ABSTRACT
Recent academic and practitioner studies have implied that customer relationship management (CRM) provided improved business opportunity yet it has received sundry performance reviews in the present literature. The pharmaceutical industry, in Bangladesh, is in the midst of fundamental changes. Situational regulations have been placed for decades that minimize pressure from competitor companies, and application of modern information technologies that improved the customer knowledge about better service, force the pharmaceutical companies to build relationship with their key customers, such as physicians. This research explored the affiliation among CRM philosophy acceptance, market orientation and relationship marketing, and the subsequent impact on business relationships and relationship performance. A strategic model was developed based on the literature and information obtained through interviews.
Key words: Customer relationship management (CRM), hospital pharmacy, physician
Pharmaceutical corps, as a very rapid growing sector in Bangladesh and as a part of export industries, to comply with the global competition, has to upgrade themselves and also need to use modern sophisticated strategies. Customer relationship management (CRM) is such a philosophy which helps a company to best deal with its level of customers. To create a framework that estimates the relationship between service qualities attributes, customer satisfaction, retention and loyalty, and to conduct customer segmentation, CRM is a very important tool of modern marketing. Being in institutional regulations and competitive pressure forces, pharmaceutical companies need to adopt customer oriented strategies.
Market orientation in the pharmaceutical sector differs from any other market, as pharmaceutical companies cannot directly sell their products to consumers; rather sales depend on the prescription of physicians and the needs of the patients. In this division, the main customer segments are physicians.
However, the patient's perspective as the end user of the products should be considered, as sales not only depend on the prescription of physicians but also on the needs of the patients. Severity of disease, cost of buying goods, or socio-economic condition of patients are considered to be significant factors that influence the purchasing of any medication. Hence, the responsibility of the pharmaceutical industry for a contribution to a functioning adequate health system and consumers’ access to medicines cannot be spared out. Patients are indirect customers; pharmaceutical responsibility for end user should not only focus on sale/profit, but also economic contribution to health sector improvement. Therefore, a successful pharmaceutical business must arrange its strategy to build a profitable and trustful relationship with physicians. At the same time, it also needs to consider the patients’ need as well as socio-economic condition.
CUSTOMER RELATIONSHIP MANAGEMENT (CRM)
Today, marketing must be understood not in the old sense of making sales – “telling and selling” – but in the new sense of satisfying customer needs (Kotler, 2007). Marketing, according to Kotler, is the process by which companies create value for customers and build strong customer relationships in order to capture value from customers in return. Hence, in these modern days, companies are very much interested in building a relationship with customers and maintaining it for long. Customer relationship management (CRM) philosophy comes forward with a view to handling the relationship with customers.
CRM applications, which are relatively new, were visualized for the first time in the 1980s, but only attaining marketing prominence in the late 1990s, primarily due to progresses in information technology, data management systems, better analytics, enhanced communications, systems incorporation and the rapid adoption of the Internet (Berry, 1995). Another commonly used definition is given as: “CRM is an approach or business strategy which provides seamless integration of every area of business that touches the customer” (Bose, 2002). Grönroos (2004) explained that an on-going relationship amid customers will aid in providing a sense of security, trust and feeling of control. Xu and Walton (2005), through studies, have concluded that the key reasons that CRM implemented by corporate managers are as follows:
1. Comprehend customers’ needs,
2. Preserve existing customers,
3. Attract new customers,
4. Persuade former clients back into the fold,
5. Reduce customer management costs and increase profits through customer satisfaction.
In pharmaceutical industries of Bangladesh, physicians are considered to be the key customers; major amount of medicine purchase is done by patients according to the prescription written by them. Consequently, physicians’ relationship with pharmaceutical companies is the driving force of the industry. The rationale of this research is to explore this relationship.
Specific research objectives
The key relation cascade, in pharmaceutical industry, flows through pharmaceutical companies - physicians - patients. The objective of this thesis is to explore this relationship and its critical factors including:
1. Assessment of physician-patient relationship,
2. Choice of a medicine brand,
3. Handling procedure of customer complaints,
4. Importance of call centers to pharmaceutical-physician relationship,
5. Electronic procedure of collecting and restoring patients’ information,
6. Satisfaction of the physicians while prescribing a company's product,
7. Introduction of health insurance may improve service quality to patients,
8. Implementation of e-customer service,
9. Structure IT and analytic keeping with the patient confidentiality and privacy.
Changes are compulsory regarding policy, processes as well as system design. To build up an integrated CRM strategy, this research draws on elements from established business redesign.
Broad objective
To provide the best possible products and services to the customer segments, identify the role and length of relationship with customers, and factors guiding their satisfaction.
According to Zikmund (2000), research could be done either to explore, describe or bestow details of a particular phenomenon.
Exploratory research
Robson (2002) described exploratory research as a valuable means to find out what is happening, to seek new insights, to ask questions to evaluate phenomena in new light, to generate ideas and hypotheses for future research. Zikmund (2000) on the other hand, defined exploratory research as a lesson conducted to clarify ambiguous problems. According to him, an inquiry for conclusive evidence follows exploratory studies, and it is carried out during the initial stage of the research process; and the initial activities are carried out to refine the problems into a researchable one. According to Samouel et al. (2013), exploratory researches are used to develop better understanding, when there is a little supposition to guide predictions. He further stated by quoting Swaddling and Zobel that “exploratory research presents a system that hooked on consumer perceptions, behaviors, and needs”. Moreover, better understanding of customer offers better decision making power and better acknowledgment of market opportunities in favor of companies.
Descriptive research
Descriptive research, according to Robson (2002) is carried out for portraying a precise summary of persons, events or situations. Zikmund (2000) defines descriptive study as one which depicts the characteristics of a population or phenomenon. Samouel (2013) says that descriptive research uses descriptive information, including frequency counts (how many), measures of central tendency like the mean or mode, or quantify variation resembling standard deviation. Solely, the study is exploratory because of the need to find out 'what is happening’, to seek fresh insights, to ask questions to evaluate phenomena in new light, to generate and figure out hypotheses about customer relationship in pharma-ceutical sector.
The design of the research was developed using the following steps:
1. Questionnaire design
2. Hypothesis
Questionnaire design
There are two crucial objectives of questionnaire design correlated to data quality: First, to diminish non-response, and second, to reduce or avoid measurement errors (Alreck and Settle, 2004)
Questionnaire design process
This is depicted in Figure 1. Information needed for the research has already been clarified in the objective part. In the methodology, the ‘interviewing method’ has already been illustrated. The question structure is a mixture of ‘open ended’ and ‘close ended’ questions. To eradicate complexity as well as wrong meaning, and toreproduce the questionnaire, questions are translated from ‘English to Bangla’ then ‘Bangla to English’ and are tested for language appropriateness. Finally, pretesting is done with the help of selected samples to eradicate bug in the questionnaire.
Example of questions (questionnaire): How do physicians assess their relationship with patients when they come in contact with patients? Answer choices: a) Very Formal. b) Formal. c) Neither. d) Friendly. e) Very Friendly
Research question
Research question 1 (RQ 1): How do physicians assess their relationship with patients while patients visit them in hospitals?
Research question 2 (RQ 2): Do patients use their judgment to choose a particular brand?
Research question 3 (RQ 3): Do general practitioners grant patients’ right to choose medicine brand?
Research question 4(RQ 4): How do physicians handle customer complaints about a pharmaceutical product?
Research question 5 (RQ 5): In hospital areas, pharmaceutical representatives are frequently visiting, how do physicians feel about their movements?
Research question 6 (RQ 6): Are doctors satisfied with various promotional activities of pharmaceutical products?
Research question 7 (RQ 7): Can introduction of health insurance offer better service to customers?
Research question 8 (RQ 8): Do the involvements of electronic procedures for collecting and restoring information provide better patient care?
Research question 9 (RQ 9): What is the impact of call center on physician-pharmacist relationship?
Research question 10 (RQ 10): What are the Physicians’ opinions about the execution of e-customer service?
Research question 11 (RQ 11): What physicians think that online prescription, online appointment service, and online registration to hospitals, physicians and therapeutic search will improve the health sector?
Research question 12 (RQ 12): A pharmacy should be included in every hospital for the elevation of quality of patient care.
Research question 13 (RQ 13): Do physicians think it is essential for the pharmaceutical companies to offer service supports for the specific customer segments?
Hypothesis
The following hypotheses are proposed for Bangladeshi Pharmaceutical Industry based on literature review on CRM.
H1: Patients may be given right to choose his/her medicine brand.
H2: Physicians’ views on the implementation of e-customer service.
H3: Physicians’ opinion about online prescription, online appointment service, and online registration to hospitals, physician and therapeutic search.
H4: Call center plays a vital role in physician – pharmaceuticals relationship.
H5: To attribute more quality service, hospitals should include hospital pharmacy.
H6: Health insurance will introduce better service to customers.
H7: Movement of representatives in hospitals has significant effect on the CRM.
H8: Electronic procedure of collecting and restoring information about patients may increase the quality of medical service.
Research procedures
The following procedures are included in the research methods.
Scaling
As the research is non-comparative and is designed to measure the attitude of customers, hence, 'non- comparative scaling (Likert scale) technique is selected as a sampling technique Neresh (2009)
Sampling
This involves the collection of elements or objects that possess the information sought by the researcher and about which inferences are to be made (Neresh, 2009). For this research, physicians are conceded as the target population.
Sampling frame is a representation of the elements of target population. It consists of a list or set of directions for identifying the target population (Neresh, 2009). Here, the doctors in Dhaka district are conceded as to be representing sampling frame.
Sampling technique
Quota sampling is selected as sampling technique. Quota sampling may be defined as non probability sampling technique that is a two stage restricted judgmental sampling. The first stage consists of developing control categories or quotas of population elements. In the second stage, sample elements are selected based on convenience or judgment. The only requirement is that the ele-ments selected fit the control characteristics (Neresh, 2009).
In the first stage, quotas of control categories – doctors of Dhaka district are selected. In the second stage, some territories of Dhaka district (based on convenience) are selected as the target population, meaning that the doctors, to be selected as samples, must have to work in selected areas.
Sample size
Total number of Physicians in Bangladesh is 22,120 and the number in Dhaka District is 8,203 (Department of Public Health and Social Service).
Sample size formulas for our sample size determination
Here, Z = Z value (1.96 for 95% confidence level), p = percentage of picking a choice, expressed as decimal, in this case, 20% to response (0.2 used for sample size needed), c = confidence interval, expressed as decimal (for example, 0.05 = ±5). Therefore, ss = 246.
Where: pop = population=8203. So, final sample size = 239
Interviews and interview guide
In structured interviews, a predetermined or standardized set of questions was asked; whereas in semi-structured interviews order of questions can be varied depending on the flow of conversation (Neresh, 2009).Consider, for example, the following question designed to measure attitude of doctors toward patients:
How do you explain your relationship with patients?
a) Very Formal b) Formal c) Neither d) Friendly e) Very Friendly
This survey method has several advantages. First, the questionnaire is simple to administer. Second, the data obtained are reliable because the responses are limited to the alternatives stated. The use of fixed-response questions reduce the variability in the results that may be caused by differences in interviewers. Finally, coding, analysis, and interpretation of data are relatively simple (Neresh, 2009).
Depth interview is an unstructured, direct, personal interview in which a single respondent is probed by a highly skilled interviewer to uncover underlying motivations, beliefs, attitudes, and feelings on a topic (Neresh, 2009). Churchill and Dawn (2002) suggests that depth interviews suits exploratory research because freedom is provided to the interviewer in conducting the depth interviews and interviewers may try to follow the rough outline, but the order and framing of the questions can be changed. Saunders (2003) says that an interview can be conducted by meeting the person face-to-face or on telephone. “Face to face interviews” was performed for our data collection. Dutka (1995) has mentioned that depth interviews are face-to-face interviews conducted on one to one basis and a detailed discussion outline must be designed. Accordingly, questions must allow the respondents to state whatever thoughts come to their mind. Therefore, due to the nature of research purpose and research questions, there is a mixture of ‘fixed-alternative questions’ and ‘open ended questions’ which have been selected for in-depth face-to -face interview.
Statistical analysis
Most frequent answers from the physicians of the questions are listed in the Table 1.
Descriptive analysis
The descriptive analysis of the data was undertaken in order to identify any erroneous values.
Reliability testing
The validity of the instrument or questionnaire was first determined using the reliability test by finding out the value of Cronbach’s alpha (Cronbach, 1951) which was found to be reliable. Cronbach's alpha is a measure of internal evenness, that is, how closely related a set of items are as a group. It is a measure of scale reliability. However, a "high" value for alpha does not entail that the measure is one-dimensional. If, in addition to measuring internal consistency, we wish to give evidence that the scale in question is one-dimensional, supplementary analyses can be performed. Exploratory factor analysis is one method of checking dimensionality.
Crosstab analysis
The data collected from the physicians were purely categorical. In Crosstab analysis (Karl Pearson, 1904), dependent variable is doctors’ satisfaction about the promotional activity of pharmaceutical companies (satisfaction), which is categorized into 5 categories, respectively: very dissatisfied, dissatisfied, neutral, satisfied and very satisfied. Category neutral is assumed as reference group. Independent variables are relationship of doctors with patients (relation), patient being given right to choose his medicine brand pharmaceutical companies (brand), doctors evaluation about the movement of representatives of pharmaceutical companies (representative), introduction of health insurances will improve service quality (insurance), electronic procedure of collecting and restoring information of patients may increase quality of patients service (electronic procedure), call center play a vital role in doctor pharmaceutical company's relationship (call center), e-health service will improve satisfaction level of patients (e-health), hospital should include hospital pharmacy to improve patient service (hospital pharmacy), service support for specific customer segment (service), patients choose medicine brand themselves (brand choice), doctors dealing with complaints of patients regarding pharmaceutical products (complaints), doctors evaluation about using internet by pharmaceutical companies to promote their product (e-detailing). These 13 items or independent variables were first found whether they were significantly related to the dependent variable (satisfaction of the physicians) at a confidence level (α) of 0.10% level, using crosstabs analysis. The 7 independent variables identified in the crosstabs analysis were then used in binary logistic regression analysis in order to find which tools used by the industry executives have an impact on the physicians of Bangladesh. The variables that signify in Crosstabs analysis are:
1. Brand.
2. Representative.
3. Insurance.
4. Call center.
5. Age.
6. e-health.
7. Hospital pharmacy
Logistic regression is used to predict a categorical variable from a set of predictor variables.
Multinomial logistic regression
Since Physicians satisfaction about the promotional activity of Pharmaceutical companies (satisfaction) was categorized into five mutually-exclusive groups which carry different implications in customer relationship management (CRM), a multinomial logistic regression was performed to estimate the odds ratio (OR) and 95%
confidence interval (CI) taking ‘neutral’ as reference category (Greene, 2012). The estimated coefficients and their exponential transformations that yielded the ORs are always relative to the reference category. Thus, the odds of a person with ‘satisfied’ to ‘neutral’ is the probability of being satisfied divided by the probability of a person within the neutral category.
Physicians’ satisfaction about the promotional activity of pharmaceutical companies
1. In multinomial logistic regression, depended variable is doctors’ satisfaction about the promotional activity of pharmaceutical companies (satisfaction), which is categorized into 5 categories, respectively: very dis-satisfied, dissatisfied, neutral, satisfied and very satisfied.
2. Category neutral is assumed as reference group.
3. Independent variables are patient with given right to choose his/her medicine brand pharmaceutical compa-nies (brand), doctors evaluation about the movement of representative of pharmaceutical companies (representa-tive), introduction of health insurances will improve service quality (insurance), electronic procedure of collecting and restoring information of patients may increase quality of patients service (electronic proce-dure), call center play a vital role in doctor pharmaceu-tical company's relationship (call center), e-health service will improve satisfaction level of patients (e-health), hospital should include hospital pharmacy to improve patient service (hospital pharmacy), and age.
4. In the table, p-value ≤0.05 is accepted.
5. Variables that satisfy the condition and signify are brand, representative, insurance, and call center.
Interpretation
In Table 2, regarding categories Neutral vs. Very dissatisfied, the estimated value of B = -2.890 (for brand), which implies that the estimated change in the logit/log-odds is -2.890 and odds ratio (OR) or Exp (B) for very dissatisfied category is 0.056 than neutral category, this means the very dissatisfied category have 94.4% lower support to give patients “sometimes” right to choose his/her medicine brand than the neutral category. Exp (B) =148.413 (movement of representative), implies that the very dissatisfied category 148.413 times more neutrally reacts to the movement of representatives than the neutral category. It is clear from the interpretation that physicians in Bangladesh are more interested to prescribe the medicine brand themselves than to give patients flexibility to choose brand. Besides, doctors are very dissatisfied about the movement of the representatives in the hospital areas.
In Table 3 regarding categories Neutral vs. Dissatisfied, the lowest value of B = 2.113 (for insurance), which implies that the estimated change in the logit/log-odds or odds ratio (OR) for dissatisfied category is 2.113 than neutral category and Exp (B) =8.217, shows that the dissatisfied category 8.217 times more agree to introduce insurance for the improvement of the health service to the patients than neutral category.
In Table 4, regarding categories Neutral vs. Satisfied, the value of B = 2.565 (brand), which implies that the estimated change in the logit/log-odds or odds ratio (OR) for satisfied category is 2.565 when the change in neutral category is 1 and Exp (B) =0.977 shows that satisfied category’s support about how ‘Often’ patients may be given right to choose his/her medicine brand is 2.3% lower than neutral category. Values of (B) = -21.403, - 22.522, -23.316, -21.403 (for call center) and Exp (B) was almost zero, which implies that the satisfied category has shown its view on call center very much lower than neutral category. It is obvious from the interpretation that physicians who are satisfied about the activities of representatives of pharmaceutical companies are less likely to grant patients’ right to choose medicine brand than physicians who show neutral view about the movements of representative. It is also seen that satisfied physicians are less interested about the opening of call center for patient service.
In Table 5, regarding categories Neutral vs. Very Satisfied, values of (B) = -32.749, -33.916,-33.333,-32.749 (for representative) and Exp (B) is almost zero which implies that very satisfied category has shown its view on call center very much lower than neutral category. It is obvious that very satisfied physicians are less interested about the opening of call center for patient service.
Hypothesis test
Therefore, from aforementioned result of the analysis we can draw the conclusion that the following 4 hypotheses are tested to have significant effect on the physician’s satisfaction:
1. Brand.
2. Insurance.
3. Call center.
4. Movement of representative.
DISCUSSION AND OUTPUT MODEL
Regression model
The Block 0 output is for a model that includes only the constant (or intercept). Given the base rates of the two decision options (13% were dissatisfied, and 57% were satisfied), the Hosmer and Lemeshow chi-square test (Hosmer and Lemeshow, 2013) of goodness of fit is the recommended test for the overall fitness of a binary logistic regression model. Since the H-L goodness-of-fit test statistic for the model is 0.685 (greater than 0.05), the zero hypothesis that there is no difference between observed and model-predicted value, is rejected. In other words, this implies that the model’s estimate fit the data at an acceptable level.
An omnibus test of model coefficients (an alternative to the H-L test) gives a Chi-Square of 145.110. Under model summary the -2 Log Likelihood statistics is 71.991. The Cox and Snell R2 (0.222) can be interpreted like R2 in a multiple regression. In other words, this model explains 22.2% of the total variation of the independent variable (satisfaction of the physicians). From the variables in the equation output, the following variables or predictors were identified to be significantly affecting the dependent variable (physicians’ satisfaction which leads to prescribing the company’s product):
1. Brand
2. Insurance
3. Call center
4. Movement of Representative
These elements are shown in the output model. Figure 2 illustrates a correlated satisfaction of physicians with brand, insurance, call center, and representative. From the figure, it is clear that four hypotheses (earlier mentioned) are shown to be effective tools for CRM of Bangladeshi Pharmaceutical market. Therefore, following hypotheses are proven by regression model as crucial elements of CRM for Bangladeshi Pharmaceutical Industry:
H1: Patients may be given right to choose his/her medicine brand.
H4: Call center plays a vital role in physician – pharmaceuticals relationship.
H6: Health Insurance will introduce better service to customers.
H7: Movement of representatives in hospitals has significant effect on the CRM.
From the regression model obtained, the following specific research objectives have been answered as well:
1. Determine how a medicine brand is chosen.
2. Evaluate the importance of call centers to deal physician – pharmaceutical company relationship
3. Evaluate the satisfaction of the physicians with a company's product.
4. Introduction of health insurance to provide better service to patients.
5. Evaluate the movement of representative in hospital area.
Strategic model
Without planning, strategic decisions are not possible. Planning is something that throws spotlight on goals, finds the limitations and finally determines an extensive way to achieve the goal. Recent academic and practitioner studies imply that CRM provides improved business opportunity, yet has received sundry performance reviews in the present literature. In addition, the firm’s market and technology orientation was considered vital antecedents to the development of CRM strategic model. Therefore, a strategic model for Bangladeshi Pharmaceutical market can be developed as in Figure 3.
Scholars throughout the world have profound attention towards the methods of CRM. The number of organizations, which are adopting customer-centric strategies, programs, tools, and technology for efficient and effective customer relationship management, are increasing day by day. Their key concern is the need for in-depth and integrated customer knowledge in order to build close cooperative and partnering relationships with their customers. The materialization of new channels and technologies (like e-marketing) radically alter how companies interface with their customers, a development which brings about a greater scale of integration between marketing, sales, and customer service functions in organizations. For practitioners, CRM symbolizes a consolidate method for developing full-knowledge regarding customer behavior (Parvatiyar and Sheth, 2000).
Accordingly, the future of CRM technology signals indispensable improvements in CRM systems, which would be able to progress electronic and direct marketing programs, enhance prediction models, improve planning systems of the project resources and transform the agenda and the organizational culture (Baran, 2008, pp. 474-488).
The pharmaceutical industry in Bangladesh is in the midst of fundamental transformation. With the advent of different sophisticated equipment and communication devices, the application of modern information technologies become a very important means to deal with customers. Moreover, improved customer knowledge about better service force and increased competition, forces the pharmaceutical companies to build relationship with their key customers, such as physicians. The affiliation among CRM philosophy acceptance, market orientation, and relationship marketing are explored in this research.
A conceptual model was developed based on the literature and information obtained through interviews. The model incorporated key relationship constructs: trust, vow and interaction quality; and investigated the impact of CRM strategy adoption on these relationship performances. The research consisted of CRM tools development stage, creating, testing and finalizing the research apparatus, followed by a qualitative study of customer’s satisfaction. The model applies to Bangladesh, respectively for the regions where the questionnaire interviews were performed.
LIMITATIONS OF THE RESEARCH
Due to time constraint, pharmaceutical marketing personals could not be interviewed, that also have given a better weight into the mode. While assessing questions, respondents’ failure to understand the premise of questions, inappropriate or misleading answers, and error during data input might have impeded the appropriateness of the results.
A potential methodological limitation was the small sample size; making the study prone to Type II error. Thus, the statistical tests might have failed to detect significant relationship. Furthermore, the data collected was limited to the time frame given to complete this research. The measurement items and relationship constructs might be imperfect; there might have addi-tional variables which could have been included in the measurement of satisfaction.
The present research focused only on getting a snapshot CRM in Bangladeshi Pharmaceutical market, and the study tried to construct a CRM model after testing hypotheses. In the broad process of CRM, some of the identified variables, such as market orientation, or customer satisfaction should be expected to change over time and across firms.
Scope for future researches
This study is exploratory in nature. The motives for this study are the relative novelty of the objects of the study (CRM initiatives) and the relative lack of strategic premise to describe such initiatives. Hence, there are still bounties of untapped research opportunities. With growing attentions and momentous investments being made in CRM systems, several empirical opportunities will emerge. The combination of marketing and information provide a lot of opportunities for research and the results of this study have opened a number of avenues for further investigation. An additional research can be conducted to explore the regional barriers in Bangladesh that are impeding and/or slowing down the speed of CRM maturity. More so, since the current study was conducted in Dhaka division of the country, it might be a good idea to use the proposed model to further assess CRM maturity in other region of the country. Finally, the research can also be carried out using specific groups of specialized physicians.
The authors have not declared any conflict of interests.
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