Pharmacies, medical stores, or chemist’s shops are the first point of health care in Nepal. People visit pharmacies for various medical conditions ranging from fever, diarrhea, contraceptives, skin infections, injury to blood pressure monitoring, and administering injections. They are considered to be cost-effective and accessible to the general public, as they are available to provide medicines and health advice on a walk-in basis, without the need for an appointment.
However, pharmacy practice in community pharmacies in Nepal is very poor. Practice in this setting is characterized by poor knowledge and non-adherence to dispensing and counseling guidelines. It is a common practice to dispense prescription drugs such as antibiotics without prescriptions. Patients/customers hardly receive any information on the rational use of medicines, drug interactions, and adverse effects. For example, a patient at the pharmacy with complaints of sore throat and fever may be given an antibiotic without any prescription or physician consultation and often without any relevant drug information.
Even though deplorable, this practice is not surprising because, in the majority of the community/retail pharmacy settings in Nepal, pharmacy services are provided by “Professionalists” who have received a meager 45 hours to 3 months of training from the department of drug administration (DDA). Some are operated by pharmacy assistants with a 3-year-old diploma in pharmacy and others by health assistants (HA) and community medicine auxiliaries (CMA). Only a handful of community pharmacies are run by registered pharmacists with 4 to 7 years university pharmacy degree. At times, no trained staff or pharmacists is onsite in the pharmacies and the dispensing is carried out by a relative(parents, spouse, siblings).
In contrast, community pharmacies in the developed countries are managed by University pharmacy graduates. For example, in the US, all the community /retail pharmacies are managed by college graduates with a BS in Pharmacy or Pharm D. (Doctor of Pharmacy) degree. They are involved in processing prescriptions, dispensing, and counseling of drugs, disposing of medications, health promotion, chronic disease management, medication therapy management, and smoking/alcohol cessation programs. Similar to “Professionalists” and pharmacy assistants in Nepal, there are pharmacy technicians in the US, but they too have to undergo rigorous training and work under the supervision of registered pharmacists. The reason behind quoting the US example is that Nepalese pharmacy education has tried to bring reform to match global standards and undergone some promising changes in the last couple of decades.
The three months of training from the DDA to produce “Professionalists’ stopped in 2000. And there are pharmacy programs run by the Institute of Medicine, Tribhuvan University, Kathmandu University Pokhara University, and Purbanchal University. Moving a step forward, Kathmandu University started a Post-Baccalaureate PharmD (Doctor of Pharmacy) program in 2010. And In 2015, the Nepal Pharmacy Council (NPC) introduced a licensure examination for pharmacists and pharmacy assistants.
Despite these positive changes, there is a dearth of registered university graduate pharmacists working in the community pharmacy setting. Currently, the majority of pharmacy graduates work in the pharmaceutical industry, few in hospitals, government, and academia. Worldwide, the pharmacy profession is shifting from product-centered to patient-centered services such as preventive screenings, immunizations, and disease state management, efforts should be made to encourage them to practice in the community setting. That said, the following challenges lie ahead to materialize this in the context of Nepal.
Since B Pharm or Pharm D degree is “not” the basic educational requirement to operate a pharmacy in Nepal, anybody with DDA’s training or 3-year diploma after school can practice in a community pharmacy. In Nepal, pharmacists are still often called as mere compounders and considered not any better than the general store owners. Consumers and patients consider a visit to the medical store to purchase drugs in much the same way they consider a visit to a grocery to purchase food items. Thus, not considered a prestigious career, many graduates are reluctant to enter into community or retail as people may look down upon them for working in a drug store after spending years in the university.
2. Conventional education and training
Pharmacy education and training in Nepal are heavily industry-based,focusing on chemistry, pharmaceutics, drug development, and manufacture.There is very little training in clinical pharmacy,pharmaco-vigilance, health care policies, patient counseling, and ethics. Additionally,the concept of Continuing Education (CE) for pharmacists to enhance their professional knowledge is non-existent.
Recommendations for enhancing pharmacists’ engagement in the community pharmacy
3. Prioritize BS or Pharm D graduates
Currently, anyone with a brief training and 3 years diploma can receive a license to operate Pharmacies. This should be changed by allowing only BS or Pharm D graduates to obtain a license to open and manage a pharmacy.“Professionalists” and “Pharmacy assistants”or other health personnel owning a pharmacy should have to hire a Pharmacist with BS or Pharm D degree to run their pharmacies.These pharmacies can set fees for professional services delivered outside their usual and customary dispensing activities, to generate enough revenue to cover the costs of employing qualified pharmacists. Additionally, the setup of the community pharmacy should be changed to look different than a grocery shop. It should look like a professional healthcare setup and the pharmacist should wear professional attire anda white coat. Only a professional setup and properly attired individual create a positive impression that can garner respect and confidence from the consumer and patients.
4. Development of a standard for pharmaceutical care activities
Currently, there is insufficient attention in monitoring if proper guidelines and standards are followed in providing services at the community pharmacy. The adoption of standards for conducting pharmaceutical care activities in the community pharmacy is an important step towards improving patient care and accountability. Nepal pharmacy council, universities, and other healthcare stakeholders should work together in developing a nationally mandated standard to ensure quality pharmaceutical care practices in community settings.
5. Revamp the pharmacy curriculum
The pharmacy curriculum in the Nepalese colleges and universities should be revamped to emphasize pharmaceutical care courses. Pharmacy students should be trained on pharmacotherapy, rational use of medicines, and patients counseling so that they can offer patient oriented services through the community pharmacy.
6. Continuing Education (CE) programs
Continuing Education(CE)is an internationally recommended approach that allows pharmacists to acquire the knowledge, skills, and ethical attitudes necessary to stay current and competent in their practice. Currently, there are hardly any such programs in Nepal. Accredited agencies should offer CE to the community pharmacists on medication management, chronic condition management, care coordination, health, and wellness services, etc. to update their skills and knowledge.
In a nutshell, the continuous growth of the pharmacy profession inevitably requires both expansion and modernization, justifying the need for the shift of BS and Pharm D graduates to the community pharmacies. This paradigm shift in the community pharmacy setting will introduce a skilled workforce to improve the health-related quality of life of patients, rather than simply dispensing products.
Smita Rawal is a Ph.D. student & Graduate Assistant in the Department of “Pharmaceutical Health Services, Outcomes, and Policy (PHSOP)" at the University of Georgia.