My perspective on the pharmacy industry in rural Bangladesh

This past week I have been able to learn a lot about the pharmaceutical industry in Bangladesh. It is one of the fastest growing industries and is quickly developing into one of the largest sectors in the economy. Some pharmaceuticals companies, such as Square Pharmaceuticals have even ventured out into the global market exporting to Europe and with future plans of getting FDA approved.

The way the drug industry is regulated and operated is very different from Canada. The legislation seems to exist however it is not strictly regulated. I believe this is having catastrophic results in providing patient care. I read a journal article entitled: Frequently used health care services in urban slums of Dhaka and adjacent rural areas and their determinants. One study performed indicated only 8% of street pharmacies were able to properly diagnosis and treat dysentery which is a very common condition here. When we approached a street pharmacy with a sore throat the drug of choice they gave us was erythromycin, we did not have a prescription and had not seen a doctor for a diagnosis. Overuse of antibiotics is a massive problem here. When I asked in a government hospital the most common drugs dispensed were: levofloxacin, amoxicillin, tetracyclin, ciprofloxacin, domperidone, antacid, antihistamine, paracetamol, and metronidazole.  In rural areas access to a doctor are limited by socio-ecomic factors, location, culture, and wait times so as a result self diagnosing at pharmacies is a common occurrence and I question the reliability of the diagnosis and treatment of choice.  Last year, The Dhaka Tribune published an article about unregistered drug stores and this is an expert from the article:

There are allegations that untrained people, who do not have the least of ideas and knowledge about the dosage and utility of medicines, are running thousands of stores across the country. These untrained people are, only running the pharmacies, they are illegally prescribing drugs, especially antibiotics, and treating complicated diseases, something that only trained physicians would do. Rural people who have little education and awareness are the biggest victims. Wrong prescriptions often results in various complications even deaths, which, however, hardly ever get publicised, due to lack of monitoring and enforcement by the authorities concerned.

Another study also indicated pharmacies were the most common health care service that the lower socio-economic population used for various reasons: short distance, easy accessibility, and reduced treatment cost. Some problems with the current situation are irrational prescribing of drugs such as antibiotics, poor counselling on drug use age and side effects. With pharmacies being the major point of contact for health care related concerns, I believe huge opportunities exist for improving patient knowledge on health and improving patient care. The people working in these street pharmacies should have at least basic training on drug mechanisms, usage, side effects, drug interactions, etc and should be able to counsel effectively on basic health concepts.  Some topics that could be promoted and counselled on are the health risks associated with smoking, which is very common here and the average age people start is 12 years. Other topics could include: promoting vaccinations, importance of hand washing, sanitary bathroom conditions, when to see a doctor, and nutrition concepts with the importance of eating a balanced diet. 

The infrastructure of this industry is also very different. We have visited two government hospitals, various NGO hospitals, talked with a large group of drug representatives, and visited many street pharmacies but I have yet to meet a qualified pharmacist. From my understanding qualified people with pharmacy degrees work for the drug companies performing research and formulating the drugs. I was fortunate enough to have a meeting with representatives from all the major drug companies. From my understanding they have to have a masters but it can be in any subject and get formal training from the companies. I questioned them about antibiotic resistance and if they understood it was a global concern and had the potential to become the biggest health care crisis in the near future. The pharmaceutical reps danced around the issue and blamed chemist shops in rural areas for illegally handing out antibiotics and didn't seem concerned which I found very alarming. Another concept I also found interesting is drug companies were not permitted to advertise at all, where in Canada newspapers, magazines, bus stands, commercials, etc are all advertising drugs. I think that is a good idea here because with little drug regulation, extremely easy access to drugs, and people not having education on basic health care advertising could have a catastrophic effect. However, the pharmaceutical reps are allowed to advertise their products to the doctors. I know in Canada when drug reps talk to a pharmacist or a doctor a lot of research goes into evaluating the studies to make sure the claims are accurate. In the government and NGO hospitals I did not see computers so I question how the doctors could perform research to ensure the claims the drug reps are making are true and the best treatment option are going out to the patients. The pharmacies in the market are actually called chemist shops and they are available in every market and usually every second store is a chemist shop. These chemists are supposed to have a secondary education degree, speak english, and have a 3 month course on the basics of drugs science. The Directorate General of Drug Administration claims there are 101 354 registered drug stores in the country but the actual number of stores could be three to four times higher then the official figures.

From our various visits to different health care facilities I have noticed that doing actual diagnosis, such as pathogenesis and lab tests, are not common here and people diagnosis and treat based of symptoms. I believe a lot of unnecessary drug treatments are given and we have even experienced this when one of our group members got sick and was given unnecessary treatment. I wonder if the cost of diagnosing, access to testing materials, and proper training in medical schools is the barrier to getting a proper diagnosis.

I do appreciate the fact that the cost of drugs are very cheap. People do not have drug insurance here so by keeping the cost low most people are able to have access to treatment. Also, I saw a prescription from a private hospital and was very impressed with how thorough it was. It included the patient's name, diagnosis, symptoms, lab values, doctors signature, prescription with the drug name, amount, duration, and directions for the patient, and any counselling that had to be given. In the government hospital prescriptions were written on scrap paper and did not have the patients name or directions, they basically just had the name of the drug and how much to dispense. In one of the NGO hospitals the pharmacy dispensed over a thousand prescriptions a day. The women working there was not a pharmacist but she seemed confident in her abilities and I was impressed. When handing out the drugs to patients she counselled on how to take, side effects and when required gave a measuring device.

One last area of health care that I found interesting was the concept of privacy here. In the hospitals people are lined up and crowded inside the room that the nurse or doctor is performing the checkup or procedure. The doors are wide open and anyone can hear what the interaction between patient and health care provider. When in line at the dispensary/pharmacy in the hospital and the street people again are all crowded together and everyone knows what drug is being given. Also, records are all kept as paper and we have seen rooms with random piles of peoples health records. I no longer take privacy for granted, it is a privalage we are lucky to have.

 I am confident with more regulation and training pharmacies in the future will be the most important health care sector in Bangladesh for helping provide improved patient care and increasing knowledge on various health care issues.