Pharm World Sci DOI 10.1007/s11096-008-9246-z
COMMENTARY
Social pharmacy strengthening clinical pharmacy: why pharmaceutical policy research is needed in Pakistan? Zaheer-Ud-Din Babar Æ Shazia Jamshed
Received: 24 March 2008 / Accepted: 23 July 2008 Ó Springer Science+Business Media B.V. 2008
Abstract Pakistan has a population of more than 160 million and is the sixth most populous country in the world. Drugs are the most common form of treatment modality; however, inappropriate use of medicines is a crucial issue in the country. In Pakistan, recently there is a surge of number of pharmacy schools, the pharmacy degree (B. Pharm) has been changed to Pharm D and there is a lot of rhetoric about ‘‘clinical pharmacy’’. However, whether this change has brought any significant improvement in drug use situation; it is still a moot question for academics and policy makers. Authors feel that before embarking upon on clinical pharmacy at an institutional level, it is important that basic pharmacy system should be in place. Thus, a strong culture in social pharmacy or pharmaceutical policy research will not only be helpful to establish clinical pharmacy practice, but it would also be supportive enough to provide manpower to the country’s proposed drug regulatory authority. Keywords Clinical pharmacy Pakistan Pharmaceutical policy research Pharmacy education Social pharmacy
Z. U. Babar (&) School of Pharmacy, Faculty of Medical & Health Sciences, The University of Auckland, Auckland, New Zealand e-mail:
[email protected];
[email protected] S. Jamshed Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
Health and pharmacy system in Pakistan In this commentary we present our thoughts regarding the need of developing social pharmacy research in Pakistan. Pakistan has a population of more than 160 million and is the sixth most populous country in the world. Total Life expectancy at birth is 64 years; infant mortality rate is 66.95 deaths/1,000 live births while in 2005 2.1% of Gross Domestic Product (GDP) was spent on health [1, 2]. Health promotion activities are scant and as a result majority of the health expenditures are used at tertiary care. In Pakistan, like many developing countries, drugs are the most common form of treatment and Pakistanis are spending 77% of their healthcare budget on buying medicines [3]. Inappropriate use of medicines is also a crucial issue and studies have shown that over 70% of the patients were prescribed antibiotics and up to 90% of injections were estimated to be unnecessary [3]. As pharmacists are considered medicines experts, if their skills and knowledge are properly used, they can be very helpful to improve quality use of medicines as well as strengthening the ‘‘pharmacy system’’ in the country. ‘‘Pharmacy System Research’’ [4] encompasses areas related to drug distribution, drug regulation, drug selection, procurement, pricing, generic medicines, pharmacovigilance, and access and affordability to medicines. However, the study and practice of ‘‘Pharmacy System Research’’ which is predominantly related to social pharmacy [5] has not been given due importance in the pharmacy curriculum in Pakistan [6].
Clinical pharmacy or social pharmacy In Pakistan, recently there is a surge of number of pharmacy schools, the pharmacy degree (B. Pharm) has been
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changed to Pharm D and there is a lot of rhetoric going on regarding ‘‘clinical pharmacy’’ [6]. Though the goal of clinical pharmacy is to promote the correct and appropriate use of medicines [7] there is substantial evidence that this change has not brought any significant improvement in drug use situation in the country [6–8]. In developed countries, ‘‘clinical pharmacy’’ was only started and conceptualized when a stable ‘‘pharmaceutical system was in place’’. A stable pharmaceutical system at ‘‘institutional level’’ ensures that drug distribution, procurement, and drug selection are properly established and then pharmacist can move on to more specialized patientoriented services. However, in Pakistan, though ‘‘pharmaceutical care’’ is popular and the numbers of years have been extended in pharmacy schools, the true nature of clinical pharmacy has been poorly understood [6]. At an individual level, ‘‘pharmaceutical care’’ is the responsible provision of drug therapy to achieving definite outcomes that improve a patient’s quality of life [9]. While ‘‘population-based pharmaceutical care’’ uses demographic and epidemiological data to establish formularies and develop pharmacy policies, conduct drug utilization reviews and educate providers on medicine policies and procedures [10]. Though difficult to draw a line, loosely we can say that ‘‘individualized pharmaceutical care’’ is related to clinical pharmacy while ‘‘population-based pharmaceutical care’’ is associated with social pharmacy or pharmaceutical policy and system research. We also believe that social pharmacy has two distinct dimensions; one is associated with researching the attitudes and behaviors of practitioners’ regarding medicines, and is also related to humanistic and outcome research [11], while the second one is more related to legal, regulatory, and cost-effectiveness issues in the medication use cycle [5, 12]. In Fig. 1, we have tried to explain that how second dimension of social pharmacy research can provide support to clinical pharmacy practice and health system in large.
Developing social pharmacy research in Pakistan As Pakistan does not have a good drug regulatory structure and still there are unsolved problems related to drug quality, selection, and procurement, it will be important to contemplate how clinical pharmacy would be practiced when in many hospitals; drugs are not properly stored even. We argue that there is a need to develop social pharmacy research in Pakistan. In Pakistan, in the past, ‘‘Pharmaceutical Policy Research’’ has not been considered as ‘‘academic enough’’ and has been only conducted in ‘‘pockets’’ by non-governmental organizations [13, 14]. However, as the country
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• • • • • • • •
Drug Regulation Drug Safety Drug Efficacy Drug Quality Medicines and cost effectiveness Access to Medicines Pricing of Medicines Pharmacovigilance Programmes
Population Based Pharmaceutical Care
• Quality Use of Medicines • Clinical Pharmacy Practice • Patient Oriented Pharmacy Services
Individualized Pharmaceutical Care
Fig. 1 Social pharmacy strengthens clinical pharmacy
is moving forward with increasing pharmacy institutes, this area demands complete support from academic institutions as well as from the government organizations. A strong culture in social pharmacy research will not only be helpful to establish clinical pharmacy practice, but it would also support to provide manpower to the country’s proposed drug regulatory authority. How this research can strengthen the healthcare system and clinical pharmacy practice in the country, we will elaborate it by quoting the following examples. Medicine access and affordability are crucial issues in Pakistan. How good a pharmacist clinically trained be, can not practice clinical pharmacy, if there are problems at the supply chain and the drugs are not available. There could be many reasons to inaccessibility to medicines which include (but not limited to) high drug prices [15], issues of transparency, missing essential drugs, and the widespread use of branded medicines. We argue that these areas are scientific enough in nature to develop hypotheses and research questions and demand serious attention from academicians. The issues regarding drug pricing can not be left alone to bureaucrats and pharmaceutical industry so it is vital for the pharmacist to learn the judicious use of costeffective medicines. Generic medicines could be a viable option to improve affordability of medicines in the country; however, only 50% of medications were prescribed as generics in Pakistan [1]. Many patients consider them as substandard medicines and there is a need to sensitise patients, prescribers, and pharmacists to improve the quality use of generic medicines. It has been estimated that in Pakistan the average number of drugs prescribed per patient is three or more drugs (per prescription), which is above then the world average [3]. Also, an analysis of data from Pakistan revealed that 75–99 of the patients diagnosed with an upper respiratory tract infection (URTI) received antibiotics [3]. Pharmacoepidemiological research is needed to quantify the drug needs as well as for the estimation of adverse drugs reactions. Large
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scale presence of counterfeit drugs in the country also signals the need of pharmacovigilance expertise. Entering the future Above-mentioned examples hint that pharmaceutical policy research is vital to support the health system of a country. However, doing such a research requires a new breed of researchers with some integration with other academic disciplines such as health economics, sociology, psychology, biostatistics, and political science. Also, new techniques drawing upon from ‘‘qualitative methods’’ and ‘‘action research’’ are needed to conduct pharmaceutical policy research. Perhaps this is the need of the hour that pharmacy academics and researchers embark upon a new journey to shape and develop a vibrant health system in Pakistan. Acknowledgments We thank Medicines Pakistan International www.medicinespakistan.org for being a useful forum for constructive discussions. Funding
None.
Conflicts of interest
None.
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3. The World Medicines Situation. World Health Organization. 2004. http://www.searo.who.int/LinkFiles/Reports_World_Medicines_ Situation.pdf. WHO/EDM/PAR/2004.5. Accessed 22 May 2008. 4. Laing R. Health and pharmacy systems in developing countries. Paper presented Hosbjor Norway. 2001. http://www.wto.org/ english/tratop_e/trips_e/hosbjor_presentations_e/05laing_e.pdf. Accessed 9 April 2001. 5. About social pharmacy. Faculty of Pharmacy, Universitetet I Oslo. http://www.farmasi.uio.no/seksjoner/farmasoytisk/english.html. 6. Babar ZU. Pharmacy education and practice in Pakistan. Am J Pharm Educ. 2005;69(05):2–3. 7. Clinical Pharmacy. European Society of Clinical Pharmacy. http://www.escpweb.org/site/cms/contentViewArticle.asp?article= 1712. Accessed 20 May 2008. 8. Babar ZU. Pakistan’s National University of Pharmaceutical Sciences. Am J Pharm Educ. 2006;70(5):123. 9. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–43. 10. Weidenmayer K, Summers RS, Mackie CA, Gous AGS, Everard M, Tromp D. Developing pharmacy practice: a focus on patient care. Working draft for the filed testing and revision, World Health Organization (WHO) and International Pharmaceutical Federation 2006. WHO/PSM/PAR/2006.5. 11. Desselle SP. The birth of research in social & administrative pharmacy: a sincere welcome to subscribers, readers, and authors. Res Social Adm Pharm. 2005;1:1–4. doi:10.1016/j.sapharm.2004. 12.001. 12. Department of Social Pharmacy Faculty of Pharmacy. University of Kuopio. http://www.uku.fi/farmasia/sofa/english/. Accessed 19 May 2008. 13. The Network for Consumer Protection. Islamabad, Pakistan. http://www.thenetwork.org.pk. Accessed 6 April 2008. 14. Nishtar S. The Gateway Paper: the health systems in Pakistan—a way forward. http://heartfile.org. Accessed 27 May 2008. 15. Babar ZU. Rationale Behind Drug Pricing. 2008. http://www. dawn.com/2008/02/26/letted.htm#2. Dawn 26 Feb.
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