Self-medication in Bangladesh: significance of drug control and distribution by pharmacists

Self-medication is an imprudent practice that refers to obtaining medication without a prescription, reusing expired prescriptions, sharing information about medication with friends and family, and using stored medication, which is seen to be a common practice in Bangladesh1,2. Several studies have been conducted in various districts of Bangladesh to understand the extent of self-medication. These studies have shown that antibiotics such as ciprofloxacin, doxycycline, amoxicillin, and metronidazole have the highest self-medication rates, reporting about 26.69% prevalence of self-medication with antibiotics3–5. Other most commonly misused drugs are for abdominal pain, menstrual irregularities, fever, scabies, and throat pain4. This is particularly concerning as there is evidence of increasing antimicrobial resistance (AMR) due to the abuse of antibiotics in the country6. The World Health Organization (WHO) has identified Bangladesh as one of the countries with a high burden of AMR7. In Bangladesh, there is no prescription-only drug control system in place, which means anyone can buy drugs like sedatives and antibiotics without a prescription, even in rural areas4. This is a public health threat that has not been adequately addressed by politicians, public health professionals, and consumers. The lack of awareness of the mortality and morbidity associated with AMR may further complicate the problem of self-medication4. We have underscored various challenges as to why this problem persists in Bangladesh (why isn't the situation changing) and have classified them into seven root problems that serve as the axle for hindering change. Self-medication practices in Bangladesh are notably exacerbated by a pervasive lack of awareness among the population. This deficiency in knowledge is particularly pronounced concerning the potential risks and dangers associated with self-medication. To address this issue, urgent measures are warranted, including enhanced access to healthcare services and comprehensive public education initiatives focused on enlightening the public about the inherent risks of self-medication8,9. A significant proportion of self-medication practices in Bangladesh is attributed to socioeconomic factors. The prevailing health infrastructure and coverage in the country are suboptimal, with a disproportionately low fiscal allocation to national healthcare, accounting for only 2.64% of the gross domestic product (GDP). This inadequacy results in the absence of viable health insurance options, both national and private, exacerbating the prevalence of self-medication10. A noteworthy proportion (77%) of literate individuals in Bangladesh tend to seek guidance from retail medicine vendors for minor health issues, including but not limited to fever, common cold, allergies, and diarrhea. This underscores the urgent need for interventions that redirect reliance toward qualified healthcare professionals and away from informal sources11. The motivations behind self-medication practices are multifaceted, encompassing factors such as dissatisfaction with local health services, the financial burden associated with physician consultations, the perceived simplicity of ailments, and a scarcity of time. Addressing these motives requires a comprehensive approach that not only improves healthcare services but also tackles the economic and accessibility aspects that drive individuals toward self-medication9. Structural barriers at the policy level further complicate the landscape of self-medication. The enduring public financing structure, reminiscent of the colonial era, introduces a considerable degree of inflexibility. Within the health sector, intricate challenges in implementation arise, encompassing issues pertaining to human resources, political intervention, monitoring, and supervision. Moreover, obstacles originating from the demand side, including sociocultural aversion, historical mistrust, and a deficit in empowerment, collectively contribute to the sustained prevalence of self-medication practices10. Geographic factors also play a role in promoting self-medication, as evidenced by the proximity of community pharmacies compared to healthcare facilities. The study reveals that most participants had access to nearby community pharmacies within 1.5 km of their residences, while healthcare facilities were situated 2–4 km away. This underscores the importance of geographic accessibility in influencing healthcare-seeking behaviors and the prevalence of self-medication12. Pharmaceutical companies are major players in health reform. However, the establishment of a centralized prescription verification system can impact their profits for each type of drug, especially those commonly used for self-medication. They in turn, through advertisement and the spread of online quick fix/quick relief strategies, in turn, instigate the population to indulge further in self-medication practices, and they become advocates for the same, promoting 'instant relief' which translates into 'instant profit' for them. People often rely on recommendations from friends and peers and may not have accurate information about the indications or symptoms that a drug is intended to treat. Additionally, studies have shown that many individuals discontinue medication as soon as they start feeling better, which can lead to decreased drug efficacy and relapse of symptoms and, in turn another cycle of self-dosing and abrupt discontinuation4. The shortage of qualified experts in the pharmacy field is also a concern. Currently, there are only 2897 registered pharmacists and 36 068 registered pharmacy technicians in the country. This leaves a significant number of pharmacies without qualified pharmacists4. The roles of a pharmacist in reducing self-medication are drug counseling, identification of drug interactions, monitoring for adverse effects, encouraging prescription for medication, and providing education and awareness. Urgent intervention necessitates a comprehensive strategy, beginning with an extensive public education campaign and improved healthcare access to underscore the perils of self-medication. Addressing socioeconomic factors mandates a strategic increase in healthcare funding, surpassing the current 2.64% of GDP, and the establishment of robust national and private health insurance systems. Immediate measures are imperative to shift reliance from informal sources to qualified healthcare professionals, involving stringent regulatory measures to enhance credibility. A holistic strategy should encompass dissatisfaction with local health services and economic barriers to physician consultations, necessitating improved healthcare services, reduced consultation costs, and enhanced accessibility. Reforming the colonial-era public financing structure is pivotal, requiring flexibility, streamlined human resources, minimized political interference, and reinforced monitoring. Simultaneously, overcoming demand-side barriers demands cultural sensitization and empowerment initiatives. Optimizing healthcare accessibility involves strategic facility placement and mitigating the influence of geographic factors on self-medication. Regulatory measures are essential to counter the sway of pharmaceutical companies on health policies, emphasizing transparent prescription verification systems, public awareness campaigns, and prioritizing long-term health benefits. This comprehensive approach aims to navigate the intricate challenges, fostering a more enlightened, accessible, and secure healthcare landscape in Bangladesh. Additionally, we also recommend the creation of a drug distribution and control board (DDCB), which may regulate the sale of drugs under specially constructed guidelines by the Ministry of Health banning over-the-counter sale of antibiotics and high dosage pain killers without prescription. This body may also conduct randomized inspections across pharmacies/drug outlets in the country to check if all pharmacies/drug outlets have at least one pharmacist overlooking the day-to-day sales. The DDCB may also match the sales with a master database of drug import into the country in order to locate nuances and errors. Pharmacists' Association of Bangladesh may facilitate the government in the adoption of the DDCB. Special courses for pharmacy technicians may also be devised under this framework in order to achieve these goals. Ethical approval Not applicable. Consent Not applicable. Sources of funding Not applicable. Author contribution All the authors contributed equally. Conflicts of interest disclosure There are no conflicts of interest. Research registration unique identifying number (UIN) Not applicable. Guarantor Dr Ahmad Neyazi.