Community pharmacy and emerging public health initiatives in developing Southeast Asian countries: a systematic review

The impact of a multi-faceted intervention on non-prescription dispensing of antibiotics by urban community pharmacies in Indonesia: a mixed methods evaluation

INTRODUCTION

Non-prescription antibiotic dispensing is prevalent among community pharmacies in several low- and middle-income countries. We evaluated the impact of a multi-faceted intervention to address this challenge in urban community pharmacies in Indonesia.

METHODS

A pre-post quasi-experimental study was carried out in Semarang city from January to August 2022 to evaluate a 7-month long intervention comprising: (1) online educational sessions for pharmacists; (2) awareness campaign targeting customers; (3) peer visits; and (4) pharmacy branding and pharmacist certification. All community pharmacies were invited to take part with consenting pharmacies assigned to the participating group and all remaining pharmacies to the non-participating group. The primary outcome (rate of non-prescription antibiotic dispensing) was measured by standardised patients displaying symptoms of upper respiratory tract infection, urinary tract infection (UTI) and seeking care for diarrhoea in a child. χ2 tests and multivariate random-effects logistic regression models were conducted. Thirty in-depth interviews were conducted with pharmacists, staff and owners as well as other relevant stakeholders to understand any persistent barriers to prescription-based dispensing of antibiotics.

FINDINGS

Eighty pharmacies participated in the study. Postintervention, non-prescription antibiotics were dispensed in 133/240 (55.4%) consultations in the participating group compared with 469/570 (82.3%) in the non-participating group (p value <0.001). The pre-post difference in the non-prescription antibiotic dispensing rate in the participating group was 20.9% (76.3%-55.4%) compared with 2.3% (84.6%-82.3%) in the non-participating group (p value <0.001).Non-prescription antibiotics were less likely to be dispensed in the participating group (OR=0.19 (95% CI 0.09 to 0.43)) and more likely to be dispensed for the UTI scenario (OR=3.29 (95% CI 1.56 to 6.94)). Barriers to prescription-based antibiotic dispensing included fear of losing customers, customer demand, and no supervising pharmacist present.

INTERPRETATION

Multifaceted interventions targeting community pharmacies can substantially reduce non-prescription antibiotic dispensing. Future studies to evaluate the implementation and sustainability of this intervention on a larger scale are needed.

Trends, Capacity Growth, and Current State of Community Pharmacies in Saudi Arabia: Findings and Implications of a 16-Year Retrospective Study

Purpose

Community pharmacies provide access to medicines and pharmaceutical services. Consequently, adequate availability and sufficient workforce capacity must be ensured for effective healthcare delivery. This study assessed the community pharmacy sector in Saudi Arabia, including density, workforce capacity, and evolution from 2007 to 2022.

Methods

This retrospective study measured community pharmacy infrastructure and workforce capacity using international indicators and standardized measures, including community pharmacy and community pharmacist density per 10,000 people and ratio of community pharmacists per pharmacy. Several data sources and platforms were used to collect the data including the Ministry of Health, Saudi General Authority for Statistics, and Ministry of Human Resources and Social Development.

Results

The number of community pharmacies increased by 89.30%, from 5466 in 2007 to 10,347 in 2022, and density increased from 2.25 to 3.22. However, density varied by region, from 3.97 to 1.95. The number of community pharmacists increased by 98.02%, from 10,932 in 2007 to 21,648 in 2022, and community pharmacist density increased from 4.51 to 6.73. However, the ratio of community pharmacists per pharmacy remained unchanged (2.0 in 2007 and 2.1 in 2022). Female pharmacists were first issued licenses to practice in community pharmacies in 2016, and the proportion of female pharmacists to total increased from 0.29% (n=42) in 2016 to 10.95% (n=2370) in 2022. The nationalization policy for community pharmacies was implemented in 2020, and the proportion of Saudi pharmacists increased from 3.08% (n=581) in 2019 to 19.90% (n=4306) in 2022, while proportion of expatriate pharmacists decreased from 96.92% (n=18,292) to 80.10% (n=17,342).

Conclusion

The findings showed that the community pharmacy sector in Saudi Arabia recently experienced substantial growth comparable to high-income countries. However, further improvements are required in some regions to increase community pharmacy density. Moreover, the ratio of pharmacists per pharmacy should be improved to meet the healthcare system needs.

Assessing consumers' perception and demand on the community pharmacists' dispensing

BACKGROUND

This study aimed to assess the general public's perception of services provided by community pharmacies, their willingness to utilize these services, their satisfaction with and understanding of community pharmacists, and their views on dispensing separation and pharmacy medicines (P medicines).

METHODS

An online cross-sectional study was conducted, in which questionnaires were distributed among the general public. A novel questionnaire was designed and validated specifically for this study. It was composed of six sections: demographics, pharmacy usage and service preferences, understanding and satisfaction with pharmacists, views on dispensing separation, private community pharmacies, and knowledge of P medicines. Statistical analyses such as one-way ANOVA, independent t test, and binary logistic regression were employed, with a p value of < 0.05 considered statistically significant.

RESULTS

The study received 222 responses. The majority of the respondents were females within the 20-29-year-old age group (62.2%). Most respondents preferred to consult doctors for medical treatment, with their primary reason for visiting community pharmacies being to collect prescribed medicines. About 52.7% of respondents expressed their willingness to avail of screening services and treatment for minor illnesses at community pharmacies. A statistically significant difference was found among different age groups regarding their views on the dispensing separation system, with those aged 41-50 years demonstrating higher scores. However, the binary logistic regression analysis did not reveal any statistical significance when comparing the understanding of P medicines among respondents.

CONCLUSIONS

In general, the public prefers to consult doctors for medical treatment and visit community pharmacies predominantly to collect prescriptions or purchase over-the-counter medications. Nonetheless, they are also open to utilizing services provided by community pharmacists, particularly screening services and treatment for minor illnesses.

Evaluation of routine practices of dispensing pattern among community pharmacists in Can Tho city, Vietnam: A cross-sectional simulated patient approach

Background

Drugstores are preferred patients' channels of contact when getting minor ailments. Given the hike in both the prevalence and severity of influenza and acute childhood diarrhea, the role, and performances of pharmacy staff should be examined.

Design and methods

A team of pharmacy students was voluntarily recruited and trained to play the role of simulated customer visiting 228 chosen community pharmacies in six districts in Can Tho city. This process is conducted from 2021 to 2022.

Results

The study reveals detailed information about symptoms is the most common inquiry (99.2% in scenario 1). The consulting quality is poor, 85% of instances recorded to have no medical guidelines for influenza circumstances. Meanwhile, nearly four-fifths of pharmacists provide instructions on dosage intake. It is also found that length of services is statistically different between influenza and watery diarrhea (p < 0.05, CI = 95%).

Conclusions

Clinical practices of community pharmacists, overall, are disappointing and far below expectations.

Mapping access to drug outlets in Vietnam: distribution of drug outlets and the sociodemographic characteristics of the communities they serve

Background

Drug outlets are a vital first point of healthcare contact in low- and middle-income countries (LMICs), but they are often poorly regulated and counter staff may be unqualified to provide advice. This introduces the risk of easy access to potentially harmful products, including unnecessary antimicrobials. Over-the-counter antimicrobial sales are a major driver of antimicrobial resistance (AMR) in LMICs. We aimed to investigate the distribution of different types of drug outlets and their association with socio-economic factors.

Methods

We mapped the location of drug outlets in 40 randomly selected geographic clusters, covering a population of 1.96 million people. Data including type of drug outlet, context, operating hours, chief pharmacist name and qualification, and business registration identification were collected from mandatory public signage. We describe the density of drug outlets and levels of staff qualifications in relation to population density, urban vs rural areas, and poverty indices.

Findings

We characterised 1972 drug outlets. In the study area, there was an average of 102 outlets/per 100,000 population, compared to the global average of 25. Predictably, population density was correlated with the density of drug outlets. We found that drug outlets were less accessible in rural vs urban areas, and for the poor. Furthermore, for these populations, degree-qualified pharmacists were less accessible and public signage frequently lacked mandatory registration information.

Interpretation

Drug outlets appear over-supplied in Vietnam compared to other countries. Unregistered outlets and outlets without degree-qualified pharmacists are prevalent, especially in poor and rural areas, posing a risk for inappropriate supply of antimicrobials, which may contribute to AMR, and raises questions of equitable healthcare access.

Funding

This study was funded by a grant from the Australian Department of Foreign Affairs and Trade.

Differences in Older Patients' Attitudes Toward Deprescribing at Contextual and Individual Level

Background

Deprescribing requires patients' involvement and taking patients' attitudes toward deprescribing into account. To understand the observed variation in these attitudes, the influence of contextual-level factors, such as country or healthcare setting, should be taken into account.

Methods

We conducted a systematic review of studies using the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire among older adults. We searched articles in Medline and Embase up to 30 June 2021. PRISMA guideline was used for the search process and reporting. We summarized the outcomes from the rPATD and compared attitudes at study population level between high or low-middle-income countries, global regions, and healthcare settings using ANOVA testing. Correlations of the rPATD outcomes with the mean age of the study populations were tested. Associations with the rPATD outcomes at individual patient level extracted from the included studies were summarized.

Results

Sixteen articles were included. Percentages of patients willing to stop medication were significantly lower in low-middle-income countries (<70% in Nepal and Malaysia) compared to high-income countries (>85% in USA, Australia, European countries). No significant differences were observed when results were compared by global region or by healthcare setting but a high willingness (>95%) was seen in the two studies conducted in an inpatient population. A higher mean age at study level was associated with a higher willingness to stop medication. At individual level, associations between patient characteristics, including demographics and education, and attitudes toward deprescribing showed inconsistent results.

Conclusion

Findings about attitudes toward deprescribing are influenced by contextual factors. Future research should pay more attention to the influence of the healthcare system and setting as well as the culture on patients' attitudes.

Towards Better CARE for Superficial Fungal Infections: A Consultation Guide for the Community Pharmacy

Superficial fungal infections (SFIs) are among the most common skin diseases worldwide and are common in many parts of Asia. Community pharmacists are well-placed to help identify and manage SFIs. However, effective management may be hindered by a suboptimal consultation process, attributed to the misalignment between consumers' and pharmacists' viewpoints. The Fungal CARE (Care, Assess, Recommend, Empower) guide, a patient-centered collaborative framework, was developed to improve pharmacist-led SFI consultations in community pharmacy. A survey on real-world consumer experiences with SFIs provided insights for aligning the Fungal CARE guide with consumer perspectives. To further optimize the guide, community pharmacists were surveyed on their current practice and challenges of managing SFIs, as well as views on the usefulness of the Fungal CARE guide. The pharmacists' survey indicated that respondents engaged with some but not all of consumers' top concerns with SFIs, such as emotional and social aspects. Pharmacists identified their greatest challenges as poor compliance with SFI treatment and limited confidence in identifying and/or managing SFIs. Encouragingly, when presented with the Fungal CARE guide, nearly all pharmacists agreed it would be helpful and would use it in practice. Implementing the Fungal CARE guide may help improve pharmacist-led consultations for SFIs and encourage better treatment outcomes.

Antimicrobial Resistance and Community Pharmacists’ Perspective in Thailand: A Mixed Methods Survey Using Appreciative Inquiry Theory

Global action plans to tackle antimicrobial resistance (AMR) are the subject of ongoing discussion between experts. Community pharmacists have a professional responsibility to tackle AMR. This study aimed to evaluate the knowledge of antibiotic resistance and attitudes to promoting Antibiotic Smart Use (ASU) amongst part and full-time practicing community pharmacists across Thailand. An online mixed-method survey applying Appreciative Inquiry theory was validated and conducted in 2020. Non-probability sampling was used, with online survey dissemination via social networks. A total of 387 community pharmacists located in 59 out 77 provinces seemed knowledgeable about antimicrobial resistance (mean score = 82.69%) and had acceptable attitudes towards antibiotic prescribing practices and antimicrobial stewardship (mean score = 73.12%). Less than 13% of pharmacists had postgraduate degrees. Postgraduate education, training clerkship, preceptors, and antibiotic stewardship training positively affected their attitudes. The community pharmacists proposed solutions based on the Appreciative Inquiry theory to promote ASU practices. Among these were educational programmes consisting of professional conduct, social responsibility and business administration knowledge, up-to-date legislation, and substitutional strategies to compensate business income losses.

Is there a time and place for health education in chain pharmacies? Perspectives of Polish community pharmacists

Pharmaceutical practice has evolved significantly from the provision of drugs to a more patient-centred model. However, the ownership structure of pharmacies may impact the level of cognitive services provided by them. The discrepancy may be observed between pharmacists' opinions on how involved they should get and their actual involvement in health promotion and disease prevention. Given the growing market share of pharmacy chains in Europe, this study aimed to investigate the attitudes of pharmacists employed in them towards their role as health educators. It applies Ajzen's theory of planned behaviour to examine pharmacists' perspectives with the use of semi-structured in-depth interviews. A total of 10 semi-structured face-to-face interviews were conducted in May 2017 among Polish pharmacists employed in chains. Obtained results showed that respondents welcomed the possibility of providing health education, but simultaneously they seek physicians' and patients' acceptance for undertaking this task. Competency gaps and unfavourable working conditions may also decrease pharmacists' intention to serve as health educators. Including the role of a health educator to the scope of the pharmacists' practice requires a precise definition of their competencies and responsibilities together with additional training aimed to fill potential gaps in their qualifications. The pharmacists' image as a health educator should also be widely communicated to patients and other healthcare professionals.

Rapid Assessment of Price Instability and Paucity of Medicines and Protection for COVID-19 Across Asia: Findings and Public Health Implications for the Future

Background: Countries have introduced a variety of measures to prevent and treat COVID-19 with medicines and personal protective equipment (PPE), with some countries adopting preventative strategies earlier than others. However, there has been considerable controversy surrounding some treatments. This includes hydroxychloroquine where the initial hype and misinformation lead to shortages, price rises and suicides. Price rises and shortages have also been seen for PPE. Such activities can have catastrophic effects on patients where there are high co-payment levels and issues of affordability. Consequently, there is a need to investigate this further. Objective: Assess changes in the availability, utilization and prices of relevant medicines and PPE during the pandemic among a range of Asian countries. Our approach: Narrative literature review combined with interviews among community pharmacists to assess changes in consumption, prices and shortages of medicines and PPE from the beginning of March 2020 until end of May 2020. In addition, suggestions on ways to reduce misinformation. Results: 308 pharmacists took part from five Asian countries. There was an appreciable increase in the utilization of antimicrobials in Pakistan (in over 88% of pharmacies), with lower increases or no change in Bangladesh, India, Malaysia and Vietnam. Encouragingly, there was increased use of vitamins/immune boosters and PPE across the countries, as well as limited price rises for antimicrobials in India, Malaysia and Vietnam, although greater price rises seen for analgesics and vitamin C/immune boosters. Appreciable price increases were also seen for PPE across some countries. Conclusion: Encouraging to see increases in utilization of vitamins/immune boosters and PPE. However, increases in the utilization and prices of antimicrobials is a concern that needs addressing alongside misinformation and any unintended consequences from the pandemic. Community pharmacists can play a key role in providing evidence-based advice, helping to moderate prices, as well as helping address some of the unintended consequences of the pandemic.

Primary health care policy and vision for community pharmacy and pharmacists in Indonesia

The practice of community pharmacy in low and middle-income countries, including in Indonesia, is often described as in the state of infancy with several intractable barriers that have been substantially and continuously hampering the practice. Such description might be valid in highlighting how pharmacy is practiced and the conditions within and beyond community pharmacy organizations. Therefore, it is not surprising that the concept of integrating community pharmacy into the primary care system may not be considered in the contemporary discourse despite the fact that community pharmacy has been operating within communities for years. However, in the case of Indonesia, we argue that changes in the health care system within the past decade particularly with the introduction of the universal health coverage (UHC) in 2014, may have significantly amplified the role of pharmacists. There is good evidence which highlights the contribution of pharmacist as a substantial health care element in primary care practice. The initiative for employing pharmacist, identified in this article as primary care pharmacist, in the setting of community health center [puskesmas] and the introduction of affiliated or contracted community pharmacy under the UHC have enabled pharmacist to work together with other primary care providers. Moreover, government agenda under the “Smart Use of Medicines” program [Gema Cermat] recognizes pharmacists as the agent of change for improving the rational use of medicines in the community. Community pharmacy is developing, albeit slowly, and is able to grasp a novel position to deliver pharmacy-related primary care services to the general public through new services, for example drug monitoring and home care. Nevertheless, integrating community pharmacy into primary care is relatively a new notion in the Indonesian setting, and is a challenging process given the presence of barriers in the macro, meso- and micro-level of practice.

The Role of Pharmacist in the Health Care System: Current Scenario in India

Pharmacists are society's specialists on drugs. The Pharmacist of today is a drug-maker, drug-dispenser, drug-custodian, patient-counselor, drug-researcher, and drug-educator and above all an honest and patriotic citizen. The techno-proficient foundation of the drug expert gives him/her the certainty of providing services with a moral way to deal with the satisfaction of patients. The consecrated qualities are required to be cherished and professed by the pharmacist. Pharmacists assume a significant job in giving health care services, benefits by means of community pharmacy services in rural areas where physicians are not accessible or where physician services are unreasonably expensive for meeting the health care necessities. The paper at that point recognizes how pharmacists give expanded services, identifies key challenges and barriers, and suggests rules and regulations that could help secure open doors for pharmacists to play out an extended job.

Pharmacist contributions in the treatment of diabetes mellitus in Southeast Asia: a narrative review

Background The growing burden of diabetes mellitus (DM) in Southeast Asia puts pharmacists in the ideal position to provide management of DM. This narrative review aims to describe the evidence of pharmacist contribution in improving DM in Southeast Asia. Content A literature search was conducted to identify relevant research articles published from 2010 to 2018 in four databases (Scopus, Pubmed, MEDLINE, and Springerlink) describing pharmacist roles and activities intended to improve management of DM in Southeast Asian countries. Results were synthesized narratively and divided into three main sections: (1) the role of pharmacist in DM management, (2) the impact of pharmacist role, and (3) the barriers to the implementation of services in DM management. A total of 16 studies were identified, of which ten studies mentioned services that were conducted exclusively by a pharmacist and the remaining collaborated with other health professionals. A number of pharmacist services were reported including prevention, dispensing, medication review, drug information services, patient counselling and education, monitoring, follow-up, and referral. Barriers related to individual, organizational, and public recognition were described. Summary and outlook The Pharmacist can contribute to improve DM management in a variety of settings. Action research on pharmacist intervention in DM is recommended.

Targeted and tailored pharmacist-led intervention to improve adherence to antihypertensive drugs among patients with type 2 diabetes in Indonesia: study protocol of a cluster randomised controlled trial

INTRODUCTION

Current intervention programme to improve drug adherence are either too complex or expensive for implementation and scale-up in low-middle-income countries. The aim of this study is to assess the process and effects of implementing a low-cost, targeted and tailored pharmacist intervention among patients with type 2 diabetes who are non-adherent to antihypertensive drugs in a real-world primary care Indonesian setting.

METHODS AND ANALYSIS

A cluster randomised controlled trial with a 3-month follow-up will be conducted in 10 community health centres (CHCs) in Indonesia. Type 2 diabetes patients aged 18 years and older who reported non-adherence to antihypertensive drugs according to the Medication Adherence Report Scale (MARS) are eligible to participate. Patients in CHCs randomised to the intervention group will receive a tailored intervention based on their personal adherence barriers. Interventions may include reminders, habit-based strategies, family support, counselling to educate and motivate patients, and strategies to address other drug-related problems. Interventions will be provided at baseline and at a 1-month follow-up. Simple question-based flowcharts and an innovative adherence intervention wheel are provided to support the pharmacy staff. Patients in CHCs randomised to the control group will receive usual care based on the Indonesian guideline. The primary outcome is the between-group difference in medication adherence change from baseline to 3-month follow-up assessed by MARS. Secondary outcomes include changes in patients' blood pressure, their medication beliefs assessed by the Beliefs about Medicines Questionnaire (BMQ)-specific, as well as process characteristics of the intervention programme from a pharmacist and patient perspective.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethical Committee of Universitas Padjadjaran, Indonesia (No. 859/UN6.KEP/EC/2019) and all patients will provide written informed consent prior to participation. The findings of the study will be disseminated through international conferences, one or more peer-reviewed journals and reports to key stakeholders.

TRIAL REGISTRATION NUMBER

NCT04023734.

Regulating pharmacists as contraception providers: A qualitative study from Coastal Kenya on injectable contraception provision to youth

Introduction

Young people worldwide are often reticent to access family planning services from public health facilities: instead, they choose to get contraception from private, retail pharmacies. In Kenya, certain contraceptives are available in pharmacies: these include injectables, which can be dispensed but not administered, according national guidelines. However, Kenya struggles with enforcement of its pharmacy regulations and addressing illegal activity. Therefore, in this qualitative study, we assessed private pharmacies as an existing source of injectable contraception for young Kenyans (age 18–24), and investigated the perceived quality of service provision.

Methods

This study used: focus group discussions (6) with young community members; in-depth interviews (18) with youth who had purchased contraception from pharmacies; key informant interviews with pharmacy personnel and pharmacy stakeholders (25); and a mystery shopper (visiting 45 pharmacies).

Results

The study found that for injectable contraception, private pharmacies had expanded to service provision, and pharmacy personnel’s roles had transcended formal or informal training previously received–young people could both purchase and be injected in many pharmacies. Pharmacies were perceived to lack consistent quality or strong regulation, resulting in young clients, pharmacy personnel, and regulators being concerned about illegal activity. Participants’ suggestions to improve pharmacy service quality and regulation compliance focused on empowering consumers to demand quality service; strengthening regulatory mechanisms; expanding training opportunities to personnel in private pharmacies; and establishing a quality-based ‘brand’ for pharmacies.

Discussion

Kenya’s recent commitments to universal health coverage and interest in revising pharmacy policy provide an opportunity to improve pharmacy quality. Multi-pronged initiatives with both public and private partners are needed to improve pharmacy practice, update and enforce regulations, and educate the public. Additionally, the advent of self-administrable injectables present a new possible role for pharmacies, and could offer young clients a clean, discreet place to self-inject, with pharmacy personnel serving as educators and dispensers.

A Distance-Learning Course to Improve Drug-Dispensing Behaviors Among Brazilian Community Pharmacists

Objective. To evaluate the effectiveness of a distance-learning course in the training of pharmacists in drug dispensing. Methods. This interventional study was carried out with community pharmacists throughout Brazil. A 12-week distance-learning course was conducted. Pharmacists' knowledge and performance during drug dispensing were evaluated before and after completion of the course. Results. Community pharmacists' knowledge of drug dispensing was greater after completing the distance-learning course than before (mean=5.7, SD=2.8 points vs mean=3.8, SD=1.9 points, respectively). However, no improvement was observed in pharmacists' drug-dispensing practice. Almost all participants (96.5%) considered that they were more qualified to perform the drug dispensing after the course. There were 1492 pharmacists enrolled in the course, of which 1061 were included in the study, and 472 completed the surveys. Only pharmacists from Ribeirão Preto, Brazil, were invited to take the mytery shopper evaluation (n=26). However, 10 pharmacists completed the mystery shopper encounter. Conclusion. A distance-learning course was effective in improving community pharmacists' knowledge. However, the course did not seem to improve overall drug-dispensing performance. Additional educational strategies should be adopted in future studies to address this gap.

Assessment of pharmacists' knowledge, attitude and practice in chain community pharmacies towards their current function and performance in Indonesia

BACKGROUND

The introduction of universal healthcare coverage in 2014 has affected the practice of community pharmacies in Indonesia. Studies regarding the practice of pharmacist in the chain community pharmacy setting in Indonesia are very limited. The chain community pharmacies in Indonesia are operated and controlled by the same management. The chain community pharmacies usually show better services compared to independent community pharmacies in Indonesia.

OBJECTIVE

The study aimed to assess the knowledge, attitude and practice (KAP) of pharmacist working in chain community pharmacy towards their current function and performance in delivering pharmacy services.

METHODS

A cross-sectional study using questionnaires was conducted between January and March 2017 in KF, one of the largest chain community pharmacies in Indonesia. The total sampling method was used in the recruitment process. The data were analyzed using descriptive statistics, independent t-Test and one-way ANOVA. The KAP scores were assessed and categorized as "poor", "moderate" and "good" based on the standardized scoring system.

RESULTS

A total of 949 KF's pharmacists (100% response rate) were participated in the study. The majority of pharmacists showed a good score in terms of knowledge and attitude, which is in contrast to practice as majority only obtained a moderate score. Working experience, age and the availability of standard operating procedures (SOP) for both dispensing and self-medication services were found to be statistically significant (p<0.005) aspects to KAP of pharmacists in delivering pharmacy services.

CONCLUSIONS

This study identified several important aspects that could affect the KAP of pharmacists working in chain community pharmacies in Indonesia. Specific policies should be conceived to improve the competencies of pharmacist and to ensure the compliance with the SOP and standardization system within pharmacy sector.

Multiple policy approaches in improving community pharmacy practice: the case in Indonesia

BACKGROUND

Health reform has been an ongoing agenda in many countries with community pharmacy increasingly gaining attention for contributing to healthcare improvement. Likewise, multiple policy approaches have been introduced to improve community pharmacy practice in Indonesia yet no studies have evaluated their effectiveness. Therefore, this study aimed to identify and collate information on approaches intended to improve practice in Indonesian community pharmacy and subsequently examine the perceptions of key stakeholders in healthcare and community pharmacy about these approaches and the extent to which they have affected community pharmacists as a profession.

METHODS

This study reviewed the grey literature related to community pharmacy policies published by government and pharmacy organisations in Indonesia since 2009 and broadened the search to other relevant databases. In-depth semi structured interviews were conducted with a wide range of key stakeholders in pharmacy and healthcare between February and August 2016 to evaluate these policy approaches.

RESULTS

Seventeen policy documents were identified with the majority published by the Indonesian Pharmacists' Association (8 documents) and Ministry of Health of Indonesia (6 documents). Most documents (15 documents), either the updated version or new policy, were published since 2014 indicating the recent enthusiasm of pharmacy stakeholders to improve community pharmacy practice. Twenty-nine key stakeholders participated in the study, and highlighted three main themes regarding the policy approaches: barriers to effective policy implementation, need for policy changes and strategies to cope with policy challenges. Poor policy enforcement was commonly expressed by participants as a major challenge, with participants anticipating the need for a unified stakeholder vision to improve the current situation. Participants also mentioned several local initiatives which they claimed were improving practice but evidence was lacking.

CONCLUSION

The introduction of policy initiatives within the past ten years has highlighted the enthusiasm of policy makers and pharmacy stakeholders to improve community pharmacy practice in Indonesia. However, some of the initiatives were conceived and enacted in a piecemeal, sometimes conflicting and uncoordinated way. Overall, fundamental and entrenched barriers to practice need to be overcome to create a more professional climate for the practice of pharmacy in Indonesia.

Prioritising recommendations to advance community pharmacy practice

INTRODUCTION

The nature of community pharmacy in many countries has changed. Despite the significant efforts made to change practice, there is a paucity of literature that highlights consensus on the approaches that should be prioritised for advancing practice particularly in the context of developing countries.

OBJECTIVE

To systematically identify and prioritise a range of potential recommendations to improve practice in Indonesian community pharmacy from the perspective of pharmacy stakeholders.

METHODS

Qualitative research using Nominal Group Technique (NGT) was conducted in July 2017 involving 34 nationwide pharmacy stakeholders. Participants were assigned to four nominal group discussions based on the areas for action as developed by researchers. The results were thematically analysed.

RESULTS

Nine priority recommendations were generated from the group discussion reflecting four main themes to advance community pharmacy sector, namely improving professional pharmacy practice, reforming pharmacy education, enforcing policy and regulation and enhancing public recognition of pharmacists. The analysis using the culture-structure-agency approach highlights that the top down structure in terms of policy and regulatory framework has not been effectively enforced. In addition, the role of pharmacists as the central agency in delivering pharmacy services has been limited due to their common absence from practice. The approach, however, provides an alternative to advocate changes by locating the role of pharmacists and community pharmacy as central agency within the challenging health system structure.

CONCLUSIONS

The recommendations generated from and approach used in this study provide an impetus to advance community pharmacy practice in Indonesia. Amongst the important solutions, there is substantial need to provide evidence of pharmacists' contribution to healthcare.

Challenges in the management of community pharmacies in Malaysia

BACKGROUND

The provision of professional pharmacy services by community pharmacists continues to be limited, particularly in low and middle income countries. It was postulated that multiple management challenges faced by community pharmacists contribute to this situation.

OBJECTIVE

The primary aim of the research was to determine the challenges faced in the management of community pharmacies in Sarawak (the largest state in Malaysia), and practical strategies to cope and overcome the challenges.

METHODS

Semi-structured interviews were carried out with community pharmacists practising in Sarawak. Purposive and snowball sampling were employed to ensure a diverse group of informants. The interviews were audio-recorded and transcribed verbatim, with the resultant data analysed using thematic analysis. Data collection, coding, interpretation were carried out iteratively until theoretical saturation.

RESULTS

Twenty respondents from different demographic characteristics were recruited. Six major themes were identified. Management challenges faced by community pharmacists traverse five major domains: market competition, legislative issues, customers' knowledge and expectations, macroeconomic impacts and operational challenges. Most of these challenges require government intervention to be resolved. In the meantime, improving customer service and expanding the range of professional services were seen as the most viable strategies to cope with existing challenges. The main concern is that current legislative and economic landscape may hinder these strategies. Enactment of dispensing separation and more protective measures against market competition were suggested to alleviate the challenges faced.

CONCLUSION

Numerous management challenges faced by community pharmacists that distract them from delivering professional pharmacy services have been highlighted. Urgent affirmative actions by the government are warranted in supporting community pharmacists to realise and maximise their potentials.

Engagement of the private pharmaceutical sector for TB control: rhetoric or reality?

BACKGROUND

Private-sector retail drug outlets are often the first point of contact for common health ailments, including tuberculosis (TB). Systematic reviews on public-private mix (PPM) interventions for TB did not perform in-depth reviews specifically on engaging retail drug outlets and related stakeholders in the pharmaceutical sector. Our objective was to better understand the extent to which the World Health Organization's (WHO) recommendation on engaging retail drug outlets has been translated into programmatic policy, strategy, and intervention in low- and middle-income countries.

METHODS

The study included a content analysis of global-level documents from WHO and the Stop TB Partnership in five phases. A country-level content analysis from four data sources was performed. Global-level findings were tabulated based on key messages related to engaging retail drug outlets. Country-level findings were analyzed based on four factors and tabulated. National strategic plans for TB control from 14 countries with varying TB burdens and a strong private sector were reviewed.

RESULTS

33 global-level documents and 77 full-text articles and Union World Lung Health conference abstracts were included for review. Based on experience of engaging retail drug outlets that has emerged since the mid-2000s, in 2011 WHO and the International Pharmaceutical Federation released a joint statement on promoting the engagement of national pharmacy associations in partnership with national TB programs. Only two of 14 countries' national strategic plans had explicit statements on the need to engage their national pharmacy professional association. The success rate of referrals from retail drug outlets who visited an approved health facility for TB screening ranged from 48% in Vietnam to 86% in Myanmar. Coverage of retail drug outlets ranged from less than 5 to 9% of the universe of retail drug outlets.

CONCLUSIONS

For WHO's End TB Strategy to be successful, scaling up retail drug outlets to increase national coverage, at least in countries with a thriving private sector, will be instrumental in accelerating the early detection and referral of the 3 million missing TB cases. The proposed PPM pharmacy model is applicable not only for TB control but also to tackle the antimicrobial resistance crisis in these countries.