On Tuesday afternoon we interviewed a pharmacy which is well known in the local area (according to our fixer, her friends and family) for selling antibiotics over the counter (OTC) without prescriptions. She had even observed them selling a box of paracetamol for a customer's unwell dog (!). Although we hoped they would give us honest insight, we found them pretty vague and unwilling to share some of the reality of selling dispensing OTC without a prescription. So, we decided to focus our time doing mystery shopping and intercepts with 8-10 pharmacies around the city, from chains to independents, to find out for ourselves how things are really working.
1. Broad spectrum antibiotics are sold like sweets
Low level AB's are sold OTC without question for 'quick relief' of common colds, coughs and flu symptoms. Pharmacies even offered mixtures of antibiotics, suggesting we could first try one type and then another if it didn't work. When we asked if we could just have a few days' worth to save money, we were often given cut up strips for just 2-3 days.
"Yes, you can have this (taking out the packet), it's good for a cold, a cough." "Don't we need a prescription?" "No, no, it's just low level, not a prescribed drug" (about Amoxiclin). A low level chain pharmacy with 20,000 outlets in 8 states.
"You don't need a prescription for the antibiotics we give for cold, cough or flu. Just for H1 antibiotics" A more upscale chain
Pharmacists seem to think it's their job to offer quick, effective relief for symptoms people describe, with no questions asked. They're both keen to sell and to help, so it doesn't make sense for them not to do so. When probed, there was very low (cited) awareness of the dangers of AMR. There was a strong sense that there was no real need for caution in relation to this specific class of low level antibiotics, because they're 'not strong'.
2. Dispense, or someone else will
Almost all of the pharmacists we talked to claimed that availability of medicine was their biggest competitive advantage. With only one qualified pharmacist per shop legally required, many of the staff there are simply running a business and dispensing as much as possible.
"We need to make sure we have the medicines in stock and available for our customers, or they will go somewhere else"
"If I say no to someone, they will go and buy it across the street"
"We sell 50-70,000 Rs a day worth of medicines"
"Everyone round here is giving discounts, I give 10%"
Without much sense of obligation to care for customers health, most of the pharmacists we spoke to were motivated to keep customers happy and fulfil their requests. They don't see it as their job to push back - it would be the equivalent of telling someone they shouldn't buy a coke if they want one.
3. Prescriptions are easily acquired and reused
"You need a prescription for that, but you can go to the doctor next door right now and get one" (implying it was not a diagnosis that was needed but just getting the piece of paper - a formality). NB This was the only pharmacy that insisted on a prescription, attached to a private medical clinic.
We got an appointment at the outpatient clinic in a central private hospital next door, paying 400 rupees for a consultation. Kosta was seen by the doctor in 15 mins and on a 30 second examination was prescribed antibiotics as well as 3 other medicines (with no actual symptoms). The medicines cost total 320 Rs, and Kosta was told that it was ok to stop taking it after 2 days if he felt better. The prescription itself was not stamped or held onto by the pharmacy upon dispensing - he was free to use it again and again.
The reality of prescription re-use seems very common in Bangalore, it can be both the physical paper or just the words repeated at a pharmacy counter. This might be a really interesting opportunity for design - HMW design prescriptions that are only usable once?