What the rise in self-medication tells us about the country’s healthcare system

Nasrin Akhter, a 32-year-old private sector employee, was buying antibiotics from a pharmacy at the Moghbazar intersection for her three-year-old son. Her child had been suffering from a fever since the previous night. Surprisingly, Nasrin did not have a prescription and did not feel that she needed one. 

"This fever has been a recurring issue for my child, and once the doctor prescribed him one particular antibiotic. Now that the symptoms are the same, I think this medicine will suffice," she said. 

Nasrin added that she had been continuing this practice for a while now, not only for her child, but also for herself and the other members of her family. 

Rakib Bhuiya, a second-year student at Dhaka University, follows the same logic as Nasrin. For any "normal" illness that he doesn't feel requires specialist attention, he simply matches the symptoms with potential remedies found online, and buys the medication from the pharmacy.

"Why bother going to the doctor when finding the right medicines is just one Google search away?" he asked.

Nasrin and Rakib are not alone; several studies published in internationally renowned scientific journals this year highlight this problem of self-medication. 

According to a study by the Center for Health Innovation, Research, Action, and Learning (CHIRAL), 64% of parents in Dhaka misuse antibiotics, 58% administer antibiotics to their children without consulting a doctor, and 36% prefer obtaining antibiotics from pharmacies rather than from doctors.

Another recent study on self-medication practices among university students indicated that they generally have a positive attitude towards self-medication and adverse drug reactions (ADR). Physical convenience was behind them opting for self-medication, while the inconvenience associated with prescribed medication contributed to its lower prevalence.

The study described that one reason for the rise in self-medication is the abundance of health information available online. This allows people to research symptoms, diagnoses, and treatments independently, fostering a sense of autonomy and confidence in making health decisions without consulting professionals. 

It also mentioned that difficulties obtaining advice from healthcare professionals further exacerbate the problem. "This situation can be directly attributed to the low healthcare budget in Bangladesh, which is one of the lowest in South Asia, accounting for only 5.4% of the total GDP [in the FY 2022-23]," it noted. 

Both these studies have been published in the Scientific Reports by Nature. 

Several other studies conducted in various districts of Bangladesh have also shown that antibiotics such as ciprofloxacin, doxycycline, amoxicillin, and metronidazole have the highest self-medication rates, reporting about 26.69% prevalence. Other commonly misused drugs are for abdominal pain, menstrual irregularities, fever, scabies, and throat pain.

This is particularly concerning as there is evidence of increasing antimicrobial resistance (AMR) due to the abuse of antibiotics in the country. The World Health Organization (WHO) has identified Bangladesh as one of the countries with a high burden of AMR. 

According to the WHO's Tripartite AMR Country Self-Assessment Survey (TrACSS) Report 2021-22, in 2019, there were 26,200 deaths attributable to AMR and 98,800 deaths associated with AMR in the country. 

To put this into perspective, the number of AMR deaths in Bangladesh surpasses the deaths from chronic respiratory diseases, respiratory infections and tuberculosis, maternal and neonatal disorders, diabetes and kidney diseases, and digestive diseases.

Md Jubayer Hossain, Executive Director of CHIRAL Bangladesh, emphasised that aside from ADR and AMR, self-medication also poses other risks. These include masking the symptoms of potentially serious underlying conditions and delaying proper diagnosis and treatment.

"This can lead to deterioration of health and increased morbidity," he said. 

Md Ashfiqur Rahman, Assistant Professor of Development Studies at Khulna University and co-author of the second study, provided another example, stating that "even frequent consumption of paracetamol from nearby pharmacies can potentially damage kidneys."

Despite these warnings, experts believe there's no respite in sight. While the findings of the studies underscore the importance of increasing public awareness, more importantly, they starkly expose the true vulnerability of the country's healthcare system.

Government policy prohibits the sale of antibiotics without a prescription and the legal requirement is for staff in drug shops to have a minimum Grade C (certificate) pharmacist qualification. 

In reality, there are no effective rules and regulations in place to control the sale of unprescribed medicine in Bangladesh, as pointed out by Dr S M Abdur Rahman, Chairperson of Clinical Pharmacy and Pharmacology at Dhaka University.

The practice of self-medication also reflects the lack of trust among the general public in the country's healthcare system. Dr Rahman emphasised that nowadays, people in the country often lack interest in seeking treatment from doctors as they find the entire process troublesome.

"From seeking appointments to queuing and waiting in hospitals, to limited consulting time, people simply don't appreciate the quality of patient care in Bangladesh," Dr Rahman said. "So, they often find it preferable to self-medicate."

And those who have money in their wallet prefer to go abroad, even if it's just to India, for treatment. 

So, the most crucial step to deter people from self-medication is to improve the country's healthcare system by increasing manpower, believes Dr Be-Nazir Ahmed, a public health expert and former Director of the Directorate General of Health Services (DGHS).

Even 20 years ago, 80% of the population relied on public hospitals. However, that figure has now dropped to just 20% due to dissatisfaction with the services provided in public healthcare facilities. People often don't receive satisfactory treatment in private hospitals either.

"Additionally, the shortage of specialist physicians in the country forces each specialist to see hundreds of patients daily, leaving them with limited time to address each individual's concerns; typically just two or three minutes per patient," he said.

According to the World Health Organisation's health worker density in South Asia data, in 2020, there were six doctors for every 10,000 patients in Bangladesh, which puts the country at the second position from the bottom, among the South Asian countries. 

And this inevitably impacts the quality of patient care in Bangladesh. According to a 2017 British Medical Journal publication, the average duration of physician consultations in Bangladesh in 2015 was a mere two minutes. 

"It's not like Bangladesh's physicians are bad. But the shortage makes it difficult for them to meet the needs of the vast population," said Dr Ahmed.

It is necessary to assign specialist physicians in every union across the country and multiple specialists in densely populated city wards to ensure adequate healthcare coverage.

"And, of course, our government must ensure that every family in our country has access to their own General Practitioner (GP). Only then can we effectively control the practice of self-medication," he added.

The Directorate General of Drug Administration (DGDA) should also take stronger measures to regulate the sale of medicines without prescriptions in pharmacies. This includes implementing clear guidelines and ensuring compliance among pharmacies.

"However, from my personal experience working on various projects with them, I've observed that they are significantly understaffed for effective regulation," remarked Dr Rahman.

DGDA Director Md Ashraf Hossain, however, claimed that they were in fact working on stopping the sale of medicines without prescription, particularly antibiotics. 

"Mobile courts have been actively operating to regulate the unauthorised sale of antibiotics. Thanks to this, the number of unauthorised sales of antibiotics have dropped significantly in the past few months," he claimed.