On our second afternoon in Bangalore we had an interview and observation session with a buzzing independent pharmacy. *NB, the pharmacy didn't want their name to be recorded.
As part of a chain of six, all run by the same extended family, this outlet was run by four brothers and usually has 7 people working behind the counter. It was specifically chosen because it is known on the strip for dispensing medicines without prescription. They said that 70% of their drugs sales are non prescription and 30% require a prescription.
Here's some key learnings:
1. On the same road there are at least 10 other pharmacists within a 10 minute walk, so they must work hard to keep the 100 customers they see per day loyal:
"The two ways to remain competitive are your relationships and the availability of drugs. You also can't have one without the other"
"We are a person to person society here in India" - he didn't like the idea of putting something in between him and the customers, in response to Symptom Tree concept
"My biggest challenge is stock management. We make orders but we don't know what is in stock until we get the delivery. We have to quickly bring drugs from our other outlets otherwise we might lose our customer"
This made us realise how counterintuitive it would feel to this pharmacist to deny a customer a drug, when their mode of operation is to relentlessly fulfil requests. It was clear how the pharmacy doesn't see it as their role to advise or counsel, just to meet demand - something we'd see was a trend in India.
2. They see it as 'good care' to offer poorer patients relief when they can't afford a consultation:
“Some people are very poor and can’t afford to go to the doctor. I would give cotrimoxazole for a poorer patient”
This is done with good intentions, to offer quick relief for those in need. But, the pattern of providing those with the least likelihood of having seen a doctor with antibiotics is really worrying when the opposite should be happening.
3. Most people don't want to be on medication
"They may delay going to the doctor because they’re busy, they think they might get better if they wait, and they may not want to spend the money”
"Patients are always happy to be reducing their medications. For those with hypertension we warn them that steroids can harm their bones"
Contrary to what it might be tempting to think - that people are 'keen to take medication' or taking it mindlessly, this was a good sense check for us. A lot of patients actually don't want to be on any drugs at all, it's just that when they do get sick, they want relief that feels failsafe - hence why antibiotics are so popular. The perceived risks are so low, and the benefits are so easily remembered or communicated between people. It was also interesting to see that they shared the dangers taking too much of other medication like steroids, but not antibiotics - is this because it's easier to explain 'weak bones' than 'AMR'? or because they make more money from frequent sales of antibiotics than other drugs?