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How to revitalize community pharmacy in India?

Dr Anantha Naik Nagappa
Wednesday, February 1, 2023, 08:00 Hrs  [IST]

The pharmacy profession is fragmented into different streams like academic pharmacy, industrial pharmacy, regulatory pharmacy and community pharmacy.

There are professional organizations representing each stream. As a result of it, there is hardly any communication between a pharmacist and the public. Unlike medical and nursing professions who directly in live contact with patients and are recognized in the society, the pharmacist in our country were happy to work behind scene and this has become the usual practice.

The community pharmacy which is the public face of the profession, is hardly professional by any standards. The community pharmacists are nicknamed as retail traders who are engaged in handing over the prescribed medicines to the patients and earns trade margins provided by the manufacturer.

Usually, a retail pharmacy is managed by a family business which are rarely run-on professional lines. Apart from medicines they cannot offer any information about drugs, and technical information as patients wants to know.

Hence medical stores and person who runs medical stores goes unnoticed by patients and health consumers. Due to this simplicity in medical store running, other competitors are posing challenge by offering heavy discounts and door delivery through online pharmacy.

This model is detrimental to patients and health consumers. The patients and health consumers are at great loss as they don’t have any access to pharmaceutical care which is fundamental to any therapeutics.

Pharmacy Practice Regulations
Though the Government of India, has enacted Pharmacy Practice Regulations in 2015, nearly eight years have passed away without starting any activity of pharmacy practice despite gazette notification.  

The Pharmacy Council of India is responsible for implementation of the PPR 2015. They have recently asked all registered pharmacist to provide Pharmacy Practice as per PPR 2015.

In most of the countries, the role and responsibility of pharmacist are mandatory for getting a license to start a community pharmacy and also very high standards are fixed to work as pharmacist.

One has to clear pharmacist registration board exams. Recently exit exams were conducted for diploma passed out students for registration of pharmacist in all state pharmacy councils. It is the first step in this direction to improve and provide pharmacy services to patients and health consumers. That is the main cause for pharmacy is unheard in India in public health and services.

The current model of medicine usage is product -centric instead of patient- centric. The wide competition among pharmaceutical companies and investing in brand image development is self - serving the industry and is detrimental to patients and health consumers.

The heavy budgetary allocations for marketing are making product -centric therapeutics. The product -centric marketing has given birth to unethical practices like irrational use medicines, influencing prescription habits of doctors, self- medication by patients and pushing of medicines by counter sale by pharmacists.

The list is endless like patients are made to pay more for medicines as they become more expensive due to added packaging cost, promotion cost, discount sale for pharmacist. In patient-centric care, all these practices are put to an end.  The world Health Organization is constantly sending alerts to governments about perils of product-centric market.

The best way to ensure patient safety, is to engage pharmacist in the country to begin pharmacy practice in a wider scale. Pharmacy faculty who are having extensive knowledge and expertise in the matter of life style disease should be put to work in WHO-FIP model, and can be trained to provide services to the patients, health consumers and public.

In this model, a pharmacist monitors the patient regularly and maintains the patient records. This can be done at retail pharmacy, primary healthcare centres, nursing homes, diagnostic labs and hospitals. The pharmacy students of diploma, degree and Pharm D can be included in the programme as interns and motivate them to become practicing community pharmacists.

Pharmacy practice module is given in fig 1.

In this module, patients visit community pharmacy and asks for prescription medicines by giving the prescriptions. After going through the prescription, and discussing with the patient, the pharmacist prepares a customized pharmaceutical care plan.

In the mean while he assesses the prescription and tries to identify drug problems that are likely to cause to the patient. He also explores the patient by asking him about his current life style, habits diet and day today physical activities. The pharmacist after having a dialogue with patient, is in a position to make a customized care plan.
At the same time, pharmacy assistant fills the prescription and prepares bill which is communicated to patient to make payment at the counter. The medicines are handed over to pharmacist for dispensing to the patient.

Dispensing involves patient counselling and explaining the medication and precautions about medication storage, how to take prescription medicines as per the instructions mentioned in the prescription.

The patients are instructed to report to pharmacy for refilling the prescription. At that time pharmacist in charge discuses with the patient about issues faced after first visit, any problems faced by the patient due to disease, drugs etc.

After taking a note of the discussion, the pharmacist analyses the information provided by the patient. If the issue raised by the patient is regarding diagnosis or nursing care, he refers the patient to see doctor or nurse.

If the issue is due to drugs, then the pharmacist resolves the issue by patient counselling. Usually for chronic conditions like Type II diabetes, hypertension and asthma, patients are required to visit pharmacy six to eight times. In three months, a community pharmacist is able to impart the skills to the patients to ensure self -management of the condition by patient himself becomes possible.

Patient ignorance and inertia

The biggest challenge in therapeutics is patient ignorance and inertia. The patients need support to get motivated and start complying with the treatment. The behaviour of patients always is in a flip flop mode.

Patients agree with health care team as long as a disease is causing suffering to them but becomes non-compliant as soon as they get better as the treatment progress. This is a universal phenomenon and health care teams are struggling to educate patients.  

The non-compliance by patients is the root cause for anti- bacterial resistance and poor outcome to treatment. The consistent patient behaviour is possible to achieve by constant monitoring of the patients and counselling by health care professionals.

The community pharmacist is best suited to tackle the challenge effectively. Due to over- load of patients the physicians, nurses don’t have  time to work on patients, especially ambulatory patients, who are unable to  access  doctors and nurses or even clinical pharmacist or hospital pharmacist.

The community pharmacists are easily accessible to patients who does not require prior appointments. A patient can check in pharmacy counter and ask for assistance by community pharmacist. This model of practice is prevalent in developed countries.

The patient counselling services by pharmacists are compensated by health care department, insurance companies and and patients themselves. When a pharmacist’s income is not dependent on pharmacy manufacturer or marketing team, he prefers to work for patient’s interest.

In India also, the government is making regulatory reforms for improving pharmacy practice in the country. The pharmacy practice guidelines enacted on January 16, 2015, empowers the registered pharmacist to engage in pharmaceutical care services.

Pharmacy practice

The PPR 2015 defines pharmacy practice as “interpretation, evaluation and implementation of medical order, dispensing prescription and medical orders, participation in drug and devise selection drug administration, drug regimen review and drug related research”.

PPR 2015 clearly talks about duties of registered pharmacists to their patients. The registered pharmacists are obliged to the sick to provide pharmaceutical care (in addition  to the provisions of Drugs and Cosmetics Rules 1945 and Schedule N of  the said Rules ).

The following provisions shall be included:  No person other than a registered pharmacist shall compound, prepare, mix, dispense or supply of any medicine on the prescription of a registered medical practitioner (Schedule H & X drugs); A registered pharmacist shall review the patient record and each prescription presented for supply for the purpose of promoting therapeutics appropriateness by identifying:

i.    Over -utilization or under -utilization
ii.    Therapeutic duplication
iii.    Drug- disease interactions
iv.    Drug-drug interactions
v.    Incorrect drug dosage or duration of drug treatment
vi.    Drug -allergy interactions
vii.    Correlation of availability of drugs (to avoid artificial shortage of drugs)
viii.    Clinical abuse/misuse.

It should be noted here, upon recognition of any of the above, the registered pharmacist shall take appropriate steps to avoid or resolve the problem that shall, if necessary, include consultation with a registered medical practitioner.

Challenges and initiatives to tackle them

Community pharmacy in India was neglected for several reasons. The pharmacists who are engaged in community pharmacy are mostly under qualified and are having no motivation to take the professional practice.

The earnings in retail pharmacy are mainly the trade margins which the pharmaceutical industry fixes a percentage of margin, which depends on company’s whims and fancies. If the product is found fast moving the trade margins are at minimum. They increase in case sales of the product is faced with poor sales. There are no guidelines by the regulators. Medicine prices vary with lots difference. The product may be available at Rs. 10 and same product may be available as branded medicine at Rs. 100.

Online pharmacies are grabbing the business of retail pharmacies by offering discounts ranging from 30 to 50 per cent. Online pharmacies are advertising in public mass media to attract customers.

The retail pharmacies are unable to impress upon the patients and health consumers, that they are better than online pharmacy in terms of service apart from medicines. The public image of pharmacist is poor as there are no professional sophistication visible like doctors and nurses. They don’t even wear a white apron, which is a symbol of health care profession. Their main focus is on maximization of the turnover.  From this mindset we have to change over from product-centric to patient-centric.

The Pharmacy Council of India has now permitted several diploma colleges, degree colleges, degree & diploma colleges and several Pharm D colleges.  Here we have learned faculty who can be oriented to pharmacy practice and should be engaged in providing pharmaceutical care in the community they live. They can also engage the students who are going to be future registered pharmacists.

The Pharmacy Council should impress upon the state and central government to invest money to initiate pharmacy practice in the country. They should come out with a model for remunerating the pharmacist for providing the services of pharmacy practice to patients and health consumers.  The PPR 2015 although permits pharmacists regarding charging professional fee for services, there is a dilemma as how to begin this.

The government has established a model of Pharmacovigilance where in pharmaceutical industry is responsible for periodical submission of data of Pharmacovigilance for the products they market in the country. Similarly, a model for remunerating pharmacist should be started. This investment of government can be a stepping stone from a product-centric market to a patient-centric market.  

(The author is President, Association of Community Pharmacist of India, Karnataka)


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