Role of pharmacist in the healthcare system

The recently published 29th report of standing committee on Petroleum and Chemicals (2002) under Ministry of Chemicals and Fertilizers (Department of Chemicals and Petrochemicals) has once again sidelined the professional role of a pharmacist. In the report, presented to Lok Sabha on November 25, 2002, the committee has recommended that "The Govt. should explore the possibility of relaxing the provisions of The Drugs and Cosmetic Act, 1940 so that educated persons other than pharmacists could sell the medicines after some short training through "public distribution system" or "sarvapriya scheme". According to the standing committee, the clause of employing pharmacists was more relevant when the statutory acts were written in 1940 because the drugs were dispensed by the chemists by compounding and mixing whereas now most of the medicine are available in ready to use form." The committee further stated that "The pharmacist is the main hurdle in easy accessibility of medicines and this move will provide better job opportunities to educated persons other than pharmacists." The learned members of the committee have probably not gone through the document `The Role of the pharmacist in the health care system' published by World Health Organization (WHO). The document is a report of a WHO consultative group meeting held in New Delhi during December 13-16, 1988 and highlights professional role of pharmacists. If the committee is of the option that 'mixing medicines' is the only job which a pharmacist is supposed to do, then it can be argued that the learned members have incomplete comprehension of the role of pharmacist in the healthcare system. Over the years the professional role of pharmacists have evolved considerably. The WHO report states "Effective medicine can be practiced only where there is efficient drug management." The report further states, "Time and again, in less affluent settings, inadequacies in the provision of primary health care are attributable to shortcomings within the drug distribution chain. Only when the pharmacist has been accepted as a vital member of the healthcare team can the necessary supporting services be organized with the professionalism that they demand." The WHO report further clarifies that pharmacists are uniquely qualified because: - They understand the principles of quality assurance as they are applied to medicines; - They appreciate the intricacies of the distribution chain and the principles of efficient stock - keeping and stock - turnover; - They are familiar with the pricing structures applied to medicinal products obtained within the markets in which they operate; - They are the custodians of much technical information on the products available on their domestic market; - They are able to provide informed advice to patients with minor illnesses and often to those with more chronic conditions who are on established maintenance therapy; - They provide interface between the duties of prescribing and selling medicines and in so doing, they dispose of any perceived or potential conflict of interest between these two functions. In a diverse country like India, with more than 70,000 pharmaceutical formulations in the market, maintenance of standards for quality of drugs is a stupendous task both for central and state authorities related to drug-control. Preventing proliferation of adulterated, misbranded or counterfeit drugs itself is an uphill task. There is no doubt that distribution of drugs has to be eased out and drugs should be readily available to the average consumers. However the best policy instrument to achieve the laudable objective is to follow the policy of essential drugs as suggested by the World Health Organization (WHO) way back in 1977. A large number of developing countries have followed the policy. The state of Delhi has followed the policy of essential drugs; but with irrational policy and drugs being sold in other states of India, an isolated state may not be able to make enough dents in the easy availability of drugs to average consumers. The right remedy for many ills in the distribution of the drugs is to scale down the number of drug-formulations in Indian market to a minimum of say 1,000 instead of more than 70,000. Our country certainly does not need such a huge number of formulations. More the number of formulations, more is the administrative load over drug-control and more is the number of manpower needed to monitor it. In the post-liberation years, the size of government is reducing gradually and with the dictum of "That government is best which governs least", availability of really needed minimum number of drugs in Indian market will reduce the burden of government authorities over control of drugs. It is irony of fate in our country that the ministry of chemicals and fertilizers rather than ministry of health declare the drug policy. Probably there is a feeling in Central block that chemicals and fertilizers rather than lifestyle are more intimately related to health. The remark of the standing committee that "Pharmacist is the main hurdle in easy accessibility of medicines" is certainly unfounded. With the kind of political, administrative and social structure in our country, there is a lot to be done in distribution of drugs. The WHO report on "The role of the pharmacist in the healthcare system" states that the competence of the pharmacist is already proven and evident: - In the direction and administrative of pharmaceutical services; - In drug regulation and control; - In the formulation and quality control of pharmaceutical products; - In the inspection and assessment of drug manufacturing facilities; - In the assurance of product quality through the distribution chain; - In drug procurement agencies and - In National and institutional formulary committees. Unfortunately because of following factors, pharmacists have not been able to pursue their international mandate in our country. - Lack of understanding of the role of pharmacist in health care. - Lack of identification of 'Health-care-team' as a policy concept and center-stage role only to medical professionals in the maintenance of heath. - More stress on curative measures rather than preventive measures for health related issues. - Lack of national objectives of professional education being reflected in policy implementation. - Peripheral role of pharmacist in health care only towards manufacture and distribution of drugs. In developed countries like USA the role of pharmacist is next to the clergyman and he is looked as the main source of correct information and availability of drugs. He is never a "hurdle", and in fact will prove a boon in distribution of drugs. Medication errors are a big issue even in developed countries like USA and pharmacist has a central role in preventing medication errors and improving life expectancy of average consumers. It is estimated that in USA, injuries caused by medical management are 2.9 to 3.7%. Preventable adverse event is a leading cause of death in USA. When extrapolated to over 33.6 million admissions to US hospitals in 1997, it was observed that between 44000 - 98000 Americans die in hospitals each year as a result of medication errors. It is the eighth leading cause of death comparable to deaths caused by motor vehicles (43458), breast cancer (42297) or AIDS (16516). Medication errors can certainly be minimized with more and more involvement of pharmacists in the administration of drugs. There is enough evidence for the economic value of pharmacists in developed countries like USA. A growing body of literature has emerged that supports the value of pharmacist's patient care interventions in a wide range of patient groups, health care settings, and disease states. - Over 20 studies and demonstration projects confirm that pharmacists add value to the health care system by improving care and decreasing cost. - During a six months period pharmacists joined doctors, residents and other members of the patient care team on patients round in the intensive care unite at a large, urban teaching hospital. Result showed that - Preventable adverse drug events decreased by 66% - A projected $ 270,000 related to adverse drug events could be saved annually - 366 of the 400 pharmacist interventions were related to medication errors. - Pharmacist interventions helped prevent incomplete orders, incorrect dosages and frequency, less-than - optimal drug choices, and duplicate prescriptions. - Pharmacists working in their communities produced a 74% increase in vaccination rate by advising high-risk patients of infection risk and describing where to go to be vaccinated. - Patient acceptance was excellent, with pharmacists administering 1060 doses of influenza vaccinations and 198 pneumococcal vaccinations to 1067 patients. - Pharmacist reviewed drug therapy and found ways to improve medications used in nearly 65% of all patients. - The bulk of savings were not related to drug costs, rather they were associated with fewer unscheduled physician visits and fewer hospital days. - Consultant pharmacist-conducted drug regimen review increases the number of patients who experience optimal therapeutic outcomes by 43% and saves as much at $ 3.6 billions annually in costs associated with medication - related problems. - Pharmacists working with patients in their community provided targeted patient education, systematic patient monitoring, patient feedback and behavior modification. - Savings for monthly medical cost ranged from $ 143.96 to $ 293.39 per patient per month. The result of these studies suggest that a broad range of hospital-based pharmacist-provided patient care activities either save lives or reduce health care costs or both. In a study evaluating the effect of clinical pharmacists on the economic outcomes of patient care an average benefit of $ 16.70 of value to the health care system was realized for each $ 1 invested in clinical pharmacy service. Drug therapy changes based on pharmacists' recommendation reduced unscheduled hospital visits, urgent care visits, emergency room visits and hospital days, saving over $ 640 per year in health cost per individual ($ 280,000 per year per pharmacist). In order to have such an important role for pharmacist in Indian health care, objective based education oriented towards the purpose needs to be implemented. In a multifaceted country like India, what happens in politics is reflected in all walks of life. Division amongst people is advantageous to certain sections of society. The same policy is being unfortunately implemented in the health profession. Physicians, pharmacists, nurses and other health-related professionals should work in harmony towards the central benefit of "PATIENTS". Patients, rather than any professionals should be at the center-stage of health policy and professionals should not quarrel amongst themselves for their central or peripheral role in the well being of patients. It is the lack of this understanding on part of honorable members of the standing committee that has lead to the belief that "Pharmacist is the main hurdle in easy accessibility of medicines". World over pharmacist is one of the important member of the health-team including clinical research. If Indian pharmacist is not fulfilling this role, then he should be appropriately trained and be oriented as a health - care provider to the vast rural population. He can be used intelligently as an alternative manpower towards the sacred goals of: - Immunization - Minor dressings - Family planning - Preventing tropical diseases - Providing drug-information - Monitoring adverse drug reactions - Monitoring and minimizing adverse drug interactions - Preventing misuse of drugs - Preventing medication errors - Preventing abuse of tobacco, alcohol Much of the role of preventive and social medicine can be attributed to pharmacists. In fact pharmacists can be real 'bare-foot' doctors to average consumers of rural India. What we need is the vision of policy-makers rather than marginalizing role of any professional in the health-care team. Pharmacist is certainly not a "Hurdle but can be a boon and facilitator in the process of efficient drug - distribution. -- The author is principal, Government College of Pharmacy, Osmanpura, Aurangabad. The views expressed here are his personal opinions.