Antibiotic price disparities: A comparative analysis of Jan Aushadhi, National Pharmaceutical Pricing Authority and commercial markets

INTRODUCTION

Access to affordable antibiotics is crucial for public health, particularly in low-and middle-income countries like India, where infectious diseases remain a major cause of morbidity and mortality. The high cost of these essential medications often results in financial hardship, increasing outof-pocket healthcare expenditures for many households. To address this issue, the Government of India introduced the Jan Aushadhi (JA) scheme in 2008, aiming to provide quality-assured generic medicines at significantly lower prices through a dedicated network of JA Kendras. The scheme is managed under the Pradhan Mantri Bhartiya Janaushadhi Pariyojana, which focuses on expanding affordable medicine availability and promoting the use of cost-effective generic drugs to reduce the financial burden on patients.^[1]

To regulate and monitor the prices of essential medicines, the National Pharmaceutical Pricing Authority (NPPA) was established under the Department of Pharmaceuticals, Government of India.^[2] Through the drug price control order framework, NPPA sets price ceilings to prevent uncontrolled market inflation, ensuring essential medications remain accessible to the public.^[3] In addition, along with offline pharmacies, the rapid growth of online pharmacies, such as Tata 1 mg, PharmEasy, MedPlus and Apollo, has reshaped the pharmaceutical landscape by offering competitive pricing and convenience.^[4]

The coexistence of government-subsidised pricing models, NPPA-regulated drugs and market-driven commercial pricing underscores the need for a comprehensive analysis of antibiotic pricing across these sources. This study aims to decipher and compare price variations in antibiotic pricing across JA, NPPA and commercial sources to evaluate economic feasibility and accessibility.

MATERIALS AND METHODS

This cross-sectional observational study was conducted at King George’s Medical University, Lucknow, over a 6-week (January to February 2025) period to analyse price variations in antibiotic tablets across JA, NPPA-regulated pricing and commercial sources (both online and offline pharmacies).

RESULTS

‘Amongst the 130 anti-infective drugs, 15 antibiotics in tablet form were found to be common to both the JA list and the NPPA list’.

Statistical comparisons revealed significant price variations across different sources. The Wilcoxon signed-rank test showed that JA prices were significantly lower than NPPA prices (P = 0.022) and maximum market prices (P < 0.001). However, the difference between JA prices and minimum market prices was not significant (P = 0.277). Similarly, NPPA prices were significantly lower than maximum market prices (P = 0.001) but showed no significant difference from minimum market prices (P = 0.561).

Comparative price analysis (bar chart)

The comparative price analysis of antibiotics across groups [Figure 1] highlights significant disparities in pricing. Maximum market prices were substantially higher than both NPPA and JA prices across all antibiotics. The most significant price discrepancies were observed in Ofloxacin 400 mg (₹35.36), Cefuroxime 500 mg (₹57.5) and Cefadroxil 500 mg (₹29.1), where market rates significantly exceeded NPPA-regulated prices. While NPPA prices were consistently higher than JA prices, they exhibited relatively lower inflation compared to maximum market prices.

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Figure 1:

Bar diagram. Comparison of JA, NPPA, maximum and minimum market price per tablet. JA: Jan Aushadhi, NPPA: National Pharmaceutical Pricing Authority

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Figure 1 visually illustrates this pricing disparity, where JA prices are consistently the lowest, NPPA prices fall in between and maximum market prices exhibit significant inflation. The minimum market prices show variation, with some aligning closely to NPPA, while others still remain higher.

PPD analysis with JA as baseline

The PPD heat map analysis [Figure 2], with JA as the baseline, revealed major price inflation in maximum market prices across most antibiotics. Ofloxacin 400 mg had the highest PPD (~1507%), followed by Cefadroxil 500 mg (~1448%) and Cefuroxime 500 mg (~349%), indicating extreme overpricing in the open market.

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Figure 2:

Percentage price difference. JA: Jan Aushadhi

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Certain antibiotics had minimum market prices below their JA price and had negative PPD values ranging from −27% to −98%, indicating that the minimum market price was significantly lower than JA pricing. Conversely, NPPA prices were generally higher than JA prices, though the extent of variation remained moderate across most antibiotics.

CI analysis

Figure 3 provides further insight into market-driven price disparities. Amongst the antibiotics analysed, Ofloxacin 400 mg exhibited the highest CI (~14.73), meaning its maximum market price was nearly 15 times the NPPA-listed price. Cefadroxil 500 mg (~6.54), Cefuroxime 500 mg (~4.71) and Norfloxacin 400 mg (~4.05) also showed significant cost inflation, highlighting major price discrepancies within commercial markets.

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Figure 3:

Cost index. NPPA: National Pharmaceutical Pricing Authority

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DISCUSSION

This study reveals substantial price variations across JA, NPPA-regulated prices and commercial market sources, highlighting inconsistencies in antibiotic affordability. NPPA prices were generally higher than JA prices [Figure 1], indicating that while NPPA sets a regulatory ceiling, it does not always ensure affordability, as NPPA prices were multiples of the JA price. Maximum market prices exhibited significant inflation, particularly for costlier antibiotics, raising concerns about potential price manipulation in commercial markets. CI with NPPA as baseline (CI) values confirmed extreme pricing disparities, with Ofloxacin 400 mg (~14.73 times) and Cefadroxil 500 mg (~6.54 times) showing the highest discrepancies, reinforcing the ineffectiveness of price control mechanisms in regulating commercial pricing. Conversely, some antibiotics had Minimum Market Prices below their JA price, reflecting competition in certain brands. However, the majority of minimum market prices remained higher than JA prices, confirming JA as the most cost-effective option for essential antibiotics. The PPD analysis further revealed that commercial pricing is highly variable, particularly for fluoroquinolones and cephalosporins, which are widely used broad-spectrum antibiotics.

Providing fair and affordable access to essential antibiotics is vital for protecting public health in India. Ensuring price stability is critical for the National List of Essential Medicines (NLEM) compliance, as all analysed antibiotics are part of NLEM.^[8] Since these drugs are widely prescribed for infectious diseases, any price variation can significantly impact patient adherence, especially for prolonged treatments (5–7 days or more). While per-tablet price differences may seem minimal, the cumulative cost for a full course imposes a substantial financial burden on economically disadvantaged populations. Disparities in essential drug pricing can restrict access and undermine progress toward universal healthcare. Effective regulation of NLEM-listed antibiotics is essential to mitigate cost barriers and promote affordability.

Despite NPPA’s role in setting price ceilings, enforcement gaps persist, allowing commercial prices to exceed price ceilings. Strengthening oversight, real-time monitoring, and stricter penalties are essential to translate NPPA regulations into actual cost reductions for consumers. While JA remains a commendable initiative, its reach must be expanded and its implementation strengthened. Increasing the availability of JA Kendras, improving public awareness and ensuring consistent drug supply will further enhance its impact. In addition, more stringent penalties for non-compliance with NPPA regulations could deter excessive price markups in the commercial market.

Lessons from global models, such as the UK’s National Health Service (NHS) and Canada’s Patented Medicine Prices Review Board (PMPRB), highlight that direct price negotiations and strict regulation can prevent extreme price inflation while ensuring accessibility.^[9,10] The NHS negotiates drug prices directly with manufacturers, preventing extreme price variations, while Canada’s PMPRB regulates patented medicine pricing, enforcing strict price ceilings to maintain affordability. These systems demonstrate that proactive price control policies, combined with transparent monitoring mechanisms, can prevent excessive commercial price inflation. India’s regulatory framework can benefit from adopting similar strategies to ensure fair pricing of essential medicines.

The substantial differences in antibiotic pricing may contribute to inappropriate antibiotic use, exacerbating antimicrobial resistance (AMR). Higher prices in commercial markets may drive patients towards incomplete antibiotic courses, self-medication or irregular adherence, leading to suboptimal treatment and increased risk of resistance. Conversely, JA’s affordability ensures access to essential antibiotics, but awareness and availability remain concerns. Without decisive action, pricing disparities will continue to threaten antibiotic accessibility, increasing financial burden and potentially exacerbating AMR. India must prioritise integrating cost regulation with antibiotic stewardship programmes to ensure affordability without fuelling resistance.

CONCLUSION

This study confirms significant pricing disparities across JA, NPPA-regulated and commercial markets, exposing gaps in regulatory enforcement. While NPPA sets price ceilings, the substantial inflation in maximum market prices suggests price manipulation, particularly for higher-cost antibiotics. Inconsistent pricing of NLEM-listed antibiotics threatens affordability and accessibility, impacting patient adherence and public health.

A multipronged strategy is essential to bridge these gaps. Real-time price tracking, stricter NPPA enforcement, JA expansion and targeted subsidies can help establish a more transparent and equitable pharmaceutical pricing system in India. International models, such as the NHS (UK) and PMPRB (Canada), demonstrate that stricter price controls and direct negotiations can prevent excessive cost inflation. India must adopt similar best practices to strengthen regulatory frameworks.

Addressing pricing disparities is also critical for combating AMR. Unregulated commercial pricing may encourage incomplete antibiotic courses and self-medication, fuelling resistance. Integrating price regulation with antibiotic stewardship programmes will help mitigate both economic and clinical risks.

Future research should evaluate the impact of pricing disparities on prescribing trends, patient adherence and AMR progression. Strengthening India’s pharmaceutical pricing policies is imperative to ensuring long-term affordability, accessibility and equitable access to life-saving antibiotics.