India, the second largest demographic nation in the world, with 28 states and 7 union territories, has a population of more than one billion. On 15th August 2007, India celebrated 60 years of freedom. For half a century before independence, the Indian economy registered virtually no growth at all. It followed with 3.5 per cent per annum in first three decades, nearly 6 per cent in middle three decades and recently it has marked closer to 9 per cent growth. During the last sixty years, we have produced world class scientists, entrepreneurs, doctors and journalists. They have been instrumental in transforming our country into modern resurgent India. Democracy, information technology and world class corporate sector has been the principle elements that have made India a force to reckon with in the world today.
Health scenario
India made a noticeable growth in health sector too. Since independence, life expectancy has gone up from 32 years to 65 years. Smallpox and guinea worm disease have been eradicated and polio is on the verge of eradication. Also, leprosy, kalaazar and filariasis are expected to be eliminated in near future. But the sad part of the story starts now. Almost 80 per cent of total population lives in rural areas, while 80 per cent of total doctors in India live in urban areas. This has created a huge imbalance between the health care availability for people in urban and those in rural villages. Many villages do not even have primary heath check-up facilities and they have to travel miles of distances to see a medical practitioner. Some smart people have been taking advantage of illiteracy, poverty and blind-faith of villagers by treating diseases by magic.
Many villagers including Adivasis are still treating their ailments with crude natural remedies. Some of them travel long distance to take modern medicines and this, inevitably, delays diagnosis and treatment. By the time patients reach a doctor, they are in the later stage of the illness. Most of the villagers are farmers by occupation and their income is entirely dependent on their crop. A poor crop or drought drastically reduces their income and most of them cannot meet their medical expenses. National Health Scheme of Central Government aimed primarily to provide medical benefit to all citizens, especially rural India. It is reaching the homes of villagers for immunisation like DTP, polio, BCG and measles. Unfortunately, in some parts of the country, it is still believed that injections by nurse would change their religion and people are apprehensive towards availing medical benefits.
Modern India, on one hand is triumphant in eradication of infectious diseases whereas on the other hand is struggling to combat the recurrence of diseases like tuberculosis associated with HIV/AIDS.
Pharmaceutical care
There has always been confusion between medical care and pharmaceutical care. Medical care is basic health care related to overall disease treatment. It includes core responsibilities of doctors and nursing professionals like diagnosis of disease, prescribing medicines and recommending corrective measures, including surgical and post operative care to treat the disease or symptomatic relief. Pharmaceutical care is an extension of medical care and it is a separate task, mainly comprised of drug related services. The access of patient to pharmaceuticals and their adherence to treatment are key factors to successful clinical management of many diseases, which is fundamental to pharmaceutical care. A community pharmacist working in medical store is a vital component of pharmaceutical care, as he looks after all the activities that begin from receiving a prescription from a physician to the proper storage and administration of medicines.
Pharmacists are primary custodians of drug and are therefore critical to the achievement of all health outcomes in which pharmaceuticals play a role. In present days, pharmacists activity is not only restricted to the supply of medicine but he has to ensure safety and suitability of the medicine for a patient and proper dosing of medicines. Checking drug-drug and drug-food interactions, identification and reporting of adverse drug reactions, assuring the medication adherence and patient counselling about medicines are different aspects of pharmaceutical care.
Medical & pharmaceutical care in rural areas
To explain the medical and pharmaceutical care, rural section can be categorised into three types on the basis of socio-economical developments like poorly developed and isolated, moderately developed villages and big sspvillages close to cities.
Small, poorly developed and isolated villages: These comprise of villages with population less than 1000 and usually situated in remote area. Though, numerous efforts have been taken to connect the different parts of the country, such villages still remain inaccessible. Many villagers in Konkan area still use crude mode of transport like walking across distances or swimming through water bodies. They have low standards of nutrition, hygiene and lack primary education facilities. Such villages have been out of the reach of government health related schemes and their medical problems have been unattended. They may not have even heard the word "pharmacy" and "pharmacists."
Taking such facts into consideration, Indian government has made provision in the form of Schedule K in drug laws. This law allows a non-pharmacist to sell commonly required medicines like aspirin, paracetamol, quinine sulphate, antacids, expectorants, pain balms, counter irritants, calamine etc. Although villagers can get access to such medicines from non-pharmacists, it never guarantees the safety of the medicines. A person having acidity/ gastric ulcer may take aspirin like irritant drug, patient may take excess dose of liver damaging paracetamol, he/she may experience drowsiness due to expectorants containing antihistaminic, or one may take irrational dose of antimalarial drugs.
Moderately developed villages: These are villages having population of around 2000 to 5000 and are about 20-50 km away from cities. They have slightly improved medical care system but marginal pharmaceutical care. With the farmers as the main class, some grocers, one or two medical practitioners and medical store sum up the composition of such villages. Though primary health care centres exist, villagers remember it only for immunisation. The qualification of private doctors here is either experienced RMP, homeopathic (D.H. M.S./ B.H. M. S) and ayurvedic (B.A.M.S). Doctors with MBBS qualification hardly work here. Many doctors themselves dispense medicines and medical stores have to sell stationery, cold drinks and milk products along with medicines.
Patients' beliefs and expectations sometimes become a hurdle for pharmaceutical care. For example, there is a common belief that injections are more powerful than tablets or capsules and patients at clinics often insist on injections, even when parenteral treatment is not indicated. Consequently, the pharmacist dispenses a large number of prescriptions for paracetamol and multivitamin injections, instead of oral preparation. A pharmacist is projected only as a medicine supplier and not as medicine advisor. Thus ultimately, pharmacist can deliver medicines only and not pharmaceutical care.
Big villages close to cities: Private hospitals and clinics run by doctors qualified in allopathic and ayurvedic systems makeup the medical care team of the big villages. Primary health centers (PHC) usually have facilities for gynecological care and also a pharmacist. Five to six medical stores and a pharmacist from PHC make the pharma care team in this place. Small scale pharmaceutical companies have more market share in big villages. Here propaganda marketing and different discount schemes work better rather than the detailing by medical representatives of national or multinational pharmaceutical companies. Pharmacists do good business by sale of OTC medicine, where prescription drugs are also sold as OTC drugs and this matter has been ignored.
Common factor in all the classes is economy. Some patients cannot buy every item on their prescription and will often ask the pharmacists to give the most important medicine in their prescription. It is a difficult task for the pharmacist to persuade the patients to obtain the full quantity of medicine that has been prescribed.
Modern dispensing pharmacy
Amidst all these difficulties in pharmaceutical care, modern dispensing pharmacy comes to the rescue. Interpersonal interaction between pharmacist and patient, less professionalism and strong individual relations among villagers and villagers and pharmacists are the key points to design, plan and implement modern aspects of dispensing pharmacy. With this aim in my mind, I authored a pioneer book "Modern Dispensing Pharmacy (Career Publications) in 2004, where I have tried to explain novel modules for community pharmacy in Indian context. Many of these are especially applicable to rural area. Some of the highlights are:
● Patient medication record: Pharmacist encounters a limited number of patients in rural areas and by making good relations with individuals and their family it is easier to prepare and maintain PMR of patients. It can be prepared in association with doctors. It will not only improve adherence to medication but also produce health profile of a village
● Product information leaflets: PIL is written information provided with medicines. It gives all positive and negative points about the medicine including dosing schedule. However, English language makes it useless. Rural pharmacists have more opportunity to prepare PIL in the local language
● Pictograms: Since, illiteracy is one of the main barriers for patient counselling, pharmacist can utilise pictorial presentations for better understanding by villagers
● Participation in NHS: Immunisation, treating calcium and iron deficiencies like activities are conducted under National Health Scheme (NHS). A team comprised of trained but non-qualified staff conducts such activities in primary health centers or in primary schools. Though the staff is trained for administration of dose, they are unaware of many drug related aspects like stability, storage and drug interactions. A pharmacist can help NHS team in these aspects including advertisement of such programmes
● Education: Pharmacists is the most respected after a doctor and a teacher. He can educate the villagers about healthy life style, personal and social hygiene and proper use of medication
By participating in public education and health promotion, provision of pharmaceutical care and involvement in surveillance and national programmes, pharmacists can help to improve the quality of the life in our country.
(The author is professor of pharmaceutics with BU Poona College of Pharmacy, Pune)