Community Pharmacy in India -- a Practical Approach

Wednesday, December 24, 2003 08:00 IST R Srinivasan If there is one industry that has the potential to replicate the Indian software success story globally, it is pharma. So many things are happening -- biotechnology, the human genome project, genetic mapping, new drug discovery. Is Indian pharmacist aware of the future challenges, changes, and opportunities? Unfortunately Pharmacy practices in India has not been recognized as an integral part of the emerging pharmaceutical challenges and the attention it requires to prepare them to play their role as resourceful Community Pharmacists. This paradoxical situation has to be corrected before it is late. There is a 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 GP and community pharmacist have a common ancestor in the apothecary, an adviser on health and dispenser of medicines. Merely comparing the pharmacy practices in developed countries and prevailing practices in India without considering certain realities will be a subjective assessment. We have to take an objective approach to change this situation. The necessity to improve the pharmacy practices on professional scales cannot be ignored nor delayed in the context of emerging changes, when India is becoming a fast developing nation in the world. This calls for innovative marketing dynamics in every industrial activity. In pharmaceuticals as a health care industry, India has already proved its technical competence and capabilities by producing basic drugs and formulations, in every therapeutic segment including preventive medicines for both domestic and global markets. By 2005 Indian drug manufacturers are expected to become major exporters to European countries and in USA, in generics. This major transformation in R&D, production, marketing etc., however, has not penetrated down the line to -- the vital link in supply chain -- the pharmaceutical Trade. Ensuring quality of medicines till they reach the consumers is as vital as GMP. A well-defined distribution practice right from warehousing, transportation, proper storage, handling and dispensing at the retail counters is therefore a logical extension GMP in supply chain. In this chain - the ultimate and vital link is Community Pharmacy. The need to redefine the pharmacy practices is precisely what we have to focus and as the core issue and in the interest of the customers.

Let us now, analyze the India specific pharmaceutical care with its unique paradoxical environment. Size of population, second largest in world next to China; vast rural and micro interior penetration required to take the health care needs to the rural and urban masses these are to be viewed from some of the peculiar situations as listed below: Illiterate rural masses vs. educated enlightened consumers. Non-availability of basic vs. emerging quality medical health care in urban centers. Quackery practice in vs. highly competent medical rural areas profession. Vast number of drug vs. awareness to develop stores/medical pharmacies. Non availability of vs large turnout of qualified pharmacists. Small sector vs large scale Indian/MNC pharma companies. Weak regulatory vs efficient State level Drug agencies in control. We can add several such contradictory factors but cannot escape from the necessity to look forward to improve the quality in pharmacy practices. Otherwise they will be helplessly witnessing an impressive growth of pharmaceutical Industry vs. outdated, unskilled medicine dealers defeating the very purpose of making the quality medicines available to the public with professional care and advice. Role of professional & trade associations: In this context it is crucial that we take bold initiative to educate the practicing pharmacists, change their mind set and prepare them as Community Pharmacists by introducing refresher courses at State and district Head quarters with a time frame. Scope for training: Everyday, the pharmacist is asked by customers for advice about minor ailments. The may require advice on symptoms; may ask for a medicine by brand name; may require general health advice e.g. about dietary supplements, precautions etc. The pharmacist's role in responding to symptoms and overseeing the sale of over-the-counter (OTC) medicines is substantial and requires a mix of knowledge and skills in the area of diseases and their treatment. Basic knowledge about the drugs and diseases: In the ever growing OTC segments of products, lay press advertisements, self medication, drug abuse, non-compliance of dosage regimen, mixing of OTC medicines with prescription medicines; changing life style and food habits' prevalence of diseases like asthma, tuberculosis, diabetes etc., there is need to educate and advice the consumes on proper and safe use of medicines- and it requires regular refresher courses to prepare the community pharmacists in patient care and counseling. With the advent of IT, a wealth of information is available through web sites and Drug Information Centers on Drugs, their actions, indications, side effects etc. Community pharmacists must provide a computer in their pharmacies for access to all these information through the Internet and its most essential to maintain a patients' profile for their regular customers, specimen of Community Pharmacy Medication record recommended is given

below: Patient name; Address Physician; Age; Telephone number; Sex M/F; Phone Number; Allergies; Medication Record; Date; Rx no; Physician; Drug & Strength Quantity; Sig/dosage Refills; Pharmacists' notes & other patient Information - Eg: Date Comment: OTC drugs dispensed/used Need to maintain proper statutory records: It is in the interest of pharmacists that they buy the medicines from authorized sources with proper purchase records. Maintain sales memos with patients name and address, batch number of the medicines sold, as a legal requirement and to safeguard themselves in the event of any drug found substandard or unsafe requiring recall etc. Need to provide patient information brochures: Pharmaceutical associations, manufacturers can provide brochures to be distributed to patients at the counters on disease like asthma. diabetes, hypertension, epilepsy even common cold and cough, with Dos and Don'ts etc,. To provide information: for Immunization and if space permits, vaccination programs can be organized with the help of manufacturers in the pharmacies. Geriatric care: Elderly patients tend to get confused or forget to take medicines properly. Complementary packs for keeping each medication separately with dosage marked will help them to take medicines as prescribed. Need to provide basic monitoring/test devices: In the counseling area pharmacists can provide BP apparatus, devices are available to test blood sugar etc Proper Storage: All medicines are temperature sensitive and to retain their potency and efficacy proper storage is essential, protected from sunlight and heat. While it is recommended that all Community Pharmacies are air conditioned, there is a proposal to amend D&C Rules to provide air conditioners compulsorily. Access: to Drug Information centres/ reference books/ web-sites on drug information: This is possible by providing Computers and Inter-net connectivity. Communication skills: As pharmacists, to understand customer needs, it is necessary to develop listening skills, questioning skills. To develop a positive mind set for ethical pharmacy practices, evolving all professional, legal and moral obligations to the society. These should be basic parameters on which we must introduce a practical approach to Community pharmacy environment in India. Community Pharmacy Division of IPA with All India Organization of Chemists & Druggists with State Pharmacy Councils as nodal centres, can organize jointly, structured programs to train practicing pharmacists in every major towns so that before 2005, we can bring a perceptible change in pharmacy practices in India.

As a supplementary activity, a Journal dedicated to Community Pharmacy is necessary to constantly update their knowledge on new molecules, and this should reach all leading pharmacies in India. Such professional Journals can be sponsored by manufacturers. Role of community pharmacist in ensuring better healthcare

Wednesday, June 30, 2004 08:00 IST Ishita, Deepak Kaushik & Harish Dureja Health is a word very familiar to us but it also carries a lot of complications and problems. According to the World Health Organisation, health is a state of complete physical, mental and social well-being and not merely absence of any illness. To make the above definition of health practical we have to depend upon a "health care team". A health care team is the group of people who share a common health goal and common objectives determined by community needs. India with the greatest cultural diversity, health though an important issue is being neglected due to many hindrances. The condition is further worsened due to insignificant drug use problems. On the spurge of many spurious, duplicate and adulterated drugs, it is in the hands of the pharmacist particularly the community pharmacist, to take up the challenge for providing better health care and better outcomes economically. Role of community pharmacist A community pharmacist is the professional who would be in direct access to the public and whose duties are widely sought after by the public and patients. He dispenses medicines with a prescription and in certain cases without a prescription where applicable (OTC drugs). As he is the person who will be in direct contact with the public, he has to play an important role in decreasing the mortality and morbidity in the public. Community pharmacy practice evolved in the post second World War period. A pharmacist not only began to perform functions that were new to pharmacy, but they began to innovate functions and make original contribution to literature. The popular motto of "patient oriented practice" and "drug use control" came into practice. But unfortunately the role of community pharmacist is not so much recognized till today especially in India and needs strong efforts. Although community pharmacist is of key importance in providing better healthcare, it is the matter of shame for us that the Indian patient does not find any difference between the grocer and the pharmacist. Despite of major role of community pharmacy, the situation and condition of the community pharmaceutical service has stood where it was like a man walking on a treadmill. He walks and walks and sweats, but remains in the same place. Until and unless the link between the people and physician i.e. the pharmacist does not get its proper recognition any dreams of making India, a healthier nation cannot be fulfilled.

The need of the hour is to make community pharmacist a key towards better health care. The community pharmacist can take part in health promotion campaigns, locally and nationally, on a wide range of drug related and health related topics. A community pharmacist involvement could play an important role in the following areas of health care. Nutrition Counseling Community pharmacist can make, significant contributions in assuring adequate nutrition by advising his patients about basic food needs, keeping to correct improper food habits in children, advising on special requirements, suggesting special diet instructions for diabetic patients and people with food allergy and participating in school lunch programs and schemes like mid-day meals etc. in rural areas. There are certain facts such as women who often eat fish or omega-3-fatty acids are less likely to suffer stroke, symptoms of hyper vitaminosis result in irregular menstrual cycle and excessive intake during pregnancy may cause birth defects. The pharmacist can tell these facts to people to ensure better health. Now a days designer foods i.e. nutraceuticals/ dietary supplements have not only gained considerable acceptance but also have newfound use and applications. They are considered to provide medical or health benefits. The community pharmacist could explain these new innovative products and their standardization. Women Welfare-Pregnancy and Infant Care A famous Sanskrit Shloka from Manusmriti scriptures goes as "Yatra Nariyastu Poojayanta, Ramante Tatra Deva" which means, "where women are worshipped Gods preside there". Women are the corner stone for effective public health and investing in women translate into investing in family, community and the Nation. Against the backdrop of a hectic and demanding schedule, women's health receives the least priority when it should be the first. A woman goes through different stages throughout her life, each of which has specific need and the presence of a counselor is needed in each one of them. The pharmacist who understands the normal course of pregnancy and infancy is at a distinct advantage as he or she can guide the mother in simple matters of hygiene and management. The community pharmacist can encourage breastfeeding and can play a major role by guiding the mother for the protection of the child by following proper immunization schedule. Efforts are definitely underway in this area. The US FDA's office of women's health has created "women's health: take time to care", a national public awareness campaign, where apart from giving information about safe medicine use, they also hold local interactive sessions led by pharmacists and other health care professionals.

Rational Use of Drugs A community pharmacist can also advise on the administration of the medication, provide information on the storage of the medication and wherever necessary he can counsel the patient. Education regarding the disadvantage of polypharmacy can also be given to the patient. Drug information system should be set up and access to adverse drug reaction system should be made. A community pharmacist should do therapeutic drug monitoring and he should have a sound knowledge of genotype reporting i.e. predictive pharmacology. Drug information awareness programmes should be conducted to make people aware of side effects of certain OTC drugs e.g. Aspirin - a wonder drug also has many side effects like gastric ulceration; asthma and large doses may cause tinnitus. Regular use of paracetamol can cause harm to the liver. How many amongst the common people know that drugs such as Action 500, Coldarin can increase blood pressure in patients having hypertension. Even pain shows difference between men and women. Where women respond better to the opiods such as morphine, pentazocine and pethidine men respond better to the non-steroidal anti-inflammatory drug, ibuprofen. Considering the above examples, in the best interest of public health a community pharmacist can provide counseling to common people unaware of these side effects. Moreover the definition of an OTC product should be that "which does not require the prescription of a registered medical practitioner but which can be sold only under the supervision of a pharmacist". In a nut shell there should be rational use of drug i.e. right drug in right patient in right dose at right time. A community pharmacist is one of the inevitable members of the health care team who can help to achieve the goal of rational use of drugs by following good pharmacy practices. It is found that interventions by pharmacists in explaining the patients about medicines prescribed to them can significantly enhance patient knowledge of correct use of medicines from 56 per cent to 90% per cent. There is yet another role of the community pharmacist in India and that is enhancing the availability of essential drugs. Nearly 70% population in India is deprived of essential drugs for a variety of reasons including non-availability of health professionals and improper professional advice about the usage of drugs. In India, one pharmacist for two thousand persons can improve access to medicines and their safe utilizations. The existing pool of community pharmacist can become an important instrument in bringing about this change. For setting higher standard for pharmacy practice in the country the essential drug list should be received by the government and the availability of the essential drugs should be enhanced through the pharmacists. Sexually Transmitted Diseases-AIDS India has 3.5 million HIV positive cases, which is about 10% of the global HIV cases and barely second to South Africa. HIV drugs are expensive and beyond the reach of common man.

Huge resource of community pharmacist can educate people in the prevention and information of HIV/AIDS. For this, Federation of Indian Pharmacists project in India on involvement of pharmacist in fight against AIDS is very relevant. Another sensitive issue is the increasing number of women patients suffering from AIDS. The number rose from 7% in 1985 to 18% in 1995. Although many classes of antiretroviral are available like protease inhibitors, nucleoside reverse transcriptase inhibitors and nonnucleoside reverse transcriptase inhibitors, patients need close monitoring and strict dietary regimen. Explaining to what HIV is, its transmission, risk reduction, patient counseling are the components of the counseling that a community pharmacist can provide. Alcohols, Drug Abuse and Smoking Cessation The diseases of alcoholism and drug abuse also come under the preview of the community pharmacist. The pharmacist has a key role to help individuals who become dependent upon alcohol. Drug abuse is similar to alcoholism yet different because it has been gaining more acceptances among young people. Annual mortality from tobacco use exceeds that from all other causes combined. Smoking is the greatest single preventable cause of morbidity and mortality in India. It is the responsibility of a community pharmacist to take an active role in helping the smokers to stop smoking. Following a number of smoking policies through out the pharmacy, by written information and posters, can do this. The pharmacist can advise on the products available to assist the patient in giving up smoking. Counselling sessions can be made by the community pharmacist to stop smoking. Family Planning One of the greatest needs of the hour is to control the tremendously increasing population in India. A community pharmacist is the one who can control this rising population by counseling with people and doing programmes which exhibit the problems related with large families. He can tell the various families planning measures that are available in the market at affordable prices. He can educate the people and convince them about the advantages of having small families. So, like all other aspects community pharmacist plays a very important role in this case also. Individualization of Drug Therapy Today the latest concept in medicine is towards individualization of drug therapy. Where judicious patient care is needed individualization of drug therapy becomes a need, and a pharmacist can play a vital role in this. A physician who is preoccupied with patient diagnosis and treatment may not spare time for patient counseling regarding pharmaco-economics, drug information, alternative therapy, moral supporting etc. A pharmacist can set up a separate consultation room and provide counseling to the patient. He can store the details of patient history, allergies and other details necessary for therapy so that the concept of individualization of drug therapy could be implemented.

The ideal frontline pharmacist of the future has been described as a seven star pharmacist-some one who is equal in excellence to a five star hotel yet accessible to everyone from the richest to the poor. The future 7 star pharmacists will have seven principal roles to play: -- Care giver; -- Decision-maker; -- Communicator; -- Leader; -- Manager; -- Life long learner and -- Role model. The community pharmacist with the above skills and attitudes should make himself an indispensable partner in health care system of a nation. Conclusion In the Indian health care system, pharmacist is under utilized because community pharmacy and pharmacy practice are yet to be established strongly and pharmacists working in community pharmacies do not provide patient counseling in the usual situation. We need to work closely with the pharmacist associations and share our common experiences and frame appropriate guidelines for India so that community pharmacist who plays a major role in providing better health care can be recognized. In a nutshell, pharmacist in the health care system is like circumcenter of a triangle with physicians, patients and nurses at the corners of the triangle. He has direct contact with all health care professionals and patients. It is really important to appreciate the fact that a patient finds himself to be much more comfortable in a drug store than in a physicians dispensary. The role of community pharmacist is indispensable in providing better health care. Steps should be taken by the government and the pharmacist himself to make his recognition in the community as a better health care provider. The National pharmaceutical associations like Indian Pharmacists Organization, Federation of Indian Pharmacists, Indian Hospital Pharmacists Association and All India Organization of Chemists and Druggists etc. will have to be committed to change and use their influence to convince community and the government that pharmacists can play a significant role in national health care programmes. The main driving force will have to come from pharmacists themselves. They are best able to decide what can be achieved and within what time scale. Every community pharmacist should always remember, the following lines: "Do all the good you can, In all the ways you can; In all the places you can, At all the times you can; To all the people you can, As long as ever you can".