A total of five in-depth interviews were done with pharmacy professionals from the community pharmacies in Addis Ababa. Three of the participants were pharmacists holding bachelor degree in pharmacy (B. Pharm) while the rest were druggists holding diploma in pharmacy. Their age range from 27–37 years. In terms of job experience, the participants had worked in community pharmacy for a range of 2 to 8 years.
Antibiotics dispensing practice
All (n = 5) study participants agreed that the dispensing practice was not up to the standards set by the regulatory authority. The participants also mentioned that majority of the pharmacy professionals didn’t comply with the country’s law, professional code of ethics and regulatory guide of good dispensing practice. Non-prescription sale of antibiotics was recognized to be a growing public health problem by all participants. Majority (n = 4) of them believed the trend was of nonprescription sale as increasing. This was strengthened by one of the participant that:
“….. Although we professionals know antibiotics are prescription only medicines that shouldn’t be dispensed without prescription, most of us failed to do so. Antibiotics are highly misused medicines and nonprescription sale of these medicines is increasing from time to time (CMP003).
One of the participants however was uncertain on whether such practice is increasing or decreasing. He pointed out that “the trend of nonprescription sale of antibiotic in each pharmacy seems slightly decreasing but there is an increase in the number of pharmacies dispensing antibiotics without prescription. Hence, cumulative effect of OTC sale of antibiotics might be higher or lower which calls for a wider comparative research (CMP001).”
Although majority (n = 3) of the participants noted that the nonprescription sale was a common practice in most of the community pharmacies, all Kenema public or government pharmacies and very few private pharmacies were not victim of this irrational dispensing practice. Findings from the observation also indicated that the practice of OTC antibiotic dispensing was common practice in five of the community pharmacies. It was found that pharmacy professionals were seen selling antibiotics without prescription. This is further substantiated by one of the participants that;
“…….if someone needs and asks to get antibiotic, s/he can get whatever antibiotics s/he needs from any pharmacy regardless of its level (generation). I mean the practice is not in line with what we know as a standard and such practice is becoming common. Yet, nothing has been done to control nonprescription sale of antibiotics (CMP002).”
Characteristics of customers requesting OTC sales of antibiotics
Finding on who frequently demand OTC sales of antibiotics shows that customers come from all segment of the population. However, it was found that often the poor, less educated and older age groups seek nonprescription sales of antibiotics. This was underscored by one of the participant that:
“We encounter all population categories who seek to get antibiotics without prescription. Nevertheless, the older and less educated ones are those who frequently demand nonprescription sales of antibiotics. Such customers assume their demand of OTC dispensing of antibiotics is normal (CMP001).”
Contrary to this, one of the participants stated that the educated customers are the ones who were frequently demand for nonprescription sales of antibiotics. He went on stating that “educated customers come with information on their problem and medicines and at the pharmacy they request us for specific antibiotics (CMP004).” Some participants (n = 2) mentioned that the younger age group are the ones who frequently go to pharmacy for antibiotics without prescription. Observations at the five selected pharmacies also revealed that relatively younger age groups of the population were found to seek antibiotics without presenting prescription.
Antibiotics frequently sold without prescription
Finding shows that Amoxicillin, Ciprofloxacin and Cotrimoxazole were the most common antibiotics sold in community pharmacies without prescription. These drugs were identified for presumed treatment of diarrhea, common cold, tonsillitis and other respiratory infections. One of the participants stated that:
“….these times, Amoxicillin is a famous medicine and everybody including children are coming to buy this medicine. My experience showed me that Amoxicillin is the most commonly nonprescription sold antibiotics here. Nonprescription sale of Ciprofloxacin is also becoming common. You know, it is worrisome that the future of these antibiotics and others is daunting given customers tend to get medicine without prescription and professionals continue to sell such medicines (CMP005).”
Similarly, during the time of observation, many customers were buying Amoxicillin and Ciprofloxacin without prescription. In almost all of the cases pharmacy professionals were dispensing those medicines without valid prescription.
Reasons for over the counter sale of antibiotics
All participants argued that the situation of OTC dispensing practice of antibiotic in Addis Ababa was becoming common and different reasons were identified for such practices. Four major reasons were identified to explain OTC sale of antibiotics. These were attributed to customers, owners of pharmacies, professionals’ interest and regulatory mechanism.
Customers’ demand
It was found that continued customers’ demand is a major reason for maintaining OTC sale of antibiotics. The study participants reported that factors related to customers’ previous experiences, lack of awareness about risks of nonprescription use of antibiotics, prolonged waiting time at the health facilities to get prescription, unnecessary and high costs of physician visits were frequently mentioned reasons by their customers to demand antibiotics without prescription. When pharmacy professionals advise customers to visit health facilities, majority of the respondents (n = 4) stated that customers mostly reacted negatively. This was strengthened by one of the participants that:
“…customers who relish benefits from taking antibiotic usually wanted to get the same antibiotic without prescription. If we refuse to dispense and advise them to go to clinics, most of them are not willing to do so. Longer waiting time to get prescription in public health facilities and higher cost of visit in private clinics are most of the complaints of the customer (CMP003).”
Physician visits for diagnosis was considered unnecessary if customer is familiar with the symptoms and previous experience of getting relief by taking the antibiotics s/he is requesting for. It was gathered that if pharmacy professionals refuse to sale antibiotics without prescription, customer would easily get it from another pharmacy and the professional who insist not to dispense without prescription would loss his/her customers ultimately affecting the business. Thus, majority (n = 4) of participants contend that it is both not easy and counterproductive to convince customers to produce prescription to buy antibiotics. This was further substantiated that:
“……customers believed that going to clinic have additional cost that they prefer to buy antibiotics from pharmacy without prescription. If you are not willing to sale without prescription, some of them confront you and would get the medicine from other pharmacy without prescription anyway. Besides, professionals are indirectly obliged to dispense antibiotics without prescription since they don’t want to lose their job (CMP005).”
Another participant strengthened this:
“I was one of the opponents of OTC dispensing of antibiotics. When I refuse to do so, many of my customers were telling me that they will get it from other pharmacy. They always tell me either to sale antibiotics without prescription to increase my profit or leave the business. I think it seems they were right and to be honest, now I am dispensing antibiotics without prescription (CMP001).”
The behavior of prescriber was also influencing the customer behavior and one of the participants mentioned that even some of their customers were arguing them not to visit the health facilities because in the previous time they repeatedly obtained the same antibiotics. One participant stated this” “….some of the customers complained to me that even they go to the clinics, they always obtained the same prescription like Augmentin (Amoxicillin clavulanate) as mentioned by most of my customers. As a result, most of the customers questioned the necessity of going to clinic as they expect same antibiotic will be prescribed again and hence they opted to buy the same antibiotic directly from the pharmacy (CMP004).”
Owner’s expectation
Findings related to owners expectation shows that majority (n = 3) of participants raised owners influence as one of the reasons for increasing OTC sales of antibiotics. In this regard, most of the owners expect professionals to dispense medicines without prescription. One of the respondents stated that “….if we don’t dispense antibiotics without prescription, there is pressures from both sides i.e. the customer needs medicines and owners expect us to sale more no matter how (CMP004).”
Some (n = 2) of the professionals also commented that even if one pharmacy insist not to sell medicine without prescription, nearby pharmacies as well as clinics would so contributing to OTC sales of antibiotics. This has been stated by one participant that “…you can see many clinics around here that I guess are selling medicines although they are not allowed to do so. I am saying this because I haven’t received prescriptions from them whatsoever. So, you can imagine how difficult it would for the owner even to pay for house rent unless I sale antibiotics in any ways possible (CMP003).”
Professionals’ conflict of interest
Pharmacy professionals who participated in the study were all employed by owners. All participants (n = 5) pointed out that making financial profit is basic expectation from owners. As such every professional intends to draw as many customers as possible to maximize profit and maintain position. Consequently, majority (n = 4) of respondents pointed out to ignore their professional code of ethics. This was stressed that:
“…….for someone in business, s/he needs to satisfy the customer. These days the purpose of dispensing is becoming solely to retain the customers and maximize profit. That is the expectation from the customers as well as the owners (CMP001).”
All participants, however, reflected that nonprescription sale of antibiotic is wrong practice. One participated strengthened this: “every professional knows nonprescription sale of antibiotics is illegal and unethical practice. But the practice continues as professionals’ main interest is to maximize their profit (CMP002).”.”
Weak regulatory mechanism
Finding shows that weak regulatory mechanism to enforce implementation of policies restricting nonprescription sale of antibiotics was mentioned by all (n = 5) respondents as one of the major reasons for nonprescription sales of antibiotics. All respondents indicated that the unethical dispensing of antibiotics without prescription is not because of lack of knowledge or awareness about its consequences but due lack of strong regulatory enforcement mechanism. Participants agree that customer’s demand for antibiotics without prescription and owner’s interest to reap more profit is reinforce by lack of functioning regulatory mechanism. One of the participants argued that:
“….these time we can say there is no regulation of antibiotics and I think the weak regulation system is the main reason for continued and expanding sale of antibiotics without prescription. But I don’t think there is knowledge gap on consequence of antibiotic misuse among professionals including druggists. Unlike antibiotics, Narcotic and Psychotropic substances for example are not sold without prescription. I will never dispense it to you at any cost for fear of serious cost me to the extent of getting my license revoked and closure of the pharmacy (CMP002).”
All participants called for strong regulatory mechanism to control nonprescription sale of antibiotics and limit its associated consequences. All participants suggested to strictly forbidden nonprescription sales of antibiotics and penalize violators as emphasized by one of the participants:
“…..Generally, in our country we respect laws instead of moral authority. So, the Regional Health Bureau, FMHACA and other concerned bodies should consider strictly prohibiting nonprescription dispensing of antibiotics (CMP002).”
Another participant also stated that:
“…..to me putting regulatory mechanism would help. We know antibiotics are prescription only medicine and OTC sale of antibiotics is a violation of the regulatory standards. Hence, strong enforcement just like Narcotic and Psychotropic substance is needed (CMP003).”
Although majority (n = 3) of participants don’t feel professionals’ have knowledge problem about the consequences of antibiotic misuse, they insisted the need to continuously update on the extent and burden of the problem in connection to nonprescription sales of antibiotics. One of the participants stressed that: “professionals may know the consequence of nonprescription dispensing of antibiotic. But, I don’t think they are well aware of its burden. Thus, repeated educational campaigns should be organized to show them its level of health and economic impacts which then can contribute to decreasing OTC sales antibiotics (CMP005).”
