Dispensing of prescriptions is the primary duty of community pharmacies and remains their core activity. Pharmacists dispense medicines at the order of a prescriber, typically a physician but possibly a physician assistant, nurse practitioner, optometrist, or dentist as well. While community pharmacies are the main source for filling prescriptions for most patients, other sources include hospitals, health maintenance organizations, community clinics and internet mail-order pharmacies. Cost and convenience are two important factors in determining where individuals fill their prescriptions.
Pharmacies generate revenue from prescription dispensing based on a mark-up on drug product plus a small dispensing fee for cash-paying consumers. Practice of community pharmacy is based on estimated acquisition price approach, which is based on a discount from the average wholesale price (AWP). However, most pharmacies are able to acquire drugs below the AWP, particularly if the drug is available as a generic product (i.e. no longer under patent).
The services of community pharmacy should include patient advice, correction of prescription errors, maintenance of patient medication records, co-ordination with the other allied professions like nursing and doctors in the matters concerning medicine. The role of community pharmacy is to act in an important and responsible manner for the propagation of national health programmes. World Health Organization (WHO) has clearly defined the roles and responsibilities of community pharmacists. Apart from dispensing prescription medications, other professional roles of pharmacist include patient counselling, clinical pharmacy services, drug information and health promotion. The closer professional relationship between the pharmacists and general practitioners is always essential in improving the quality of patient care.
In countries like the US and the UK the professional relationship between the doctor and the pharmacist are cordial since pharmacist has a bigger role to play. There, the pharmacists are patient counsellors and drug information providers. Everyday scores of people visit community pharmacies for their health care needs. Due to free accessibility and friendly approach, pharmacists are placed at first point of contact in the health care system. The health - advice roles of the pharmacists in these countries are highly appreciated and accepted by all. The community pharmacists here are involved in prescribing advice, monitoring the repeat prescriptions and formal reporting of adverse drug reactions. In certain countries like UK , the pharmacists have prescribing rights for certain diseases. In Australia, the community pharmacist does the home medication review where he visits the patient at his residence with prior appointment and analyses the clinical condition, reviews the prescription, identifies drug-related problems.
The pharmacist in developed countries is prompt in upgrading his knowledge and refining his professional skills and hence well respected. Various professional bodies of pharmacists are also supporting and encouraging the pharmacist participation in health care programmes. The community pharmacists are well paid and are highly respected.
Overall, the health profession and particularly community pharmacy in developed country are well grown due to the following factors:
Like sizeable population and reasonable land limits, well developed areas with better facilities, well educated and enlightened consumers, quality medical health care, highly competent medical professionals, availability of only approved dosage formulations, efficient and well developed state level drug authorities. superior and well qualified pharmacists with sound knowledge in pharmacology of drugs and good coordination with physicians etc.
Community pharmacy in India
The size of the population of India is huge, next only to China. The geographical topography is huge. The concept of community pharmacy in India is almost non-existent and the role of pharmacist both in community and hospital pharmacy is not defined clearly.
We are still suffering from wide rural set-up with minimum facilities, illiteracy of the population, non-availability of basic drugs, rampant quackery (non-qualified medical practitioners), vast number of drugs and availability of irrational combinations, inefficient and week drug regulatory authority, mediocre professional competency of qualified pharmacists and poor co-ordination between pharmacist and the physician.
Community pharmacy in India is still at the stage of confusion and the role of pharmacist is limited to drug store management and prescription filling. Although, the Drugs and Cosmetics Act 1940 and the Pharmacy Act 1948 have provisions and guidelines for establishing a strong pharmacy profession, somehow changes have not taken place as expected. In India, as per the requirements of Section 65(1) and (2) of Drugs and Cosmetics Act 1940, a qualified person is essential to open and run a community pharmacy which is otherwise called a medical shop.
Challenges faced Poor educational standards
The first challenge is that the community pharmacist is not being equipped in terms of educational standards. Degrees and diploma are completed with an industry-centric approach and the students who register themselves as community pharmacist have little knowledge of clinical pharmacy.
Lack of public awareness
The second basic challenge is lack of public awareness. When people are not aware what a pharmacist is, what pharmacy is all about, how they will understand the role of a community pharmacist?
Bribes and schemes
Bribes and schemes promoting sale of substandard drugs. India’s health care system is suffering from lack of strong political will to enforce laws and regulations against substandard drugs.
Shortage of pharmacists
Due to lack of proper incentives in India, pharmacists are not attracted towards the community pharmacy job. The current ratio of community pharmacist to the general public in India is 1:235, which is an indication on the work pressure on each pharmacist. Due to this ratio the system is suffering from poor attention of the patient which ultimately leads to ineffective patient counselling and poor patient compliance. The recommended ratio of pharmacist and patients is 1:20.
Hence, there is a strong demand for more pharmacists particularly in community pharmacy set up due to tremendous prescription growth. The substantial growth in medication expenditure in retail and institutional settings increase the economic stake held by pharmacists and aggravates the impact of the pharmacist shortage upon the nation's overall health care economy. Increased demand of pharmacists in one sector can affect the supply of pharmacists available to other sectors. Thus technology advances, market changes, and other professional opportunities have all contributed to a dynamic market for pharmacists within the last few years.
Poor communication with patients
The constantly busy dispensary coupled with lack of privacy makes the counselling difficult. Many languages are spoken in India and this can further complicate the communication with the patient.
Lack of up-to-date knowledge in relevant field
Once qualified, most pharmacists in India do not go for additional training which is essential to update their knowledge related to the their own field and other allied fields like pathophysiology, diagnosis of diseases, genetics, clinical pharmacy, drug-drug interactions and any new advancement in medication. Knowledge of above fields is necessary in proper patient care system.
High cost of medical treatment
As a hospital’s income comes from patient’s fees , it cannot afford free medical treatment to many patients. In addition to consultation and overnight fees, patients are charged for medicines, intravenous fluids and all disposable equipment such as needles, syringes etc. The hospitals offer 95% refund on unused (in unopened containers) medicines and equipment. Due to high costs, patients many a time don't buy all items of the prescription. Generally patients often ask the pharmacist which is the most important medicine out of the prescribed. Non-essential medicines are are not bought at all.
Due to high cost of therapy, it is sometimes difficult to persuade patients to finish the course of antibiotics when they feel better because they know they can get refund for any unused medication. In India patients are also not willing to purchase full quantity of medicines prescribed. Such attitudes on the part of patients do not augur well for the current pharmacy practice.
Patient’s beliefs & expectations
Sometimes patient’s belief and expectation also challenging. For example there is a common belief in India that injections are more powerful than tablets and capsules, and patients at the hospitals often insist for parenteral therapy even when the drug treatment is not indicated. Consequently a pharmacy dispenses large number of paracetamol and multivitamin preparation in parenteral form even though an oral preparation would have been sufficient.
Thus patient’s wrong beliefs sometimes put the pharmacy practice in dilemma about patient satisfaction and proper pharmacotherapy.
Rural health care system
In India , about 80% of doctors live in urban areas while 80% of population lives in rural villages. This result in huge imbalance between health care available for people in cities and in rural areas. People have to travel long distances for diagnosis and treatment of disease. Patients living in villages often go for treatment in the last stage of illness. As community pharmacist is a link between doctor and patient, the profession is suffering from this imbalance of therapeutic strategy available for people in cities and in villages as poor patient compliance for the drug therapy has been reported in patients living in villages.
Misconceptions in current health care system
India is suffering from many misconceptions regarding the job profile of physician and pharmacist particularly in rural areas like the misconception that in India all medicines, including those falling under Schedule H of the Drugs & Cosmetics Act are freely sold over the counter by pharmacists without prescriptions. In most of the developed countries the system clearly defines the role of physicians prescribing and the pharmacists dispensing, while in India the functions are overlapping mostly in rural areas. There are unqualified doctors in rural areas and qualified doctors prescribe and dispense medicines in their clinics not only to their patients but others too. Historically the physician and community pharmacist have a common ancestor in the apothecary, an adviser on health and dispenser of medicines
Preservation and storage of drugs
Now-a-days with advancement in pharmacotherapy protein & peptide drugs and vaccines, there is a need for the adequate storage facility to retain their potency and efficacy proper storage, to protect drugs and vaccines from sunlight, heat and excess of moisture or other contamination.
It is possible in urban area to preserve drug substances as stated in their storage conditions with appropriate temperature and other criteria. But it is almost impossible to arrange advanced storage facility in rural areas where even if pharmacy wants to set-up the storage rooms, it would not be possible to maintain the same with problems like frequently power cuts , water shortage, lack of public awareness regarding cleanliness etc. Due to this, current community pharmacy is facing problems relating to preservation of drugs which is needed for emergency care or vaccination.
Lack of advanced modes of communication
In rural areas which lacks internet facility, pharmacists are unable to keep pace with with the advancements in health care system. With the increasing population, the need for the therapeutics also has increased, which has resulted in research and development of new therapeutic strategies. Information about these ongoing research projects in universities and industries are available in the websites of a particular research group. Also drug information centres and reference books are now available on internet. Due to the lack of internet facility, a pharmacist working in rural areas cannot access the current information regarding new developments and strategies in therapeutics. Ultimately the pharmacist remains stagnant in the field which proves to be a hurdle to perform effectively.
Prof. Dr. G. Vidya Sagar is Professor & Principal & Nipa H. Thacker is lecturer, Veerayatan Institute of Pharmacy, Jakhania, Gujarat