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Using Persuasion to Influence Pharmaceutical Use

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  • 181
    CHAPTER 11
    Using Persuasion to Infl uence
    Pharmaceutical Use
    Persuading citizens to change how they buy and use pharmaceuticals—and
    convincing doctors and medicines sellers to interact di erently with
    patients and customers—is not easy. Public health has a long history of
    unsuccessful attempts at changing individual behavior, attempts often
    driven by the mistaken belief that simply providing better information will
    produce the desired change. In fact, behavior refl ects the infl uence of many
    more forces than just the information someone has about a situation. The
    good news is that when the full range of causal factors is considered and
    acted on, behavior can be changed, as illustrated by public health successes
    on tobacco control. This chapter fi rst discusses some of the motivations that
    drive all human behavior, including pharmaceutical use. It then explores
    some general lessons from the fi eld of social marketing about what it takes
    to infl uence behavior. Next those lessons are applied to changing the behav-
    iors that are important to pharmaceutical sector performance in low- and
    middle-income countries.
    Elements of Human Decision Making
    Several aspects of human decision making are particularly relevant to
    patients’ choices about pharmaceutical use: the limits on our analytical
  • 182 Pharmaceutical Reform
    capacities, the role of decision rules in light of those limits, and the role of
    emotion and instinct.
    In fact, human beings are not very good at weighing diverse conse-
    quences to make even moderately complicated decisions. Our analytical
    capacities are actually quite limited. It is not easy for us to compare out-
    comes that have multiple dimensions—especially when one option is better
    in one way and another option is better in a di erent way. When the rele-
    vant outcomes are not fully known or are uncertain, our ability to make
    careful comparisons is rapidly overwhelmed
    Consider the decisions that medicine buyers in low- and middle-income
    countries face all the time. They go to a retail outlet to purchase a particular
    medicine and fi nd that they have three choices: the high-price originator
    brand; a midprice branded generic; and a low-price, unbranded generic.
    Such buyers face many questions. Is it worthwhile to save money by pur-
    chasing the unbranded generic that mayor may not—have di erent
    pharmacological qualities and, at fi rst glance, looks less attractive? Alterna-
    tively, is the higher-price, brand-name generic likely to be of better quality,
    and if so, how does that potential but uncertain benefi t compare to the price
    di erence? Finally, is it worthwhile to play it safe and pay even more for the
    originator brand, or is that option more likely to be counterfeit?
    Formal methods exist—known as “decision analysis”—for making such
    complex choices. But they require a great deal of time, e ort, and sophisti-
    cation, as well as a good deal of di cult-to-obtain data. Even a simplifi ed
    analysis of the kind of decision just described would make for a good term
    paper in a graduate course in this subject. Thus although the formal meth-
    ods may be helpful to a university-trained, large-volume, professional buyer
    making an important decision, they are of no practical use to individual con-
    sumers purchasing retail medicines.
    How do real people make such decisions, when a full, “rational” analysis
    is beyond their capacity and they have only a few minutes to devote to the
    purchase? One common way is to use “decision rules” or standard operating
    procedures. Over time, people tend to develop relatively simple approaches
    to certain classes of repeated decisions, and they follow their approach
    without thinking much about it. A pharmaceutical example might be, “Don’t
    buy either the least expensive or the most expensive option, but look for an
    option in-between that has a recognizable brand name and comes in pack-
    aging that doesn’t look too scru y or like a fake.” Notice that that decision
    rule may not be fully conscious. To the customer it is likely to seem that
    what they are doing is making a reasonable compromise.
    Patterns of choice that are so routinized that customers are barely aware
    of them can be thought of as habits. We necessarily rely on habits to guide
  • Using Persuasion to Infl uence Pharmaceutical Use 183
    much of our daily behavior. They allow us to get on with our life and reserve
    our scarce attention and conscious decision-making capacity for those
    instances where they are really needed.
    Brand loyalty is an example of such a habit. If a particular brand name is
    known and familiar, consumers often choose that product more-or-less
    refl exively. It is a way of making choices (partly based on one’s own experi-
    ence and partly based on reputation, which is refl ective of other people’s
    experience) without expending a lot of decision-making e ort. In many
    low- and middle-income countries, many relatively established generic
    products, in addition to the originator brands, have developed a substantial
    level of what marketers call “brand identifi cation.
    Over time, consumers may readjust their decision rules if they don’t
    lead to satisfactory results. The Nobel Prize–winning economist Herbert
    Simon (1956) called that process “satisfi cing.” If I get richer or poorer, or if
    I have a bad experience with some choices, or if I impulsively make an
    exception and it turns out well—any of those can lead me to change my
    decision rule.
    In any one area of life, at any one time, my decision rules are not likely to
    give me the best possible results. In contrast to the assumptions of the nor-
    mal economic model, I am not “maximizing” my gain. But the rules that I
    use yield results that are satisfactory enough that I spend my time doing
    something else besides trying to improve them. I spend a few minutes in the
    drug shop and make my purchase; I don’t spend all day at it. Instead, I go on
    my way—to work or to do more shopping—or I go home and make dinner
    for my family. If I face what seems like a big decision—on a cancer drug
    instead of cough syrup—I may put my decision rule to one side and give the
    options additional consideration and analysis.
    An individual’s specifi c decision rules are shaped by their more general
    system of ideas, theories, and approaches. I cannot, every time I have a deci-
    sion to make, go back to fi rst principles and re-ask basic questions such as,
    “Do I believe that illness comes from evil spirits, so that I should consult the
    local shaman, or do I accept the germ theory of disease, which means that I
    should go to the drug shop?” Instead, my more specifi c decision rules—when
    a child has a fever, go and get medicines—are likely to refl ect the implicit
    answers I give to those more general questions. Here is another example: Do
    I presume that a medicine that looks, smells, and tastes good will be good for
    me, as is presumed in many cultures, or bad for me, as is presumed in a few?
    (Think of the reliance in 18th- and 19th-century Europe and America on
    foul-tasting doses of castor oil.) We all have an extensive set of beliefs about
    how the world works, and those beliefs provide a basis or framework for
    much of what we do in our daily activities.

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Using Persuasion to Influence Pharmaceutical Use

Discusses some of the motivations that drive human behavior, including pharmaceutical use, then explores some general lessons from the field of social marketing about what it takes to influence behavior as they apply to changing the behaviors that are important to pharmaceutical sector performance in low- and middle-income countries. The relevant behaviors include how and where people seek treatment, how health professionals (and others) prescribe and dispense medicines, and the extent to which patients follow recommended regimens for taking medicines. Persuading individuals to change their behavior is a central task that pharmaceutical reformers often confront, and efforts often require the use of other controls, such as payment control, reimbursement rates, or profit margins affecting prescribing behavior. In examining how a change in rules might be enforced, use of regulation and the challenges of enforcement are relevant, because proposals to change behavior of specific groups can raise political and ethical dilemmas.

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