Introduction

As human being we have the fundamental right to have access to health services. While viewing the health related issues we hardly can be oblivious about any medicine or drug. Now a days around the world mass people collect medicines with or without the prescription of the physicians. There are some medicines that may be sold without a prescription, in contrast to prescription drugs—these drugs are termed as Over-the-counter (OTC) drugs. Over-the-counter (OTC) drugs are non-prescription drugs sold in convenience stores, grocery stores and health shops. They range from pain relievers, cough and cold remedies to sleeping aids, weight reducing aids, and vitamin supplements. The OTC drugs are characterized as less risk taking, less dynamic, non-maintenance therapeutic pharmaceutical drugs. The efficacy and potency of these drugs have been well established. OTC drugs play an increasingly vital role in health care system. Some medicines considered safe in general terms may be available in general stores, drug stores, supermarkets etc. The rules for collecting those OTC drugs vary considerably from country to country. For example, in the United States, the manufacture and sale of OTC substances is regulated by the FDA. Generally FDA controls the operational and marketing activity of the manufacturers so that the customers ultimately get the safe and secured medicines. As a general rule, over-the-counter drugs have to be primarily used to treat a condition that does not require the direct supervision of a doctor and must be proven to be reasonably safe and well-tolerated. OTC drugs are usually also required to have little or no abuse potential, although in some areas drugs such as codeine are available OTC (usually in strictly limited formulations or requiring paperwork or identification to be submitted during purchase).

Over time, drugs that prove themselves safe and appropriate for self-medication may be switched from prescription to OTC. An example of this is Diphenhydramine (Benadryl®) which once required a prescription but now is available OTC nearly everywhere in the USA. Diphenhydramine is a deliriant; nevertheless, most recreational drug users find its effects uncomfortable rather than exciting. In our country, according to the physicians and pharmacists only a few drugs like paracetamol, ranitidine, metronidazole, omeprazole ORS saline, diaclofenac sodium, and aspirin are supposed to be sold as the OTC drugs. But the unscrupulous drug sellers sell almost 90% of the stocked drugs without prescription. Even the sedatives are also being traded like fast food in Bangladesh. According to the 1982 Drug Ordinance, The pharmaceutical industry is monitored and guided by the government under the ministry of health. Under the ministry of health the director of Drugs Administration supervises various key tasks ranging from the manufacture to the marketing of the drugs. The present study is an attempt to explore the issues related to OTC drugs with strong focus on the identification of the factors that affect the choice and selection of OTC Pharmaceutical products.

Methodology

This is an empirical study conducted over the inhabitants of Dhaka and Rajshahi city of Bangladesh who were picked up randomly. A total of 280 persons, (from Dhaka 147 and from Rajshahi 133) representing different walks of life, were selected to survey using mall intercept method and mail survey method using a structured questionnaire with 5-point scale (1 indicates strongly disagree and 5 indicates strongly agree). Prior to that, secondary sources were explored rigorously to identify 18 pharmaceutical product buying variables and then the variables were used to develop the questionnaire to see the respondents' reaction.

Figure 1

Table 1: Distribution of sample respondent in terms of gender

Figure 2

Table 2: Distribution of sample respondents in terms of level of education, income, age and profession

Data have been analyzed using both descriptive and inferential statistical tools. Descriptive statistics such as mean, standard deviation, frequency etc. were used to describe and identify the comparative importance of the 18 variables. Multivariate Analysis technique such as Factor Analysis was used to reduce the data and identify the factors responsible for buying drugs and medicine. SPSS (Statistical Package for Social Science) is used primarily for the analysis of the data.

Literature review

The term “over-the-counter” is somewhat confusing to some, since these items can be found on the shelves of stores and bought like any other packaged product in some countries or in others may be bought “over the counter” from the pharmacy, while prescription drugs are sold at a pharmacy counter. The term likely dates back to before self service shopping became common, when most goods were obtained by requesting them from a clerk at a sales counter; while prescription drugs required a visit to the doctor first, these drugs could be purchased “over the (sales) counter” just like other goods (wikipedia, 2007). Home care is a common response to illness that allows the caregiver time to monitor a child before making the expensive decision to seek help outside. Home care often starts with medicines already at home that were left over from previous prescriptions or bought from patent medicine vendors (PMVs) or home remedies that include local herbs. Home treatment can also combine over-the-counter (OTC) drugs and herbs. Prompt first-line treatment is facilitated by purchase of OTC drugs from retail outlets (Afolabi, 2007). In every country the pharmaceuticals industry is being controlled by a well established regulatory board. Presently the pharmaceuticals industry in Bangladesh is being controlled by the Drug Ordinance of 1982. At present, there are 231 Allopathic companies operating in Bangladesh (Drug Administration website, 2007). The Directorate of Drug Administration (DDA) under the Ministry of Health & Family Welfare, Government of the People's Republic of Bangladesh, is the drug regulatory authority of the country. Mission of the DDA is to ensure that the common people have easy access to useful, effective, safe and good quality essential and other drugs at affordable price (Islam, 2006). Before 1982, The Drugs Act 1940 was in place. The drug ordinance '82 was established to promote the local companies into the pharmaceutical industry. Before that policy's enactment there were about 3,500 brands of drugs in the market including necessary, unnecessary and even harmful drugs. No structured national committee or regulatory body was present to regulate the business in this sector and no price control was maintained. Using the brand and corporate image, the multinational companies charged as much as possible and used aggressive selling campaign to grab market share from the counterpart MNC's and local companies. Local companies were a bit down as they were unable to compete under the situation of superfluous production. Moreover the misuse of drugs increased day-by-day. Out of this necessity the Bangladesh Pharmacy Council was established with members from concerned community of doctors and social workers. They brought a major change in the earlier drug act of 1940 and named it as drug ordinance 1982. It took the boldest step to ban production of drugs out of a prescribed list with an immediate order. The new ordinance also imposed some restriction on the formulation of different drugs in the list and their pricing. After 1982, production of drugs was limited to 150 essential drugs provided by WHO. As an after effect of the ‘82 Ordinance, today nearly 25% of the market share in the pharmaceutical industry is owned by the two local companies- Beximco and Square. These two companies had no significant presence in the pharmaceuticals industry before 1982. Currently Beximco and Square both have started exporting their products in more then 20 countries and thus contributing toward the foreign exchange earning of the nation.

Bangladesh drug market is flooded with over 8,000 formulations compared to 117 essential drugs and 100 supplementary drugs listed on the essential drug list. Among 231 allopathic drug manufacturers, top 30 companies are considered as large scale units and these are enjoying major share of the total market (http://www.ddabd.org/). Interestingly, Bangladesh owns about 70.9% of generic medicines in terms of total sales among the 48 least developed countries of the world (WHO report, 2004). At present there are about 30,000 legal and more than 70,000 illegal drugstores according to the Bangladesh chemist and druggist association (The Daily Star, November 14, 2004). These are alleged to sell substandard or fake, poor quality, smuggled and adulterated medicines. Most of them are selling medicines without registered doctors' prescription (The Observer, November, 17, 2003).

The per-capita annual drug expenditure in Bangladesh remains extremely low at $4 compared to $9, $28, $191 and $412 for China, Mexico, United States and Japan respectively (Source: WHO report, 2005). This is expected to increase as healthcare awareness rises and as increasing urbanization leads to sales growth of the more expensive lifestyle segment drugs. The per capita expenditure of Govt. for public health is gradually increasing and stood at USD $ 4 in 2004. In the health sector, Govt. has made an allocation of BDT 3,732 crore combining revenue and development in the budget of 2004-05, which is around 59% higher than the previous year (ADB annual report, 2005).

In real sense, there is no ‘prescription only drug' in Bangladesh at present. One can get any drugs from anywhere. Only need is money; no prescription indeed (Islam, Goldman, Kunin, 1996). Over the counter (OTC) drugs have emerged recently as drugs of serious misuse across Bangladesh, and other neighboring countries. Self-care is a predominant therapeutic activity consisting 30-40% of the disadvantaged populations including women, elderly, ethnic minorities and poor in Bangladesh (Ahmed, 2005). Self-medication as a mean of self-care through the purchase of over-the-counter (OTC) medicines is, and always has been common in the society for a wide variety of minor ailments, such as headaches, colds and indigestion. But such products can often be misused or abused (Wazaify, 2005). One report estimates that there are four million drug misusers in the South Asian region, with Bangladesh accounting for nearly 500,000 (Mudur, 1999). Self-medication in a population with low literacy level like Bangladesh are very challenging, which poses risks such as incorrect diagnosis, absence of knowledge of alternative treatments, irrational use of drugs and neglecting side effects and drug interactions. Study showed that around 30%-- 40% of disadvantaged population including the women, elderly, ethnic minorities, poor / ultra-poor undertake self-medication for managing illness (Ahmed, 2005). Over-the-counter medicines have emerged as drugs of serious misuse across Bangladesh, and other neighboring countries. Along with the common practices of self medication, almost every drug store salesperson is illegally involved in the recommendation and sells of prescription only medicines in Bangladesh (Roy, 1997). Self-medications in a country with low literacy level like Bangladesh is very important where prescription medicines are freely available. This may pose serious risks related to inappropriate and irrational personal use of medicines. Like all other developing countries, irrational and inappropriate use of medicines is very common in Bangladesh (Ronsmans, Islam, Bennish, 1996) Recent study showed that about half of the antibiotics were sold without any prescriptions, and even ordinary people without any knowledge of medicine asked the drug seller for specific antibiotics (Mamun, Tabassum, 2006). Almost every drug store salespersons illegally recommends and sells prescription medicines people often do not buy all the drugs as prescribed for them because of financial constraint.

Discussion

From the study it has become evident that 56.2% people believe that each and every medicine should be bought according to the prescription of a physician though in reality 83.4% people have bought drugs or medicines in life without a formal prescription of a physician. Before assisting in this study 54.8% had knowledge about the term Over the Counter (OTC) drugs. Factor analysis is conducted to find out the influencing factors for buying the OTC drugs. The following table (table 1) shows that the KMO value (both in Principal Component analysis and Maximum Likelihood methods) is more than .60 (actual is .628) which authenticates the adequacy level of sample as tested by the KMO and Bartlett's Test. More over the significance value of Bartlett's Test of Sphericity is less than .05.

Figure 3

Table 3: KMO and Bartlett's Test

Factors for choosing the OTC drugs: The factor analysis results show that the people of Bangladesh are selecting OTC drugs for 11 factors. The factors are (i) Company's promotional activity, (ii) Past experience with the drugs, (iii) Company and brand image, (iv) Safe to use, (v) Level of education, (vi) Preference of brand name over the generic name, (vii) Distrust over the physicians, (viii) Prior assumption of physician's prescription, (ix) Information on the label and package, (x) Side effect of the selected drug and (xi) Awareness about the medicines (Table 4).

Figure 4

Table 4: Factors contributing to the choice of Over The Counter (OTC) drugs by the people of Bangladesh

The factors explain around 71% variance of the data. Amongst them the past experience with the drugs contributes mostly to the purchase decision of any OTC drug with eigenvalue 3.297 and it can explain 12.681% variance. This factor is followed by the company image and brand identity of the drugs. Brand Identity refers to the fact that people are aware about the brand from any other sources. This awareness enables the purchaser to make decision. This factor can describe as much as 10.352% variance with eigenvalue of 2.691. The table enlists rest of the factors' position in a descending order. The cumulative variance confirms that the study result is quite acceptable as the extracted factors should account for at least 60 percent of the variances (Malhotra, 2003). While selecting the factors only those are being extracted which has eigenvalue over 1.

Figure 5

Table 5: Past experience about the drug

This is the most contributing factor to choose any OTC drug by the Bangladeshi people. Our previous experience with any medicines ignites us to make the repeat purchase and usage of the drug. As we have found out that the medicine has not done anything wrong to me and my disease related problem has been solved, I become interested to continue its purchase. This factor is loaded with some other variables like Past experience with the drugs (.669), 15. Not having enough money to consult a physician (.614), Availability of the drug stores (.571) and Easy application (.431). As the unprescribed drugs are easy to administer and apply purchaser donot have to undergo the hassle of using that.

Figure 6

Table 6: Company and brand image

While choosing any OTC people generally prefer the image of the company. Good corporate image directly influences the customers' choice of the drug. The corporate brand has equity which is reaping up the benefit when the customer donot know either the generic and brand name of the drug. The variables that constitute this factor are Good image of the company (.673), Drugstore retailers' opinion and responsiveness (.521) and Brand identity (.486). Some common brands like Napa, Paracetamol, Ace, and Dispirin have a very good brand image. Most of the purchasers of these drugs buy these for their high brand equity. The survey outlines that Napa is the mostly purchased as an OTC drug by the customers (93%). Drugstore retailers also suggest the customer about the choice of any drug.

Figure 7

Table 7: Safe to use

Customers have a positive feeling about the OTC drugs. People believe most of the drugs to be safe to use. Consuming those drugs will not give any kind of trouble to the consumer. People purchase the OTC drugs as they have adequate knowledge and experience about the disease(s). Many people buy OTC drugs after they collect appropriate information from the current or previous users. This factor includes Safe to use (.582), Adequacy of knowledge about the disease (.443), and Collection of information from the users (.422). In fact the OTC drugs are perceived as the safe medical products to be consumed.

Figure 8

able 8: Level of education T

This factor comprises Level of education (.779) and Common family practice (.480) as its principal loaded variables. Many people with low level of education donot have the simplest idea that any unprescribed drug can bring any fatal aftermath. Some people purchase the OTC drugs as they have inherited that from their family members. Buying OTC drugs is a common practice in the family.

Figure 9

Table 9: Preference of brand name over the generic name

Each and every drug has its own generic name. the companies, keeping the generic name unchanged, brand their produced drugs in different ways. Generally the generic names are cumbersome and difficult to remember and pronounce. But the name reflects the generic name and an easy-to-pronounce feature. Mass customer most of the cases recall the name of the brand rather than the generic name. This factor includes Consideration of the brand names over the generic names of the drugs (.698), Following of medicinal system [Allopathic, Ayurvedic, and Homeopathic] (.516) and Lack of regulation (-.533).

Figure 10

Table 10: Distrust over the physicians

Many customers have found the physicians to be too much nonparticipative and ‘not so experienced and skilled'. Such attributes of the physicians have forced the customers to purchase some kind of OTC drugs. In many of the areas of Bangladesh we donot have adequate number of physicians. The physicians' unavailability has forced the inhabitants of those areas to select the drugs personally. While buying those drugs people obviously rely on their past experience and information collected from acquainted people. This factor seems to be a little bit unusual especially for any health related issue but the respondents have opined that they can not fully trust the physicians for some of the practical reasons. This factor with the variables like Distrust over the physicians (.704) and Inadequacy of physician (-.541) show good relational value to contribute to the development of the factor.

Figure 11

Table 11: Prior assumption of physician's prescription

This is actually the outcome of the customers' previous experience with the physicians. With a factor loading of .603 it is stated that customers buy OTC drugs as they know what the physicians will prescribe for that particular disease. That is why, on many occasions, they donot even consult a physician about the medication. Their assumption is primarily based on first hand experience and knowledge about the disease.

Figure 12

Table 12: Information on the label and package

This factor is constituted with the variables like Labels adequate information provided by the labels and packages (-.653) and Peer influence (.567). without consultation and prior experience about the disease and proper medication when the customers go to collect the drugs they rely on the information provided in the labels and package of the drugs and information provided by the peers and colleagues. But this is particularly possible for the people having good command over the language and idea about the ailment.

Figure 13

Table 13: Side effect of the selected drug

This single variable (with factor loading .773) factor states that people think of the side effect while purchasing any OTC drugs. Generally, customers donot choose those drugs without prescription which may produce some kind additional health hazard whether mild or severe

Figure 14

Table 14: Awareness about the medicines

The purchasers of OTC drugs buy the drugs without prescription as they have adequate awareness about the medication system. This awareness has been made through the interaction with the concerned people and emission of information from media. People's trust over the drug producing pharmaceutical companies also influences the purchasing decision. This factor has variables like Adequate awareness about medicines (.633) and Trust over the pharmaceutical companies (-.5250.

Figure 15

Table 15: Company's promotional activity

In Bangladesh no pharmaceutical companies are allowed to run any kind of advertisement regarding their products. Yet some drug stores hold different stickers, specialty items and leaflets that portray the positive sides of the drugs. Moreover now a days different TV & Radio channels and newspaper provide information that induces the people to choose any kind of OTC drugs. This variable contains variables like Appeal of the company's promotional activity (.638) and Media (Radio, TV, Print etc.) influence (.585). The communication activity promulgates about the brand efficacy of the pharmaceuticals.

Concluding remakes and recommendation

In Bangladesh almost all types of medicines are really very available. Day by day the demarcation line between prescribed and nonprescribed drugs is getting blurred despite the non promotional activities of the pharmaceutical companies. The tendency to purchase and sell OTC drugs bears the risk of circulation of unauthorized drugs among the mass people. The factor analysis has extracted 11 factors which contribute to the selection of any medicine without the proper medical documents. The above analysis has shed light on factors of multiple dimensions.

Amongst the most important factors for purchasing an OTC drug, past experience, corporate image and brand identity, prior assumption of physician's prescription, awareness about the medicines are mentionable ones. In the rural areas, where the physicians are not very easily accessible, people have to rely on their past experience and own knowledge about the disease. In Bangladesh, promotional activity in mass media of pharmaceutical products is strictly prohibited. That is why; the companies have to rely solely on the sales force and physicians for promoting their products. Brand identity grows among the mass people just through personal experience and Word of Mouth Marketing. There are some brands which are like grocery items to us. Govt. in Bangladesh has restricted the boundary of OTC drugs. But that margin has been crossed grossly long time ago. This type of phenomenon is a desired one for the marketers as they are reaping the benefit without making any significant marketing effort but it may not be a healthy practice for the consumers as they are simply a layman to take decision regarding medication to heal any disease. So to cease this type of tendency in Bangladesh, the concerned authority should focus, on the outset, on the variables that force the customer to buy any drug without proper document and create awareness about the negative side of this practice.

Acknowledgments

Appendices

Figure 16

Appendix 1: Mean and Standard Deviation of the variables contributing to the purchase of the OTC drugs by the people of Bangladesh [N=280 and area is Dhaka (capital of Bangladesh)]

Figure 17

Appendix 2: Communalities