knowledge about these diseases in and around La Hicaca is incomplete and partially related to poverty status. These data will help inform educational and preventive efforts in the region.

Background: The urban poor in India rely upon private general practitioners (GPs), who often have no formal training in modern medicine, in order to access allopathic medications. While prior studies have researched the practices of these GPs, no recent studies have investigated their pharmaceutical distribution networks. Our study fills this gap by documenting this pharmaceutical distribution network and its effects on medical practice in the peri-urban areas of India.
Methods: We conducted 132 in-depth qualitative interviews with households, GPs, chemists, distributors, medical representatives and manufacturers in Mumbai and its surrounding areas. We solicited interviewees through in-person visits and phone calls.

Findings:
The market for drugs in Mumbai is primarily physiciandriven, with very little distinction drawn between allopathic and non-allopathic providers. Most poor households do not use generic drugs even though they are far cheaper. A majority of providers also stock loose drugs dispensed directly to patients, because of patient demand.
Through these interviews, we gained information about regulations, pharmaceutical marketing and supply chain practices. We found heterogeneous enforcement of medical regulation. While the Food and Drug Administration (FDA) recently increased enforcement of regulation on chemists' practices, provider practices remain relatively unencumbered by existing legislation. Medical representatives from pharmaceutical companies provide gifts, invitations to conferences and other special privileges to encourage prescriptions of their medications. Fierce competition among the distributors and wholesalers in the supply chain facilitates lower prices and wide access to medications.
Interpretation: While we must consider selection bias, our analysis indicates a shifting medical landscape toward a general practitionerdriven market. The relatively strict medical practice enforcement of chemist compared to GPs has increased the role of GPs in primary care. At the same time, an abundance of wholesalers and distributors has created easily accessible and relatively cheap medications for these GPs to dispense from their clinic. Finally, pharmaceutical company incentives shape the knowledge and practice of these GPs without necessitating regard for consumer welfare.
Funding: We were funded through the Policy Implementation Lab, a division of the Freeman Spogli Institute, at Stanford University.

Abstract #: 2.089_NEP
Investigating the knowledge and impact of dengue and chikungunya in a rural population in Yoro, Honduras Nathaniel Warner 1 , Daniel Olson 2 , Nadia Nasroor 3 , Bako Sanogo 4 , Gonzalo Bearman 3 , Michael Stevens 3 ; 1 Internal Medicine, Virginia Commonwealth University, Richmond, VA, 2 School of Medicine, Virginia Commonwealth University, Richmond, VA, 3 Infectious Diseases, Virginia Commonwealth University, Richmond, VA, 4 Virginia Commonwealth University Medical Center, Richmond, VA Background: Dengue and Chikungunya cause significant morbidity in Latin America. While Dengue has been endemic in Honduras for many years, Chikungunya was only recently introduced and has spread rapidly throughout the country with over 50,000 endemic cases thus far in 2015 alone. There is no data on the impact of these diseases in the local populations surrounding La Hicaca, a rural, mountainous region in Yoro, Honduras.
Methods: In June of 2015, a fifty-question survey was given to the villagers of La Hicaca and seventeen surrounding villages to investigate the impact and local awareness of Dengue and Chikungunya. Survey was IRB approved and written informed consent was obtained prior to participation. Fifty-eight surveys were completed. Respondents were grouped by relative poverty level and descriptive and comparative analysis was performed.
Findings: 62% of respondents reported at least daily mosquito bites and 33% reported having had Dengue in the past. One patient reported having Chikungunya but this was self-diagnosed. 79% of respondents knew Dengue was transmitted by mosquitoes versus only 33% who knew this about Chikungunya (p<0.0001). The poorest respondent group was less likely to know that Dengue is transmitted by mosquitoes (60.0% vs 93.9%, p¼0.00168), and less likely to know that mosquitoes lay their eggs in standing water (36.0% vs 81.8%, p¼0.0004). There was very little knowledge about Chikungunya and the largest knowledge deficits were seen in the poorest respondents. 58% of respondents emptied standing water around their homes to prevent mosquito bites. Respondents listed poor access to resources and lack of funds as the main barriers to mosquito prevention.
Interpretation: Despite Dengue and Chikungunya being endemic in the region, knowledge about these diseases in and around La Hicaca is incomplete and partially related to poverty status. These data will help inform educational and preventive efforts in the region.