An Assessment of the Availability of Essential Medicines in Gadag Taluk, Karnataka: A Study of Primary Health Centers

Background Essential medicines are those that meet the priority healthcare needs of most of the population and are included in the 2030 Agenda for Sustainable Development. The national list of essential medicines should be tailored to the specific needs of each nation and should always be accessible at reasonable prices and with guaranteed quality. Methods A cross-sectional study was done to assess the availability of essential medicines in primary health centers (PHCs) in Gadag Taluk. The data for the assessment of availability was collected using a checklist, which was prepared after reviewing the Karnataka list of essential medicines, surgical items, and miscellaneous items from 2021 to 2022 for PHCs. The sampling design was a universal sample of all 15 PHCs, as per health management information system data, to assess the availability of essential medicine in PHCs. Results Results indicate that the availability of essential medicines in 15 PHCs in Gadag Taluk is 74.20%. The availability of anti-allergic drugs and drugs used in anaphylaxis was around 88%, whereas the availability of antidiabetic drugs and non-steroidal anti-inflammatory drugs was 86.88% and 86.66%, respectively. All other categories of drugs are available above 50%, except ophthalmic and ear, nose, and throat drugs. Conclusion The public sector should be strengthened by making sure that patients have access to free essential medicines and that essential medications are always available. This would help patients spend less money out of their own pockets and move India closer to achieving universal healthcare.


Introduction
Medicines are indispensable and necessary for the health needs of the population. They should always be available, in the proper dosage forms, to all segments of society, including the lowest level [1]. WHO has identified "essential medicines" as those that satisfy the priority healthcare needs of a population [1]. The necessity of having access to drugs is expressly acknowledged in the 2030 Agenda for Sustainable Development. Almost all of the health-related sustainable development goal three targets, including those pertaining to malaria, non-communicable diseases, maternity and child health, and sexual and reproductive health, depend on improved access to drugs. The significance of having access to medications and vaccinations is explicitly highlighted by targets 3.8 and 3.b [2]. In 1970, Tanzania was the first country in the world to build an essential medicine list. Following that, the World Health Assembly requested in 1975 that WHO support member nations in selecting and obtaining medicines while ensuring premium quality at competitive prices. About 186 drugs made up the initial WHO model list of essential medicines, which was later made public in 1977 [1,3].
Patients often assess a primary healthcare system's quality based on the qualified medical staff and accessibility to essential medications. A key element of the National Health Policy 2017 and universal healthcare is free access to needed medications. This is considered an important measure in the proposed National Health Assurance Mission of the government of India for 2014 [4]. Households in India are required to pay out-of-pocket expenses for medication, which is the second largest expense after food [5]. This is due to the limited availability of medicine in the public sector. In developing countries, up to 90% of the population pays for medication with out-of-pocket payments [6]. India is no exception, with 48.21% of the cost of healthcare being paid out-of-pocket and medication taking up 70% of that cost [7]. According to a study done in the union territory of South India, the availability of 50 essential drugs was found to be between 66% and 80% in the 10 public health institutions surveyed [8].
The provision of all essential medications at a fair price for the public is one of the key goals of Indian health policy [9]. The availability of medication is inconsistent in developing nations like India, particularly in public health facilities [10]. Surveys conducted across India revealed a shortage of necessary medications, particularly in public health facilities [11]. The availability of necessary medications has a direct impact on how well healthcare facilities operate [3]. The continuously shifting nature of the world economy and the scarcity of resources make the essential medicine concept more important than ever. The majority of healthcare requirements can be met with a small selection of well-chosen medications. The essential medicine concept is globally relevant and provides the most economical answer to healthcare requirements. This survey was conducted to assess the availability of essential medicines in primary health centers (PHCs) in Gadag Taluk, Karnataka. The findings of this survey could be utilized by healthcare decision-makers to comprehend the current state of accessibility to essential medicines in Gadag and recommend strategies to enhance availability, which would be to the advantage of patients.

Study design
A research study using a cross-sectional design was conducted to assess the availability of essential medicines in PHCs in Gadag Taluk.

Study duration and location
This research was conducted between November 2021 and March 2022 in Gadag Taluk, Gadag District, Karnataka.

Study sample size
The sampling design and size were universal, and all 15 PHCs in Gadag Taluk, as per the health management information system list of Karnataka, were selected.

Data collection tools
A comprehensive checklist of key medicines was developed following a review of the Karnataka list of essential medicines, surgical items, and miscellaneous items from 2021 to 2022 for PHCs. The Karnataka list of essential medicines for PHCs contains a total of 501 drugs, of which 104 are classified as essential, most essential, and very essential. These 104 drugs were employed to assess availability in the current study.

Data collection
A pilot study was conducted to ensure data collection was feasible. The list of medicines to be surveyed was kept private to not create any bias. On the day of the survey, the pharmacies of the health facilities were observed directly in the presence of pharmacists and medical officers to get data on the availability of essential medicines.

Data analysis
The quantitative data collected was processed with Microsoft Excel 2019 (Microsoft, Washington, USA) to generate frequencies, percentages, and graphs. The medicines were divided into therapeutic classes, and the percentage availability of a therapeutic class in a PHC was calculated by dividing the number of medicines available within that category in a PHC on the day of the survey by the total number of medicines within that category that should be available as per the list of medicines prepared. The percentage availability of individual medicines in all surveyed health facilities (number of PHCs in which individual medicines were available/total number of PHCs) was also calculated. A drug was thought of as accessible if it was in the inventory on the day of the research.

Ethical clearance
The Karnataka State Rural Development and Panchayat Raj University Institutional Ethical Committee (RDPRU/SEP/IEC/3/2021) gave its approval to this work. The District Health and Family Welfare office (2021-22/494) of the Gadag District was also consulted regarding administrative authorization for data collection from state government public health facilities.

Results
The availability of essential medicines in 15 PHCs in Gadag Taluk is 74.20%. The availability of antiallergic drugs and drugs used in anaphylaxis was around 88%, whereas the availability of antidiabetic drugs and non-steroidal anti-inflammatory drugs (NSAIDs) was 86.88% and 86.66%, respectively. All other categories of drugs are available above 50%, except ophthalmic and ear, nose, and throat (ENT) drugs. The percentage of medicines available by therapeutic category in PHCs in Gadag Taluk is given in Table 1.

Sl. No
Essential drug categories % availability (n=15)  The findings of this study demonstrate that essential medicines have a wide availability range across the PHCs of Gadag Taluk. PHC 4 has the highest availability rate of 94.17%, while PHC 1 has the lowest availability rate of 45.45%. These results show that the availability of essential medicines is highly dependent on the PHC and highlight the importance of increasing access to these essential medicines in areas of low availability. The percentage availability of essential medicines in Gadag Taluk PHC (facility)wise is shown in Figure 1. Out of the 104 medicines assessed, glyceryl trinitrate and anti-D immunoglobin are two essential medications that are unfortunately not available in any PHC. This is extremely concerning, as these medications are essential to treating certain medical conditions. This lack of availability could be potentially life-threatening for many individuals, and it is imperative that steps are taken to ensure these medications are made more accessible. An in-depth breakdown of each medication's availability by percentage in the PHCs surveyed is given in Table 2

Discussion
The availability of medications at each facility is an essential performance criterion [12]. If necessary medications are not easily accessible, patients may be deterred from visiting medical institutions or may even cease using the healthcare system altogether [12]. This study has provided a glimpse of the availability of essential medicines in the PHCs of Gadag Taluk, with results indicating an overall median availability of 74.20%, slightly lower than the 80% benchmark set by WHO and Health Action International [13,14]. There could be several factors contributing to the insufficient availability of medications in the public sector, such as inadequate funding, the purchase of unnecessary medications, inaccurate forecasting of demands, and inefficient management of the drug supply chain [14].
This research's outcomes are consistent with those reported in a different study that was done in South India, wherein the availability of the essential medicines that were looked into in the public sector was seen to be 76% [8]. This study's findings are higher than the findings of other similar studies conducted in Odisha, five Indian states, Delhi, Chhattisgarh, Punjab, and Haryana, where the availability of surveyed essential medicines in the public sector was found to be 17% in Odisha [15], 41.3% in Delhi [16], 64.5% in Chhattisgarh, 45.2% in Punjab, and 51.1% in Haryana [17], respectively. The findings of this study are lower than those of other studies conducted in Shivmoga [18] and Andhra Pradesh [19], both of which reported the availability of surveyed essential medicines in the public sector to be 82% and 100%, respectively. All of these previous studies only looked at a selected basket of drugs, and until now, there have been no studies conducted in India or Karnataka that have assessed the complete essential medicine list. This study is the first of its kind to do so.
The investigation done in this study revealed that the overall availability of NSAIDs was 87.7%, which is higher than the other studies carried out in Haryana and Punjab [17]. Additionally, the availability of a selected number of drugs within the NSAID category was found to be higher compared to other drugs in the same group, possibly due to a better supply of the selected medications and the prescription patterns of physicians. The availability of affordable, high-quality antibiotics is a major global issue. Without these medications, the risks of surgery and the management of communicable diseases rise. It is critical for the prevention and treatment of bacterial infections, yet excessive and inappropriate use must be discouraged in order to avoid antibiotic resistance. According to the present investigation, the average availability of antibiotics is 74.7%, which is higher than the results from other research studies conducted in Haryana, Punjab, and 20 low-and middle-income countries, with percentages of 59.1%, 50.8%, and 48.9%, respectively [17,20].
The present study revealed that the availability of antiallergic medicines was 88%, which is higher than the 49.6% and 59.7% availability of essential medicines in the public sector in Punjab and Haryana, respectively [17]. This indicates good utilization and supply from the warehouse. Similarly, the availability of cardiovascular drugs was found to be 71.43%, which is comparable to the 70% availability of essential medicines in a Sri Lankan district [21]. The findings of the current research reveal that the supply of antidotes, vaccines, and serum is at 65.56%, which is below the standard set by the WHO [13,14], which may be because of a shortage of supply from the warehouse. When specific antidotes are not available, the life of a patient is in jeopardy. Thus, it is essential to ensure that a continuous supply of essential drugs is available in order to provide three levels of care to seriously ill patients.
A key drawback of this research was that the quantitative results were only collected on the day of the survey, potentially not providing an accurate representation of the monthly or yearly availability of the medicines.

Conclusions
The present study aimed to assess the availability of essential medicines in PHCs in Gadag Taluk. The findings of the study revealed that the availability of essential medicines in PHCs in Gadag Taluk was 74.20%. This research provides valuable insight into the situation of essential medicine availability in Gadag Taluk. The primary conclusion of this research is that although the availability of essential medicines in PHCs in Gadag Taluk is relatively high, there are still gaps in the supply of essential medicines. This indicates that there is a need to further improve the availability of essential medicines in order to ensure access to quality healthcare for all. The key takeaways from this research are that there is a need to further invest in the health infrastructure of Gadag Taluk to ensure that all PHCs have adequate supplies of essential medicines. Furthermore, it is important to create awareness among the people of Gadag Taluk about the availability of essential medicines and their importance in providing quality healthcare.

Appendices
The list of essential medicines used in the survey has been listed in Table 3.

for PHCs
The list is available on the Mahitikanaja Karnataka government website.