Factors influencing community pharmacist decision to dispense generic or branded medicines; Eastern Province, Alahsa, Saudi Arabia.

BACKGROUND: Rising costs of medicines have increased the interest of policy makers in generic medicines. However, consumers' and health care providers' perception and attitude towards generic medicine act as a main barrier to the promotion of generic medicines.
OBJECTIVE: To explore the factors community pharmacists consider while dispensing branded or generic medicines to consumers.
METHOD: A qualitative study was planned; twenty community pharmacists (ten hospital affiliated pharmacies and ten non-hospital affiliated pharmacies) were approached using a convenient sampling method. Interviews were recorded and later were coded into themes. RESULT: Overall, it is seen that generic medicine stock was available for antibiotics, pain killers, cough syrups, antihistaminics and antacids. Pharmacists working in hospital affiliated pharmacies were more concerned about the quality of drug before dispensing it to the consumer and they believe that what is prescribed is best for them and substitution or switching is unnecessary while for pharmacists in the non-hospital affiliated pharmacies, appearance of the client was found to be the main factor influencing them to dispense generic (low cost) or branded (expensive) medicines.
CONCLUSION: Physical appearance of the consumer is revealed to be one of the main factors affecting the pharmacist decision to dispense generic or branded medicine. Pharmacists practising in hospital affiliated pharmacies were found to be influenced by physicians' recommendation, and prefer to dispense good quality medicines.

Introduction

Rising costs of medicines have increased the interest of policy makers in generic medicines (Borger et al., 2006). Unfortunately, consumer knowledge remains low on price facts for generic and branded medicines (Hassali et al., 2005; Stewart et al., 2010). In addition, consumers’ beliefs in high efficacy and safety of branded medicines are another barrier to the use of generic medicines (Sansgiry et al., 2005; Shrank et al., 2009). Moreover, physician and pharmacist knowledge and safety concerns about generic medicines are perhaps other barriers to the promotion of generic medicines (Allenet and Barry, 2003; Babar et al., 2011; Mason and Bearden, 1980; Siam et al., 2013).

Addressing this issue in Saudi Arabia, in 2006 the Saudi drug market is expected to reach 7 billion USD by 2018 (MRO, 2013). While assessing Saudi consumer awareness about generic medicines, it was found that most were lacking appropriate knowledge/awareness about generic medicines (Albarraq, 2013). However, physicians were found to be supportive, but in life threatening situations the use of branded medicines was preferred and it is emphasized to increase the check and balance over the quality of generic medicines (Alghasham, 2009). Generic medicine is too broad an area to understand, and in the Saudi setting there is huge potential for future research in this area. In Saudi Arabia, both public and private sectors are offering health service, and to support the community need of medicines, community pharmacy setup is offering its services. Moreover, like in many other developing nations, Saudi consumers also enjoy easy access to medicine (Emeka et al., 2012; Khan and Ibrahim, 2013). However, in Saudi Arabia factors that may modify the community pharmacist’s attitude to dispense generic or branded medicine are never addressed. The current study aims to adopt a qualitative study design to conduct a pilot exploration of facts in this regard.

Method

A qualitative study was planned among the community pharmacies functional in Alhafoof, eastern region, Alahsa, Saudi Arabia. A structured interview format with pre-defined themes was adopted; twenty pharmacists were approached for their participation in this study (10 hospital-affiliated and 10 non-hospital-affiliated community pharmacies). A convenient sampling method was adopted to approach the respondents. The theme focuses on the “Issues a pharmacist considers while dispensing a cheap or expensive medication”.

Definitions

Hospital affiliated Pharmacies, were those community pharmacies that are attached with private hospitals.

Non-Hospital affiliated Pharmacies, were those community pharmacies that are either chain pharmacies or independent pharmacies, but have no affiliation with any private hospital.

Ethical approval

The study protocol was dually approved by the college of clinical pharmacy, King Faisal University and Deanship of scientific research at the King Faisal University. Furthermore, verbal consent was taken from the community pharmacists and the relevant hospitals to participate in the interview.

Results

All the community pharmacists who participated in this study were expatriates i.e. Egyptian and Jordanians, most having bachelor of pharmacy degree with a job experience of more than three years (Table 1). The theme entitled “Issues a pharmacist considers while dispensing a cheap or expensive medication” mainly focused on two issues; one to see the availability of the generic products in the pharmacy and second is to see the factors that may affect the selection of the generic and branded products. Upon coding of themes, the following responses are gathered upon interpretation.

Table 1

Demographics of respondents.

Demographic of respondents	Independent/Non Hospital affiliated pharmacy N(10)		Hospital affiliated pharmacy N(10)
Gender
	Male	10 (100.0%)	10 (100.0%)
Nationality
	Egyptian	8 (80.0%)	10 (100.0%)
	Jordanian	2 (20.0%)	–
Age
	Ph1	34	37
	Ph2	38	39
	Ph3	40	41
	Ph4	35	41
	Ph5	45	38
	Ph6	47	40
	Ph7	43	35
	Ph8	44	37
	Ph9	38	39
	Ph10	40	45
	Mean age	40 ± 4.3	39 ± 2.7
Educational level
	Bachelor of Pharmacy	8 (80.0%)	10 (100.0%)
	Master of Pharmacy	2 (20.0%)	–
Job experience
	3–5 years	4 (40.0%)	6 (60.0%)
	6–10 year	6 (60.0%)	4 (40.0%)

Subtheme 1: availability of the generic products in the pharmacy

Non-hospital affiliated pharmacies

Ph 1, 7, 10 have generic substitutes 3–4 for 60–70% of the analgesic oral/topical, antibiotics (caps/tabs/suspensions/eye–ear drops). However, people prefer more the products that are from multinational firms or foreign companies.

Ph 2, 5: We have alternatives for antibiotics, painkillers, vitamins and irons supplements as these are the commonly requested products in my pharmacy.

Ph 4: I have different alternatives for antibiotics and pain killers.

Hospital affiliated pharmacies

Ph 3, 5: Hum we have generic substitutes for anti-histaminics, cough syrups, pain killers and antibiotics. These are the fast moving drugs in our pharmacies, so we have to keep the alternative.

Ph 1, 6, 7: Antihistaminics and antibiotics are the common items in which we want to keep variety of products.

Ph 4, 9: Antacids, anti-histaminics and antibiotics are the common products prescribed by our hospital that we want to cover with alternatives.

Sub theme II: factors that may affect the choice of low price or expensive medicine

The second sub theme was focusing on the factors that may have affected pharmacist decision/choice of low price or expensive medicine for the consumer.

Ph 1, 10: Normally we give them the medicine they ask for or written in the prescription.

Ph 2, 3, 5, 6, 8: See the dressing and condition of the patient. If he is well dressed then expensive medicines is not a problem for him. Ph 2, 5, 8: In case if he is not, can think about giving him a cheaper medicine, if he requests. Ph 3, 5: Sometimes patients ask for less expensive medicines. So we give them less expensive medicines.

Ph 4, 9: We will give him the good quality medicine (branded medicines) no matter it is expensive or not.

Ph 1–6: We will give him the medicine that is prescribed in the prescription. There is no need of amendment.

Ph 7, 9: We will give him a good quality medicine (branded medicines) that suits best to his condition. In critical conditions, it is wise to go for good quality/foreign made medicines.

Discussion

For decades, researcher has associated consumers’ and health care providers’ concern about safety and quality as a barrier to promotion of generic medicines. However, in developing countries, like Saudi Arabia where consumers do practise self-mediation, the role/decision of community pharmacist becomes influential or final in the purchase or selection of generic/branded medicines. In general one can assume three possible options that have a major influence in the selection of medicines.

Selection of medicine is mainly dependent on the prescription that is written by the physician, especially in private practice where physician prescribes only those medicines that are available at their clinic pharmacy. Moreover the physician’s concerns for quality and efficacy of generics can also affect prescription pattern. Thus consumers have no choice, except to take what is dispensed to them (Valles et al., 2003).

From another point of view, community pharmacist can affect the selection of generic or branded medicines by recommending a substitute that can be a generic or a branded medicine (Allenet and Barry, 2003; Babar et al., 2011; Mason and Bearden, 1980; Siam et al., 2013). However, it may not work in all situations, particularly if the consumer is aware or knowledgeable he/she can ask for the same medicine which they use i.e. generic or branded medicine.

While the third and the last one can be the consumer’s positive or negative perception towards generic medicine which will affect the decision making process (Hassali et al., 2005; Sansgiry et al., 2005; Shrank et al., 2009; Stewart et al., 2010), what to choose, generic medicine or branded. Moreover, some consumers’ decision is overruled by the physician selection and they believe what is selected for them is best.

Considering the findings of the current study, community pharmacist role in selecting the generic or branded medicine is based on appearance of the consumer. Overall, it is well known that Saudis have negative beliefs about the quality and efficacy of generics and they prefer to go for European or branded medicines (Sarah, 2013). However, community pharmacist decision for drug selection, based on physical appearance perhaps will act as a major barrier to the promotion of generic medicines in Saudi Arabia. Pharmacists who were practising in hospital affiliated pharmacies, prefer to follow what is prescribed and they have belief to dispense good quality medicine which is perhaps branded medicine. The generic substitutes are available mainly for antibiotics, pain killers, cough syrups, antihistaminics and antacids. Pharmacists practising in hospital affiliated pharmacies were found to be more influenced by physicians’ instructions and only go for a different option when the drug prescribed is not available. Regarding community pharmacists practising in chain or non-hospital affiliated pharmacies, it is unclear as to what are the factors responsible for this attitude, is it the effect of marketing by branded manufacturers or is it the profit margin for the pharmacist to sell branded medicine (Joey, 2012). Future research should focus on this deficit in the literature to be explored in detail so that Saudi generic medicine policy makers consider room for reforms to address such practical challenges to generic medicines in Saudi community pharmacies. Till date, general public prefers to access free health services provided in public hospitals. Very few, perhaps can afford to visit private hospitals and get their requirements from community pharmacies. It is possible that in future private health care services are preferred by Saudis due to immediate access and less waiting time. If it ever happens in Saudi Arabia, community pharmacists will be playing a major role in improving generic substitution and promotion of Saudi counterparts.

The findings of this study are alarming for the Saudi health policy makers to voice in favour of promotion of generic medicines in chain and independent community pharmacies (Dylst et al., 2012) to ensure cost effective access to the Saudi population.

Conclusion

Physical appearance of the consumer is revealed to be one of the main factors affecting the pharmacist decision to dispense generic or branded medicine. Pharmacists practising in hospital affiliated pharmacies were found to be influenced by the physician’s recommendation, and prefer to dispense good quality medicines.