FEATURE Report of an all India Quantitative study of Consumer perceptions, availability, role, services provided, medicines and expectations

of pharmacists in India
PART II: PROFESSIONAL ASPECTS OF PHARMACEUTICAL SERVICE BY PHARMACIST
D B Anantha Narayana1*, Kusum Devi2,, Asha A N2, Nimisha Jain2,Uday Bhosale 2, T Naveen Babu 2And co-investigators Roop K Khar3,Moitreyee Mandal 4, Manjiree Gharat5 1* Managing Trustee, Delhi Pharmaceutical Trust, New Delhi. 2 Dept. of Pharm.Marketing and Management, Al-Ameen College of Pharmacy, Bangalore. 3 Dept. of Pharmaceutical Sciences, Jamia Hamdard, New Delhi. 4 Dept. of Pharmacy, J.C.Ghosh Polytechnic, Kolkata. 5 K.M.Kundnani Pharmacy Polytechnic, Ulhasnagar, Maharashtra. The authors have already reported ndings of an all India quantitative survey of perception and views of 3086 respondents across the country (Bangalore, Kolkata, Delhi and Mumbai) 1 .Part I of the report covered professional and general aspects of Consumer perceptions on availability, role, services provided, medicines and expectations of pharmacists in India. Readers may refer to the above paper to get details of objectives of the survey, methodology, data acquisition and analysis, IT tool used for the analysis and other aspects. We now report ndings of the survey related to professional services rendered by the Pharmacists as on today, consumer views of what they consider as common ailments, when they prefer to go to a chemist rather than a doctor and their future expectations regarding additional services to be provided by a pharmacist. Keywords: pharmacist, retail outlets and availability, rst all India survey, quantitative survey

Asking for and Handling Prescriptions

On enquiring about this specic aspect, 38% respondents opine that a pharmacist does ask for the prescription and 10% are of the opinion that the pharmacist dispenses medicines without a prescription. However, a major 52% are of the opinion that the pharmacist sometimes asks for the prescription before dispensing. The above nding is based on the overall survey. Only a maximum of 13% respondents felt that a chemist always asks for the prescription which is fairly encouraging and indicative of presence of professional ethics during dispensing. In Mumbai, it was encouraging to note that 50% of the respondents opine that chemists always ask for prescription. Additionally 42% said that sometimes they were required to produce prescription. Only 8% opined that chemist did not ask for prescription. In the three cities, viz., Bangalore, Kolkata and Delhi, there was a signicant difference in opinion in between the urban and rural respondents with Mumbai being an exception. These ndings could be attributed to the fact that prescriptions are not being asked when dispensing medicines for chronic problems or for minor problems such as headache, body pain, cold cough etc.

Disease Conditions where Prescription is insisted on

A maximum of 45% people opined that chemist always insisted on prescription for sleep problems, 30% for chest problems and 25% for stress problems. Similar trends were observed in Mumbai, Bangalore and Kolkata. However, in Delhi, a slight difference in response was obtained with 36% & 40% of population opining that the chemist insisted on prescription for sleep problems and chest/throat problems respectively.

Patient Counseling
To determine the access to information regarding the patient counseling aspects a question was posed to the respondents. In total, 52% people have problem in accessing such information and 48% people did not have any problem in procuring the necessary information. In Mumbai, Kolkata, Delhi and Bangalore 44%, 49%, 61% and 55% people respectively feel that they have problem in accessing information and 56%, 51% 39%

Figure 1: Frequency of asking for prescription by chemist

*E-mail: dptrust@gmail.com Pharma Times - Vol. 43 - No. 08 - August 2011 32

Figure 2: Disease conditions for which prescriptions are insisted upon by the chemist

after purchase. However, 74% of urban population and 85% of rural population feel that it is the duty of pharmacist to give such information. Surprisingly, in Delhi 49% population showed willingness to pay, with 16% people ready to pay ve rupees and 22% ready to pay one rupee to the pharmacist for providing professional services. In Kolkata, Mumbai and Bangalore the percentage of people willing to pay an amount between one to ve rupees for the much required information on medicines was 12 %, 12% and 18% respectively.

Extent of Brand Substitution

To nd out the extent of substitution by the chemist, a question asking the same was posed to the respondents. 58% of the population feels that the chemists substitute the brand prescribed after informing the consumer while 15% feel that substitution of the brands prescribed is done without informing. 20% feel that chemist never substitutes the brands prescribed. The percentage of people feeling the same in individual cities, viz., Bangalore, Delhi, Kolkata and Mumbai was 14%, 15%, 12% and 39% respectively. While 66% of the population in Bangalore and Delhi feels that the chemist substitute the medicine brands prescribed after informing them, 16 % and 14% population in the same cities feel chemist substitutes without informing them. In Kolkata and Mumbai, 55% and 46 % of the population respectively feels that the chemist substitute the medicine brand prescribed after informing them and 21% and 10% feels chemist substitutes without informing. Deliberate substitution with costlier brands of the same therapeutic moiety or with brands which give higher prot margins should be seriously viewed upon and needs corrective measures. Substitution of medicines could probably be associated with non-availability of prescribed brands in the retail outlet which requires the respective Pharma companies to adopt efficient distribution channels. Another reason for non-availability could be that chemist is deliberately stocking only expensive or the brands which offer high returns. Although the percentage is low but 11% people feel that the chemist deliberately gives expensive brands. 7% people feel that the chemist substitutes cheaper brands on request by the consumer. Overall more percentage of rural population feels that chemists substitute brands to dispense expensive brands. Similar trends are observed in Bangalore, Delhi and Mumbai.

and 45% respectively feel that they did not have problems in accessing information on medicines. It is quite alarming that 61% people in the capital city have problem in accessing the much needed information on medicines. It is not comfortable to know that on an average 50% of the medicine buyers are nding it difcult to get information related to proper usages of medicines. As around 50% of population is not facing problem in getting information on medicines, we posed one more question to nd out if the chemist is the information provider for the patients or not. We asked them if their chemist is giving them information on use of medicines or not. It was heartening to know that all over India, 69% people opined that chemist is giving them information on use of medicines. A more number of rural population as compared to urban population is in favor of pharmacist as the information provider. A similar response was obtained in Bangalore.

Usefulness of Information given by Chemist

Further, to check the usefulness of information given, we asked consumers whether the information given by the chemist in the past helped them to get better with the medicines or not. All over India, 67% of the population feels that information given by the chemist in the past did help. The percentage of people feeling the same in the following cities was 75% in Mumbai, 67% in Bangalore, 64% in Kolkata and 62% in Delhi. Interestingly, more number of female population beneted by the information as compared to male population.

Willingness to pay money for getting Professional Information

Survey revealed that 78% of the respondents feel that it is the duty of the chemist to provide the information on the use of medicines but 22% showed willingness to pay an amount between 1-5 rupees for getting additional information on medicines

Figure 3: Patient counseling provided by the chemist

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Figure 4: Level of brand substitution by chemist.

Instances of Prescriptions being Referred back to the Doctor

To nd out aspects related to the above issues, we asked respondents under what conditions does the chemist ask/insist that they go back to the doctor, even though they have a prescription. 18% opined that they were sent back if prescription was more than 3 months old, which points to the high level of ethics being practised by pharmacist. 45% people said that the pharmacist asks/ insists them to go back to doctor when there is some doubt in the prescription. The concern of the pharmacist for the health of medicine buyers is evident by the fact that 17% of consumers were sent back to doctors due to health issues. Also, 20% of people said that they were never asked to refer back to the doctor. The same opinion was reected by 30% of retired population. This is further reected by 49% retired people in Bangalore. In Mumbai, 51% were sent back particularly when there was a doubt in the prescription.

the chemist they were enquired about the same. The quarter (25%) on a totality said that they wanted facilities for BP check from chemist with almost a similar percentage (22%) mentioning rst aid followed by 20% who said body weight measurement. The number of respondents opting for body temperature measurement was lower (16%) followed by an even lower percent (11%) for blood sugar determination. The age wise trend was similar to the total trend in Mumbai, Bangalore and Delhi with Kolkata being a little different. Here 31% of the respondents opted for BP check which is higher than that obtained in total and in other cities.

In fact, it has been observed in actual practice that patients sometimes ask a chemist to give them medicines for their problems without consulting a doctor. In relation to this, a question was posed to the respondents to nd out for what conditions would they prefer to visit a chemist and not consult a doctor. The survey revealed that 53%, 65%, 45% of the total respondents preferred to go to chemist for conditions like fever, cold/cough, and pain/ache respectively. The number of patients willing to go to a chemist for the treatment of stomach pain was comparatively lower at 33%. Small differences in percentage were observed in the responses obtained from the four cities in comparison to the total percentage.

Conditions for which the consumers preferred to consult a chemist without visiting doctor.
Condition City Mumbai (%) Bangalore (%) Kolkata (%) Delhi (%) TOTAL Fever 42 62 69 37 53 Cold/ Pain/ Stomach cough ache pain 68 78 65 47 65 44 53 41 40 45 30 31 45 29 33

NOTE: The total numbers of responses add up to more than 100% as the question was a multiple choice one. In continuation to the above query, the respondents were asked if they would want the chemist to be allowed legally to give medicines for nine common medical problems varying from aches/pains to loose motions. The total responses showed that 49%, 49%, 57%, 39% and 47% of the respondents wanted the chemist to be allowed legally to give medicines for aches/pains, fever, cold/cough, minor burns, minor cuts/wounds respectively. However, the percentage of patients wanting the chemist to dispense medication in treatment of sudden and severe pain, allergy, nausea/vomiting and loose motions was comparatively lower at 30%, 23%, 27% and 27% respectively.

Trust on Pharmacist for Prescribing

In continuation with the previous queries, respondents were asked if they trust the chemist to give them medicine when they approach him without going to the doctor. The response was encouraging on an overall basis and individual city wise with 69% of the total respondents opining in the afrmative and 31% saying the contrary. This indicates that the number of people having a trust in the pharmacists knowledge about medicines is more than double the number of people who do not. This is a positive nding as pharmacist is that person in the drug distribution chain who would be in direct contact with public and patient.

Issue of Bill on Purchase

On a total basis, 36% of the respondents opined that chemist does not give a bill when the amount involved is too small, with 34% mentioning that it happens when they dont ask for one. An encouraging nding is that only a considerably lower percentage of respondents (16%) said that chemist does not give bill when he is too busy. An almost similar trend was observed in Mumbai and Kolkata with responses in Bangalore and Delhi differing marginally. These findings indicate that the regulatory mechanism should become tougher so that the chemist will issue the bill for every sale irrespective of amount or consumer requirements. Also consumer awareness should be increased and they should insist on bill for every purchase.

Consumers opinion on legally allowing the chemist to dispense medications for common medical problems.
Condition City Mumbai (%) Bangalore (%) Kolkata (%) Delhi TOTAL (%) Aches/ Sudden/ Fever Cold/ AllerPains severe Cough gy Pain 50 56 49 36 49 21 25 32 40 30 38 57 67 33 49 59 68 54 47 57 20 17 29 25 23 Minor burns 39 30 35 50 39 Minor Nausea/ Loose cuts & vomiting motions wounds 34 37 43 51 47 26 23 33 24 27 28 29 28 21 27

Requirement of Additional Services

In order to determine if the public would want any additional services from

NOTE: The total numbers of responses add up to more than 100% as the question was a multiple choice one.

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The responses to both the questions reveal that a significant percentage of patients would want the chemist to dispense medication for conditions like cold/cough, fever, pain/aches and minor cuts and wounds. Allowing the chemist legally to dispense medicines for above conditions for a short duration like a maximum of two days can be considered. But importance should be given to the type of pain killers that can be dispensed taking into consideration that drugs like Ibuprofen, Diclofenac sodium, Aspirin, are contraindicated in certain groups of patients. So, training of chemist in this regard is an absolute necessity before any decision is taken. Further, one more open-ended question was posed to the respondents to list the problems for which they would trust a chemist to give them medicines. The respondents gave a list of following problems: Problem Fever Cold Pain Cough Head ache Stomach pain Body pain Vomiting/ nausea Cold/cough Wounds and cuts Quoting Frequency 980 877 736 592 274 108 59 39 39 39

pharmacists and get medicines for few days. They put themselves on these medicines, which more than 50 % have found to be useful and meets the need to treat such common ailments. They recognize that such a practice is good and must be encouraged and legally allowed. They also recognize that many pharmacists refer to doctors and stay away from giving/dispensing medicines for many diseases where pharmacists consider it is not good to give medicines, say like sleep problems, severe chest infections etc.

Health care delivery models need to be reviewed at National levels to involve pharmacists fully and major reforms in the same need to be thought of. Preparation of a list of common & minor diseases, medicines for treating such diseases need to be prepared. Drugs and Cosmetics Act and Rules need to be reformed to review Schedule H drug list, outing in pace a clear OTC drug policy, and also publish/notify a Pharmacist dispensing list of drugs and Pharmacists to refer to Doctor list of diseases/medicines. Such a move will be expected to have a number of benefits including improving access to medicines, reducing health care costs, etc. Such a move will face stiff opposition from many quarters which will be interested in Protecting Turf wars or Territory marking tendencies, which need to be objectively discussed in multi-functional/professionals meetings openly. Authors would be happy to receive inputs on the study, and hope professionals and regulators will take note of the ndings.

Recommendations:
Based on the survey ndings, the authors have the following recommendations: The Professional associations in Pharmacy need to continue and also enhance continuing education proProblem Allergy Minor burns Loose motion Throat pain First aid Chest pain Constipation Acne Joint pain Stress Quoting Frequency 30 29 16 08 08 05 02 02 02 01

REFERENCES
1. D B Anantha Narayana, Kusum Devi, Asha A N, Nimisha Jain, Uday Bhosale, T Naveen Babu. Report of all India quantitative study of consumer perceptions, availability, role services provided, medicines and expectations of pharmacists in India Part I: Report of the study on professional and general aspects. Pharma Times, Vol.43, No. 04, April 2011, 12-17. D B Anantha Narayana, Brijesh Regal, Kusum Devi, Asha A N, Nimisha Jain et al. Perceptions of consumers about Pharmacists- Report of the results of a market research conducted amongst consume in Bangalore and Delhi. Pharma Times-Vol 41, No. 9, September 2009, 15-18.

Results and Authors Views:

In studies like these, it is not possible to draw specic conclusions and authors want to deliberately stay away for doing so, as there can be many perspectives. However, the study ndings taking both part 1 and part 2 of the Reports in totality, the following can be summarized: There is a denite trend in the consumers feeling the importance of the Pharmacists, recognition of their role in health care, trust factor has gone up from what it was a decade ago. Consumers are getting useful information from the pharmacists about disease and medicines although they want more from all the pharmacists and are not willing to pay for such information and counseling provided. Consumers have more demands in various services provided by the pharmacists. Consumers have on their own drawn up what they consider as common ailments that are not serious, and visit

grammes for current pharmacists in retail outlets. This work needs to be enlarged to cover all pharmacists across the nation. Programmes to build Skills and Competencies, as well as desired domain knowledge need to be drawn up and put in place. A habit for reading and hunger for information needs to be created amongst pharmacists. Pharma Industry which focuses on Doctors alone needs to be made to think of the obligation to educate pharmacists too, as well as building better and not trade only relations with chemists.

2.

Indian Pharmaceutical Association

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