WHAT FACTORS MAKE MEDICAL PRACTITIONERS IN BULGARIA DECIDE WHAT TREATMENT IS BETTER

 

                                              Nikola Toromanov



 

 

ABSTRACT

The main objective of this paper is to clarify the most important motivational factors influencing the buying decisions of Bulgarian general practitioners when choosing between medical products or treatments, the relative weight of each factor and the different value of those factors for different groups of doctors in the three biggest cities – Sofia, Plovdiv and Varna. The influence of the doctors’ own and key opinion leaders’ experience with products, the pharmaceutical companies’ experience in terms of sales representatives and managers interaction with the general practitioners, the brands of the product and the company, the numerous informational resources (the internet, specialized periodicals, brochures and ads, scientific events locally and abroad, etc.), the price of the medical product, as well as that of generics, were studied. A wide-range literature review of the theories on consumer buying behaviour was done. Three recent studies on the doctors’ decision influencing factors in the healthcare sector were analysed and compared to the results of the current research. 194 self-administered questionnaires were gathered – 97 in Sofia, 48 in Plovdiv and 49 in Varna. Questions serving as a basis for replication of previous research and for comparison of results were used. Three completely different decision processes were being evaluated. The first situation presented choosing between several products, the second one reveals a case of two ethical companies’ original products and the last one concerned the challenge of deciding between an original product and a generic one. Data comparative analysis shows that the influence of the interaction with sales representatives together with personal experience with the product and local and international events proved to be the most important factors determining Bulgarian general practitioners buying behavior and decision. The implications of these results are discussed and future research suggestions are being provided.

Keywords: Motivational factors, buying behavior, general practitioners, Bulgaria

INTRODUCTION

Nowadays, the pharmaceutical industry is considered to be one of the biggest and most profiting industries (Johnson et al., 2011). The welfare of  society, hence its most important ingredient – people’s health – is being directly influenced by the actions of different participants in the healthcare sector business (WHO, 2013). Industry marketing expenditures are incredibly huge, according to one US study (Manchanda et al., 2005). The results from it showed that the sales force expenditures ($ 7 billion annually) and media advertising costs ($ 2.8 billion annually) are bigger in comparison with any other industry. The participants in the process of selling and buying medicines are under the big impact of a number of influencing factors, each one playing a substantial role in the buying decision process (Evans et al., 2013). The list with the players in the pharmaceutical business, apart from the end-consumer (the patient), is quite long and consists of medical products producing companies, the physicians, governments and municipalities, state and private healthcare insurance funds, distributors and privately-owned pharmacies.

The lack of good practices and treatment guidelines in Bulgaria leaves doctors in a situation of taking decision based on information from different sources, often contradictory . Thus, prescribing a medicine has turned out to be a reflection of the skills and efforts of the companies’ sales representatives and their managers’ marketing and sales philosophy excellence, rather than an evidence-based medicine result. General practitioners are under the heavy influence of the huge amount of information being delivered over numerous channels by the pharmaceutical industry, but still Lodorfos et al. (2011) argue that real buying decision on which medicine would be prescribed is actually very often based upon marketing tricks stimuli used by the drug-producing companies and their local distributors.

The main purpose of my research is to critically assess the buying decision motivating factors as per Bulgarian doctors, and especially general practitioners, exerting influence on the process of prescription of medicines or initiation of a certain treatment. It also aims at identifying the relative weight for the treating physician of each of the factors suggested as a result of recent similar studies review. Thirdly, the research will present a comparative analysis (Saunders et al., 2009) of the degree of importance of those factors within the different groups of general practitioners divided on the basis of location, age, gender, income, number of patients in the practice and time to process patient’s documentation.

Any research on the factors motivating people to reach a buying decision in the field of healthcare requires understanding of the way medical practitioners think and come to a conclusion which treatment is better, hence which product will be prescribed. The process is quite different for the hospital specialists on one side, and the outpatient care physicians – the general practitioners (GPs), on the other. Nevertheless, all of them are under the influence of the pharmaceutical companies (including an army of sales representatives and managers), the enormous amount of information available via numerous sources (the internet, specialized periodicals, brochures and ads, scientific events locally and abroad, etc.), the ever continuing process of medical product price fluctuations, and last but not least government efforts to cut down spending by either limiting funds and resources or via a policy of wider usage of cheap generics.

Doctors are suffering from the implications of the ongoing financial crisis, and the greatest majority of general practitioners are widely depending on the limitations in most of the NHIF-reimbursed examinations, treatment options, procedures and regulations in Bulgaria (NHIF, 2012). Bulgarian doctors have already been once adversely affected in the past by the harsh economic changes (Milanova, 1999). Frequent price changes, the registration of a great number of new foreign brands (NHIF, 2013) and ever continuing changes of the product and different formulations range (BDA, 2013) have additionally raised physicians’ confusion. The high level of deceptive advertising, the constant closures of pharmacies as well as the increasing number of general practitioners and young doctors leaving the country for economic reasons (Medical News, 2013) adds on to the feeling of uncertainty and further makes it more difficult for physicians to make their buying decisions on the basis of clear motivating factors and evidence-based information. For many of them this market reality is quite unfriendly and deserves considerable adjustments in their own decision making process. Bulgarian doctors have reacted to the pressure and distress following limitations, lack of funds or predictability in different ways of adopting their buying decision process, which makes the current research very interesting and in line with the changing environment.

My main goal is to outline and evaluate the specific factors motivating Bulgarian general practitioners in their everyday decision making (prescribing) process. to find the relative weight of each factor in the different groups of general practitioners, assessing the influence of age, gender, income, location, etc., and to estimate the relative value of each of these factors in different buying situations.

Literature Review

Nowadays, general practitioners are facing a situation of over production and offering, which in turn leads to almost entirely psychologically and emotionally driven buying behavior (Solomon, 2011). Managers should evaluate exactly how the ad, the changes in packaging, different promotions, and any other stimuli affect the demand and the customer’s buying decision. The different choices that general practitioners make could be controlled and directed by the careful managing of the marketing stimuli mentioned above (East et al., 2013). Certain past purchases driven association with a product might lead to a typical buying decision based on habit (Blythe, 2013). Such behavior excludes planning and diminishes experiments, saves time, gives a feeling of safety and leaves space to concentrate on more complex decisions (Payne et al., 2013). Continuous or intermittent reinforcement of the stimuli together with shaping and modifying the process, finally shifting it to the desired direction (East et al., 2013, p.13), is what marketers real job is about. This is the way that a doctor might be persuaded and convinced to see a new problem and seek for the best solution.  A number of other factors (social, economical, political, technological, legal),subject to PESTEL analysis, exert specific influence on the customer and his decision to buy, but processes in the head of the customer are being more or less ignored according to the stimulus-answer model. Companies cannot limit or manage the environmental factors, but those should be for sure investigated and their influence upon the buying process should be foreseen. The effects of the stimuli are easy to measure – the place to buy, the amount of goods bought (prescriptions written down), brand choice and brand loyalty - but the exact process in the mind of the doctor still remains unclear. Finally, these factors exert different influence and effect on the different doctors. One would get happy of what the stimuli have provoked and that would result in a prescribing decision. Another doctor might feel that this is only interesting information to be kept for the future. A third one might even not notice the respective stimulus or marketing mix element. One very interesting example in this respect is the effect of the growing usage of Internet. East et al. (2013) claim that thanks to the World Wide Web, customers and particularly doctors could very fast consult and make much better choices in terms of product brands, price, availability, etc. However, it is still not quite clear how and to what extent this process actually happens. The described model could comparatively well be used to predict marketing mix influence on the doctors as a group, rather than as individual customers. Finally, the model shows how choices and decision could be modified and controlled by certain environmental factors in favour of a specific alternative over another. Changing doctors’ current beliefs by modifying or changing their current needs might well work for some of them but could produce limited results for others.

Prescribing a medicine or picking up a definite alternative treatment is a long process starting with need recognition and ending with all the post-purchase thoughts and feelings a customer comes upon. Being involved in all of these stages is what marketers and sales teams in every business are focusing their efforts to create and gain competitive advantage of their products.

Many authors (Evans et al., 2013, Kotler et al., 2014; Armstrong et al., 2013) insist that the features of the products turned skillfully into benefits satisfying certain needs lie in the basis of customer alternatives’ evaluation process that leads to the final buying decision. This is the time for the customer (a general practitioner) to compare different products. During this problem-solving stage, the consumer is picking up alternatives on the basis of psychological and functional benefits (Solomon, 2011). Hence, the brand name of the product usually provokes in the mind of a customer meeting of specific needs. Most naturally what follows as an outcome of the above explained process is a purchase or a prescribing decision, which, in fact, presents a process of choosing an alternative – a product or a service, combined well with adequate timing and method of purchasing (Payne et al., 2013, p.138).

In my experience, working for a number of pharmaceutical companies, the pyramid of Abraham Maslow together with 80/20 Pareto rule are probably the two models all sales and marketing people have been taught about right from the beginning of their induction trainings, and both of them are still the most accepted and widely recognized by internal and external coaches and consultants in their efforts to show what drives customers in our world oversaturated with information. As per Maslow (Mullins, 2005), buyers are much more interested in somebody meeting the highest levels of their own pyramid – the self-actualization, rather than their physiological needs.

Fine experience with a specific medicine, reported by a key opinion leader in the field of medical science, has been reported to be the most valued reason, as 67% of doctors found it the best motivator to choose between different medicines in their everyday practice. This was reported by a study recently carried out in Bulgaria among 100 general practitioners. The same study included a number of other factors to be assessed as customer behaviour drivers of this particular group of customers – the doctors. Those were as follows, pharmaceutical companies’ local seminars and events, congresses and symposia held abroad, information available on internet, short educational courses, specialized periodicals, the brand name of the company and of the product, the sales representatives, brochures and gimmicks, and last but not least personal experience with the respective medicine. Other conclusions of the authors of that study were that doctors are very practical, and brand loyalty (33% of the respondents) and pure scientific information (21%) are far less important than their personal satisfaction following attendance of specialized events held in exotic destinations abroad (66%), and even sales representative skills excellence (58%) is perceived as the ability to ensure more such experiences. Getting invitations for any kind of scientific symposia combined with new scientific data, delivered by a KOL was looked upon as the perfect triad of factors influencing the prescribing decision.  Most astonishingly, the needs of the patient as the final consumer of the product are being considered as a moderate-weight factor (44%) motivating the doctor for the final decision.

Similar results were found in a study conducted in the second half of 2012 by the leading research company in the field of pharmaceutical industry – IMS (Intercontinental Medical Statistics).Personal experience with the respective medicine (67% of the answers) together with personal relations with company repreventatives (55%) seems to be the winning combination in the minds of the prescribing physicians. Going deeper into the study results, it was clearly underlined that the more often competent sales representatives make face-to-face visits to the doctors and the more frequently the managers of those companies see the physicians, the higher the numbers of prescriptions of the respective company products are. Another major factor (63%) enlightened by the study as a leading motivator was the participation in short scientific events in Bulgaria.  International congresses and symposia were important for 60% of the respondents.The results of the same study clearly showed that getting information from specialized medical magazines accounted for less than 1% of the reasons upon which doctors make a final decision on the best treatment for their patients .


According to Corporate Executive Board members of the leading Swiss pharmaceutical company F. Hoffman La Roche, customers do need a highly differentiated sales experience (Roche, 2013) and it is the greatest reason for the buyer loyalty. It was found out in a recently held internal study (Roche, 2013) that 53% of the customer loyalty was driven by sales experience, and company and brand impact accounted for only 19% of the customer loyalty contribution factors. Another 19% were reported due to product and service delivery, whilst benefit-price ratio was important for 9% of the doctors only.

Source: Roche (2013)

METHODOLOGY

For the purpose of this paper, I have decided to use a survey (Lancaster, 2005) as the strategy of my research. It is often associated with the deductive approach, also used by me in this paper. It requires less administration and data gathering time compared to other strategies (Saunders et al., 2009).

The objective of my paper has influenced the selection of quantitative data collection (Ghauri et al., 2005), provided the usage of the convenience method of approachability (Burns et al., 2012). The quantitative method is superior to the qualitative one (Collis & Hussey, 2009) for standardised analysis. In contrast, qualitative research aims at collecting detailed information by the means of open questions and in-depth interviews with a comparatively limited number of responders, therefore a smaller sample (Ghauri et al., 2005).

The survey population is formed by medical practitioners - the general practitioners working in the three most populated towns in Bulgaria. It might be a matter of a further research to find the differences between doctors working in the big towns and in small places and villages. Nevertheless, for the purpose of the immediate research and comparability, I have chosen to stay with the big cities physicians only.

I was granted a good access to the respondents in the study thanks to my personal contacts with physicians all over Bulgaria and especially in the three cities chosen for the research, which was a result of my working experience of nearly 15 years in the field of pharmaceutical industry.
The sampling frame of this research is based on the general practitioner lists in the top three towns in Bulgaria in terms of (number of people living there) – Sofia, Plovdiv and Varna. The sample frame was selected from the database of the National Health Insurance Fund which is publically available and is formed as a gathering of the official lists of physicians registered in the Regional Healthcare Centers.  Based on the central limit theorem (Saunders et al, 2009), I concluded that the sample should exceed 30. The respondents’ target group has all the elements of the population we are looking for (Malhorta, 2010). The number of general practitioners in Bulgaria is a little over 4000, so it was not hard at all collecting the number of answers targeted.

The non-probability method of sampling was used (Kothari, 2004), which granted a freedom of picking up from the list of general practitioners only those who see more than 1000 patients monthly and made sure we have the right selection of doctors. Thus, the sample choice was determined by the research strategy and the questions. A greater number of people were contacted to ensure the targeted response numbers would be met.

The convenience method of approachability (Burns et al., 2012) was used and quantitative data were collected from a given cohort (Ghauri et al., 2005) of general practitioners in Sofia, Plovdiv and Varna. The targeted total number of people was 200, divided into three as follows – 100 doctors from Sofia, 50 from Plovdiv and 50 from Varna.

Choosing a qualitative research method to get more detailed information through in-depth interviews and open questions would have been an alternative that could not fit the targets of my research. This method presents many limitations in terms of the low number of responders, hence a smaller sample (Ghauri et al., 2005).

The questionnaire was divided into three parts as follows: Part One – multiple choice questions to determine which factors are motivating general practitioners to decide which medicine or treatment regimen is better; Part Two which consists of thirteen multiple-choice questions to measure the weight of the different factors listed; and Part Three presenting questions to depict the social-demographic characteristics of the physicians that have responded to the survey.
As already mentioned in the sampling size section, the fact that only physicians from the three biggest cities in Bulgaria were included in the sampling frame makes the study partially representative and brings out the concern for the external validity of the research (Saunders et al., 2009). Thus, it has no value representing the opinion of general practitioners from the middle and small size towns and the villages, where the results might be slightly different to those of the chosen sample. However, the sample does produce enough representative picture and the answers to the research questions would most probably do not deviate much from the answers of the whole general practitioner cohort, if studied in detail.

FINDINGS AND ANALYSIS

The actual number of answered questionnaires collected was 194 – 97 in Sofia, 48 in Plovdiv and 49 in Varna. Hoping for 200, the number achieved represents 97% of the total targeted, and the same implies for Sofia (97%), with 96% for Plovdiv and Varna.

The number of respondents suits the purpose of the MBA dissertation, but the results would have presented a much more detailed picture of the factors motivating doctors in their prescription habits, should there be enough time and resources to address also a representative number of specialists in the public and private hospitals. The different working environment of the general practitioners and the hospital specialists on one side, and the strikingly different conditions between public (government or municipal) and private hospitals for doctors working there on the other, would make a future research in the field utterly interesting and perhaps would produce somewhat different results.

Overall, women were more responsive accounting for 55% of the cohort (107 answers). The male/female distribution city by city was as per the figures below with male prevalence only in Plovdiv 58 to 42%.

The age characteristics of the respondents show that nearly 75% from all participating doctors are between the age of 36 and 65 years old, which ensures a good coverage of the most active part of the doctors.  A little over 11% represented the group of the “over 65” or the most experienced ones.

As many as 45% of the doctors enjoy comparatively big practices and practically have over 2000 patients in their practices. At the same time we have in our cohort 25% of respondents who have less than 1500 patients in the practice, a finding that gives a good opportunity to compare both groups in terms of prescribing habits, time to process a patient and finally yearly income. The overall number of patients’ distribution remains the same city by city which means that the doctors chosen from the three biggest cities are comparable in that respect.

More than half of the respondents (54%) reported a yearly income of more than 25000 BGN, and even one fourth of the physicians make more than 30000 BGN per annum. The intercity deviations show higher percentages for the “25000-30000 BGN” group in Sofia and Plovdiv – 32% and 31% respectively, whilst the “above 30000 BGN” group accounts for 21% only in Varna, which is a little bit awkward given the results of the ever increasing GDP per capita locally in Varna for the period 2001-2011 (NSI, 2013).

A very interesting factor is the time needed by a respondent to fill in the documentation including the writing of a prescription once the physical exam of the patient has been finished. It seems that it takes a different amount of time for the respondents, the cohort being   approximately equally divided between the three possible groups – up to 10 minutes, 10 to 15 minutes and above 15 minutes. Nevertheless, the National Healthcare Insurance Fund requirements for filling documentation (The National Healthcare Insurance Fund of Bulgaria, 2012) are “eating up” a considerable amount of the doctor’s time, with more than 68% of the physicians wasting more than 10 minutes per patient in paperwork. All this diminishes the time for real prescribing decision making, which in turn pays a certain role in the customer behavior process amongst those people.

What I find really important is that 47 out of the 64 respondents(75%) who needed less than 10 minutes for documentation, enjoy income of more than 25 000 BGN annually.

Three practically completely different motivating factors decision processes are being assessed in my study. The first one concerns the situation when a general practitioner has to decide on a best treatment or medicine irrespective of the brand name of the company or the product or the number of competitor products available. The second one pictures a specific case when the decision has to be made between two ethical companies’ original products. The last one presents the respondents with the challenge of choosing a better medicine between an ethical company original product and a generic company product. The results proved the coincidences in all three cases, but a number of important differences were found which will be discussed in detail. Price was deliberately omitted of the first question and deliberately included in the other two, as far as the research was aiming at finding non-financial key motivators for the general prescribing decision of general practitioners in the three biggest cities in Bulgaria on one side, and was evaluated in the situation of direct competition between two products, on the other.

Thirteen factors which motivate doctors in their decision to choose a treatment or medicine have been listed in the first question of the study. Those were as follows:

  1. key opinion leader shared experience
  2. your participation in seminars and eventsin Bulgaria, organized by scientific societies
  3. your participation in stand-alone seminars and eventsin Bulgaria, organized by pharmaceutical companies
  4. your participation in congresses and symposia abroad
  5. articles read on the internet
  6. your participation in short 1 to 2 days educational courses
  7. specialized periodicals (magazines)
  8. the brand name of the product
  9. the brand name of the company producer
  10. frequent face-to-face visits by competent sales representatives
  11. visits by the managers of the pharmaceutical companies
  12. brochures and advertising materials
  13. your personal experience with the respective medicine

Respondents were asked to underline all relevant answers helping them to decide on the best treatment. Later on every single factor of the above list was evaluated by its importance on a five step scale from “not important” to “very important”.
The results from the first question are shown in the figure below.

For 80% of the general practitioners living in the three biggest cities, the key motivating factor for their prescribing decision is the pharmaceutical companies own seminars and symposia in Bulgaria. Physicians consider personal experience with the medicine as the  second most important reason (74%) thus, in combination with the first factor, proving the existing secondary data results (Roche, 2013; TNS, 2012; IMS Health, 2012). Relations with the companies’ sales reps (68%) remain another solid influencer onto the process of making buying decisions. The latter, combined with the 44% of doctors who would like to be visited by the managers of the companies, proves the importance of recognition by the partners in a process (Mullins, 2005; Armstrong et al., 2013) via more frequent visits. Key opinion leaders experience is essential for a little more than half of the responders (53%), and almost equal number of doctors prefer getting scientific information directly from the source – the internet (47%) or Bulgarian scientific societies’ events. Company brand name is important for 40% on average, though there are considerable differences city to city (Figure 13), which will be discussed further on. Congresses abroad are valued by less than a third of the general practitioners (30%), almost as equal as the product brand name and the short educational courses. Specialized periodicals and product brochures and ads are practically seldom considered as a motivating factor (24% and 9% respectively). This fact surprisingly coincides with some of the studies available (Roche, 2013; TNS, 2012).

Almost all motivating factors being underlined by doctors as “meaningful” in the process of buyer decision making, were rated “important” or “very important” in the questionnaire with a ratio of 30% to 70% respectively. That means that a little more than two thirds of the respondents considered their chosen motives as really “very important”. There is a clear result that doctors above the age of 55 present higher percentages of the “very important” choice (above 72% on all answers), whilst younger doctors are much more confident of what is “not important at all” – more than 76% of the cases. Surprisingly to me, the percentage of the “I cannot tell” answer to any of the thirteen motivational factors is way below 10% with two interesting exceptions – one being the Internet (18%) and the other one being the scientific congresses and symposia abroad (17%).

More than half of the people who earn more than 25000 BGN yearly come from Sofia (54%) and the doctors from Plovdiv and Varna with such an income are almost equal in numbers (24% from Plovdiv and 22% from Varna). It is obvious that in this respect again, there is a clear distinction between the capital and the rest of the country.
Finally, doctors earning more than 25000 per year are motivated by a bigger number of factors (82% of them choosing more than 6 factors), which proves the initial hypothesis (Burns et al., 2012) of my research that the final buying decision of the general practitioners in the three biggest Bulgarian cities is formed by a combination of a number of factors.

 

As shown in figure 10, 80% of Bulgarian general practitioners value the local stand-alone seminars organized by the pharmaceutical companies as the most important reason why they choose a medicine as the best one. Obviously, those events are considered to provide enough scientific information on one side, and on the other as a good place to share experience and information with the colleagues. Being usually organized in nice places, these events are also considered as a good way of combining learning with having good time. Proving the theory that buying behavior is a process of making decisions and acting accordingly as a result of already existing purchases and usage of products, hence on the basis of one’s own experience (Baines et al., 2011), doctors were found to put their own personal experience with the medicine on the second place (74%). I observed similar result in the case when general practitioners were to choose between two original products (79%), but the picture was totally different compared to the situation when a generic product was included as an option (32% only). Probably, the most consistent finding in all primary and secondary data results is the importance of the interaction with the companies’ sales reps and their influence on the decision process. Absolutely all studies present the importance of the personal relations with the sales reps (Roche, 2013; TNS, 2012; IMS Health, 2012). Contemporary world customers are facing a situation of over production and offering, which in turn leads to almost entirely psychologically and emotionally driven buying behavior (Baines et al., 2011; Kotler et al., 2013;). Differentiated sales experience importance in the minds of the customers gives the sales representatives a unique opportunity for driving loyalty by delivering insight (East et al., 2013; Evans et al., 2013; Blythe, 2013). This means offering unique and valuable perspectives, navigating through alternatives, helping in avoiding potential problems, widespread support. Thus, competent sales representatives and managers of a company are more and more key-account focused and are continuously optimizing the business around each customer, going and fighting for share of customer.

Sources: Roche (2013), TNS (2012), IMS Health (2012)

Sales force experience is one of the two motivating factors that are being evaluated in all primary and secondary data reviewed. The second one is the brand name of the product. Another 2 factors (personal experience with the respective treatment or medicine and attending international congresses and symposia) have been studied in at least 3 of the four researches. All these results are summarized in the following chart as a comparison of the major motivating factors from the current paper with all other available studies.

Sources: Roche (2013), TNS (2012), IMS Health (2012)

The findings of my study clearly confirm the pattern of influence of sales reps contact (Collins, 2001; Baumgartner et al., 2012) and personal experience with the product (Baines et al., 2011) on the buying decision of the general practitioners. Product brand name is obviously considered as a far less motivating factor amongst all doctors, contrary to the understanding of a number of people of thought (Payne et al., 2013; Kotler et al., 2014; Armstrong et al., 2013) that skilful transformation of brand product features to product benefits lies in the basis of customer alternatives’ evaluation process. One of the most interesting finding observed was the very low motivating value of the international congresses and symposia participation as a kind of specific need satisfaction (Hoyer et al., 1997). Only 30% of the respondents in my research consider it important, which could be explained either by the fact that general practitioners are rarely being invited to such events, or by the idea that they are so busy working that they cannot afford losing a considerable amount of time travelling abroad. Only 20% of the doctors from Sofia value this factor, with Plovdiv and Varna physicians find it a little bit more important. Young respondents practically neglect it at all (only 4 of the 71 doctors up to the age of 45 underlined it in their answers). Presumably, the percentage would have been much higher should hospital specialists are included in the study, which might be a good basis for further research.

As many as 44% of doctors would also reflect the importance of the visits of the managers of the pharmaceutical companies, though the lower percentage shows much more practical approach on this matter. Doctors do prefer to interact with immediate partner, rather than his or her boss. Therapeutic area experts (KOLs) opinion is valuable for more than half of the doctors (53%), but the percentage shows than the other half makes buying decision based on other evidences, presenting a clear independent way of making-up one’s mind of the general practitioners. This is immediately seen in the next two indicators - scientific information is derived almost equally from the internet (47%) or from the local scientific societies’ events (46%). Contrary to that, specialized magazines are an important influencer for less than a fourth of the responders (24%), and company produced ads and materials (brochures, hand-outs, leaflets) are virtually put in the trash immediately after being presented by the sales rep (9%), both of these facts proving entirely secondary data findings (Roche, 2013; TNS, 2012). Brand names of the company and the product are less important for the general practitioners in the overall process of decision making. Nevertheless, I found clear differences in the product brand name’s importance between Sofia (32%) and the rest of the country (Plovdiv - 23%, Varna – 22%), both these factors lay far below in the mind of Bulgarian general practitioners.

There are some other major differences (Fig.13) city-to-city concerning the answers of the first question. Though universally accepted and acknowledged as one of the most important motivators (Stanton et al, 1994; Armstrong et al, 2013), doctor’s good relations with the responsible sales representative show some differences inside the big cohort. Respondents from Plovdiv differ by more than 10% on this factor, and at the same time show lower percentages in a couple of others - key opinion leaders experience and the internet as sources of information. The same doctors like to meet the managers of the companies, probably proving the theory that the respect shown by other and especially by managers is highly appreciated and needed (Mullins, 2005; Collins, 2001; Kotler, 2013). Sofia general practitioners show a different tendency. They show a lot less interest in the managers’ visits, perhaps due to the fact that living in Sofia makes those interactions more frequent and not so fruitful. It is also very interesting that Sofia doctors are still keen on reading specialized periodicals (28%) and brochures (12%) almost twice as more as their colleagues from Varna (20% and 4%) and Plovdiv (19% and 6%). All these results are shown in figure 13.

When it comes to buying decisions concerning picking up the better medicine out of two specific ethical companies’ products, I found big differences in the behaviour of the doctors as customers compared to the above findings. My respondents (Fig. 14) chose almost equally important to be their own experience with the medicine (79%) and good personal relations with representatives of the company (76%). This corresponds very well to the findings of the study done by Intercontinental Medical Statistics – Bulgaria (IMS Health, 2012), that two of the most powerful decision driving factors are the doctor’s experience with the medicine (67%) and good personal relations with sales repreventatives from the company producer (55%). The latter figure also confirms the findings in the Roche study about the interaction with the sales force (53%) as a key motivator (Roche, 2013), which is named sales experience and particularly emphasized by Baumgartner et al. (2012). Baines et al. (2011) and Kotler et al.(2013), on the other side, point that a great deal of decisions are taken on the basis of one’s own experience. At the same time, price (31%) and the distributor (25%) are clearly viewed as of much less importance compared to the other factors. The Roche study reported even smaller figures – only 9% were motivated by the price and 19% by the product delivery (Roche, 2013).

The big difference comes with two other factors - the brand names of the company and the medicine. In my study, nearly 60% of the respondents find them very important when choosing between two original products (Fig. 5.4). This could be as a result of the question being widely asked and not focused on particular brand names, or on the fact that doctors would pretend they do not follow brands as reasons for their decisions officially, but are more sincere when reporting it for an anonymous study.
The overall distribution was as follows:

Another interesting finding is that only 5% of the respondents chose only one factor of the five possible. Those doctors – a total of 10 - are equally distributed between the three regions, 9 having more than 1500 patients in their practices, and all of them having yearly income more than 25000 BGN. The major “only” factor was again the sales force experience with one single customer claiming price is the key driver. Interestingly, all but one representative of this group needed less than 15 minutes for documentation. On the other hand only 3 people (1,5%) chose all factors as important for their decision when picking up a better treatment between two original products. This means that around 95% of the respondents perceive the process as a complex one, the actual buying decision being formed by a bunch of factors, each one of them with different weight (Stanton et al., 1994; Blagoev, 2003; Brassington and Pettitt, 2006; Kotler et al, 2013).

Younger doctors (up to the age of 45), are relying more on the sales experience than their older colleagues (81% versus 67% respectively), whilst more experienced physicians are more in favour of the personal experience with the product and the brand name.

When analysing the buyer behaviour of doctors choosing between two original products, there are almost exactly the same results between the three cities concerning distributor and sales force experience There are clear differences, though, between the results in the capital Sofia and in the country – Plovdiv and Varna when evaluating the importance of factors like the brand name, the price and the experience with the medicine (Fig. 15). Though, price is considered as an important motivator by less than one third of the respondents, the data are showing distinctively lower percentage for the price factor in Plovdiv (27%) and in Varna (31%) as compared to Sofia. On the other hand, results in Plovdiv show much higher results for the brand name (69% versus 55% for Sofia and 57% for Varna) and lower for personal experience with the medicine, which is probably due to the male respondents’ prevalence in Plovdiv. Brand loyalty is found twice as important as the price or the distributor in any of the three cities, a fact showing that the medical society has the typical features of a cast society whose members are prone to choose predominantly socially renown and accepted brands (Brassington et al, 2006).

The picture gets totally different when the buying decision concerns choosing between an ethical medicine and a generic one. The price of the generic medicine gets clearly the highest vote of the respondents with 73%. Second and third most important motivators, when it comes to choose generics, are the company’s reps influence (sales force experience) with 59% (which corresponds to the results in all other studies (Roche, 2013; TNS, 2012; IMS Health, 2012), and the distributor (50%). It seems that here the winning combination includes the efforts of the producer and the power of the wholesaler both in the direction of better service and lower price. As far as the increased use of generics is what governments are aiming for (Johnson et al, 2011), and their practices and legislative actions go in that direction, the brand name (41%) and the personal experience with the product (32%) mean a lot less for the treating physician. This is a direct result of the government policy of price reduction and protection of local companies (Johnson et al., 2011, p. 550)

One fact about the results worth pointing at, concerning doctors’ buying behaviour when choosing between an original and a generic product is that only 4 people (2%) underlined all factors as important for their decision. The one common thing between those doctors was the number of patients in their practices – over 2000. Another 19 doctors (10% of the cohort) are influenced by one major factor and for 12 of those 19 (63%) that was the price. 11 out of those 12 price-sensitive doctors (92%) make more than 25000 BGN per year.

We see a colorful pattern of both decision-important factors and city-by-city percentage distribution of the different factors’ importance when general practitioners should choose directly between an original and a generic medicine. In this case price sensitivity is alike and occupies the first place in the minds of the doctors. Clear discrepancies appear in the percentages of the answers of doctors living in the capital Sofia in light of the factors concerning the influence of the companies’ representatives (55% in Sofia against 63% in Plovdiv and 65% in Varna) and the power of the distributor (39% in Sofia against identical percentages in Plovdiv and Varna). One good explanation could be the higher number of reps and distributors’ offices and agents concentrated in Sofia, due to the fact that the head offices of those companies are situated in the capital. The process of human resources allocation and rightsizing in the different companies in the pharmaceutical sector obviously favours the generic ones, which rely on both own sales force and the network of their distributor (usually their own trade company).

Despite all differences of the two cases when general practitioners had to choose between clear alternatives, all of them fall perfectly into the patronage motive group (people looking for the experienced sales people, good services, the price, etc) of the Stanton et al. (1994) model, confirmed by the conclusion that people buy only benefits of the products to meet their personal needs (Collins, 2001; Kotler et al., 2013; Payne et al., 2013).

 

CONCLUSIONS AND RECOMMENDATIONS


The basic conclusions are as follows:

  • 95% of the respondents perceive the process as a complex one proving my initial research hypothesis, the buying decision being influenced by a bunch of motivating factors with different relative weight (Stanton et al., 1994; Blagoev, 2003; Brassington and Pettitt, 2006; Kotler et al, 2014).

  • 80% of the general practitioners in the three biggest cities (Fig. 10) find pharmaceutical companies’ own events as the most important decision motivator.

  • Doctors’ own personal hand-on experience with the medicine (Fig. 10) is considered the second most important motivating factor (74%) proving the existing secondary data from similar studies (Roche, 2013; TNS, 2012; IMS Health, 2012).

  • 68% of the physicians (Fig. 10) pay great attention to their relations with the companies’ sales reps and another 44% care for the managers’ visits, thus satisfying their personal recognition needs (Mullins, 2005; Armstrong et al., 2013).

  • Key opinion leaders experience was valuable for half of the responders (53%) which showed both independence of opinion and still valuing expert’s advices (Fig. 10).

  • Almost equally 47% of the doctors prefer trusting the internet for reference (Fig. 10)

  • Bulgarian scientific societies’ events (Fig. 10) mean something for 46% of respondents, though considerable intercity differences are observed.

  • The same applies for company brand name (Fig. 10)

  • Congresses and symposia abroad, as well as product brand name and short educational courses, are addressed as important decision motivating factors from less than 30% of doctors (Fig. 10), which is an interesting niche for the companies to fill in.

  • The almost complete uselessness of specialized periodicals and product brochures was found (Fig. 10), as 24% and 9% respectively do not read them at all, which surprisingly again proves the results of other available studies (Roche, 2013; TNS, 2012).

  • Picking up between two original products (Fig. 14) showed the equal importance of one’s own experience with the medicine (79%) and good personal relations with representatives of the company (76%), corresponding with the findings of IMS Health (2012), Roche (2013) and the theory (Baumgartner et al., 2012; Baines et al., 2011; Kotler et al., 2013).

  • Price gets the highest vote of respondents (73%) choosing between an ethical and a generic medicine (Fig. 16), with second and third most important motivators being company’s reps influence and the distributor – perfectly matching similar studies’ figures (Roche, 2013; TNS, 2012; IMS Health, 2012).

  • Doctors outside Sofia (Fig. 17) reflect highly the influence of the sales force, the power of the distributor and product brand name making it crucial for the ethical companies to work on harmonizing human resources allocation and rightsizing.

 

Altogether, though with small variations in the different situations (Fig. 10, Fig. 14, Fig. 16), Bulgarian general practitioners’ buying behavior and decisions are highly affected by a number of motivating factors like their participation in local company stand-alone seminars, key opinion leaders’ shared experience and doctors’ personal experience with sales representatives, managers and the medicine itself. Less influence exert factors like the Internet, product and company brand names and local scientific society events participation (Fig. 4.10). Short educational courses, attending congresses and symposia abroad and marketing tools like brochures and advertising materials together with specialized magazines play a minor role for less than one third of the doctors (Fig. 10).

I would recommend that pharmaceutical companies use the results of this research to develop and amend their induction trainings, selling skills courses, and sales force excellence programs accordingly.

I would also suggest that the managers of the companies bear in mind the findings when preparing marketing plans, market access strategies and new product launches to fully match the expectations of the general practitioners in the biggest cities.

I would strongly recommend the product managers of the companies to assess the quality of the brochures, ads and all other advertising materials and gimmicks, and their role as a motivating factor influencing doctors’ buying (prescribing) decisions.

I would encourage the managers of the companies to address the Internet as a factor gaining more and more power each day and start considering seriously the necessity of e-detailing implementation.

I would suggest that medical and marketing departments of pharmaceutical companies turn very specific attention to their own stand-alone events, and include even more evidence-based medical information and key opinion leader shared experience in their programs to achieve sustainable effects.

I would recommend that the same medical and marketing departments reevaluate the importance and potential benefits of international congresses and symposia attendance by the GPs, given the results of my research.

I would be happy to see as a result of the analysis of this work that Bulgarian medical societies and Bulgarian Doctors Union sharply and thoroughly change the philosophy, organization and management of the educational courses program they are carrying out.

I would sincerely hope that the results could well serve the medical authorities, and especially the National Health Insurance Fund and the Ministry of Health when considering the new 2014 contract on the reimbursement of medicinal products in outpatient and hospital care in Bulgaria.

 

 

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