Table 4 Healthcare professionals’ specific themes

Negative influence of shortage on practice and pharmaceutical business

Impact on physicians

• Patient dissatisfaction

• Personal dissatisfaction

“Its effects physician’s credibility. If physician prescribes a short brand to patient, patient thinks that physician is taking incentives for this brand that’s why he is prescribing this despite shortage.” (Physician 12)

“Physician faces problem, as he loses confidence. When he usually prescribes some trustworthy brands but if he has to switch to other brands or local brands due to shortage, then he remains uncertain that whether it has same efficacy and gives same results or not, my patient will be satisfied or not…” (Physician 5)

Impact on business

• Credibility loss

• Financial loss

“Impact on the pharmacy business depends on brands whose shortages occur because some pharmaceutical companies provide more margins to pharmacies for specific brands. So if those well-known brands get into shortage, then there will be profit loss.” (Pharmacist 5)

“Financial losses are obvious and then there are credibility losses. One of the major losses is that your customers are dependent on your drug. So your relations with them are disturbed. So both financial and credibility losses happen.”(Pharmacist 4)

Healthcare professional level barriers to solutions of medicines shortages issue

• Excessive advertisement and promotional campaigns of short brands

“Incentives play a key role here, if pharmaceutical companies provide incentives to create demand of their product. They do good marketing and continually approach physicians. As a result, physician will prescribe more of their short brand and patient suffers.” (Physician 7)

“According to medical representatives, customer is not patient but a physician. They directly convince the physician that if they prescribe short brand then they will get reward or incentives in return. In such cases, patient continues to experience due to unavailability of medicines. If physicians easily switch to alternative, they can manage the shortages very easily.” (Pharmacist 7)

• Inferior generics

“Secondly, in Pakistan the quality also matters, if there are multinationals then they are of good quality while the local are not of high quality sometimes.so there is an issue. Different brands have different quality; good brands show good effect like we have omeprazole of Esomepra, it is very much better as compared to any other company’s brand.” (Physician 6)

“One issue is efficacy of alternatives. Local companies don’t conduct comparative bioequivalence studies and there is no data about its efficacy. Second many pharmaceutical companies use substandard excipients to manage the price of product. As a result, quality of generic products is poor as compared to branded medicines.” (Pharmacist 1)

• Poor collaboration and communication between physicians and pharmacists

“Major issue is poor collaboration, which leads to poor demand prediction in hospitals. Demands are not based on actual needs of patients. Medicines having very low demand are purchased in large quantities and medicines having high demand are purchased in small quantities. We cannot blame administration for this. It is the duty of pharmacists and physicians to decide which medicine is needed in large quantities, but as you know physicians and pharmacists do not collaborate much in our hospitals.” (Pharmacist 5)

• Patient psychological acceptance and rigid perception

“It’s not related to physicians but is based on patient satisfaction of its own. It is also based on patient psychology that if they are satisfied with a specific brand then they think they will be harmed by switching to generic. So, they resist changing brand, demand the same.” (Physician 7)

“Patient trust physician so he sets his mind on brands prescribed by physician. He thinks physician is always right. For instance, there was a case when Calpol was prescribed by the physician and I dispensed Panadol to the patient due to shortage, but he refused to take that. Its patients’ psychological issue that they think physician has prescribed this brand, so we have to take this, otherwise we would not get treated.” (Pharmacist 10)

Suggestions to effectively assuage the impact of medicine shortages

• Generic prescribing/ Prescribing by international nonproprietary name (INN)

“If government changes its policy and promotes generic prescription instead of brand, and compels companies to market medicines with the generic name only then branded shortage issue can be managed or entirely vanished.” (Physician 7)

“There should be generic prescription, like in European countries. Even in Pakistan, there is only generic prescription in some high-level hospitals, such as Shaukat Khanum hospital and Agha khan hospital. But, there is brand prescription in government or some other hospitals due to incentives. Because incentives are only received on brands and not on generics. If they shift to generic, then all brand authority will shift to pharmacist. Pharmacist will be responsible for brand selection. When prescription comes with generic, pharmacist will provide patients with the best brand available.” (Pharmacist 9)

• Check and balance on pharmaceutical promotion to avoid incentives driven irrational prescription of short brand

“Physicians should not stick to one brand because of any agreement. Companies should be punished for luring physicians through incentives.” (Physician 1)

“Again I would say that the government should keep an eye on promotional practices of pharmaceuticals. Also they should bound physicians not to make deals with the companies. If physicians are strictly punished for being biased towards a brand, this issue will vanish by itself…Physicians need to work ethically and prioritize patients rather than personal gains.” (Pharmacist 12)

• Be aware of shortage and prescribe accordingly

“If a medicine is not available, physician should be aware of shortage. If he knows then he should shift his patients to alternate brand as soon as possible.” (Pharmacist 2)

“Sometimes, physicians don’t have information about brand shortage. If medical representatives have not informed the physician, then he will continue to prescribe that brand.” (Physician 8)

• Patient education about safety of generics

“If any patient is taking one brand of antihypertensive or anti-diabetic, then physician should educate him that other brands are also available. Whether patient is educated or not, educates him as much as you can; that this medicine is available under different brand names, but salt is same in each brand. This brand suits you but in case if shortage of that brand occurs then you can switch to another brand....” (Physician 1)

“Patients should have knowledge of brands if one brand is short in market then there is always an alternative of that brand available. Based on the mind of our patients, it is the duty of physicians to spread awareness among patients about alternative brands” (Pharmacist 11)

• Collaborative/mutual efforts of physicians and pharmacists to better procure, select cost effective alternative and optimize selected alternative therapy

“If we don’t know which alternative brand is better or at least equivalent in terms of efficacy then pharmacist should guide us. Also he should tell us all the possible side effects if they suggest any new salt because many times we resist switching just to avoid negative impact on patient.” (Physician 1)

“The collaboration between physician and pharmacists should be promoted, because as I said before procurement of medicines in hospitals is heavily affected due to this issue and leads to shortage.” (Pharmacist 5)