challenges&opportunities before pharmacists by bava

A REPORT ON

Challenges & Opportunities

Communit

tal i p s Ho

SEARPharm Forum

South East Asian FIP-WHO Forum of Pharmaceutical Associations

P He ubl al ic & th R

ur al

for Pharmacists in Health Care in India

Government

WHO-India Country office

A REPORT ON

C hallenges & Opportunities for Pharmacists in Health Care in India Prafull D. Sheth

SEARPharm Forum, New Delhi

M. V. Siva Prasada Reddy SEARPharm Forum, New Delhi

Raj Vaidya

Indian Pharmaceutical Association Panaji, Goa

Manjiri Gharat

Indian Pharmaceutical Association Mumbai, Maharashtra

Dr. K. G. Revikumar

Govt. College of Pharmaceutical Sciences Medical College, Calicut, Kerala

Dr. Subhash Mondal

Indian Pharmaceutical Association Kolkata, West Bengal

Dr. Nirmal K. Gurbani

Pharmacy Department, Public Health Training Institute Jaipur, Rajasthan

Prof. KPR Chowdary

AU College of Pharmaceutical Sciences Andhra University, Visakhapatnam, Andhra Pradesh

With Technical Contributions from: Dr. P. R. Pabrai

Former Director, CIPL, Ghaziabad

Dr. B. D. Miglani

Former President, IHPA, New Delhi

Prof. S. N. Sharma

Emeritus Professor, Jamia Hamdard, New Delhi

Sunil Nandraj

Cluster Focal Point, HSD, WHO-India, New Delhi

Prof. G. P. Mohanta

National Technical Officer, EDM, WHO-India, New Delhi

SEARPharm Forum FIP-WHO Forum of National Pharmaceutical Associations for South East Asia Region In Collaboration with

WHO-India Country office

ABBREVIATIONS AACP: American Association of Colleges of Pharmacy ACT: Artesunate Combination Therapy ADR: Adverse Drug Reaction AIDS: Acquired Immune Deficiency Syndrome AIOCD: All India Organization of Chemists and Druggists ANM: Auxiliary Nurse Midwife ANMs: Auxilliary Nurses & Midwives APTI: Association of Pharmaceutical Teachers of India ART: Anti-Retroviral Treatment ARVs: Antiretroviral Drugs ASHP: American Society of Hospital Pharmacists AWWs: Anganwadi Workers B. Pharm: Bachelor of Pharmacy B.P: Blood Pressure BSF: Border Security Force CDSCO: Central Drugs Standard Control Organization CGHS: Central Government Health Scheme CHC: Community Health Centre CPA: Commonwealth Pharmaceutical Association CPD: Continuing Professional Development CRPF: Central Reserve Police Force D & C Act and Rules: Drugs and Cosmetics Act and Rules, 1940 D & C Act: Drugs and Cosmetics Act, 1940 D. Pharm: Diploma in Pharmacy DCC: Drugs Consultative Committee DCG(I): Drugs Controller General of India DOTS: Directly Observed Treatment Short-course EML: Essential Medicines List ESIS: Employees' State Insurance Corporation (India) FDCs: Fixed Dose Combinations FDI: Foreign Direct Investment FIP: International Pharmaceutical Federation GoI: Government of India GPA: General Physician Association GPP: Good Pharmacy Practice HIV: Human immunodeficiency virus IEC: Information, Education and Communication IHPA: Indian Hospital Pharmacists' Association IMA: Indian Medical Association IPA: Indian Pharmaceutical Association IPGA: Indian Pharmacy Graduates' Association ISM&H: Indian System of Medicine & Homeopathy IT: Information Technology ITNs: Insecticide-Treated Nets

IUD: Intrauterine Devices LVPs: Large Volume Parenterals M. Pharm: Master of Pharmacy MCH: Mother and Child Healthcare MCI: Medical Council of India MoH&FW: Ministry of Health and Family Welfare MoH: Ministry of Health MSPC: Maharashtra State Pharmacy Council NACO: National AIDS Control Programme NCMH: National Commission on Macroeconomics and Health NDPS Act: Narcotics Drugs & Psychotropic Substances Act, 1985 NGOs: Non-Governmental Organizations NHPs: National Health Programmes NHRC: National Human Rights Commission NIPER: National Institute of Pharmaceutical Education and Research NPAC: National Pharmacovigilance Advisory Committee NPAs: National Pharmaceutical Associations NPW: National Pharmacy Week NRHM: National Rural health Mission NVBDCP: National Vector Borne Disease Control Programme OPD: Out Patient Department OTC: Over-the-Counter P&TC: Pharmacy and Therapeutics Committee PCI: Pharmacy Council of India Pharmacy Act: The Pharmacy Act, 1948 PHC: Primary Health Centre PILs: Patient Information Leaflets PMR: Patient Medication Records PoM: Prescription only Medicines PPIs: Patient Package Inserts RCH - II: Reproductive and Child Health RDTs: Rapid Diagnostic Tests RMD: Rural Medical Dispensary RNTCP: Revised National TB Control Programme RUM: Rational Use of Medicines SALA drugs: Sound Alike and Look Alike Drugs SEARPharm Forum: FIP-WHO Forum of NPAs for SEA Region SOPs: Standard Operating Procedures STD: Sexually Transmitted Diseases TB: Tuberculosis TNMSC: Tamil Nadu Medical Services Corporation UHC: Urban Health Centre WHO: World Health Organization WMA: World Medical Association

DISCLAIMER This report is prepared by SEARPharm Forum in collaboration with WHO-India country office. This document is not a formal publication of the World Health Organization (WHO). The study was supported by WHO, however the views expressed are solely of the authors/institutions and do not necessarily in any way reflect the opinion or views of WHO. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or whole, but is not for sale or for use in conjunction with commercial purposes. 30 November 2007 New Delhi, India

Contents Preface

Message from the WHO Representative to India

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Message from President, FIP

Message from President, IPA

Recommendations and Conclusions

Chapter I: Pharmacists in Health Care Systems in India: Shaping Strategies

Chapter II: Positions Papers - Challenges and Opportunities for Pharmacists in 1. Community Pharmacy Practice

2. Hospital and Clinical Pharmacy Practice

3. Pharmacists in Government Practice Settings

4. Educational Reforms for Pharmacists

5. Role of National Organizations, government and other stake holders

Tables and figures

Bibliography

Directory of Pharmaceutical Organizations

Conference Participants list

Additional Contents in CD-Rom Annexure I: Examples of Pharmacistsâ&#x20AC;&#x2122; initiatives in health care activities in India Annexure II: Conference Programme Annexure III: Power point presentations made at the Conference Annexure IV: Conference Photographs iii

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Preface

A National Conference on Challenges and Opportunities for Pharmacists in Health Care in India was held in New Delhi on 30 October 2007 by SEARPharm Forum in collaboration with WHO-India. The aim of the Conference was to deliberate the role of the pharmacists:

As a knowledge worker in 21st Century in community, hospital and government practice settings As a health worker in Rural and Public Health

As a health care professional in improving access to medicines

Historically, the potential of pharmacists in community, hospital and government practice settings is not fully utilized in India. The pharmacists are seen as business people. The professional role of pharmacist is not projected in Government's health and pharmaceutical policies. This conference examined various issues, shared experiences and evidences of pharmacists' involvement in national health programmes for improving pharmaceutical care; and rolled out strategies for integrating pharmacists as team members with other health professionals. Strategies were also outlined for future role of pharmacists beyond supply of medicines, much needed educational reforms and stakeholders' involvement. I am grateful to lead authors and experts for preparing the position papers. I am also thankful to distinguished guests, speakers and participants for their deliberations and recommendations. I, on behalf of SEARPharm Forum, express appreciation to WHO-India country office for supporting the conference. I hope that the recommendations in this report will be taken up for implementation by all stakeholders in a timebound manner.

Prafull D. Sheth Professional Secretary SEARPharm Forum 30 November 2007

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Message Dr S. J. Habayeb, WHO Representative to India World Health Organization - India I am pleased to learn that South East Asia Regional Pharmaceutical (SEARPharm) Forum is organizing a National Conference on Challanges and Opportunities for Pharmacists in Health Care in India on 30th October 2007. SEARPharm Forum is one of the six regional Forums established globally through the partnership of WHO and the International Pharmaceutical Federation (FIP) to contribute towards improving pharmacy services and health. Traditionally, the pharmacy profession has revolved around medicine management ranging from supply to distribution. Due to the changing scenario of an ever growing and complex range of medicines, and poor adherence to prescribed medicines, a new philosophy of pharmaceutical care has evolved. This new concept is a patient oriented approach aimed at providing drug therapy for the purpose of achieving outcomes, and is key to the effective, rational and safe use of medicines. In order to fulfill the role of pharmaceutical care, the concept of seven star pharmacist has been advocated: care giver, communicator, decision maker, teacher, life long learner, leader and manager. I understand that the conference will deliberate on the role of pharmacists in public health and will share experience and evidence. An expert outcome is to develop a strategy for integrating pharmacists as team members with other health professionals, promote national health programmes, and improve patient care at all levels. The strategy may consider improving competency levels to deal with the challenges in pharmacy practice: from medicine management to the provision of effective pharmaceutical care. Please accept my best wishes. Dr S. J. Habayeb WHO Representative to India

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Message Professor Kamal K. Midha President, International Pharmaceutical Federation Dear Mr. Sheth Thank you for informing me regarding the SEARPharmâ&#x20AC;&#x2122;s plans to organize such an important conference â&#x20AC;&#x153;Challenges and Opportunities for Pharmacists in Health Care in Indiaâ&#x20AC;? The programme looks very good and I am confident that the deliberation at this meeting would lead to Recognition of the role which pharmacists can play in improving the health of populace of India. I do hope that this conference achieves the objectives you have set - that is the important role of Pharmacists in Public Health in Community, Hospital, and Government practice settings. It is important to realise that Pharmacists can improve a most cost effective delivery of health practices and they must be mobilised by all the parties concerned. I wish you success in these endeavours. Please do keep me posted on the outcome of this conference. Kind regards,

Kamal K. Midha C. M. Ph.D. D.Sc. President - FIP

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Message Subodh Priolkar President, Indian Pharmaceutical Association â&#x20AC;&#x153;The challenges and Opportunities for Pharmacists in Health Care in Indiaâ&#x20AC;? is the most relevant theme for a programme on the role of pharmacists in India. The role of the Pharmacists in Health Care in India is not recognized and all the stake holders must unite together and focus on the issues with the ultimate objective of upgrading the status of Pharmacist in India. But to achieve this, we must discuss the realities in India, the challenges, the emerging opportunities and our strategy to address these issues. The programme tries to address all the relevant issues. The selection of speakers is extremely good and thus I feel that the programme will achieve its goal in brain storming the issues and concluding all the thoughts and opinions in the round table. The paper published after the programme will be an important document for all the stake holders in the profession. I consider myself unfortunate to miss the programme due to my professional commitments and wish all the members attending a very interactive and satisfying experience.

Subodh Priolkar President, IPA

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RECOMMENDATIONS AND CONCLUSIONS

RECOMMENDATIONS AND CONCLUSIONS National Health Care Programmes

by scaling up contraceptive acceptance and playing an meaningful role in family planning by displaying contraceptives at a prominent place in pharmacies with appropriate signages for helping the patient in choice of contraceptives; distributing family planning literature freely; being counsellors next door; and spreading the message of small family norm and its advantages.

Pharmacists must get fully integrated in the health care ●1 team as part of the national health and drug policies. This should be facilitated by recognizing the pharmacists as human resource for health in the national policies. Policy makers should view pharmacies as part of the ●2 health care sector and pharmacists as health care professionals providing health care services and focus on them as they do with other health care professionals. The National Rural Health Mission (NRHM) is a new ●3 initiative by the government to provide health services in rural areas wherein pharmacists should get connectivity with the rural health systems and become a part of community of carers. Pharmacists should be utilized for improving access to ●4 essential medicines and their rational use in proper selection of medicines, ensuring their quality, improving logistics of their procurement, storage and distribution and providing information on medicines to the patients, physicians and nurses. The services of community pharmacists should be ●5 utilized in referring, counseling and participation in DOTS strategy of the Revised National Tuberculosis Control Programme (RNTCP). The Malaria Fact Card project found successful in ●6 Zimbabwe, Tanzania and Ghana should be adopted in India through national pharmaceutical associations for better consumer understanding of the use of malaria medications, increased awareness, prevention strategies and early treatment. should be encouraged to educate the public ●7 inPharmacists the thrust areas in Reproductive Child Health (RCH II)

Pharmacists should be integrated in NACO's programmes ●8 developed for the prevention and control of HIV/AIDS in India and should be involved in procurement, storage, distribution and proper use of quality ARV medicines. Pharmacists need to be actively involved in the ●9 surveillance of drug safety issues within the context of their practices. Greater participation by pharmacists in all practice settings would be an important tool to increase the reporting of ADRs and other drug-related problems in pharmacovigilance.

Community Pharmacy Practice

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10 The distribution and sale of medicines and cosmetics are governed by various drug laws like the D & C Act and Rules, NDPS Act, etc. The provisions of the existing Schedule N of the D & C Rules with regard to staff, equipment, space, storage conditions, GPP, etc. are inadequate to meet new challenges in community pharmacy practice. These need amendment, considering the changing practice of pharmacy.

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11 There is a need to accord legal status to Good Pharmacy Practice (GPP) concept and to create an accreditation authority for retail pharmacies to ensure high standards of pharmaceutical care.

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12 There is a need to evolve minimum educational requirements for persons engaged in pharmacies as 'Pharmacy Assistants'.

Challenges and Opportunities for Pharmacists in Health Care in India

RECOMMENDATIONS AND CONCLUSIONS

Hospital Pharmacy Practice

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13 The National Human Rights Commission (NHRC) issued exhaustive directives relating to the manufacture, storage and distribution of large volume parenterals (LVP) wherein the role of the pharmacist in drug management in Hospitals and Medical Stores Depots got highlighted. However, no practical steps have been taken by the Government to make necessary changes in policies connected with proper deployment of pharmacists. All the Recommendations of the NHRC should be implemented without any further delay.

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23 The curriculum and training for the minimum registrable qualification of degree in pharmacy course has to be modified giving main focus on subjects like pharmacy practice, rational use of drugs, pharmaceutical care and clinical pharmacy and should be more oriented towards community, hospital and clinical pharmacy practices to generate a sound foundation of professional and trained pharmacists.

14 The provisions of the existing Schedule K of the D & C Rules should be reviewed with a view to laying down standards in respect of staff, equipment, space, GPP, etc.

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15 The Department of Pharmacy in every hospital, including corporate hospitals, should have administrative structure similar to that of other Departments like Medicine, Surgery, Gynecology, etc. The structure and status to be accorded to the Department of Pharmacy as well as to pharmacists and other staff working therein should be at par with other departments.

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16 Pharmacists should be fully utilized in rendering professional services in hospitals and nursing homes. There should be adequate number of pharmacists in the above settings.

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17 The Medical Council of India should lay down the minimum standards of hospital pharmacy in terms of staff, space and equipments as they have prescribed for other departments in hospitals attached to medical colleges.

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minimum qualification for registration as pharmacist to a level capable of providing superior pharmaceutical care. For those who wish to go for pharmacy practice, the curriculum should be patient oriented.

24 For in-service and working pharmacists continuing professional development via continuing education programmes, aimed at keeping pharmacists abreast with new developments, are to be organized and made mandatory. 25 Pharmacy educators should ensure that the curriculum is so amended that the importance of pharmacists in pharmacovigilance gets properly highlighted.

Role of Stakeholders

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26 The strategies to build the image of pharmacists shall require improving competency of pharmacists at all levels. The area of pharmacy practice is the primary challenge.

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27 Associations, professional bodies, regional forums and government bodies should advocate and educate policy makers and generate general consciousness of the society for the pharmaceutical services for better health care.

18 A Pharmacy and Therapeutics Committee (P&TC) must be created in every hospital so that utilization of medicines is done judiciously and Hospital Formulary is compiled. The Head of the Pharmacy Department should be the Member-Secretary of the Committee.

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19 In order to provide up-to-date information on medicines to patients, physicians and other health personnel, it is essential to create a Drug/Medicine Information Center in every hospital pharmacy.

Implementation

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Government Pharmacy Practice Settings

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20 A uniform cadre and administrative structure may be prescribed for all the pharmacists working in various central and state government settings.

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21 The pharmacists should be trained and utilized for the benefit of the rural society under the NRHM 2005.

Pharmacy Education and Continuing Education

28 For greater recognition and appreciation, it is necessary for associations to document evidence that demonstrates the impact of pharmacists on society. In this connection, a national data base should be generated and archived.

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29 The pharmaceutical education, research and profession are presently controlled by more than one department and ministry making the whole process complicated. Government should consider creation of a separate “Department in MoH” or “Ministry of Pharmaceuticals”.

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30 To create a focus on pharmacy education and pharmaceutical services in community, hospital and government pharmacy settings, a “Planning and Coordination Body” should be established.

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31 The successful implementation of these strategies shall require cooperation among all stakeholders and sectors, both government and private.

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22 The minimum qualification for registration as pharmacist continues to be diploma in pharmacy obtained after the 10 + 2 stage of education. It is essential to upgrade 2

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES Introduction

health policy but also touch features of pharmaceutical policy.

The Alma-Ata Declaration on Primary Health Care 1978, states that “…health is a fundamental human right and that the attainment of the highest possible level of health is a most important worldwide social goal”. In addressing the main health problems in the community, Primary Health Care (PHC) must “…provide promotive, preventive, curative and rehabilitative services”. The Declaration states that PHC included at least “…prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries and the provision of essential drugs”. It recognized the role played by all health workers and the need for suitable training to enable these people to work as health care team to respond to the expressed needs of the community. Clearly, adequate pharmaceutical services, ideally provided by pharmacists, are vital component of Primary Health Care. This is recognized by the WHO; several publications of the WHO emphasized the role of the pharmacists in the health care system, as stated in Report of a WHO Consultative Group, New Delhi, India, 1988, and Role of the Pharmacists in support of the WHO Revised Drug Strategy at the 47th World Health Assembly, 1994. In December 2002, the Planning Commission of India setting the scene on health care, enshrined the India Vision 2020 for “…improving access to health services to meet the health care needs…”. There are two dominant policies of health care in India. The objective of the National Health Policy 2002 are to achieve “…an acceptable standard of good health amongst the general population of the country”. The draft National Pharmaceuticals Policy 2006 set the objective of “…making available good quality medicines at reasonable prices….”. The professional roles of the pharmacists not only fit into the

India's total expenditure on health as percentage of GDP is 5.1% of which drugs and pharmaceuticals account for almost 15% of total health care expenditure. In the current scenario, weaknesses of public health system without proper deployment of pharmacists cannot be overlooked. The pharmaceutical expenditure is subject to several components such as industry, prescribing habits, distribution interventions, retailing and taxes. Pharmaceutical expenditure should also be viewed in other contexts, such as, the level of patient adherence, expiry and spoilage problems, shortage of essential medicines at the time of the need, unnecessary overstocking, wastage etc. In India, as per the data available, there are nearly 500,000 pharmacists, mostly diploma holders. Almost 75% of them are engaged in community, hospital and government pharmacy practice. This large pool of human resource is a service provider to the society. Historically, pharmacists have not found mention in government's health and pharmaceutical policies, perhaps due to lack of clarity of their role and their potential beyond supply of pharmaceutical products. Policy makers should exploit potential of pharmacists in community, hospital and government settings for improving pharmaceutical services and health and thus relieve the doctors, dentists and nurses of unnecessary load of work. Policy makers usually see pharmacies as commercial enterprises and pharmacists as business people. Policy makers should view pharmacies as part of the health care sector and pharmacists as health care professionals providing health care services and focus on them as they do with other health care professionals. Since medicine cost is one of the major components of the health care expenditure, medicines must be used rationally.

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

Adequately trained pharmacists are an essential component of the health care team to achieve optimum results. To meet social demands and public health objectives, well trained and educated pharmacists should optimize medication management leading to positive health outcomes, generating savings to the health sector, and promoting benefits to urban and rural societies in areas like: In order to promote the role of pharmacists in health care in India, a National Conference on Challenges and Opportunities in Health Care was convened in New Delhi on Tuesday 30, October 2007. The Objectives of the Conference were to deliberate the following roles of pharmacists: l Improving access to medicines and rational use of drugs l Prevention and control and use of ARVs in HIV/AIDS l Revised National Tuberculosis Control Programme l Rollback malaria l Hypertension and diabetes screening l Prevention of poisoning l Pharmacovigilance and ADR monitoring l Family Planning and RCH l Problems of geriatric patients l Trauma management in accident cases To strengthen the professional image of pharmacists, partnerships with other stakeholders is a must. Documentary evidence in support of the benefits that the community gets by proper involvement of pharmacists has to be provided. Evidence worldwide strongly suggests that involvement of the pharmacists in providing information on medicines, health promotion, disease prevention and disease management improves efficiency of the health care system. Also, inappropriate use of medicines gets reduced. A few examples of pharmacists' initiatives in health care activities in India are included in Annexure - I. Globally for pharmacists, the competition has brought the spot light on 'Change Management'. Pharmacists in India must also embrace this change and move up from medicine management to effective collaborative pharmaceutical care. Any deficiencies in the curricula of pharmacists must be set right at the earliest and every attempt should be made to review the curriculum to keep pharmacists abreast with the current requirements. Pharmacists must get fully integrated in the health care team as part of the national health and drug policies. This should be demonstrated by recognizing the pharmacist as a human resource for health.

Shaping Strategies The Conference was addressed by guest speakers, public health experts, pharmacy leaders in community, hospital and government practice setting, representatives of national pharma associations. Sessions were chaired by experts from WHO-India, Medical Council, and MoH. During the conference, stakeholders and participants deliberated on challenges and opportunities for pharmacists' involvement in public health programmes. During the round table, a framework for policy development engaging pharmacist in health system was discussed. Based the stakeholders recommendations, the following strategies were rolled out.

Pharmacist as a knowledge worker in the 21st century in community, hospital and government practice settings The traditional role of pharmacists in community settings is dispensing of medicines. Selling of medicines without prescription and cash memo, storage of medicines under improper conditions, running pharmacies even without the physical presence of a pharmacist is not uncommon in the current scenario. If we look at the small nursing homes or small hospitals in general, they don't even have a pharmacist. In the bigger hospitals, where pharmacists are available, they have such a heavy work load that even if they wanted to contribute, they don't have time. Pharmacists in government settings have different designations and pay scales and their roles are mixed up. Mainly their role is dispensing medicines but at times they are also involved in other miscellaneous non-professional jobs. But we need to move forward if we have to enhance the image of pharmacists. If we look at the knowledge level and training of the pharmacists, they are not sufficient. The service levels of patient care also require substantial improvement. Currently, the pharmacists are not adding much value in patient care. The curriculum also needs a change as the current curriculum is not patient oriented, but has a strong bias towards industry. The ideal would be to upgrade minimum qualification for registration as pharmacist to a level capable of providing pharmaceutical services at a level comparable what are available to citizens of other countries in the world. India is the only country in the world where minimum qualification for registration as pharmacist continues to be a diploma in pharmacy obtained after 10 + 2 stage of education. As already pointed out, approximately 15% of the health related expenditure is on drugs of which nearly three-fourths is out-of-pocket. The community is looking forward to receiving a better deal from pharmacists as they are already involved in supplying medicines. India Vision 2020 calls for “……improving access to health services to meet the health care needs…..” and the Government is keen to achieve it. As far as pharmacists are concerned, the Planning Commission would like to have a CHANGE and a change is inevitable. The process has to be initiated for this CHANGE that the pharmacists should be members of the policy making body not at one level but at all levels. They should be members of the Pharmacy and Therapeutics Committee in the hospitals, involved in the selection, purchase and quality control of drugs, equipments, blood transfusion kits, etc. because they are knowledgeable in these areas. The pharmacists are currently providing product oriented services in stead of patient oriented information. As information workers, they should be involved in the drug information centers, producing patient information leaflets, monitoring ADRs and as expert staff in regulatory laboratories, etc. To bring about this change, would require a lot of advocacy and education through stakeholders, professional associations, regional Forums like the SEARPharm Forum and government bodies like the

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

Planning Commission. Education has to be imparted at all levels including trainers to improve their managerial capabilities. Today, there is a shortage of health workers. Pharmacists are not involved in National Health Programmes as a part of NRHM. Certainly, pharmacists have to be part of the health care system. The standards for pharmacists on pharmacy practice are to be developed. This Conference has initiated a process to document the success stories on evidence of the involvement of pharmacists. Such success stories should be documented further. Equally important is dissemination of documented evidences at all levels including the concerned Ministries.

The role of pharmacists in National Rural Health Mission, where pharmacists can get connectivity with the rural health and become a part of the community of carers

India are in short supply and often are on to tedious work with sometimes declining or minimum esteem and a history of being forced to remain at the fringe fulfilling the doctor's directions. Pharmacists are also a part of the supply chain. Pharmacists too, like nurses, lack self esteem since, knowledge requirement is not uniform and down scaling of knowledge in a manner meaningful and relevant to the community always lacks the sheen of the high table and also can be low on self esteem. Therefore, there is a need for doggedly down staging knowledge about ill health and its ways and the role of preventive and personal care in remaining in good health and this is required by the community in culturally compatible term. Pharmacists are ideally a good link responsible for both succor in need and for business creation in a sense linking at the low end of the table commercial enterprise and community service. Their responsibility is to listen and check appropriateness of prescriptions, provide medicines and explain their proper use, all this at a reasonable cost.

In India those most needing health care live predominantly in rural areas. Rural is a vast spread that covers not only the remote, but areas with varying levels of urbanization which will of course be the key trend as we proceed into 21st century. The needs and service available will vary among rural areas and solutions must relate to local needs. There is an opportunity to do so in which pharmacists can have a role.

Besides RCH, there are other hidden and understated areas of health care going without attention and accepted as part of living such as depression among rural women especially poor and elderly which are generally under stated. Pilot solutions should be attempted to see how far a group of knowledgeable and committed pharmacists can serve designated community of such people as part of a health care team.

In most rural communities, the primary issues are common availability of drugs, doctors, prevention of ill health, promotion of good health and an environment that promotes culturally compatible well being. Generally, there is a mismatch between prevalence of disease and facilities for care between drugs availability and doctors. What is said to be available in public sector is poor and unreliable; what is offered in private sector is beyond reach and expensive. In this scenario, pharmacists often can substitute the gap as a first port of call and create the window of connectivity in drug supply, advice on its proper use and become a link between the community and health care. How can this asset of a vast chain of pharmacies be put to good use?

The role for pharmacists will only grow in a forward looking and self confident nation wanting to be a middle income country. One way is to establish and increase the reach of rural area pharmacies, accredit them into various grades, see them grow into a community resource and even over time with a facility for being a vendor of community health insurance through pharmacists. If hospitals do so in curative care why not pharmacists be a conduit for vending local community insurance. The opportunity would be available to integrate knowledge and action through vernacular translation made appropriate to local situations, thus helping community.

NRHM is an ambitious envelope entirely rural focused program aiming at both facility creation up to standards and service guarantee to the satisfaction of patients. About 75% of funds in NRHM are decentralized of which 10-15% are untied to be spent according to local needs and decision making. A part of these funds could be pooled together for reliable, essential, quality OTC medicines to be supplied to the community by pharmacists accompanied with counseling on an experimental basis. Pharmacists who can in consultation with Dt. Health Societies can lead experiments of this kind and should be encouraged and they should be documented. There is a distinction between the front line health workers and those essential but working in the background. Further, in terms of visibility there is a high and a low table pharmaceutical companies, researchers and doctors operate from high table, the nurses, pharmacists and community health workers support and work from low table. Nurses in

Strategy for improving access to essential medicines and rational use of drugs through pharmacists The country is moving forward in the pharmaceutical sector. Several billion US dollars are going to be invested in India for conducting clinical trials and large numbers of patients are coming for patient care. There are several disquieting features of scenarios like poor access to essential medicines. About 25-30% of the population in rural area has no access to medicines. Approximately 2.3% of our population goes below the poverty line every year and remains there for the rest of their lives primarily because of treatment costs. Next to Kazakhstan, which spends 82% out-of-pocket on medicines, India is the second highest spender on medicines out-ofpocket (81%). On the other hand, people in Thailand, Sri Lanka and Bangladesh spend only about 30% out-of-pocket on medicines. What makes it worse is that almost 50% of the

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

medicines used today are used irresponsibly and irrationally in wrong doses and wrong durations. By using the enormous manpower of pharmacists for rational use of good quality medicines, treatment costs can be decreased substantially. This has already been demonstrated well by the Delhi experiment on rational use of medicines wherein doctors, pharmacists and nurses were involved in a responsible manner leading to improved access to medicines at lower costs. Thus, four areas need to be developed in collaboration with the WHO by setting up task forces so that access to medicines through pharmacists improves. These are: 1. Selection of medicines at different levels of health care: Pharmacist knows more about medicines in terms of comparative use, cost, safety and efficacy. Pharmacists should play a vital role and take the lead. 2. Quality of medicines: Pharmacists can play a vital role in curbing the menace of counterfeit and substandard medicines. Basic Tests for Pharmaceuticals and Dosage Forms developed under the auspices of the WHO can and should be used especially in developing countries. 3. Logistics of procurement, storage and distribution of medicines: Pharmacists should ask themselves as to how and why medicines are not reaching almost 50% of the rural population, when cigarettes, tooth brushes, tooth pastes, etc. are readily available? The government is planning to outsource district health centers to NGOs. Pharmacists should use the opportunity and take up a few health centers to prove their role in procurement, storage and distribution of medicines. 4. Provide information on medicines: Pharmacists should go straight to the public and provide information on medicines. People want to know about medicines that they are taking. They can go to special groups of people like the elderly who take many medicines for conditions like cancer, hypertension, diabetes, etc. and advise them on ways and means of reducing costs of treatment by rational use of medicines that are becoming costlier day by day and becoming difficult for them to buy out of their limited incomes and budgets. Pharmacists should think of changes in health care systems that are going to come. There is going to be tremendous increase in out-patients in hospitals; very sick or terminally ill cases only are likely to find places for admission as inpatients because of limited resources and increase in population at a galloping pace. Increase in the noncommunicable diseases and decrease in communicable diseases will have to be taken note of seriously. Tremendous increase in trauma cases is expected. Patient safety in hospitals due to increased possibilities of medication errors is another important factor to be taken into consideration. We are likely to see a growth in Quick Clinics (Wal-Mart Clinics) and specialized centers for treatment of conditions like shoulder pain, hernia, etc. where people want instant 6

remedies. The pharmacists need to see where they will fit in this scenario.

Strategy for pharmacists' role in Revised National Tuberculosis Control Programme Global annual incidence of TB is about 8.9 million and India has the highest TB burden in the world accounting for almost one fifth of the global incidence of TB. India is adding 1.8 million new TB cases annually. An estimated 5% of TB patients are HIV infected. About 370,000 die every year due to TB. Social and economic burden of TB in India is very high and indirect cost to the society is estimated to be $3 billion. The goal of RNTCP is to decrease mortality and morbidity due to TB and to cut transmission of infection until TB ceases to be a major public health problem in India. The objective of RNTCP is to achieve a case detection of at least 70% of new sputum positive TB patients with a cure rate of at least 85% in such patients. Political commitment of the government is through DOTS programme which is providing free TB medication under direct supervision. Being health care providers, government pharmacists have been involved as referrals of suspects and as DOT providers. In the Tuberculosis Research Centre study in 2001, the potential of private pharmacists has been recognized. Pharmacists, as the most easily accessible members of the primary health care team, can play a more proactive role in preventing and managing TB for the patients who buy medicines. This valuable resource was hardly tapped for the TB Control. Pharmacists can play an indispensable role pertaining to TB prevention and management. Patients who come to pharmacies for medicines can be counseled and guided appropriately so that they are well informed about the disease and their role in management of the same. Pharmacy students can also assist the pharmacists in this venture. Based on these views, a TB Fact Card project was launched by the Indian Pharmaceutical Association (IPA) in 2005 in Mumbai as a pilot project. The project was a collaborative project between the Commonwealth Pharmaceutical Association (CPA) and the International Pharmaceutical Students Federation, supported by the Maharashtra State Chemists & Druggists Association and the Mumbai District TB Control Society. Overall this pilot project proved to be successful in reaching out to 5000 patients to create awareness. Most of the pharmacists showed keen interest in the work and wished to continue working for such a social cause that also projected the professional role of a pharmacist. RNTCP pilot study of pharmacies carried out in 4 zones of the Chennai Municipal Corporation from April to September 2006, demonstrated the willingness of pharmacies to educate and refer TB suspects. Of the 517 pharmacies selected, data was collected from 402 (78%). 359 (89%) of the pharmacists were aware of the symptoms of TB and 193 (48%) were aware that TB was diagnosed by sputum examination. 363 (90%) interviewed pharmacies were dispensing AntiTubercular drugs, 109 (27%) of them knew the DOTS strategy. Almost all of them were willing to participate in the DOTS

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

program. The pilot study showed promising results and has indicated that the private pharmacies can be recruited to effectively contribute towards RNTCP. This evidence strongly supports that pharmacists are ideally positioned and their strong presence in the community can contribute to educating the public, directing TB suspects for check up, providing of DOTS medication and default retrieval, and addressing stigma issues. Pharmacists have a valuable public health role in promoting community awareness of tuberculosis, particularly in reducing the stigma and discrimination often associated with the disease. They can also counsel patients on proper use of their medication leading to greater patient involvement in treatment and compliance. The challenge and opportunity for the pharmacists in TB Control are to: l l l l l

increase access to the RNTCP at the community level improve quality of DOTS in the private sector establish pharmacies as key stakeholders promote IEC on TB and DOTS through private pharmacies involve academia/colleges of pharmacy and Pharmacy Council of India

Pharmacies being accessible and acceptable to the community can play a significant role in catering to the “bottom of the pyramid” right from identification of suspects to ensuring treatment completion, a vital link in Public-Private-Mix.

Strategy for pharmacists' role in Roll Back Malaria Programme A partnership between the WHO, World Bank, UNICEF, UNDP and the malaria- endemic countries with their bilateral and multilateral partners was launched in 1998. The objective of the Programme is prevention of deaths due to malaria and reduction in malaria morbidity. As per the latest estimates, there were 1.6 million cases of malaria reported in 2006. The goal of the programme is to half the burden of malaria by 2010. Core Technical strategies of the roll back malaria programme are: l

improved and prompt access to effective treatment

increased use of insecticide-treated nets (ITNs) and other locally appropriate means of vector control

early detection of and response to malaria epidemics

improved prevention and treatment of malaria in pregnant women in highly endemic areas

The Revised Drug Policy on Malaria (2007) makes diagnosis of malaria by microscopy or rapid diagnostic tests (RDTs) imperative. The new intervention is Artesunate Combination Therapy (ACT).

For chloroquine resistant P. falciparum, combi-blister packs of chloroquine+primaquine (CQ+PQ) and ACT as per age bands, fixed dose combinations, and advocacy in the private sector are recommended. At its inaugural meeting during the International Pharmaceutical Federation (FIP) Congress in Vienna in August 2000, the Commonwealth Pharmaceutical Association and WHO (CPA/FIP/WHO) Malaria Task Group recognised that pharmacists could and should play a more pro-active and coordinated role in the prevention and treatment of malaria, given the alarming global statistics relating to the disease and the enormous economic burden and the tragedy of human suffering, especially in the high risk groups of children under five years of age and pregnant women. The Malaria Task Group decided that the highest priority was for prevention of malaria through provision of consumer information. Its aim, therefore, was to provide pharmacists with the skills and resources to develop, produce and implement intervention strategies which would enable them to contribute effectively to the prevention of the disease in both the rural and urban areas of malaria-endemic countries. The project centred around a “mix of intervention strategies” consisting of two major communication tools which were relatively inexpensive to produce and easily adaptable to suit the local conditions: 1) Malaria Fact Cards for use in urban areas; and 2) Flip Charts or Pictograms for use in rural areas. The project has focussed to date on the Malaria Fact Card. Malaria Flip Charts will form Phase 2 of the project. The Fact Card Project was designed to work on three levels: 1. by providing easily accessible consumer health information through pharmacies and clinics; 2. by using pharmacists as communicators and educators as well as medication providers; and 3. by promoting the role of professional organisations within health infrastructures. The time for design, development, implementation and evaluation in each country was estimated at two years. After successfully piloting the project in Zimbabwe in 2001, the Malaria Fact Card project has since been implemented by the Pharmaceutical Societies of Tanzania and Ghana. Project outcomes were evaluated on three levels 1) pharmacists' focus group; 2) consumer survey; and 3) organisations focus group. Results revealed improved consumer understanding of the use of malaria medications, increased awareness of prevention strategies and early treatment. The pharmacists reported greater patient-pharmacist interaction and greater recognition of pharmacists' knowledge and advice. The project has enormous potential in India to develop further as a self-sustaining consumer health education programme. The fact card is developed through collaboration between the research and practice arms of the profession, distributed by pharmacists and healthcare workers in pharmacies and clinics, and resourced through public-private partnerships.

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

Strategy for pharmacists' role in Family Planning Programme Population stabilization is a priority area of the Government of India. By 2060, it is estimated that population in India would be around 1.53 billion. The major areas of concern in Family Planning Programme are poor Access to Family Planning (FP) services and poor Manpower development at state level. Identified thrust areas in RCH-II for scaling up Contraceptive acceptance are to: l l

establish quality care in FP services address the unmet need in spacing and terminal methods increase male participation through intensive promotion of Non Scalpel Vasectomy (NSV) promote contraception through increased advocacy increase basket of choices

l l l

The following temporary methods of family planning are identified: l l l l

IUD 380 A Emergency Contraceptive Pills Combination Oral Contraceptive Pills Conventional Contraceptives ( dual purpose condoms)

Newer contraceptives are Centchroman (Saheli), once a week non-steroidal pill, and injectables (Cyclofem, Net-en). Pharmacists can educate the public in the thrust areas in RCH II by scaling up contraceptive acceptance and play an important role in family planning by: l

displaying contraceptives at a prominent place in the pharmacy with appropriate signage; distributing family planning literature freely so that the customer can carry it to home; being counsellors next door; spreading the message of small family norm and its advantages; providing a reservoir of knowledge on family planning methods; helping clients in making informed choice; and contributing to population stabilization for the country.

l l l l l l

Strategy for pharmacists' role in prevention and control of HIV/AIDS As per 2006 revised estimates, there are an estimated 2 to 3.1million HIV infected person (by 2006) in India with an adult HIV prevalence of 0.36%.The HIV epidemic in India continues to be concentrated with heterogenous distribution. Based on the available data for last three years, 156 districts have been identified as Category A districts where HIV positively among antenatal mothers is more than 1 percent for priority attention. A total of 180,000 AIDS cases were reported between 1986-2006. The predominant mode 8

of transmission of infection in the AIDS patients is through heterosexual contact (85.7%), followed by Injecting drug use (2.2%), blood transfusion and blood product infusion (2.6%), perinatal transmission as 2.7% and others as 6.8%. The most predominant opportunistic infection among AIDS patients is tuberculosis, indicating a potential of future high spread of the HIV-TB co-infection. NACO has the following programmes for the prevention and control of HIV/AIDS in which pharmacists should be involved: l Blood safety l STD Control l Condom Programming l IEC and Social mobilization l Care, support and treatment of people living with HIV/AIDS l Training on HIV/AIDS/STD prevention and control l Targeted interventions l Prevent of HIV from Mother to Child l Integrated Counselling and Testing l Intersectoral Collaboration l International and bilateral cooperation l Programme financing l Monitoring and Evaluation l External Quality Assurance Scheme HIV/AIDS is a major threat to public health. It is therefore of great importance to involve pharmacists in the fight against HIV/AIDS. The International Pharmaceutical Federation (FIP) has collaborated with WHO and issued a joint declaration on â&#x20AC;&#x153;The Role of the Pharmacist in the Fight against the HIV-AIDS Pandemicâ&#x20AC;?. The joint declaration formed the basis for the development of guiding principles for pharmacists in the fight against HIV/AIDS in India by Indian Pharmaceutical Assocation through the Community Pharmacy Section of FIP. In order to achieve the objectives, a series of approaches were developed: provision of continuing education to practising community, hospital and government pharmacists. Using guiding principles, 500 pharmacists were trained in prevention and information; counselling; perils of injectable drug use; blood and blood products; diagnostic tests; proper use of anti-retrovirals (ARVs); their doses; quality control; storage; and cost of medication. The intervention clearly highlighted the role of pharmacists in national health programmes. Pharmacists were motivated to participate in similar national programmes. Opportunity was used to sensitize leaders and seek collaboration with medical professionals, non-governmental organizations (NGOs), and the National AIDS Control Organisation in India. NACO has a module on RTI/STD/HIV/AIDS for Health workers and supervisors. This module covers the basics of HIV/AIDS/STD prevention and control for the grass root-level health workers and is to be integrated into the RCH training program and covered in a half-day program. This module also has been translated into regional languages by the respective Sate AIDS Control societies. Pharmacists should be integrated in such programmes and developed for the prevention and control of HIV/AIDS in India. Pharmacists should be involved in procurement,

Challenges and Opportunities for Pharmacists in Health Care in India

PHARMACISTS IN HEALTH CARE SYSTEMS IN INDIA: SHAPING STRATEGIES

storage and distribution of quality ARV medicines. Pharmacist can administer ARV therapy, ensuring proper use of medicines which would result in safe, efficacious and cost effective treatment and rational use of ARV medication.

Pharmacists are among a large group that remains to be optimally tapped for pharmacovigilance since pharmacists are tailor-made professionals due to their education and training.

Strategy for pharmacists' role in Pharmacovigilance

Pharmacists should understand their pivotal role in the surveillance of the safe use of medicines. The pharmacy profession in India should acknowledge and promote this role of the pharmacist in the detection and reporting of suspected ADRs and other drug-related problems. Pharmacists need to be actively involved in the surveillance of drug safety issues within the context of their practices. Greater participation by pharmacists in all practice settings would be an important tool to increase the reporting of ADRs and other drug-related problems. In doing so, pharmacy educators should ensure that the curriculum is so amended that the importance of pharmacists in pharmacovigilance gets properly highlighted.

The WHO defines pharmacovigilance as the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other possible drug related problems. The objectives of pharmacovigilance in Public Health programmes are to improve patient care, public health and safety, and to encourage safe, rational and appropriate use of drugs. There is no systematic pharmacovigilance programme in many developing countries. As a result, there is little evidence on safety of drugs in many public health programmes. For example, less than 2% of all ADR data, a component of pharmacovigilance, is captured in Asia and Africa. Globally, only about 500,000 to 600,000 adverse event occurrences are captured. Low-to-middle income countries, which represent more than two-thirds of the world's population, account for less than 5% of all ADR data. As an example, the situation for pediatric antiretroviral treatment (ART) is much more severe. Patient intolerance and toxicity is a major cause of poor adherence and a common reason for changing medications and dropping out of a treatment programme. Adverse effects associated with antiretroviral medicines have been reported to occur in up to 30% of HIV-infected children on antiretroviral therapy. This is especially important since, most of the adverse effects are reversible by modifying the dosage or omitting the offending medicine. Apart from this, safety concerns with antimalarials, anti-tubercular drugs have also been established.

Monitoring strategies The successful implementation of these strategies shall require cooperation among all stakeholders and sectors, both government and private. The strategies to build the image of pharmacists shall require improving competency of pharmacists at all levels. The area of pharmacy practice is the primary challenge. The task calls for continuous review of quality of education to be imparted to the pharmacists. As they have to interact with the patient, the doctor, the nurse, and the government functionaries, pharmacists must be given special courses for improving their communication skills. The stakeholders and participants agreed to harmoniously pursue these strategies.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE I. INTRODUCTION In India, the practice of community pharmacy in its true professional sense is still in its infancy. However, emergence of large pool of pharmacists does have a major role as professional and health care service providers in the society with other health professionals. If their full potential is realized, like in other developed countries, they can be experts in medicine management and can be part of national health and pharmaceutical policies. Community pharmacy practice evolved in the post Second World War period. In developed nations, evidence exists that pharmacists not only began to perform functions that were new to pharmacy, but they started innovating functions and captured their original contributions in literature. The popular motto of "patient oriented practice" and "drug use control" came into practice. The traditional role of pharmacists to manufacture and supply of medicines has undergone a sea change. More recently, pharmacists have been faced with increasing health demands due to an evergrowing and complex range of medicines, poor adherence to prescribed medicines that have forced the evolution of the pharmacist's role into a more patient centered approach. In addition, the pharmacist assumes varied functions ranging from the procurement and supply of medicines to pharmaceutical care services thereby dispensing with knowledge and improving outcomes resulting in best treatment for patients. In India, role of community pharmacist is not so much recognized, and needs strong support from all stakeholders in fulfilling the same. Although, pharmaceutical education in India has grown from certificate level to post doctoral level, the focus has mainly been on industry and laboratory orientation. Consequently, the pharmaceutical industry in India has benefited. Today, internationally, India is the fourth largest pharmaceuticals producing country by volume. 10

Almost all essential medicines are indigenously available at most competitive prices. However, outreach of medicines continue to be a major issue. For the past 15 years, there have been dialogues and efforts by various organizations and pharmacy professionals to influence the way pharmacy is practiced in India. With the steady efforts of committed professionals and with constant infusion of ideas and encouragement, pharmacists are slowly realizing the need to further develop the concept of pharmacy practice. The efforts of the Pharmacy Council of India (PCI) to strengthen and upgrade the curricula of pharmacy to make degree the minimum qualification to practice pharmacy and to make continuing education compulsory will further provide impetus to the development of the profession. From small family-owned medical shops scattered scantily in the cities many decades ago, a transformation has taken place with rapid urbanization. There has been a rapid proliferation of medical stores in almost every nook and corner of the country. As per the latest estimates, there are approximately 5,50,000 retail drug licenses in the country. Perhaps more than 95% of these licenses fall in the category of Chemists and Druggists (Medical Stores), as they do not have the facility/approval of compounding in the premises. The number of pharmacies licensed to carry compounding is very minimal, and many of these, even though they continue to be licensed as pharmacies, have very little or no compounding activity. For practical purposes, it can be safely said that more than 99.9% of the dispensing of drugs today is of pre-packaged drugs, and compounding is less than 0.1% of dispensing activity. For ease of understanding, pharmacy is commonly used for all retail drug licenses in this report. Pharmacy is presently operated more as a business or trade selling valuable medicines, rather than as profession.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

II. PRESENT PRACTICES A. Skewed proliferation of pharmacies Even though nearly 5,50,000 pharmacies in the country do cover quite a lot of the nook and corners of the country, the proliferation is skewed, and it is seen that there is a common tendency towards larger concentration in urban areas (metros, cities, towns). On the other hand, many interior areas, remote places, rural areas and villages continue to be sparsely represented and are often without any pharmacy. The nearest pharmacy at times could be many miles away. In certain areas, there are no pharmacies. This could be because there is no doctor in the area, or the population levels are low. At times, no pharmacist wants to stay/work in pharmacies in these areas since the salary structures are low, and they tend to move towards the urban pockets where the salaries are a little more respectable. This non-uniform distribution has many shortcomings, some of which are listed below: l

Too many pharmacies in close proximity to each other especially cluttered around doctors' clinics, nursing homes, hospitals, or in a market place, means they are vying for the same business. This affects business and profits and drives some of them towards malpractices, namely, sale of prescription medicines without prescriptions, undercutting, discounts, sale of expired goods and of physicians' samples, recommending medicines unnecessarily to clients, etc. Some states (viz. Kerala, Maharshatra) have tried to put in place a legislation which prescribes certain minimum distance between two pharmacies. The government had also appointed a Committee consisting of Drug Controllers of various states to study the matter and make recommendations. However, this concept failed to find good hold due to the reason that running a business is everyone's fundamental right and no one can stop it.

In such circumstances, hiring and paying a full-time pharmacist becomes either a formality or burden or both, and many shy away from doing this.

Pharmacies selling prescription medicines without a prescription (and going unpunished) often make them more popular amongst the public than those who are strict and insist on a doctor's prescription.

B. Area of pharmacy premises The minimum area prescribed by law, for running a retail pharmacy is only 10 sq.m. (see Table A: community pharmacy practice around the world). While this is too small an area to run a pharmacy, it is a reality. Most of the pharmacies in India would have an area of anything between 10 - 25 sq.m. This means that there is a shortage of space for keeping stocks, for clients to stand inside the pharmacy, for pharmacy personnel to move around and serve the patients' needs in an expeditious and professional manner. Obviously, there is no question in such cases of having a separate area for patient care activities, or even privacy for the patients. Pharmacies

with areas of 25 - 50 sq.m. or more have a distinct advantage. However, even here, the concept of patient care area, etc. is not thought of, and the pharmacies continue selling medicines in the usual way, the typical product-oriented attitude. Community pharmacy practice - Around the world situation is shown in Table - A.

C. Ownership of pharmacies In India, ownership of a pharmacy is not an exclusive domain of the pharmacist alone, as in many European countries. This has resulted in simply anybody without proper education or qualification or background or experience starting a pharmacy. They look after it themselves, or hand over to someone (not necessarily a pharmacist) to manage. Pharmacists own few pharmacies, but a large majority are owned by non-pharmacists. Some owner-pharmacists do dedicate themselves to serving the profession and the public in the proper use of medicines.

D. Payment for drugs Reports suggest that around 33% of people in India have no access to modern medicines. The total expenditure on health care is 5.1% of which 80% is through private and the rest through public spending. Majority of people pay out of pocket for treatment and medicines; most medicines are purchased from retail pharmacies, hospital pharmacies or dispensing doctors. There is no insurance/reimbursement mechanism for purchase of medicines, unless it is associated with a 24hour hospitalization (through insurance companies). Very often patients buy only a part of the prescription (lesser than the prescribed number of items or lesser quantity of each of the items). Prescriptions of tonic and irrational drugs often result in patients not buying sufficient quantities of rational or essential drugs. The pharmacy faces a lot of problems in selling only a part of the prescription, often having to cut strips, and managing prices to suit the client's pockets. Clients may or may not come back for the rest of the prescription, either because they felt alright with what they took, or did not have the money to buy more. Employees of the government and its several undertakings are allowed reimbursement on the cost of medicines against production of sufficient documentation.

E. Storage and temperature maintenance Since pharmacies are located on busy roads without front doors, during working hours, stocks are exposed to the dust generated on roads due to traffic. Only a few pharmacies are air-conditioned. Medicines are often not stocked systematically due to lack of space, time, as well as lack of expertise. The temperature ranges in various parts of the country vary from sub-zero temperatures in the northern states to even 500C in large parts of the country. This results in exposure of medicines to temperatures other than those specified on the labels of medicines as appropriate for storage. Medicines are exposed to higher temperatures in transit during transport from the manufacturer to the retailer, and at intermediate points like C & F agents,

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

transporters' godowns, wholesalers, etc.). This exposure is most of the times not safe guarded. Attempts have been made by some state governments and drug control departments (e.g. Maharashtra, Kerala) to make it mandatory for pharmacies to have air conditioning. However, it is one of the many issues that do not get implemented because of socio-political and financial reasons.

F. Prescribing by brand name Almost all doctors in private practice (and many or most in Government hospitals too) prescribe by brand names (approximately 100,000). Generic prescribing is a rarity. India has also the dubious distinction of having the maximum number of Fixed Dose Combinations (FDCs) (approximately 5,000). There is tough competition amongst the pharma companies to market their me-too products. Doctors prescribe varied brands, and in an unpredictable manner, making it difficult for the pharmacy to know which brands to stock, and in what numbers. Besides being an inventory management problem, there is no space for pharmacies to stock and make available the brands that are being prescribed in their neighborhood. This often results in bouncing of prescriptions (forced to refuse to dispense the medicines because of unavailability of stock). This also diverts the time and attention of pharmacist into debating, which brands to stock. This large number of brands and combinations results in substitution and lack of recall in the uses, actions, dosages, precautions, etc. of drugs, a useful information for patients.

G. Dispensing doctors The Schedule K gives exemption to qualified doctors to buy, stock and dispense medicines to their own patients. They are however, expected to keep detailed records of the medicines purchased and dispensed. They do not do this, use the loophole in the law, and â&#x20AC;&#x153;sellâ&#x20AC;? medicines to the patients by including the amount in their fees.

H. Presence of pharmacist on duty As per the 2001 Population Census, there are round 5,50,000 pharmacists in the country, and the ratio of Pharmacist to Population has been worked out to 1:1840. However, this figure would be including all categories of pharmacists, and not only practicing pharmacists. Further, there is no bifurcation/separate data/statistics of practicing pharmacists (those working in retail and hospital pharmacy), and those working in other fields (industry, academia, regulatory, marketing, allied, etc.). As such, there are no correct figures available as to how many pharmacists work in community pharmacy in the country. All pharmacies are required to have the name/certificate of at least one pharmacist on their license. While this may be on paper, reality is quite different. Large numbers of pharmacies do not have a pharmacist present at all. Large numbers may have a pharmacist present for some/varying times when the pharmacy is open. Exceptional pharmacies may have more than 3 or 4 pharmacists on their rolls. Ghost pharmacists in 12

some states, the number of pharmacy licenses issued and running exceeds the number of pharmacists present in the state. Uttar Pradesh has around 20,000 pharmacists, while the number of retail licenses is around 60,000. The concept of Locum Pharmacist which is popular in developed countries to fill short-term vacancies is worth considering in India too, wherever there are shortages. Instead of developing the profession so that pharmacists are better equipped to serve the community in urban and rural areas, there is lobbying promoting the concept that there is no need for pharmacists in pharmacies. This was reflected in a Parliamentary Committee Report in the year 2002, which stated that a pharmacist was not necessary to man a pharmacy. This shocked the pharmacist community in India, since this put their identity and existence at stake. Pharmacy associations wrote to various government authorities/ officials, met and pleaded their case. Ultimately, the storm blew over, and the Report was abandoned. The lobby had lied low for quite some time, and the Pharmacist community in the country was again caught unawares when in May 2007, the Ministry of Chemicals and Fertilizers took a decision that unqualified salespersons in pharmacies be given short training of 3 months with a certificate to officiate in the pharmacies. This has again put the pharmacist community in a very piquant situation.

I. Concept of Good Pharmacy Practice GPP defines national standards that are necessary to ensure quality pharmaceutical services. GPP is an important component for reigning the standards of pharmacy services as well as professional attitude and behavior of pharmacists for improving health in the community. GPP guidelines lay standards for quality of pharmacy services in community pharmacy settings. Legislation to this effect is being sounded out in the country in the last few years. There is a need to accord legal status to this concept. The Indian Pharmaceutical Association (IPA) has drawn up GPP Guidelines (based on FIP/WHO guidelines), and prepared a detailed GPP Training Manual for Pharmacies in collaboration with WHO-India Country Office and the DCG(I). The IPA has conducted GPP workshops based on the training manual in different parts of the country, and got very good response. The IPA is now planning to spread the concept of GPP to the whole country in a systematic way.

J. Accreditation of pharmacies A basic concept which should underlie all health care services and pharmacy practice is that of assuring the quality of patient care activities. The quality assurance project of the Centre for Human Sciences in Bethesda, USA lists four core principles which have emerged to guide quality assurance in health care: 1) Focus on the patient 2) Focus on systems and processes 3) Focus on measurement 4) Focus on teamwork

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

The implementation and practice of pharmaceutical care must be supported and improved by measuring, assessing, monitoring and improving quality of pharmacy practice activities, utilizing the conceptual framework of continuous quality improvement. In India, this concept is in infancy. In Aug 2006 - Aug 2007, the IPA carried out pilot accreditation exercise in 2 localities in the country, and is working on modalities for scaling up in the entire country. The pilot exercise has received a very good response, and the pharmacies have reported every good gains from this exercise. Other pharmacies which were not part of the pilot exercise have shown enthusiasm that they be included in the next phase. There is a need to create an accreditation authority for retail pharmacies to ensure high standards of pharmaceutical care.

K. Dispensing and sale of medicines

4.Partial prescription filling Solid oral dosage forms are mostly packed in strips. Number of units per strip varies, and many a times without any rationale. Whilst the companies are keen that the units are placed in such a way that a strip is not cut, or the number of tablets in a strip is increased to 15, 20, 30, or even 40, hoping that the patient buys the entire strip, reality is far from this. Patients have their own reasons (fear of side effects, cost, â&#x20AC;&#x153;try out a few firstâ&#x20AC;?, take only as many prescribed, etc.), to buy number of units lesser than the strip size, forcing the pharmacy to cut a strip, to get the exact number desired by the patient. Strip cutting has various inconveniences and disadvantages to the pharmacy, and can be detrimental to the patient too. The Drugs & Cosmetics is not very explicit on the issue of strip cutting (strips did not exist when the D & C Act and Rules came into force, and have not been suitably modified since then). 5.Prescriptions

1.Dispensing errors Dispensing should ensure safe and effective use of medicines by patients. Interpretation and evaluation of a prescription based on doctor's handwriting is often very difficult, and with Sound Alike and Look Alike (SALA) drugs being in plenty, this increases the chances of making dispensing errors. The Maharashtra State Pharmacy Council (MSPC), under a WHO project, has prepared an extensive list of SALA drugs. 2.Sale of medicines without a prescription It is common knowledge that almost all prescription medicines can be available at almost all pharmacies without producing a valid prescription. The reasons for this are multiple which are combinations of social and economic factors. Due to longstanding laxity in implementation of drug laws, people have got into the habit of asking for medicines without prescriptions, whether the use is ongoing, genuine, or improper. Conscientious pharmacists who insist on a prescription always face arguments from clients, who have any number of reasons to tell why they have not brought a prescription, and why should be given the medicine they ask for. If the pharmacist sticks to his principles, he faces ire of the clients, and ultimately a threat that they will get the necessary medicine/s easily from the neighboring chemist. And they would easily get it too. It is a sad reality that it is easy to get antibiotics, sedatives, steroids, sildenafil, hormones, and you name it, without a prescription, and without a whimper too. The scale of misuse of medicines in the country is thus tremendous. 3.Professional fees With the aim to improve pharmacy practice standards, there is a need to create appropriate financial incentives or professional fees for pharmacists. There is no provision in the law for collecting any prescription or professional fees by the pharmacist. However, the PCI has forwarded a proposal to the government to introduce such a provision, and is awaiting approval.

People ask for prescription medicines just as if they were non-prescription medicines or grocery items. Pharmacists who insist on a prescription are often ridiculed. Besides the verbal form of asking for medicines, other popular ways in the country are by writing/scribbling the name of the medicine on a piece of paper or anything that can be written on viz. currency note, cigarette wrapper, pocket diary, on the hand, etc, through text messages on the mobile phones, by producing used strips of medicines or label/empty carton/ROPP cap of a used medicine bottle or ordered on telephone. It is also a common practice for clients to keep buying the same medicines with the same old prescription, more than once, without the doctor's advice, many times not only for months, but even years together. It is also a common practice in the country that doctors of other systems of medicine (ayurvedic, homeopathic, etc.), also prescribe allopathic medicines. In some localities, these are the only doctors available, and they practice the allopathic system of medicines. Pharmacies in such areas are required to dispense medicines against such prescriptions too. To overcome inconsistent quality of drugs and unacceptable prevalence of counterfeit drugs, pharmacists must always supply medicines with cash memo. It is mandatory to issue a cash memo against the sale of prescription medicines, however, this is not necessarily followed all the time. Either the people do not insist, or do not have the time or are not aware that they should insist on a cash memo. Many pharmacies do not give cash memos for various reasons, valid, and often not valid ones. 6.Compliance, Concordance and Adherence The ability of a patient to comply with a therapeutic regimen prescribed by practitioners is compliance. Patient compliance follows an authoritative therapeutic decision made by the practitioner rather than shared decision making process. Adherence is the ability of a patient to adhere to therapeutic regimen agreed upon between patient and doctor. Concordance is shared decision making and

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

agreement between the patient and doctor on the selected therapeutic strategy, its outcome and how it may be achieved. The number of times a medicine has to be taken is generally written on the prescription. Patients may or may not be able to decipher what has been written. Doctors many times do not have the time or inclination to explain the patient about the proper use of the medicines, including its dosage. Pharmacies often do not care to give adequate instructions or counsel the patient regarding proper use of the medicines. While verbal instructions may be given in some cases by some pharmacies, written instructions are a rarity. Some pharmacies do write down instructions as to how many tablets/ml of dose to take and how many times a day.

the pharmacy. This faith is often based on age of the person, number of years he/she has been working at the pharmacy, the effect of previous advice or medicines recommended. This faith is not necessarily based on whether the person is a pharmacist or not, because very often, people are not aware whether the person behind the counter is a pharmacist, and often there is no simple way to know it. Many people do not understand/realize that a pharmacist is needed to man the pharmacy, or they simply feel/believe/assume, that the person behind the pharmacy is some qualified person, or else, why would he be allowed to be there in the first place?

7.Labelling

Taking advantage of practice in the country that prescription medicines are sold, and also recommended/pushed by pharmacies without a prescription, lavish schemes are meted out to pharmacies to buy and sell/promote these products. Chemists are offered schemes for prescription drugs (generic or branded generics), which is an indirect incentive to push/recommend these products to their clients on verbal requests for various symptoms, e.g., buy one box and get one free.

Since, most of labels on medicines available in India do not include the exact manner of consuming the medicine, dosage etc., the concept of ancillary labeling by pharmacies by which each medicine dispensed would have had specific instruction as to the dosage (how many, how many times a day, at what intervals, before or after a meal, etc.), and any special precautions to be taken while on medication, does not exist. It is not mandatory to affix an ancillary label, as is done in developed and many developing countries. The medicine packages do not contain Patient Package Inserts (PPIs), which contain simple, specific information about the medicine. Thus, many a times, the patient has very little idea as to what he/she is consuming, the effect that it would have on him/her, and at what dosage he/she should consume, etc. Thus, verbal as well as written instructions given to the patient are quite low. Although, patient compliance statistics are not available, but generally patient compliance rates are very poor due to various factors, many of them specific to this country. Some medicine packages contain Package Inserts (which bear on them the words â&#x20AC;&#x153;For use of a Registered Medical Practitioner, nurse or laboratory). These are meant for health professionals, but are introduced into medicine packages that go in the hands of patients. These contain the details of pharmacology, and can be misleading to the patients. 8.Recommending medicines There is no separate category of medicines as Over the Counter (OTC) medicines. However, for practical purposes, all those medicines, which are not prescription medicines, are considered as OTCs by the pharma community. Pharmacies recommend non-prescription medicines as well as at times Prescription only Medicines (PoM) to clients based on symptoms described by the client. Pharmacist as well as non-pharmacist personnel at the pharmacy may do this. Clients look forward to it because they feel/ believe that the person in the pharmacy knows or ought to know about illnesses and medicines, and secondly, no fees are charged. Patients are often reluctant to visit a doctor for various reasons time spent at the clinic is long, the doctor prescribes too many medicines, the fees charged by the doctor are unaffordable. Some clients have a lot of faith in personnel in 14

9.Marketing schemes

High cost medicines sometimes have bigger schemes on offer, e.g., if a pharmacy buys 10 tablets of Mifepristone, an abortifacient, which needs to be prescribed only by a gynecologist, costing Rs. 300 each, it gets 20 tablets free. If the pharmacy buys 1 tablet of Sildenafil, it gets 4 tablets free. Similar schemes exist, which take advantage of the situation, and promote irrational and unnecessary use of medicines. It also earns bad name for the pharmacy fraternity. Such practices continue in India. India is probably the only country where the cost to consumers of branded and generic drugs is the same. It is those who are capable of pushing these generics or branded generics get the maximum benefits. However, more than 90% of pharmacy sales are for branded drugs whose profit margins range from 10-20%. Pharmacies sell various items other than medicines under the name of â&#x20AC;&#x153;medical and general storesâ&#x20AC;?. These include cosmetics, prepackaged foods, e.g., baby foods, nutrition powders, chocolates, insecticides, batteries, photographic reels, etc. Some pharmacies also sell foods like bread, butter, eggs too. Most of the times, there is no separate demarcation or signages showing or identifying various types of items. Some pharmacies also operate other services in the same premises viz. telephone booths, photocopying facilities. Many medical stores believe that they have to depend on selling general items to sustain their pharmacy. Chemists and Druggists, Medical Hall, Medical Emporium, Aushadhalay, Dava Ka Dukan, Medical Shop are different terms used to refer to a retail drug license. Pharmacies use the Red Cross Symbol to enable the public in identifying the pharmacy Some medicines which are commonly used are also sold from unlicensed premises viz. paan shops, gaadas, general stores, etc. These include some OTC medicines like antipyretics,

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

analgesics, anti-cold preparations, and also include prescription medicines like painkillers, anti-diarrhoeals, etc. 10.Compounding The preparation, mixing, assembling, packaging or labelling of a medicine is known as compounding. The art of extemporaneous preparation of medicines in the pharmacy (compounding) has almost died out. It continues in very minimal number of pharmacies across the country, and the number of such preparations is very minimal, mostly restricted to some external preparations, or dilutions of market preparations for external use.

L. Pharmacy education The pharmacy curriculum today in the country (both Diploma and Degree) is not oriented to pharmacy practice (community/hospital). The degree curriculum is mostly industry-oriented with quite a bit of unnecessary subjects of little practical value after he/she joins the job in an industrial unit. The B. Pharm. pharmacist is ill-equipped to do full justice to community pharmacy. Degree pharmacists generally seek avenues other than pharmacy practice after graduation. One of the main reasons for not entering community pharmacy is given as low remuneration. It is like the chicken and egg story: whether to have competency and give good services in patient-care first, and then earn the right to get a respectable salary, or wait for a respectable salary and then be equipped to provide professional services. The minimum qualification to be a Registered Pharmacist, i.e., to practice pharmacy in India, is Diploma in Pharmacy (D. Pharm), a 2 year course after 10+2, with 3 months practical hands-on-training at a retail or hospital pharmacy. India is perhaps the only country in the world where a 2 year Diploma is the minimum qualification for registration. Other countries have a minimum of 4 years degree programme, and some have 6 year Pharm. D. programme, to be eligible to practice pharmacy. The quality of pharmacists coming out of the colleges in India cannot always be assured. The Diploma pharmacist is more often than not, unequipped for patient care activities, as his knowledge and training during the course is limited, with very little practical exposure. The B. Pharm. pharmacist, on the other hand, undergoes in his curriculum, a very much industry oriented teaching and training, and is again ill equipped to do full justice to community pharmacy. Degree pharmacists generally seek avenues other than pharmacy practice after graduation. One of the main reasons for not entering community pharmacy is given as low remuneration. It is like the chicken and egg story: whether to have competency and give good services in patient care first, and then earn the right to get a respectable salary, or wait for a respectable salary and then be equipped to provide professional services.

M. Competence level The knowledge level of pharmacists in patient care is quite low. Besides the inadequate training before becoming

pharmacists, there is hardly any programme of formal Continuing Education. Sporadic attempts are being made to impart Continuing Professional Development (CPD) now and then. Availability of knowledge material that is easy to understand and at the same time economical is difficult. There are very few specific books on pharmacy practice published in India. Those that are available are of foreign origin and the cost is often prohibitive for pharmacies. Secondly, the concept and the interest to read and study are still not in the attitude of pharmacists. A few State Pharmacy Councils (Maharashtra, Karnataka, Goa) have started one day refresher courses, and some pharmacy associations do conduct short training programmes for pharmacists, e.g., the Indian Pharmaceutical Association and the Chemists and Druggists Associations in various districts/states. AIOCD has recently started conducting a six day patient counseling course for pharmacists, and the response has been good. The feedback received from those who have completed the course is even better. Many have reported large increase in turnovers in their pharmacy business after implementing what they had learnt during the course. However, it needs sustained efforts from all concerned, over a long period of time, to train large number of pharmacists that exist in the country. Pharmacy technicians/salespersons: The knowledge level and training of this category of personnel is not described/mentioned in the law. Therefore, there are no requirements of education, experience, training, etc., which simply means that ANY person can be a salesperson and dispense drugs under the supervision of a pharmacist as per the provision of the D & C Act. In reality, many a time, since the pharmacist is missing at the pharmacy, these persons man the shop and sell drugs, advise people on which drugs to use, what dosage, etc. While these personnel are doing the task of supplying medicines to all the parts of the country, it is an area of serious concern, that they are doing this without any basic training. There is therefore a need to evolve minimum educational requirements for persons engaged in pharmacies as pharmacy assistants. Value added services: A large number of pharmacists are not aware that they could offer services such as blood pressure measurement, blood sugar checks, weight and height checks, patient counseling, etc. However, in the past few years, awareness to such services is being made. This may have reached out to a small number of pharmacists in the country, but are certainly proving to be effective. Knowledge in Indian System of Medicine & Homeopathy (ISM&H): Education and hands-on training both on ayurvedic and homeopathic medicines, play a vital role in health care in our country. Unfortunately, the pharmacist is taught minimal, or nothing at all regarding these systems of medicines during pharmacy education. Whatever knowledge the pharmacist has is gained hands-on, or which has been passed on by senior colleagues at the workplace or through self effort, etc. Very little patient friendly literature is available in packages of these products. Pharmacists are thus not much aware of the proper use of ayurvedic and homeopathic medicines.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

At times, allopathic doctors also prescribe these products along with allopathic medicines and often for chronic illnesses like diabetes, blood pressure, etc. In doing so, the possibility of drug interactions is not considered.

N. Pharmacy chains

III. FUTURE ROLE OF COMMUNITY PHARMACISTS Product Quality l

In the last few years, retail business in pharmacy has grown rapidly. This has attracted corporates for the pharma retail space in India. Last couple of years has seen the entry of various franchises, chain pharmacies, discount pharmacies in the country, numbering close to 1500, and their number is growing steadily. New chains are also laying plans to enter the market in a big way. The Government of India has also opened up FDI in retail.

Ensure product quality. Follow protocols to avoid counterfeits, misbranded, spurious, adulterated medicines. Pharmacists should put the systems in place and train technicians to take over this role.

Inventory Control l

Supervise the order process and review the order list.

O. Public perception

Inventory control tasks should be left to technicians and pharmacist may only supervise them.

Pharmacists are not a part of National Health Policy. Attempts by pharmacy professionals and associations to get them included in the draft policy have been without success. Public awareness and importance of the pharmacist is not fully recognized. While some people believe that an experienced person behind the counter is efficient enough to manage medicines, queries, etc., others view them as traders/sellers and not professionals. The lay public is not even aware on how to get the best out of a community pharmacist.

Storage To begin with: l

Ensure Good Storage Practices, lay down systems and begin documentation.

Train technicians to eventually take over the role.

To progress with: Pharmacists do not wear apron, or put up any label on their person so that the public can identify them as pharmacists. There is no signage in the pharmacy that says a Pharmacist is available on duty. Previously, attempts have been made by the government for pharmacists to wear an apron.

P. Laws and implementation The distribution and sale of medicines and cosmetics are governed by various drug laws like the D & C Act and Rules, NDPS Act, etc. The provisions of the existing Schedule N of the D & C Rules with regard to staff, equipment, space, storage conditions, GPP, etc. are inadequate to meet new challenges in community pharmacy practice. These need amendment, considering the changing practice of pharmacy. Drug Inspectors are appointed for each state to inspect the premises and ensure proper functioning of the pharmacies. However, in most of the states, their number is much less than the designated/required strength compared to the number of pharmacies in the territory. As a result, proper coverage and necessary number of visits/inspections do not happen and violation of many Drug laws continues to take place.

Strengthen documentation

Take over the role of a supervisor and allow technicians to handle task of storage.

Knowledge Level CPD To begin with: l

Take initiative and develop reading/learning practices. Attend Continuing Education Programmes organized by professional organizations, state pharmacy councils etc. Take As a part of professional activities get involved in organizing seminars, pharmacy symposiums, conferences, dissemination programmes, read pharmacy and medical journals, take up continuing education modules on the internet, self reading, interacting with fellow pharmacists.

To progress with: l

Take pre-registration exams, ensure CPD for renewal of registration, specializations offered through courses are dutifully attended and documentation/records of the same are maintained.

Also interact with doctors in the neighborhood.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE l

Dispensing

Ensure that appropriate documentation of instructions given is maintained.

To begin with: l

l l

Learning to check prescriptions for drug interactions, medication errors, legality, validity, correctness, misuse, overuse of medicines. Get involved in assembling prescriptions, and also supervise and train technicians in assembly of medicines, billing. Ensure final check of prescription and no prescription medicines are dispensed without this step. Start advocacy to reduce sale of prescription medicines without a valid prescription.

l l l l

To begin with: l l l

Begin to put standardized ancillary labels on medicines dispensed with potent medicines. Ancillary label depicts time of administration, precautions to be taken, etc. Additionally, hand out leaflets, write-ups, PILs to encourage adherence.

To progress with:

To progress with: l

Patient Instructions (written)

Reduce role in assembly of medicines, as this is taken over by technicians. Ensure to scrutinize prescriptions for drug interactions, correctness, and dosing /medication errors. Ensure sale of medicines without prescription does not happen. Fix norms and follow for dispensing of "emergency medicines". Initiate dispensing/professional fee for services provided.

l l

Involve in constant upgradation of patient information materials. Consider forming a national body for creating patient information material that can be bought by pharmacies all over the country and in turn distribute to their patients/ clients.

Patient Counselling To begin with:

Patient Medication Records (PMR)

To begin with: l l l

Maintain personal details of regular clients (manual or electronic). Network and develop good relations with doctors and interact on regular basis. Publicize about PMRs to the public so that patient can avail of this service on a voluntary basis.

To progress with: l

l l

Prepare and supervise extemporaneous preparations. Maintain documentation.

To begin with:

Provide patient instructions to clients on drugs that are dispensed. A beginning can be made with specific class of drugs or potent medicines, where extra care is required. Gradually, start giving instructions on a larger range of medicines dispensed. Begin to document instructions given to clients.

l l

To progress with: l

Fix appointments for counseling sessions with patients. Maintain documentation.

Medicines Management

To begin with:

To progress with:

Compounding/extemporaneous preparations

Maintain PMRs of all clients at pharmacy and link records to billing software and utilize them while dispensing.

Patient Instructions (verbal)

Start providing patient counseling on disease condition and medication, especially those for long term medications, and for various medication devices. This activity is preferably done in a Patient Care Area. Begin documenting the counseling provided.

Provide patient instructions to all patients for medicines dispensed. Make patient instructions as a part of professional duty after the final review of medicines dispensed.

Initiate and implement concept of pharmaceutical care/medicine management. Achieve patient compliance, then, move towards implementation of newer concepts like adherence and concordance. Initiate working with physicians and other health care professionals as partners for providing pharmaceutical care to clients.

To progress with: l

Ensure that the concepts of pharmaceutical care/ medicines management are thoroughly implemented.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

free of tobacco initiatives. Take part in radio/TV programmes and conduct awareness camps.

Value Added Services: BP, blood sugar checks, peak flow, BMI, etc.

To progress with:

To begin with: l

Acquire theoretical and practical information about providing such services at pharmacy and begin providing these services, along with relevant advice/counseling, and written information, and doing referrals to doctors. Take initiatives for health promotion.

Conduct programmes or awareness campaigns in pharmacy and community around them on various health concerns, e.g., diabetes, asthma, breast cancer, breastfeeding promotion campaigns etc.

To progress with:

Interaction with other health care professionals

To begin with:

Become thorough in these services and perform them as routine activities.

Responding to symptoms of minor ailments Recommending OTC Medicines, Referral l

To begin with: l l l

Train in First Aid. Provide non-pharmacological measures as well as train and equip in recommending OTC drugs for minor ailments. Train in Rational Use of Medicines (RUM).

To progress with: l

To progress with:

l l l l l

Follow-up on outcome of recommended medicines. Follow-up patients on telephone and do referrals. Put staff training protocols in place. Conduct training programmes for in-service pharmacists. Undergo specialized training in RUM, diagnosis and treatment of minor ailments.

Rational Use of Medicines To begin with: l l l

To begin with:

Informing doctors about potential ADRs, safety issues, brand conflicts, etc. Check for rationality of prescriptions.

Train as Drug Information providers. Assist in setting up of Drug Information Centres.

To progress with: l

Further strengthen professional relationships with other health care professionals regarding prescriptions and information on medicines. Provide drug information to doctors about newly introduced drugs. Organize discussion and experience sharing get-togethers with doctors through national associations, MoH, WHO and other regional/international professional organizations.

Drug information to health care providers/ professionals, patients, public

Read and browse information on Rational Use of Medicines and attend training programmes. Recommend rational OTC preparations. Be alert while dispensing medicines known for abuse or misuse

Develop professional relationships with physicians and begin interaction with them on a case to case basis prescription query, doubts, pointing out medication/ prescription errors, etc. Equip thoroughly with pharmacology and therapeutics of drugs.

Specialize as Drug Information pharmacists to search, locate and provide information to health care professionals, patients, public and government.

Pharmacovigilance To begin with:

Disease Prevention

Health awareness, health promotion campaigns, National Health Programmes

To progress with:

To begin with: l

Participate and promote national health promotion campaigns, preventive health care, HIV/AIDS, TB, future 18

l l l

Maintain ADR forms, report any ADRs related by patients to the centre as applicable under the National and other Pharmacovigilance programmes.

Take up ADR reporting as a professional responsibility. Enroll with reporting centres, publicize and report ADRs. Be alert to identify potential cases/screening for ADRs.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

Domiciliary services, old age home visits To begin with: l l

Browse through concepts operating across the world. Work out a plan for implementing such concepts.

Hands-on training of pharmacy students, teacher practitioners To begin with: l

To progress with: l l

Impart training to other pharmacists to perform such duties. Emphasize incorporation of Pharmacovigilance in academic syllabus for pharmacy students.

To progress with: l

GPP and accreditation of pharmacies

Implement GPP guidelines. Evolve guidelines for self -accreditation and all other details.

To begin with: l l

To progress with: l l

Continuity of maintenance of GPP guidelines and criteria. Forming an accreditation body under a national/professional organization, accrediting pharmacies as per set guidelines.

To begin with:

Greater role in creating access to medicines in rural and remote areas. Patient instructions, diagnosis of simple ailments and recommending OTC medicines, value added services like BP, blood sugar checks, etc.

Free from tasks which can be done by technicians. Designate and implement training to experienced salespersons as pharmacy technicians so that they can carry out allotted jobs efficiently and responsibly. Prepare, document the role and responsibilities of pharmacy technicians and that of a pharmacist.

To progress with: l

Rural and Remote Area Pharmacists

Offer training in community pharmacies to students as part of academics or internship.

Professional Tasks

To begin with: l l

Identified pharmacies in localities as training centers for pharmacy practice/ community/clinical/hospital pharmacy as a part of training. Become visiting faculty.

Allot responsibilities to pharmacy technicians and pharmacists as per the prepared standard documents. Allot more time to clinical/patient oriented tasks, patient information, self-education, staff training, etc.

Laws and Code of Ethics To begin with: l

Facilitate implementation of GPP in pharmacy regulation.

To progress with:

Play clinical role to train about appropriate medicine use.

Training of Technicians

Crisis Management (man-made/natural disasters and pandemics)

To begin with: l

Practice all laws.

Form a team to decide about which aspects pharmacy technicians should be trained in and accordingly prepare a plan for syllabus, main executing body, exams, etc. Define roles and responsibilities of a pharmacist and a technician.

To begin with: l l

Learn first aid Learn emergency care

To progress with: To progress with: l l l

Continuing training programmes for pharmacy technicians Clear picture of roles and responsibilities, predetermined job profiles

l l

Providing primary/emergency care to victims of man made and natural disasters, monitoring of diagnostic parameters and recovery of patient. Emergency medicine management during disasters and pandemics. Organize camps.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN COMMUNITY PRACTICE

Indian Systems of Medicine and Homoeopathy

To progress with: l

To begin with: l l

Make it a part of academic syllabus. Collect information about ISM&H medicines (dosage, interactions with medicines of the same system or other systems including allopathic).

Full-fledged medication reviews at the pharmacy undertaken by pharmacists to encourage patient adherence/ compliance

Preventing Medication Errors To begin with:

To progress with: l

Since these have an OTC status, could be recommended for patients presenting with symptoms or requesting for remedy.

Veterinary medicines

Labels for each medicine dispensed with patient's name and personal details, instructions for use.

To progress with: l l

Home medication reviews. Monitoring patient outcomes especially in elderly patients, at old age homes, etc.

To begin with: l

Make them a part of academic syllabus.

Preventing Dispensing Errors

To progress with:

To begin with:

l l

Provide staff training on veterinary medicines and provide information for use/administration.

Pharmacist Prescribing

To progress with: l

To begin with: l

Advocacy for expansion of the list of non-prescription medicines (Jaipur Declaration) and for expanded role of pharmacists as prescribers to improve patient health outcomes for other than prescription medicines. Improve patient/community health care.

To progress with: l

Participate in CPD programmes.

Relationships with physicians and other stakeholders To begin with: l l l

Develop professional relationship. Pose queries about medicines or prescribing habits that pharmacists are concerned. Provide doctors with newsletters, information material on new and banned drugs, irrational combinations, etc.

To begin with: l l l

l l

To begin with:

Explain the patients about medicines they are taking, purpose for which they are prescribed, continuity of therapy, etc.

Information material for patients for self-care. Collaborate with national and international agencies.

Specialist Community Pharmacists Areas (genomics and beyond)

To begin with:

Advice for helping patients in responsible self care. Besides adhering to drug therapy, other self-care measures. For minor ailments, providing alternatives/options when requested with a brand name.

To progress with:

Medication Reviews

National policy for dispensing errors reporting errors that take place

Responsible Patient Self-Care

To progress with: Mutual consultation and collaborative working to achieve the ultimate goal of optimized patient health outcomes.

Frame SOPs, protocols Maintain documentation

Study the impact of genomics on discovery and development of genetic based medicines. Adequately prepare for understanding genomics and in preparing and dispensing genomic-based medicines. Be prepared to counsel patients on the appropriate use of such agents and be mindful of their role in post marketing surveillance by monitoring patients to ensure appropriate compliance with medication regimens and to detect presence of potential untoward effects.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN HOSPITAL AND CLINICAL PRACTICE

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN HOSPITAL AND CLINICAL PRACTICE I. PRESENT PRACTICES Traditional activities like procurement, preservation, storage, manufacturing, packaging, quality control, dispensing and distribution of medications to the hospitalized and out-patients are carried out by hospital pharmacies through pharmacists working in the hospital pharmacy services. While hospital pharmacy is defined as â&#x20AC;&#x153;practice of pharmacy inside a hospital close to the patientâ&#x20AC;? in an environment where physicians, nurses and other health care professionals interact with the pharmacists on matters related to medicines and other patient care items, the same cannot be said to be happening at a significant level in India. Today, in India, there are over 15,000 full-fledged hospitals with about 9,00,000 hospital beds. The hospitals are distributed in the government and private sectors in an almost equal share. The pharmacy services in hospitals are yet to be modernized. Time and again, many Committees appointed by the government have made recommendations in this regard. However, there is hardly a noticeable improvement in the structure and functions of hospital pharmacy and there is a long way to go.

Various Committees Over the past 50 years, various Committees constituted by the Central and/or State Governments to study various aspects of pharmacy have made recommendations and have helped to some extent to improve pharmacy services in hospitals. However, the major drawback has been the lack of implementation of these recommendations. The Pharmaceutical Enquiry Committee (1954) under the chairmanship of Gen. S.L. Bhatia, known as Bhatia Committee; the Expert Committee on Hospital Pharmacy (1967) under the chairmanship of Dr. H.S. Sastry in Mysore, known as Mysore Expert Committee); the Hospital Review Committee - Delhi (1968); the Committee on National Drug

Policy, known as the 'Hathi Committee (1975); the Bajaj Committee (1980); the Lentin Commission (1987); and the National Human Rights Commission's Report on Large Volume Parenterals (1999) are examples of such Committees which stressed the need to improve hospital pharmacy services in India. In spite of these recommendations, the hospital pharmacist still lacks recognition from other health care providers as well as the public and the government. Various expert committees have recommended creation of a Department of Pharmacy in every hospital on the same line as other Departments like medicine, surgery, gynecology, etc. The status to be accorded to the pharmacist heading the Department of Pharmacy should be inline with that of other departments. A suggested organizational structure of a hospital pharmacy is given in Figure - 1 which may be modified suitably as per requirements.

Profile of Hospital Pharmacist in India The exact number of pharmacists employed in private hospitals is not known. However, around 90% of pharmacists employed are Diploma holders. In some instances, especially in Medium and Large hospitals, Degree and post-graduate Pharmacists can be found working in senior positions. In small nursing homes/hospitals, pharmacist is not employed. Handling and dispensing of medicines may be done by the nurse or just a storekeeper. In the past few years, the Drug administration has been trying to impose on the hospitals to have a full-fledged pharmacy with proper drug license and pharmacist on duty. While many continue to evade, some have taken drug license for the part of the premises where pharmacy is situated within the hospital. In these hospitals, cost of medicines is incorporated in the final hospital bill.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN HOSPITAL AND CLINICAL PRACTICE

In medium or larger hospitals, one or more full-fledged pharmacies exist. They operate slightly differently from those above. Here, out-patients are free to buy their medicines from the pharmacy in the hospital, or from outside. For in-patients, either medicine is indented by the wards and incorporated in hospital bill of the patient, or the patient's relative may be asked to purchase medicines from the pharmacy and give it to the nurse at the bedside of the patient. The pharmacies in hospital premises may either be owned and managed by the management of the hospital or they may be let out or leased to a private party. As such, the pharmacies function more or less like community pharmacies. The only difference is that these are located in the hospital premises. During OPD timings and rush hours, the patient load is very high, and the pharmacy operates at high speed. This very often means that there is hardly any time for counseling or even giving instructions as to how the drug is to be used. Clinical-oriented services are almost totally lacking. l

Inthese pharmacies, pharmacists are generally present but, may do merely function of a storekeeper or dispensing medicines against prescriptions. The hospital administrators do not look out for clinical orientation or clinical specialization from them. Some large private hospitals have started looking at pharmacists to provide some clinical services. Some private hospitals have started utilizing the clinical services of pharmacists e.g. drug information, Adverse Drug Reaction reporting, clinical pharmacy courses, ward round participation, checking Drug interactions, I.V. admixture service, etc.

Kasturba Hospital, Manipal; J.S.S. Medical College Hospital, Mysore; KLES Hospital and Medical Research Center, Belgaum are involved in ward round participation, drug and poison information services, adverse drug reaction monitoring, patient counseling, publication of newsletters and continuing education programs for the hospital pharmacists.

Additionally,in J.S.S. Medical College Hospital, Mysore, clinical pharmacy services are now offered to six medical units, two pediatric units and to one psychiatry unit and treatment chart review. Establishment of a drug information and consultancy service for all prescribers, development of parenteral drug administration guidelines, development of antibiotic guidelines, preparation and distribution of educational publications and newsletters of drug and prescribing information.

standards. The absence of specific norms or standards for the hospital pharmacy services is one of the most important reasons for poor development and growth of the pharmacy services in Indian hospitals. The standards for hospital pharmacy should invariably cover aspects like the personnel (staff) including their qualifications, training, dress code, skills, etc. required for carrying out the professional responsibilities in a modern hospital pharmacy, the premises and their location in the hospital, the equipments and infrastructure facilities, constitution and working of Pharmacy and Therapeutics Committee (P&TC), procurement of medicines and their storage, distribution, dispensing and administration of medicines and various patient care activities. i) Personnel: The pharmaceutical service should be directed

by a suitably qualified and professionally competent chief or head. Ideally the head of the hospital pharmacy should be a post graduate in hospital pharmacy/pharmacy practice. A modern hospital pharmacist is required to have a thorough and up-to-date knowledge about drugs and medicines in current use. He/she should have the ability to design and develop protocols, guidelines and norms for various hospital pharmacy functions in the hospital with special reference to the storage, dispensing and other patient oriented activities. The hospital pharmacist should be able and competent to conduct and participate in various research activities in the hospital including clinical trials. He/she should possess effective communicative skills. He/she should exhibit capability to conduct manufacturing operations, if required, with ability to conduct quality control and quality assurance functions, ability to implement various inventory control activities, capability to conduct and take part in research, ability to conduct teaching and training programme, managerial and entrepreneurial skills and knowledge about the rules and regulations relating to pharmacy. The chief should be assisted by other pharmacists and secretarial staff. Job descriptions should be made for all categories of the staff and the same has to be reviewed regularly. Evidence must be provided that formal performance appraisals have been conducted in the pharmacy services, for which a documented performance appraisal can be conducted. A list of staff with contact details and designation should be made available in the pharmacy services. Various categories of staff should have approved dress code and attire on duty. ii) Area, premises and location: The hospital pharmacy

Generally, management sees main function of pharmacists as that of inventory control and sale of medicines against the prescription. Other functions which may be performed by some pharmacists may be providing instructions to patients about use of the prescribed medicines.

Standards for Hospital Pharmacies Standards are prescribed norms aimed at normal and faultfree working of a unit or an organization. Unless there are certain standards and an agency to enforce such standards, it will be difficult to develop and maintain the required

should be housed in a pre-planned area, which is readily accessible to staff and with adequate space and facilities to carryout its functional role including storage of items. The area should be secured from unauthorized access. The storage system should be one that allows ready scientific and professional storage and retrieval of drugs required. Adequate facilities for cool and cold storage of medicines should be available. The ambient temperature of the pharmacy should be appropriate for drug storage. Facilities for patient care activities like counseling and drug information services have to be provided in the suitable location in the hospital pharmacy.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN HOSPITAL AND CLINICAL PRACTICE iii) Pharmacy and Therapeutic Committee (P&TC): The

deluge of new therapeutic agents coming in the market makes it nearly impossible for the physician and the pharmacist to keep abreast with the advances in therapeutics. A judicious selection of drugs for use in the hospital has to be made. The P&TC, a policy-making body in the hospital in matters related to selection of medicines, is of vital help in this regard. The P&TC of a hospital should have the following category of members: 1. The medical superintendent Chairman 2. One representative of the Department of Medicine 3. One representative of the Department of Surgery 4. One pharmacologist 5. One microbiologist 6. One member from the nursing profession 7. One member from the nutrition group or a dietitian 8. One or two members nominated from other disciplines in the hospital 9. Chief of Pharmacy Services as Member-Secretary. The Pharmacy and Therapeutics Committee (P&TC) should be empowered to prescribe the norms for the purchase and procurement of medicines in the hospital. Policies relating to the selection and distribution of drugs for the hospital are framed by it. iv) Hospital Formulary: Hospital Formulary is an official or authorized publication containing a list of medicines approved for use in a hospital or a group of hospitals. It contains scientific information on individual drugs or therapeutic groups. v) Procurement, storage, inventory control and distribution of drugs: About one third of the hospital budget in government sector is spent on drugs and allied materials. With proper management, the hospital pharmacist can save a lot of resources by framing of storage policies and controlling inventory of medicines in the hospital. Good Storage Practices have to be adopted to ensure the stability of medicines. Close monitoring of the temperature and humidity of the storage environment is essential. A system must be in place whereby drugs which are date-expired are removed from the storage area and disposed of in a safe and secure manner. Waste matter must also be disposed of in a similar manner. vi) Dispensing

medicines and other pharmaceutical preparations for in-patients, out-patients and discharged patients: Dispensing is an important responsibility of a practicing hospital pharmacist. It involves all activities that occur from the time the prescription is presented to the pharmacist at prescription counter till the prescribed items are issued to the patient or his nominee. Hardly any compounding activity is carried out these days. Activities like receiving and confirming prescription order, checking and interpretation of the received prescription, verification including consultation, if necessary, with fellow pharmacists or the prescriber and giving suitable instructions and counseling must be carried out with care.

The hospital pharmacy should prescribe norms for the following: a) work practices related to the use of multi-dose vials; b) management of medication shortages; c) handling of incompatibilities, if any, and patient allergy; d) storage, handling and disposal of cytotoxic drugs; h) policy and procedure manual describing the pharmacy services to be provided by the hospital. vii)Drug Information Service: Drug Information is one of the

most important services provided by the hospital pharmacies. Some hospitals in India too have started this activity but a lot more needs to be done. The drug information center is supposed to provide scientific information on various aspects of medicines for the patients, doctors and other health professionals. viii)Drug Monitoring, Toxicity Studies and Pharmacovigilance:

Monitoring the effects, both desired as well as adverse, of the treatment given to the patient helps the treating physician in evaluating the therapeutic procedures adopted. Most hospitals do not have the necessary facilities for the hospital pharmacy to carry out such functions. Pharmaceutical care of the type advocated by the WHO and FIP helps in reducing the adverse effects of medicines and helps in achieving definite outcomes that improve a patient's quality of life. This should cover patient care activities like patient counseling and advice, pharmacoeconomic studies, and activities aimed at reducing medication related risks to patients.. and Training Programmes: Hardly any educational activity is the responsibility of Hospital Pharmacy in India. Of course, some hospitals have realized that this is a serious deficiency and are taking steps to rectify the same.

ix)Educational

x) Therapeutic equivalence assessment on drugs and

promotion of generic names and rational use of medicines: Prescriptions are widely written based on the trade names of medicines. The approved or nonproprietary name of a drug is known as its 'generic name' and products marketed under such names are known as 'generic pharmaceutical products'. Dispensing of a product that is generically equivalent to the prescribed item with the same active ingredient(s) in the same dosage form and identical strength, concentration and route of administration is known as generic substitution. Competitive bulk procurement by generic name is a central feature of essential drug programmes and hospital formulary concept. Hospital pharmacies having the services of qualified and trained pharmacists can establish therapeutic equivalence or bio-availability studies either as part of their professional activities or as part of research activities. Bio-availability is the rate and extent to which a medicine or other substance becomes available to the target tissue after administration. Hospital pharmacists in large, teaching and specialty hospitals do engage in various

xi) Research activities:

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN HOSPITAL AND CLINICAL PRACTICE

research projects touching upon different aspects of hospital pharmacy and clinical pharmacy. The topic of research can extend form distribution/dispensing aspects to drug utilization and patient care studies. Such studies when published will help other pharmacists to improve their practices and services. The Medical Council of India lays down standards for staff, space and equipment for recognizing hospitals attached to medical colleges for approval. However, such standards are applied to all departments of hospitals except for hospital pharmacy.

Profile of Clinical Pharmacists in India The general activity of pharmacy in a government setting includes selection, procurement, storage, distribution, dispensing, manufacturing, quality control and quality assurance and inventory control of drugs and pharmaceuticals, patient education, counseling and clinical pharmacy aspects. Clinical pharmacy (pharmacy practice) in India has hardly taken roots and continues to be still malnourished. The concept of clinical pharmacy is hardly accepted by the medical fraternity.

Professional Development Programs The Indian Hospital Pharmacists' Association (IHPA) founded in 1964 has been working for the past 5 decades towards upliftment of hospital pharmacy services in the country. Besides publishing a journal where value of hospital pharmacist is explained, IHPA does advocacy work with the Government, conducts every year a 15-day training workshop for hospital pharmacists. Practicing pharmacists like hospital, community and clinical pharmacists should have up-to-date knowledge about the modern trends and approaches in pharmacy practice. Education and acquisition of skill is a continuous process and does not end with a diploma or degree. Continuing education is mandatory in many countries for the continuation of the registration of the pharmacists. Unless a mechanism is created for making continuing education compulsory, as has been done for medical practitioners, for pharmacists for extending their registration beyond the initial 5-year period, nothing much is likely to improve.

II. Future Role of Hospital Pharmacists and Objectives of Hospital Pharmacy The status of a professional is adjudged by the knowledge he/she possesses. Since consumers of hospital services are the patients, patient care must be the focus of the hospital pharmacies. The patients use drugs which are prescribed by the doctors. The hospital has professional, legal and moral responsibility to see that the drugs are safely used by the patients. The hospital pharmacies have to play a key role in this respect. The contemporary hospital pharmacy services utilize the services of highly qualified and properly trained pharmacists. An organized movement to invite the best qualified pharmacists to hospitals was first initiated in USA in the 1950s and 60s and was later spread to other parts of the world. In 1962, the American Society of Hospital Pharmacists (ASHP) and the American Association of Colleges of Pharmacy (AACP) adopted hospital pharmacy as a specialty of pharmacy and endorsed the need for educated and properly trained pharmacists to practice hospital pharmacy. They have to educate the public that drugs, both prescription and non-prescription, are to be used with much reverence, care and caution. The primary objective of a modern hospital pharmacy service is to promote and if possible ensure - 'right drug to the right patient in the right dose at the right time through the right route in the right way'. This is hardly so in India.

Functions of a modern hospital pharmacy service The important functions of a modern hospital pharmacy include the following:

Drug Selection To begin with: l

To progress with: l

Pharmacists in teaching hospitals

Take charge of selection of drugs and allied products and their procurement, storage, inventory control and distribution in the hospital.

Assist in preparation of Essential Drug List for the hospital.

Pharmacy and Therapeutic Committee (PTC)

Pharmacists get hardly any recognition in most hospitals. They are made to sit in most worthless accommodation, mostly in a basement floor, away from the wards and patients, literally out of sight. In reality, pharmacists are not allowed to discharge â&#x20AC;&#x153;clinical servicesâ&#x20AC;?. The pharmacists are mostly used for procurement, storage and issue of medicines. There is not much difference in this regard between government and private hospitals.

To begin with: l

Initiate necessary action for forming the PTC in the hospital where the senior Hospital Pharmacist should be designated as Member Secretary. Promote effective interventions to improve drug use.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN HOSPITAL AND CLINICAL PRACTICE

To progress with: Frame policies and procedures for: l New drugs l Hospital Formulary l Non-formulary drugs l Restricted drugs l Investigational drugs l Generic substitution and therapeutic interchange l Structured order forms and guidelines l Standard Treatment Guidelines l Inventory Control l Good Pharmacy Practices (GPP) l Rational Use of Medicines l Ward Rounds l Drug Information Centre l Pharmacovigilance l Research Activities

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE I. PRESENT PRACTICES The area of government practice for pharmacists covers Rural Medical Dispensary (RMD); Primary Health Centre (PHC); Community Health Centre (CHC); Urban Health Centre (UHC); district, Sub-divisional and Rural hospitals; large tertiary care and teaching hospitals and other public hospitals including Railways, ESIS, Coal India, CGHS, MPT, Airlines, Armed Forces, Jail hospitals, etc.

National Health Programmes (NHPs) The government has been bringing health care to the public in special areas of concern through a top down approach through its various NHPs: l l l l l l l l l l l l l

National Vector Borne Disease Control Programme (NVBDCP) National Filaria Control Programme National Leprosy Eradication Programme Revised National TB Control Programme (RNTCP) National Programme for Control of Blindness National Iodine Deficiency Disorders Control Programme National Mental Health Programme National AIDS Control Programme (NACO) National Cancer Control Programme Universal Immunization Programme National Programme for Prevention and Control of Deafness National Rural Health Mission (NRHM) Janani Surakshsa Yojana

The Ministry of Health has set up a new vision for public health care by launching the NRHM which is to be implemented through its health centres. A careful scrutiny of the various National Health Programmes (NHPs) clearly shows that the pharmacist is not at all 26

considered in any of the steps of delivery of health care, whilst the other health care workers find a prominent place, and need to undergo various training programmes to carry out the programme in the community. It appears that the pharmacist is considered by the government as fit only for indenting and distribution of medicines. The National Human Rights Commission (NHRC) issued exhaustive directives relating to the manufacture, storage and distribution of large volume parenterals (LVP) wherein the role of the pharmacist in drug management in Hospitals and Medical Stores Depots got highlighted. However, no practical steps have been taken by the Government to make necessary changes in policies connected with proper deployment of pharmacists. Even though the government is spending huge sums of money on drugs yet effective health services continue to lag behind. The existing system of drug management appears to be deficient in my respects including the following: l l l l l l l l l l l l l l

Required drugs are not available in adequate quantities. Mostly there is no Essential Drug List. Even where it exists, doctors do not prescribe drugs in the list. Storage facilities, in many institutions are inadequate. Inadequate cold chain facility. Improper quantitative assessment. Lack of quality assurance. Improper selection of drugs. Due to lack of patient counseling and education, improper drug dosage regimes are followed by the patients. Absence of emphasis on rational usage of medicines. Lack of control on refilling of prescriptions. Improper inventory control. Lack of proper documentation. Lack of feedback mechanism and monitoring. Inadequate or out of date drug information with the prescribing medical officer and other health staff.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

The most bizarre situation is of pharmacists working in primary health care centers in rural areas. They are sometimes given sundry duties like making patient cards and working as a nursing assistant.

Government Hospitals and Health Centers Presently, pharmacists with diploma in pharmacy are mostly serving government hospitals under the Central and State Government health centers and hospitals. Other sectors like jail, labour department, finance department (Mint), ordnance factories, CPWD, airlines, etc. employ a sizeable number of pharmacists. In higher posts, pharmacists with degree in pharmacy are employed. A Pharmacist working under the same government may have their designations varying from department to department, and state to state, e.g., pharmacist, compounder, compounder-cum-dresser, pharmacist-cum-clerk, etc. Consequently, their pay scales and responsibilities are also different. The persons performing duties that should normally be carried out by pharmacists in the health centers do not have the requisite knowledge and training. If a pharmacist exists, he is mostly used as a storekeeper. Hardly any in-service professional training is provided to such staff. The only training that they receive in-service pertains to handling of inventory and basic documentation. The other health professionals, and even the Auxilliary Nurses & Midwives (ANMs), anganwadi workers, health workers undergo training from time to time regarding various health aspects and are involved in using this information to the public at the grassroots. In 2006, the Ministry of Health and Family Welfare launched the National Rural Health Mission (NRHM). A detailed study of documents of this scheme/programme indicates that the Pharmacist is considered unfit for any job other than procurement of drugs, management of the drug store and dispensing of medicines. Even these duties are not spelled out clearly. The number of pharmacists placed in each health centre continues to be inadequate as before. The pharmacist is thus not seen as a member of the health care team by the government, and continues to be neglected.

The procurement policy is generally made by doctors and administrators without involving the pharmacists. Unqualified persons are sometimes employed for such work. In the absence of qualified and trained pharmacists, large amounts of medicines are being wasted due to date expiry. It's not possible for a non-technical untrained individual to manage stock rotation and control inventory. We need to follow the path cleared by the Tamil Nadu Medical Services Corporation (TNMSC) in this regard. It has worked out detailed procedures for procurement, storage, and supply of medicines. The system has proven itself, and has been used as an example by the government to replicate this process. As of now, 10 states have adapted this system. There are no proper guidelines for storage of drugs at government hospitals. Storage conditions are often inadequate including space, temperature and humidity. There are no criteria for minimum area required, storage specifications, safety measures, storing of drugs, or following GPP. Most current operations are continuing by tradition. The Drugs & Cosmetics Act requires inspections to be carried out by the regulatory authorities at least once a year. However, generally no inspections take place on the plea of shortage of staff.

Policy Framing As already pointed out, pharmacists are hardly involved in preparation or revision of health care and pharmaceutical policies. Primarily, it is due to poor standards of education a pharmacist undergoes in the country. We have to give high priority to upgradation of pharmacy courses and bring them at par with the educational levels abroad. The Essential Medicines List is an important tool for implementing the Rational Use of Medicines (RUM) for improving the outcome of the existing Health Care system. Wherever degree and post-graduate pharmacists with the necessary practical training have been involved, the results have been very good. The Delhi state experience is there for everyone to see. The WHO has found it good and many states have started similar action plans. So there is no alternative but to upgrade the knowledge base of practicing pharmacists.

Government procurement system and storage

Structure for proper utilization of manpower

Presently, the Central and State governments procure a huge amount of medicines for CGHS, central medical stores, other sectors like rail, mint, ordnance factory, Reserve Bank of India, CRPF, BSF, government undertakings like public sector banks, DVC, etc.

Pharmacists are serving the health care system of our country for the last several decades, but unfortunately their services as health care providers have neither been recognized nor appreciated by the society or by the government authorities. One of the glaring examples of this is reflected by the fact that the term pharmacist does not find even a mention in the Health Policy 2002 framed by the Government of India. It is unfortunate that the policy makers failed to realize the full potential of the pharmacists as health care professionals. Steps will, however, need to be taken to fill up the gaps and deficiencies in the knowledge base of the pharmacists so that they are in a position to serve the community more

The existing procurement system does not make use of the currently available scientific procedures. Course curriculum in pharmacy in the area of Drug Procurement Management is faulty. As a result there are expiry and spoilage problems, shortage of essential medicines at the time of the need, sometimes unnecessary overstocking, wastage etc.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

efficiently. Their role and status as members of the composite health care team must be clearly defined as is done in the rest of the world. The proposed structure for pharmacists in dispensing, medical stores and hospitals is shown in Table B. Knowledge level of pharmacists is poor. The present minimum qualification for the posts should be upgraded in a time-bound manner. Higher posts should have a minimum qualification of B. Pharm. with relevant experience. It should be mandatory for pharmacists to undergo continuing professional development, and this should be linked to increments and promotions. All pharmacists working in hospitals having D. Pharm. qualification need to go through continuing and higher education courses to upgrade their qualification to B. Pharm. Necessary condensed course curricula will require to be framed for this purpose as was done for upgrading the Licentiates in Medicine to the M.B.B.S. level immediately after independence. We are already far behind in this regard and need to take accelerated action. This opportunity must be provided by the government to the in-service pharmacists. The National Human Rights Commission had recommended in 1999 that the Central Government should create a post of Joint Drugs Controller of India (Pharmaceutical Services) under the Drugs Controller General of India to look after the entire aspect of Drugs and Medicines. Similarly, it recommended that each State Government should create a post of Deputy Director (Pharmaceutical Services) to look after the area of the drugs and medicines used by the respective State government. The NHRC also recommended setting up of modern hospital pharmacies in government hospitals wherein the pharmacist-in-charge should have post-graduate qualifications with status not be less than that of an assistant professor and reporting directly to the head of the hospital.

Role of pharmacist in National Health programmes National Health Programmes are being implemented without involving the pharmacists. Apparently, the policy makers are not aware of the useful role pharmacists play as members of the health care team in other countries, developed as well as developing. Consequently, mechanisms set in to provide for involvement of pharmacists are either completely wrong or grossly inadequate. For instance, the NRHM provides for one pharmacist per center to run the pharmacy for 24 hours. At least 3 pharmacists would be required per center to provide 24 hours service. Policy makers need to be appraised about Section 42 of the Pharmacy Act.

Effective regulatory control over government pharmacies The Drugs and Cosmetics Act is applicable to all pharmacies (both private and government) but the government pharmacies are exempted from certain provisions. As per Schedule K of the Drugs and Cosmetics Rules, a government pharmacy has also to meet all provisions of the law except 28

that they are not required to obtain a licence. Inspection by a Drugs Inspector at least once a year is mandatory. However, government premises are generally not inspected due to shortage of Drugs Inspectors. On the recommendation of the Drugs Consultative Committee (DCC), DCGI has advised all state drugs controllers to arrange regular inspections at government pharmacies. This weakness is thus expected to be set right soon. Certain conflicts between the Drugs and Cosmetics Act and Rules and the Pharmacy Act with regard to control of pharmacy practice also need to be addressed as early as possible for better governance.

Dispensing and counselling in government pharmacies As dispensing is being done through small windows in most government hospitals,, where patients cannot see the pharmacist and vice versa, proper communication is not possible. As a result, there is no effective patient counseling. The dispensing counters at government pharmacies should be modified so that there is a professional and friendly contact between the pharmacists and the patients. In addition, patient-counseling areas must be created in the pharmacy so that patients can talk to the pharmacist in privacy. A minimum area having segregated space for quarantine, dispensing, patient counseling, cold storage, record keeping, etc. must be provided. There is no job specification of pharmacists working in the hospitals and health centres. Sufficient number of pharmacists should be available to efficiently handle the patient load in the government hospitals. Job profiles of different grades of pharmacists should be published both by the central and state governments on lines similar to an updated job chart for pharmacists working in the government hospitals and health centers prepared by the Government of West Bengal in 2001. The professional duties of the pharmacist should be documented. Standard Operating Procedures for patient counseling need to be prepared and followed. A basic ratio of Doctors:Nurses:Pharmacists of 1:3:1 may be considered for primary health centers. Sufficient additional numbers should there for leave vacancies. For teaching hospitals (tertiary hospitals) one pharmacist per 25 beds and for secondary hospitals one pharmacist per 40 beds are suggested for placement.

Availability Essential Medicines (EMs) at government pharmacies Hospital administration should motivate doctors to prescribe drugs listed in Essential Medicines List (EML). EML should be made for each type of government hospital. For prescribing any medicine outside the list, special permission should be required from higher authorities in accordance with procedures specially laid down for the purpose. Prescription audits should be carried out from time to time to ensure that this system is strictly followed. Pharmacists should participate in prescription survey projects. Important

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

findings should be utilized for changing procurement strategy by the authority.

To progress with: l

The pharmaceutical education and profession is presently controlled by more than one department and ministry, making the whole process complicated. Government should consider creation of a separate Department or Ministry of Pharmaceuticals just as was done in the case of Information Technology (IT). The pharmaceutical profession is a knowledge-based profession like IT and the pharmaceutical industry is also a positive exchange earner. It is unfortunate that the role of pharmacists is not clear to the politicians. They are not in a position to understand that upgradation and modernization of the training programmes will help in improving the quality of pharmaceutical services to the suffering humanity in the country. Proper utilization of the expertise of qualified pharmacists will improve the therapeutic outcomes, which in turn will extend health care to a larger portion of the population.

II. FUTURE ROLE OF GOVERNMENT PHARMACISTS

Inventory control work to be later passed on to a pharmacy assistant after adequate training.

Storage To begin with: l

Senior pharmacist should initially supervise the junior pharmacists/pharmacy assistants to ensure that drugs are stored in accordance with approved procedures with proper supporting documentation.

To progress with: l

Work to be later passed on to a pharmacy assistant after adequate training.

Good Pharmacy Practice (GPP) To begin with: l

Drug Selection

Learn about the GPP practice and devise plan for implementation.

To progress with: Pharmacist should play a major role in drug selection and preparation of Essential Medicines List for the hospital. Pharmacist should be in charge of procurement of drugs and allied products.

Pharmacy and Therapeutic Committee (PTC) To begin with: l

Dispensing To begin with: l

Properly trained pharmacists should play a crucial role in forming PTC in their hospital. Pharmacist should bet made the Member-Secretary, and should look after its day to day functioning.

To begin with: l

Advocacy with the hospital administration for preparation of a Hospital Formulary.

Pharmacists should be actively involved in all these functions. Their knowledge base in pathophysiology should be upgraded by regular in service training.

To progress with: l

Hospital Formulary

Pharmacists should start implementing GPP following SOPs and maintaining proper documentation.

The pharmacist should be trained to play a more active role in clinical pharmacy and assist the physicians in matters connected with drugs.

Patient Instructions To begin with:

To progress with: l l

Periodic review of the Hospital Formulary.

Inventory Control To begin with: l

Pharmacists begin to give necessary instructions to patients both at the OPD level as well as to in-patients with regard to proper usage of the drugs, their dosage, etc. to increase patient compliance. Sufficient numbers of pharmacists need to be employed, so that the large number of patients in Government hospitals can be served effectively.

Senior Pharmacist should get directly involved in work relating to inventory control initially.

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

To progress with:

Take steps to equip the pharmacists with all essential information so that the patient gets necessary instructions concerning use of prescribed medicines.

Ancillary Labels: Supplementary Instructions - PILs, PPIs

Pharmacists should start putting ancillary labels on medicine packs dispensed to patients, in a language or signage which is easily understood by the patient or his/her care giver, which can be followed so as to take the medicines appropriately as per instructions on the label. This activity could be initiated initially for few specific important drugs.

To progress with: l

This should eventually be mandatory for all drugs dispensed.

Patient Counselling To begin with: l

Pharmacists start getting involved in patient counseling, both at the OPD as well as in the wards (bedside pharmacy).

To progress with: l

Called upon by other health care providers on a regular basis to counsel patients in the wards on their illness and medications, as well as discharge counseling.

Promoting Rational Use of Medicines To begin with: l

Pharmacists liason with doctors to promote rational use of drugs.

To progress with: l

Being the active member in Pharmacy & therapeutics Committee, pharmacists ensure that drugs are carefully selected/ chosen, and correct prescribing information is provided to prescribers. Pharmacists take part in prescription audits, as well as contact prescribers in case of prescribing problems/errors are detected.

Prescription Audits To begin with: l

Pharmacists create awareness about rational prescribing, STGs etc among doctors. 30

Pharmacovigilance To begin with:

To begin with: l

Pharmacists initiate and conduct prescription audits from time to time at the hospital, and present findings to the health care team, and make suggestions for improving prescribing.

l l

Identifying, reporting ADRs. Awareness about the system.

To progress with: l

Pharmacists play a proactive role in having ADR detection, reporting, and monitoring system in place in the hospital. The pharmacist maintains all the records, as well as disseminates information received from the reports to the health care team.

Pharmacist Utilization Pharmacists should be utilized to perform the following duties to improve the outcome of the government Health Care system both in the Central and State level: 1. As a policy maker: It is a fact that about 15 - 20 % of the national health budget of the country is spent on medicines. Despite this, a regular supply of quality medicines cannot be uniformly achieved. Moreover, there is little scope to increase the budget allocation in consonance with the price rise of medicines. Therefore, there is an urgent need to frame a drug policy so that safer drugs reach the patient in their times of need. It should be done keeping the following objectives in mind: i)

Availability of safe and effective drugs at all the hospitals and health care facilities. ii) A good quality control and assurance system, and an updated inventory as well as logistics system to be put in place. iii) Improved procurement, storage and distribution of drugs. iv) Rational prescribing of medicines. v) Prescribing by generic names. vi) Strengthening of health education programme. vii) Research on all aspects of drug use. As per the WHO list, a small number of drugs are sufficient to treat most of the prevalent diseases, which are prevalent, apart from a few specialized drugs needed for some diseases, which are rare in this country. Each state should prepare a list of drugs needed for treatment of diseases prevalent in such state as well as drugs needed locally. Though most of the states of this country have not yet prepared such an Essential Drug list, the Central Government, Delhi State Govt., and Rajasthan State Govt. have already published an Essential Drug list. Central Govt. published the first edition of the list in the year of 1996 and has published an amended version containing 354 medicines in the year of 2003. This list could

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

be more meaningful if the participation of pharmacists are in a large scale. Being a part of the Pharmacy and Therapeutics Committee, pharmacists could contribute in framing the Antibiotics Policy of the hospital. Antibiotic use is now a well-debated issue because, inappropriate use of latest antibiotics is leading to large-scale antibiotic resistance, resulting in cost escalation as well as compromised efficiency of treatment. Also, microorganisms responsible for causing Nosocomial infections have been found to be resistant to a significant no. of antibiotics.

2.Procurement: selection, purchasing and control The selection of pharmaceuticals is a basic and extremely important professional function of the hospital pharmacist who is charged with making decisions regarding products, quantities, product specifications, and sources of supply. It is the pharmacist's obligation to establish and maintain standards assuring the quality, proper storage, proper dispensing and safe use of all pharmaceuticals and related supplies (e.g., Perfusion sets, Blood Transfusion sets, Disposable Hypodermic Syringes, Hypodermic Needles); this responsibility must not be delegated to other individuals. The setting of quality standards and specifications requires critical professional knowledge and judgment and must be performed only by the pharmacist. Economic and therapeutic considerations make it necessary for hospitals to have a well controlled, continuously updated formulary. It is the pharmacist's responsibility to develop and maintain adequate product specifications to aid in the purchase of drugs and related supplies under the formulary system. In establishing the formulary, the Pharmacy & Therapeutics Committee should recommend guidelines for drug selection. However, when his practical knowledge indicates, the pharmacist must have the authority to reject a particular drug product or supplier. Although the pharmacist has the authority to select a brand or source of supply, he must make economic considerations inferior to those in quality. Competitive bid purchasing is an important method for achieving a proper balance between quality and cost when two or more acceptable suppliers market a particular product meeting the pharmacist's specifications. In selecting a vendor, the pharmacist must consider price, terms, shipping times, dependability, quality of service, returned goods policy, and packaging; however, prime importance must always be placed on drug quality and the manufacturer's reputation. It should be noted that the pharmacist is responsible for the quality of all drugs dispensed by the pharmacy.

3.Drug storage, preservation and inventory control Storage is an important aspect of the total drug distribution system. Proper environmental control (i.e., proper temperature, light, humidity, conditions of sanitation, ventilation, and segregation) must be maintained wherever

drugs and supplies are stored in the institution. Storage areas must be secure; fixtures and equipment used to store drugs should be constructed so that drug is accessible only to designated and authorized personnel. Such personnel must be carefully selected and supervised. Safety also is an important factor, and proper consideration should be given to the safe storage of poisons and flammable compounds. Medicines for external use should be stored separately from internal medications. Separate secure storage for controlled substances must be allotted, with restricted entry by only authorized persons. Medications stored in a refrigerator containing items other than drugs should be kept in a secured separate compartment. Proper control is important wherever medications are kept, whether in general storage in the institution or the pharmacy or patient-care areas (including satellite pharmacies, nursing units, clinics, emergency rooms, operating rooms, recovery rooms). Expiration dates of drugs must be considered in all of these locations, and stock must be rotated as required. A method to detect and properly dispose out dated, deteriorated, recalled, or obsolete drugs and supplies should be established. This should include monthly audits of all medication storage areas in the institution. (The results of these audits should be documented in writing.) Since the pharmacist must justify and account for the expenditure of pharmacy funds, he must maintain an adequate inventory management system. Such a system should enable the pharmacist to analyze and interpret prescribing trends and their economic impacts and appropriately minimize inventory levels. It is essential that a system to indicate sub minimum inventory levels be developed to avoid outages, along with procedures to procure emergency supplies of drugs when necessary. As well as maintain buffer stocks.

4.Propagating the concept of Essential Drugs and Rational use of Drugs In order to maintain an efficient health care system, the drug distribution system must be cost effective and should reach out to a wide cross section of common people. This can be possible only if the drugs and formulations used are affordable by the patients. But in the present health scenario, we see the random use of multiple costly drugs which often, hovers on the border of being irrational and mostly, unnecessarily costly. Unfortunately, the basic concepts of drug accessibility and utilization are not properly conceived and practiced in our country. In order to maintain an efficient health care system, the drug distribution system must be cost effective and should reach out to a wide cross section of common people. This can be possible only if the drugs and formulations used are affordable by the patients. But in the present health scenario, we see the random use of multiple costly drugs which often, hovers on the border of being irrational and mostly, unnecessarily costly. Unfortunately, the basic concepts of drug accessibility and utilization are not properly conceived and practiced in our country. Rational Drugs are those, which are accepted world wide, and are included in standard textbooks of medicine and

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

pharmacology. Essential Drugs are those drugs, selected by each country, based on the health needs of its people, and the morbidity pattern prevalent there. Essential Drugs are basic drugs of utmost importance and are necessary to treat a large number of people thus being indispensable for a country. Essential Drug must be safe, economic and it must be therapeutically effective, have proven scientific value and must be rational. The concept of Essential Drug is very important for a country like India, where people suffer from lack of medicines, despite thousands of formulations being available in the market. It has been found in a survey that out of 60000-formulations existent in the Indian market only 25 30% have any rational therapeutic basis. The WHO has identified and listed around 400 drugs, which are absolutely essential in treating the morbidity pattern prevalent in the world. The Essential Drug list if present in a country, can assure rational drug use by limiting use of irrational and hazardous drugs, and decreases risk of iatrogenic diseases and also improve chances of monitoring Adverse Drug Reactions in patients. Rational Use of Drugs makes imperative to draw up priorities to meet the most urgent needs of people for essential health care. It also facilitates streamlining of production, storage, and distribution of drugs - due to a smaller number of drugs involved. The concept of Rational Use of Drugs can start from listing only rational formulation in the hospital formulary and making available in the country, only rational drugs/formulations. Proper training of RUD can help to move away from the practice of polypharmacy. A survey in 12 countries reveals that the average number of drugs per prescription was 1.95 in Bulgaria and 2.39 in Columbia. Though no exhaustive survey has been done in India, but some isolated surveys showed that the number of drugs per prescription is too high. As the physicians are usually busy to deal with huge no. of patients, pharmacists can play an important role in propagating the concept of Rational Use of Medicines.

5.Bulk Compounding and Dispensing There are a lot of common products, which are being purchased by the hospital authority from the market at a high price, which the pharmacists can easily prepare in the pharmacy at extremely low cost. Preparing such common formulations like carminative mixtures, lotions, ointments, disinfectants etc. will involve minimal investment by the pharmacy. But the dividends reaped will be rich - these cheap formulations can be supplied to the patients at low cost thus lowering the cost of medical care for common people. This is because, indigenous manufacturing at the pharmacy, cuts out the cost of attractive packaging, huge inventory levels, eliminates cost of transport and different taxes, and so final products are cheaper. The products prepared by in house staff will also assure that drugs dispensed are of high quality. This practice is being followed throughout the world, e.g. Nigeria, Sweden etc.

6.Clinical Pharmacy The term â&#x20AC;&#x153;Clinical Pharmacyâ&#x20AC;? was coined to describe the work of pharmacists whose primary job is to interact with the 32

health care team, interview and assess patients, make specific therapeutic recommendations, monitor patient responses to drug therapy and provide medicine information. Clinical pharmacists work primarily in hospitals and acute health care settings and provide patient-oriented rather than product-oriented services. A consorted effort of the health care team can significantly shorten the patient hospitalization time by implementing a well-designed patient management policy and implementing rational drug therapy. Hospitalization for a long time increases the medical expenditure by way of hospital charges including cost of medicines, bed charges, and miscellaneous. Reduction in span of hospitalization can also improve the efficiency of the hospital by providing treatment to a larger number of ambulatory patients per unit time. To achieve this goal, pharmacists should engage themselves in practice of Pharmacoeconomics and Outcome research in earnest.

7.Propagating unbiased information to all professionals of the health care team as well as the general public Physicians often get confused by the biased information provided by pharmaceutical manufacturers. Availability of unbiased information by physicians could help generate prudent prescriptions & consequent drug use. These unbiased sources can be standard reference books, journals & other primary information sources. Common people are also confused by the aggressive promotional propaganda, made by the pharmaceutical companies in electronic and print media with an eye towards gaining an edge in the cutthroat competition market. Sometimes consumers become more interested in medicines having no beneficial or least beneficial effects, by virtue of attractive advertisements. These products may often have some damaging effect on the health in the long run. So, the dissemination of unbiased information may restrict people from such deleterious attitudes/practices. To serve this purpose in a meaningful way, the setting up of Drug Information centre at hospital level, manned by pharmacists, is being suggested. Presently a number of Drug-information centers are doing a commendable job leaded by pharmacists.

8.Adverse Drugs Reaction (ADR) Monitoring Physicians in our country are always busy, and cannot often afford much time for a patient. Sometimes a patient needs to get an appointment to report a complaint after taking a medicine. Generally a patient chooses not to report the same, to avoid a cumbersome process of seeking an appointment. In some cases, physicians also avoid ADR reporting in anticipation that patients may get scared. Pharmacists being the most easily accessible health care professionals, can serve an important role in ADR monitoring programme, by acting as a link between the patient and the doctor / the regulatory authorities. Presently an effective Pharmacovigilance system has been established in India. Two zonal centers have been established at Mumbai and Delhi. Five regional centers were established

Challenges and Opportunities for Pharmacists in Health Care in India

CHALLENGES AND OPPORTUNITIES FOR PHARMACISTS IN GOVERNMENT PRACTICE

at Kolkata, Mumbai, Nagpur, New Delhi and Pondicherry. Twenty four peripheral centers are now operating from different medical colleges or pharmacy colleges throughout the country. The national pharmacovigilance programme encourages the reporting of all suspected adverse reaction to drugs and other medical substances including herbal, traditional or alternative remedies. Recently Schedule Y has been amended including mandatory requirement of post marketing surveillance of any new drug. A National Pharmacovigilance Advisory Committee (NPAC) has been formed to oversee the performance of various zonal, regional and peripheral centres and to recommend possible regulatory measures based on data received from different centers. Pharmacists can report any ADR detected in the centres mentioned above. Apart from this, WHO has a reporting centre at Uppsala, Sweden. Pharmacists can report any ADR online to this center.

9.Regulatory Authority Present regulatory system needs to be strengthened by providing sufficient manpower and infrastructure. As per the recommendation of the Task Force engaged by Govt. of India there is a need of 4795 drugs inspectors, whereas only 899 of them are available. Therefore more inspectors and higher officers with requisite professional qualifications require to be engaged. Infrastructure of the organization like, vehicle, information system, training facilities require to be improved.

10.Quality Control System Drug testing laboratories maintained by the CDSCO is considered inadequate both in quantity and quality. More laboratories require to be set up and existing laboratories require to be modernized by providing manpower and infrastructure. Cutting edge analytical techniques and modern instrumentation must be employed for optimum results. To utilize the maximum potential of the Pharmacists government should implement the recommendations of the National Human Rights Commission (NHRC). National Human Rights Commission has recommended that the Central Govt. should create a post of Joint Drugs Controller of India (Pharmaceutical Services) under the Drugs Controller General of India to look after the whole aspect of Drugs and Medicines. Similarly they recommended that each State Govt. should create a post of Deputy Commissioner (Pharmaceutical Services) to look after the area of the drugs and medicines used by the respective State Govts. They also recommended setting up of modern hospital pharmacy in Govt. hospitals under the aegis of a pharmacist having postgraduate qualification, whose status should not be less than an assistant Professor and who will report directly to the head of the hospital.

Challenges and Opportunities for Pharmacists in Health Care in India

EDUCATIONAL REFORMS FOR PHARMACISTS

I. Introduction Pharmacy has made enormous progress globally over the years and emerged as a distinctly independent profession with a wide range of activities related to drug discovery and development, manufacturing and supply of quality drugs through hospital, community and government pharmacy settings. The primary focus of the profession of pharmacy world over has shifted from a product oriented to patient oriented professional service. The pharmacist is no longer a mere dispenser of drugs but has assumed a more crucial role in medicine management and as overall health care provider. Pharmaceutical education and training plays vital role in developing pharmacists with knowledge and skills needed to perform their duties and responsibilities more efficiently and professionally. In order to do so, a need based relevant curriculum has to be developed for pharmacy courses.

II. Current Status of Pharmacy Profession and Education in India During the last 5 decades India has moved significantly towards self-reliance in development and manufacturing of medicines. The industrial sector has made tremendous progress in pharmaceutical manufacturing, quality control and research areas and achieved global standards providing quality products conforming to international regulatory norms. However, the other side of the profession, i.e. community, hospital and government pharmacies has been neglected and not adequately professionalized. There is no effective clinical pharmacy practice presently. There is very little focus on pharmaceutical care. The practice of pharmaceutical care, essential drugs and rational use of drugs and involvement of the pharmacist in health promotion programmes on drug-related and health-related topics is negligible. There is hardly any communication between the pharmacist and the physician. 34

Pharmaceutical education in India is a three tier system consisting of diploma, degree and PG programmes in pharmacy. Diploma in pharmacy is a two-year programme after 10+2 (intermediate) with three months' practical training in a hospital or community pharmacy. The curriculum and training for the diploma in pharmacy course are prescribed and regulated by the Pharmacy Council of India (PCI). Presently the Diploma in Pharmacy is the minimum registrable qualification for a Pharmacist under the Pharmacy Act. The degree in pharmacy is a four-year programme after 10+2 with or without practical training in industry/hospital. The curriculum and training for the degree in pharmacy course is prescribed and regulated by the Universities. If, however, one wishes to get oneself registered as a Pharmacist under the Pharmacy Act, one is obliged to complete all the courses prescribed for the Diploma course. It is estimated that nearly 5 lakh diploma and degree holder pharmacists are available in India. Very few degree holders opt for working in community or hospital pharmacies; for various reasons, they prefer to work in the industry. The diploma holders are mostly engaged in community and hospital pharmacy practice but they are neither properly educated nor properly trained in pharmacy practice and pharmaceutical care. The present curriculum and training prescribed for diploma and degree courses in pharmacy are not adequately crafted to prepare the pharmacists to perform the duties and responsibilities envisaged for a pharmacist in health care system.

III. Educational Reforms In the light of the present status and scenario of the pharmacy profession and education in India, there is immediate need to strengthen and upgrade the pharmacy curriculum to produce a work force of competent pharmacists capable of meeting the growing demands of

Challenges and Opportunities for Pharmacists in Health Care in India

EDUCATIONAL REFORMS FOR PHARMACISTS

pharmacy practice. The following are some of the educational reforms that need to be undertaken on a warfooting. 1. Up-gradation of the present diploma in pharmacy curriculum is essential but that alone cannot effectively enhance the standards of pharmacy practice as it is not possible to accommodate all the knowledge, skills and attitude needed in two-year diploma course. The patient should receive pharmacy health care not through a halfbaked pharmacist. The imperative need is the upgradation of registrable qualification accommodating relevant education and training. If citizens of developing countries like Ghana, Zimbabwe, etc can be provided with pharmaceutical care of a standard comparable to that available to a citizen of the developed world like the UK, the USA, Australia, etc, why should an Indian citizen be denied such services. The diploma should no longer be the minimum qualification for registration. The upgradation of minimum registrable qualification is needed to: l l l l l l l l l

face the challenges of healthcare of the society and nation. enhance the knowledge and skills of pharmacist working in all settings. promote pharmaceutical care and rational use of drugs. better patient care and medication management. enable the pharmacist to take part in health promotion programmes. develop professional competence. have good communication with doctors and patients. fulfill the societal expectations, and finally, attain recognition by the society. .

The Pharmacy Council of India (PCI) has proposed upgradation of minimum registrable qualification and training as a major amendment to the Pharmacy Act. 2. The curriculum and training for the minimum registrable qualification of degree in pharmacy course has to be modified giving main focus on subjects like pharmacy practice, rational use of drugs, pharmaceutical care and clinical pharmacy and should be more oriented towards community, hospital and clinical pharmacy practices to generate a sound foundation of professional and trained pharmacists.

The society expects the pharmacists to be advisors, providers of services, and performing professional duties. The design for the pharmacy curriculum has to ensure the following requirements. Advisory role: Health horizons, population control and family planning, prevention and control of communicable and non-communicable diseases, patient counseling, family welfare, diet and nutrition, drug abuse, nuclear medicine and correct and safe use of medicines (dosage, storage, toxicity, ADR, contraindications), etc. Service role: First aid and emergency management, drug information, preparation and supply of health promotion

material, immunization, providing health education on HIV/AIDS, diabetes, TB, Tobacco cessation, Malaria, etc. Professional role: Drug distribution and sale prescriptions practices, drug laws, interpretation of diagnostic tests, demonstration of correct use of gadgets and equipment, and medication for various ailments.

FIP has an elaborate statement on Good Education Practices (see www.fip.org) which can serve as a role model in framing relevant curriculum. 3. Pharmacists should be made aware of the general health policies and strategies, particularly for the control of public health programmes such as malaria, tuberculosis, HIV/AIDS, for the care of mothers and children (MCH), family planning, etc. Besides the principles of the pharmaceutical sciences, subjects associated with pharmaceutical practice such as behavioural sciences, management techniques, keyboard skills, communication and educational techniques, with particular reference to health education of the public should be introduced. 4. A time bound upgradation of existing diploma holders to the proposed upgraded level by providing education by distance mode or by short term contact (6 months to 1 year) courses. The present diploma holders may be allowed to practice, but with compulsion of a minimum number or hours of continuing education. 5. Improvement of present pharmacies (community and hospital) into more professional ones and accreditation of pharmacy educational centers by a national accreditation body. 6. A time bound upgradation of diploma institutions to impart upgraded education and training.

IV. Postgraduate Education in Hospital, Clinical and Community Pharmacy M. Pharm. course in Hospital Pharmacy was first introduced more than 25 years ago in the Delhi College of Pharmacy. M. Pharm. course in Pharmacy Practice was first introduced in India in JSS College of Pharmacy at Mysore and Ooty in the year 1991 and 2000 respectively. As of today, the course runs in 13 colleges, mostly concentrated in southern India. NIPER is the latest institution to start a Master's degree programme in Pharmacy Practice on the UK pattern. In some private hospitals, which are attached to pharmacy colleges, and which have an M. Pharm. course in Pharmacy Practice, the standard of hospital pharmacy services has considerably improved. The students of the Department of Pharmacy Practice perform various functions of clinical pharmacy, viz. patient instructions, patient counseling, ADR reporting, drug information centre, attending ward rounds along with the doctors, practice research, promoting rational use of medicines, etc. In many of these hospitals, there is a Drug Information Centre managed by pharmacists which provides useful information to the hospital staff.

Challenges and Opportunities for Pharmacists in Health Care in India

EDUCATIONAL REFORMS FOR PHARMACISTS

A significant step in the development of Clinical and Hospital Pharmacy was initiated at the National Seminar on "Hospital and Clinical Pharmacy - Perspectives and Prospects", Mysore, India (1999). Academicians, hospital and community pharmacists, drug regulatory authorities, hospital administrators, and pharmaceutical industry representatives attended the seminar and evolved a declaration document. The declaration has made an attempt to lay down criteria for development of various aspects of hospital and clinical pharmacies in India. This declaration focuses on standards for the practice of clinical pharmacy in India: 1. Training and facilities 2. Syllabus 3. Patient-focused teaching 4. Hospital infrastructure requirements 5. Resources 6. Interested and committed management 7. Inspection and approval of institutions Unlike other categories of practicing pharmacists, the hospital pharmacists work in a closed environment of highly qualified health care professionals including physicians, nurses, biochemists, microbiologists, pathologists, dietitians, etc. It requires high standards of professional education and competence for the hospital pharmacists. The contemporary hospital pharmacies in many countries utilize the services of highly qualified and properly trained pharmacists. Like the community pharmacists, the hospital pharmacists too have many vital professional roles to play in protecting the interests of patients. Knowledge base of hospital pharmacists can help to take-up various academic activities in addition to their normal professional activities in hospitals. Contemporary Indian hospitals - private, government or military have adequate facilities except for hospital pharmacies that are ill-equipped. Professionalism and scientific concepts are usually lacking. The absence of standards and job description for hospital pharmacies and hospital pharmacists is one of the major reasons for the present situation. Qualified pharmacists are yet to be attracted to hospitals. Innovations are lacking and the hospital pharmacists are generally satisfied with traditional pharmacy activities. The right administration of a wrong drug and the wrong administration of a right drug are injurious to the patients. Hospital pharmacies have to avoid both types of injuries to the patients. The country needs innovations in hospital, community and clinical Pharmacy Practice for which we have to find effective methods of changing the basic attitudes. New team of practicing pharmacists including hospital pharmacists have to be trained as administrators and pilot officers capable of introducing innovations. If the pharmacy professionals in India can rise to the occasion and utilize opportunity as was done by the American pharmacists in the 1960s, the Indian hospital and clinical pharmacy can be developed and brought to international standards within a reasonable period. Hospital pharmacy activities have to take up more patient oriented activities, 36

effective quality control measures and promote safe and rational use of medicines in hospitals and outside. The M. Pharm. programmes in Pharmacy Practice need to be publicized in the country vigorously and conscientiously to attract the graduates to this branch of post-graduate specialization. These post-graduates will then be able to orient the community pharmacy giving it a direction.

V. FOR IN-SERVICE PHARMACISTS 1. For in-service and working pharmacists continuing professional development via continuing education programmes, aimed at keeping pharmacists abreast with new developments, are to be organized and made mandatory. 2. For conducting Continuing Education Programmes for pharmacists as well as faculty of approved institutions conducting pharmacy courses, the PCI should identify and fund atleast one institution in each state to conduct such programmes. 3. Each Continuing Education Programme may be of 4 days duration and limited to a number of 50 - 100 participants. 4. The Continuing Education Programme should be intensive and brainstorming on the topics identified by PCI and involvement of participants. 5. Attending Continuing Education Programmes, atleast once in two years should be made compulsory for continuing/renewal of registration of pharmacists. 6. There is also a need to have continuing education by distance mode / web based. 7. Drug Information Centers, which can provide accurate and timely information to questions raised by the pharmacists are to be established in all approved pharmacy institutions (government and self-financed). Establishing Drug Information Center may be made mandatory for all pharmacy colleges/institutions. Especially in the context of the emerging new drugs, a database of information could be extremely beneficial to pharmacists in building their clinical knowledge. 8. Community and hospital pharmacists may be asked to maintain a stock of standard books of reference, pharmacopoeias, CD-ROM database reference sources and access to the drug information websites via computers. There is a great need to produce such educative material in India and also to make it affordable for pharmacies to purchase and stock. The educational reforms as discussed above will certainly produce professionally competent pharmacists to improve the health of the society through the promotion of safe, effective and rational use of medicines, patient counseling and monitoring of disease management through proper pharmaceutical care. These educational reforms will upgrade the profession of pharmacy in India to international standards and make Indian pharmacist a globally competent.

Challenges and Opportunities for Pharmacists in Health Care in India

ROLE OF NATIONAL ORGANIZATIONS, GOVERNMENT AND OTHER STAKE HOLDERS

ROLE OF NATIONAL ORGANIZATIONS, GOVERNMENT AND OTHER STAKE HOLDERS Pharmacists as members of the healthcare team could play a key role in ensuring affordable access to quality essential medicines, dissemination of appropriate information to patients, general public and other health professionals, participating in health promotion and health education programmes like nutrition counseling, welfare of women RCH, sexually transmitted diseases - HIV/AIDS, alcohol and drug abuse, smoking cessation, rational use of medicines, drug utilization, post-marketing surveillance towards monitoring and reporting of adverse drug reactions (pharmacovigilance) and pharmaceutical care. The Ministry of Health and Family Welfare, Government of India can use the pharmacists as work force in meeting the targets under these programmes. The Indian Pharmaceutical Association (IPA) has taken several initiatives to bring pharmacists in the mainstream of national healthcare system by conducting health-focused campaigns during the National Pharmacy Week celebrations (NPWs) and continuing education programmes. These include Good Pharmacy Practice Guidelines, Guiding Principles for Pharmacists in the fight against HIV/AIDS in India, Improving Access to Essential Medicines through Pharmacists, Pharmacists for promotion of Future Free of Tobacco and Pharma Vision 2020 - A Strategy for Pharmacy Mission and Vision 2020 (jointly with the Pharmacy Council of India). On the request of the National Commission on Macroeconomics and Health (NCMH), a paper on Pharmacists' availability and their training need assessment in India for improving access to essential medicines was submitted by the IPA in 2004. Pharmacy profession cannot exist and grow in isolation. Realising this, the World Medical Association (WMA) and the International Pharmaceutical Federation (FIP), in the year 2000, initiated a dialogue on working relationship between physicians and pharmacists with a view to demonstrating that physicians and pharmacists have complimentary and

supportive roles and responsibilities. The WHO and the FIP have also jointly identified seven core expectations from the pharmacists as 1) Care-giver; 2) Decision maker (in choice of OTC drugs given to patients in need); 3) Communicator; 4) Leader; 5) Manager; 6) Life long learner; and 7) Teacher. The New Horizon has identified 4 major areas of activities crucial to future of the profession: (i) managing prescribed medicines and helping at every stage in the chain, (ii) managing chronic conditions, offering a better quality of life to the patient with such conditions, and helping to improve the outcomes of the treatment, (iii) managing common ailments in(Checked) giving patients reassurance, advise with or without use of non-prescription medicines, and (iv) promoting and supporting healthy lifestyles helping people to protect their own health. The Indian Medical Association is a national body of all allopathic consultants and RMPs. Working with IMA and General Physician Association (GPA) to make the medical fraternity aware of the value addition offered by Community and Hospital pharmacists is highly desirable. Simultaneously, the pharmacists should be trained in clinical skills. An MoU between IMA and IPA, and on going dialogues between MCI and PCI should result in mutual recognitions of professional roles, responsibilities and obligations of pharmacists. A similar dialogue is required with the Indian Nursing Association and Nursing Council of India. In order to inspire, encourage and empower the pharmacist to find a meaningful role and recognition in the society in India by acquiring required key competencies, a modest attempt was made at Jaipur on 17th February 2002 at the time of conclusion of WHO sponsored two weeks International Course on Pharmacoeconomics, utilizing the presence of international WHO resource persons. The meeting was chaired by Prof. Roy Chaudhury, Coordinator, WHO-India Essential Medicines Programme and co-chaired by Dr. Hans Hogerzeil (now, the Director, Essential drugs and Medicines, WHO, Geneva). Leading pharmaceutical

Challenges and Opportunities for Pharmacists in Health Care in India

ROLE OF NATIONAL ORGANIZATIONS, GOVERNMENT AND OTHER STAKE HOLDERS

professionals having shown concern for the Community Pharmacy were invited to attend this brain storming session. Summing up the session Prof. Roy Chaudhury and Dr. Hans Hogerzeil welcomed this effort in identifying the Role of Community Pharmacist towards Enhancing the Access to Essential Drugs in collaboration with medical profession. "Pharmacists have an important role to play in health care, which is much more than selling medicines," said Dr Hans V. Hogerzeil. It was deliberated that the chasm between the availability and affordability continues to trouble our conscious, the chasm between affordability and rational use is a challenge to all. About 25-30% of population in rural area have no access to medicines. Pharmacists and retail pharmacy outlets (medical stores) are crucial focal point for the community, as nearly 80% of population has to bear the expenses on medicines and health care out-of-pocket. Most often, these outlets are the first-port-of-call (as primary health care) for the community. As pharmacists can communicate with the community in locally understandable languages and dialects, their outreach is tremendous for discussing their health problems and helping them to find solution to their problems. In pursuance, "The Jaipur Declaration" was issued along with the Guiding Principles.

2. Identify and understand those to be influenced 3. Get to know the people to be influenced 4. Build a strong case 5. Identify allies and experts who share our views 6. Identify and understand potential opponents 7. Develop a plan over a period of time 8. Take advantage of developments which create windows of opportunity 9. Evaluate activities periodically 10. Networking and using existing networks

Conclusion Community pharmacy practice

The Importance of Collaboration

Collaboration among pharmaceutical organisations to promote the case of pharmacist in health care is important because it:

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allows for strengths to be multiplied; ensures that relevant skill, experiences and facilities are shared; makes certain that limited resources are used in an effective way; can help to make sure that mistakes are not repeated and that good ideas are promoted and adapted.

Pharmacists in the health care system are like circum centre of a triangle with physicians, patients and nurses at the corners of the triangle. They have 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 physician's dispensary. The role of community pharmacist is indispensable in providing better health care. Steps should be taken by the Government and the pharmacists themselves to make their recognition in the community as better health care providers. In addition to IPA, IPGA, APTI, IHPA, other national pharmaceutical organizations like Indian Pharmacists Organization, Federation of Indian Pharmacists Organization, and All India Organization of Chemists and Druggists etc. should 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.

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Effective Advocacy 1. Analyse the problem and define objectives 38

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Organize conventions based on community pharmacy practice to promote among basic concepts, new advances, future expectations among pharmacy students, academicians, practicing pharmacists. Collaboration among professional organizations could help in advocacy of systems or concepts promoting community pharmacy. Work out plans to form a centre which will provide patient information leaflets etc. and other patient information material for pharmacists to buy from. This could help in promoting the role to the public. Work out strategies to support Drug Information Centres in all states so that pharmacists could call in with their queries to aid in giving prompt patient information. Work towards changing perception of the role of pharmacist among themselves. National Pharmacy Week and special campaigns round the year. Incentives for pharmacies maintaining GPP. Support in implementation, motivation, education etc. Use associations as a database/center for public information e.g. one-stop-shop on pharmacy practice at national level.

Advocacy l

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To doctors, awareness of pharmacists role through seminars organized through IMA etc. so that doctors accept pharmacists as health care team member and refer patient to pharmacists for counselling, BP monitoring, Home Medicine Review etc. Draw up an action plan short term, and long term for the pharmacy profession (practice oriented). Lobby with the Govt and other stake holders, the value of pharmacists. Make GPP for community pharmacy legal i.e. at par with GMP for pharma industry.

Challenges and Opportunities for Pharmacists in Health Care in India

ROLE OF NATIONAL ORGANIZATIONS, GOVERNMENT AND OTHER STAKE HOLDERS l

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Collaborate with other professional organisations and pharmacy related offices to promote pharmacist's role. Liaison with international pharmacy associations, WHO, etc. to enhance the role of the pharmacist and implement their guidelines. Document success stories of Pharmacists. Network amongst various pharmacy associations, as well as the pharmacists in the country. Networking with national and international bodies. Consensuses between stakeholders

Others l l

Literature on 'Pharmacists - Member of the health care' team Literature for public on 'role of a pharmacist'.

Challenges and Opportunities for Pharmacists in Health Care in India

Tables and Figures

Table A: Community Pharmacy Practice - Around the World Continent Country

Min. Qual Length of Education

Av. floor Pre license CE training Reqirements Space 2 in m

Europe

B.Pharm

200

1 year

Austria

Maintaining Dispensing patient medication with label/PIL records

Yes

Interaction with Physicain

Good

4.5 years Croatia

4.0 years

100

1 year

Yes

Loose

Denmark

5.0 years

470

Yes

Good

Finland

5.5 years

104

Yes

Some

Good

France

6.0 years

Yes

Som

Good

Germany

4.0 years

165

Yes

Some

Yes

Good

U. K.

4.0 years

1 year

Yes

Good

Greece

5.0 years

0.5 year

Some

Yes

Not so good

Hungary

5.0 years

4 years

Yes

Some

Yes

Good

Iceland

5.0 years

200

Yes

Good

Ireland

4.0 years

1.0 year

Yes

Not so good

Italy

5.0 years

Some

Yes

Good

Luxembourg NA

120

Yes

Good

Netherlands 5.0 years

240

2.0 years

Yes

Good

Norway

5.0 years

270

Some

Yes

Good

Poland

5.0 years

150

1.0 year

Yes

Loose

Portugal

5.0 years

0.5 year

Some

Not so good

Spain

5.0 years

Some

Yes

Good

Sweden

5.0 years

300

Yes

Good

Switzerland

5.0 years

217

2.0 years

Some

Yes

Loose

U.S.A

5.5 years

Yes

some

Yes

Loose

Canada

5.0 year

455

Yes

All

Yes

Good

Eritrea

5.0 years

Loose

North America Africa

Ghana

4.0 years

Yes

Good

Kenya

5.0 years

1.0 year

Some

Yes

Not so good

Austria

Australia

3.0 years

127

1.0 year

All

Yes

Good

Asia

Japan

4.0 years

Most

Yes

Loose

Korea

4.0 years

Some

Yes

Loose

India

2.0 years Diploma

Loose

Source:CommunityPharmacySection,FIP TableB:ProposedStructureingovernmentpharmacysettings Designation Duties Pharmacist Grade-III Pharmacist Grade-II Pharmacist Grade-I Senior Pharmacist Chief Pharmacist Pharmacy Officer

Will perform actual dispensing, store keeping and patient counseling Additionally will supervise the drug distribution system and record keeping Additionally will perform the inventory control and maintain relevant records for health statistics Will supervise the work of all Pharmacists Will act as overall supervisor of the Dispensary and Medical Store Will be overall supervisor of the Hospital Pharmacy service for indoor as well as outdoor dispensaries including distribution of manpower and duty allocation and take part in policy making in respect of purchase, storage and distribution of medicines in a hospital

Challenges and Opportunities for Pharmacists in Health Care in India

Tables and Figures

Figure 1: Typical organizational structure of pharmacy department

Hospital Administrator Department of Pharmacy Director Executive and Administrative Operations

Professional and Clinical Services

Professional and Clinical Services Nuclear Pharmacy Services Division

Educational and Technical Services

Drug Information and Poison Control Services Division

Unit Dose Dispensing Division

Education And Training Division

Ambulatory care & home care service division

Professional Staff Development

Intravenous Admixture Division

Residency Training Program

Sterile Products Division

Teaching Selection and Training Division

Drug Administration Division

Computerized Pharmacy Operations Division

Research and support services

Pharmaceutical and Clinical Research Division Assay and Quality Control Division

Drug Kinetics and Bioavailability Laboratory

Manufacturing and Packaging Division Purchasing and Inventory Control Division

Departmental Services Division Investigational Drug Studies Division

Clinical Pharmacy Services Division Source: Remingtons, the science and practice of pharmacy 20th edition

Challenges and Opportunities for Pharmacists in Health Care in India

BIBLIOGRAPHY

BIBLIOGRAPHY 1.

A joint declaration between DSPRUD, RSPRUD, WHOIndia EDP, DPT, SEARPharm Forum and AIOCD on “The role of Community Pharmacist in Enhancing the Accessibility to Essential Medicines in India”, Jaipur, February 17, 2002.

Action Programme on Essential Drugs, and Unit of Pharmaceuticals, Division of Drug Management and Policies, WHO, Geneva, 1990, WHO/PHARMDAP/90.1.

Frazier,Walter et al. 1954 Report of the ASHP, Committee on minimum standards, The Bulletin, ASHP, 12: 454, 1955.

Good Distribution Practices (GDP) for Pharmaceutical Products, working document QAS/04.068, World Health Organization 2004

Good Pharmacy Practice Guidelines, Indian Pharmaceutical Association, March 2002.

Good Storage Practices (GSPs) for Pharmaceutical Products at a Retail Pharmacy, Delhi Pharmaceutical Trust, September 2002.

Guide to Good Storage Practices for pharmaceuticals, WHO Technical Report Series, No. 908, 2003

Improving Access to Medicines Through Pharmacist, National Pharmacy Week 2002, Indian Pharmaceutical Association, Mumbai.

11. Mashelkar Committee report on “A Comprehensive Examination of Drug Regulatory Issues, including the Problem of Spurious Drugs”, Ministry of Health and Family Welfare, Govt. of India, November 2003. 12. Minimum standard for pharmacies in hospitals with guide to application, AJHP, 15:992, 1958. 13. Remingtons, The Science and Practice of Pharmacy, 20th Edition, Vol II, Chapter III, p. 1911-31, Lippioncott William and Willcins. 14. Pedersen CA, Schneider PJ, Santell JP. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing 2001. Am J Health Syst. Pharm 2001:58:2251-72. 15. Report of a WHO Meeting, Tokyo, Japan, WHO/PHARM/94.569; 31 August 3 September 1993. 16. Statement on the Abilities Required of Hospital Pharmacists; Am. J Hosp Pharm, 19; 9:493, 1962. 17. The Role of pharmacist in the healthcare system; Preparing the future pharmacist: Curriculum Development, Report of a Third WHO consultative group on the role of pharmacist, Vancouver, Canada, WHO/PHARM/97/599; August 1997. 18. The Role of pharmacist in the healthcare system; Report of a WHO consultative group New Delhi, India, 13-16 December 1988.

John S.Clark, Lee C.Vermeulen, Hospital Pharmacy in the United States. International Pharmacy Journal 2002; 16: 18-9.

19. Urdang, George: Ten years of the American Society of Hospital Pharmacies, The Bulletin, ASHP, 9:281, 1952.

10. Large volume parenterals: Towards zero defect, National Human Rights Commission, New Delhi, 1999

20. Developing pharmacy practice: A focus on patient care, Handbook - 2006 Edition, WHO in collaboration with FIP.

Challenges and Opportunities for Pharmacists in Health Care in India

BIBLIOGRAPHY

21. FIP Statement of: a.

FIP guidelines for “The Labels of Prescribed Medicines”, 2001.

Improving access to medicines in developing countries, 2005

Joint Statement between The International Pharmaceutical Federation (FIP) and the International Federation of Pharmaceutical Manufacturers Associations (IFPMA) on “Ensuring quality and safety of medicinal products to protect the patient”, 1999.

Joint Statement by the International Pharmaceutical Federation and the World Self-Medication Industry on 'Responsible Self-Medication', 1998. Joint statements between FIP and WMA on “Working relationship between physicians and pharmacists in medicinal therapy” (in discussion). Policy control on “Resistance to anti-microbials”, 2000.

Policy on COUNTERFEIT MEDICINES, 2003.

Policy on GOOD PHARMACY EDUCATION PRACTICE, 2000.

Policy on the Role of the Pharmacist in Promoting a Future Free of Tobacco, 2003

Principle on Pharmacist's authority in product selection Therapeutic Interchange and Generic Substitution, 1997.

Principle on SELF-CARE INCLUDING SELFMEDICATION - The Professional Role of The Pharmacist, 1996.

Principle on THE PHARMACIST'S RESPONSIBILITY AND ROLE IN TEACHING CHILDREN AND ADOLESCENTS ABOUT MEDICINES, 2001.

m. Professional standards - PHARMACEUTICAL CARE, 1998. n.

Professional Standards on CODE OF ETHICS FOR PHARMACISTS, 2004.

Pr o f e s s i o n a l s t a n d a r d s o n C O N T I N U I N G PROFESSIONAL DEVELOPMENT, 2002.

Professional Standards on MEDICATION ERRORS ASSOCIATED WITH PRESCRIBED MEDICATION, 1999.

Professional standards on THE ROLE OF THE PHARMACIST IN ENCOURAGING ADHERENCE TO LONG TERM TREATMENTS, 2003.

Standards for QUALITY OF PHARMACY SERVICES (GPP), 1997.

The role of the Pharmacist in Pharmacovigilance, 2006

THE ROLE OF THE PHARMACIST IN THE FIGHT AGAINST THE HIV-AIDS PANDEMIC, a joint declaration between the World Health Organization (WHO) and the International Pharmaceutical Federation (FIP), 1997.

Challenges and Opportunities for Pharmacists in Health Care in India

A DIRECTORY OF ORGANISATIONS ASSOCIATED WITH PHARMACY

A DIRECTORY OF ORGANISATIONS ASSOCIATED WITH PHARMACY Pharmacy Council of India (PCI) Combined Council's Building, Kotla Road, Aiwan-E-Ghalib Marg, New Delhi 110 002 Tel : +91-11-2323 9184; Fax : 2323 9184 E-mail : pci@ndb.vsnl.net.in Website: http://www.pci.nic.in All India Council for Technical Education (AICTE) I.G. Sports Complex, I.P. Estate, New Delhi-110 002 Tel.: +91-11-2339 2563, 73- 75; Fax: 2339 2554 E-mail: admin@aicte.ernet.in Website: http://www.aicte.ernet.in Indian Pharmaceutical Association (IPA) Kalina, Snatacruz (E), Mumbai 400 098 Tel.: +91-22-2667 1072; Telefax: 2667 0744 E-mail: ipacentr@mtnl.net.in Website: http://www.indianpharma.org Association of Pharmaceutical Teachers of India (APTI) Al-Ammen College of Pharmacy, Hosur Road, Opp. Near Lalbagh Main Gate, Bangalore 560 027 Tel.: +91-80-2222 5834; Fax: 2222 5834 E-mail: alameenpc@rediffmail.com Website: http://www.aptiindia.org Indian Pharmacy Graduates' Association (IPGA) C-3/402, Janak Puri, New Delhi 110 058 Tel.: +91-11-2239 3701; Fax: 2562 3355 E-mail: ipgasecretary@yahoo.co.in Website: http://www.ipga.net All India Organization of Chemists and Druggists (AIOCD) 201, Safalya Building, 2nd Floor, Opp. Jaigopal Industrial Estate, Baburao Parulekar Marg, Dadar (W), Mumbai 400 028 Tel.: +91-22-2430 6889; Fax: 2430 6973 E-mail: aiocd@vsnl.net Website: http://www.aiocd.org Organization of Pharmaceutical Producers of India (OPPI) Peninsula Chambers, Ground Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai 400 013 Tel: +91-22-2491 8123 / 2486; Fax: 2491 5168 E-mail: indiaoppi@vsnl.com Website: http://www.indiaoppi.com Indian Drug Manfacturers' Association (IDMA) 102-B, Poonam Chambers, Dr.A.B.Road, Worli, Mumbai - 400 018 Tel: +91-22-2494 4624; Fax: 2495 0723 E-mail: idma@vsnl.com / idma@idma-assn.org http://www.idma-assn.org/home.asp 44

Indian Confederation for Healthcare Accreditation (ICHA) B 7, Moti Bagh (South) New Delhi 110 021 Tel.: +91-11-2688 4335; Telefax: 2467 9272 E-mail: secretariat_icha@indmedica.com http://www.indmedica.com/icha/ All India Drug Control Officers' Confederation (AIDCOC) 28, Rajiv, Bandra-Kurla Complex, Bandra (E), Mumbai 400 051 Tel.: +91-22-2659 1424; Fax: 2655 8860 E-mail: aidcocsd@vsnl.com The Indian Hospital Pharmacist's Association (IHPA) Dept. of Pharmacy, St. Stephens Hospital Tis Hazari, New Delhi 110 054 Tel.: +91-11-2396 602127 (Ext. 590) E-mail: ihpa_upsb@yahoo.com Indian Pharmaceutical Alliance 201, Darvesh Chambers, 743, P.D. Hinduja Road, Khar, Mumbai 400 052 Tel.: +91-22-2600 0632; Fax: 2600 0633 E-mail: dgshah@vision-india.com Indian Pharmaceutical Congress Association (IPCA) Block AB, Basement, Baid Mehta Complex, 16, Anna Salai,Little Mount, Saidapet, Chennai 600 015 Tel.: +91-44-2220 0854; 2230 0992 E-mail: ipcachennai@hotmail.com Federation of Indian Pharmacists Organization (FIPO) S-1, Electric Substation, Panchsheel Marg, Chanakyapuri, New Delhi 110 021 Tel.: +91-11-2688 5405

Confederation of Indian Pharmaceutical Industry C/o Quest Life Sciences P. Ltd. SDF III, MEPZ, Chennai - 600 045 Tel: 044-2262-2727 E-mail: jaishankar@questlifesciences.com

International Organizations:

WHO: www.who.int FIP: www.fip.org IPSF: www.ipsf.org CPA: www.commonwealthpharmacy.org FAPA: http://members.surfshop.net.ph/~fapa.org.ph Pharmaceutical Group of European Union: www.pgeu.eu European Pharmaceutical Students' Association: www.epsa-online.org European Association of Hospital Pharmacists: www.eahponline.org European Society of Clinical Pharmacy: www.escpweb.org

Challenges and Opportunities for Pharmacists in Health Care in India

CONFERENCE PARTICIPANTS LIST

CONFERENCE PARTICIPANTS LIST Dr. P. C. Kesavakutty Nayar President Medical Council of India Pocket- 14, Sector 8 Dwarka Phase -1 New Delhi 110077 Tel: 25367033, 25367035

Dr. Sampada Patvardhan Director, Drug Information Centre Maharashtra State Pharmacy Council E.S.I.S. Hospital Compound L.B.S. Marg, Mulund (W) Mumbai - 400 080 Mobile: +91-9820662080

Mr. C. Gopalakrishna Murty 7-B, Sanjeeva Reddy Nagar Hyderabad 500 038 Mobile: 93910-27750

Dr. R. N. Gupta Department of Pharmacy Birla Institute of Technology Mesra, Ranchi-835 215 Jharkhande

Dr. Nilima Kshirsagar 181 Buena Vista Marg Mumbai 400021 Mobile: +91-9821036616 Mr. Raj Vaidya Vice President, IPA & Pharmacist, Hindu Pharmacy Cunha Rivara Road Panaji Goa 403 001 Mobile: 094220-62286 Mrs. Manjiri S. Gharat Hon.Secretary, CPD, IPA & Ulhasnagar-3 Maharashtra Tel: 0251 2554163 Professor K.G. Revikumar Govt. College of Pharmaceutical Sciences Medical College Calicut 673008, Kerala Mobile: 098473-22144 Dr. Subash Mandal IPA Bengal Branch 22 B, Panchanantola Road Kolkata - 700 029 Mobile: 098301-36291 Dr. N. K. Gurbani Head, Pharmacy Department, Public Health Training Institute 202, Kanwar Nagar JAIPUR - 302 002 Mobile: +91-94145 22696 Prof. K.P.R. Chowdary, Principal AU College of Pharma. Sciences Andhra University Visakhapatnam - 530 003, A. P. Mobile: +91-98966283578 Dr. P. C. Dandiya SB - 37, Bhawani Singh Road JAIPUR (Rajasthan) 302 015 Tel: 0141-270 6219

Professor Matcha Bhaskar Department of Zoology Sri Venkateswara University Tirupathy - 517502, A. P Mobile: 09393620594 Mr. V. Bhava Narayana Editor, PhaRMeD Trade News 3-3-62/A New Gokhale Nagar Ramanthapur Hyderabad 500013 Mobile: +91-98495-51183 Dr. Ramesh Adepu Professor, Dept. Pharmacy Practice JSS College of Pharmacy SS Nagara Mysore 570 015 Mobile: +91 99455 20215 Ms. Bhuma Shrivastava HT Media Ltd 16th Floor, HT House 18-20, Kasturba Gandhi Marg New Delhi 110001 Mobile: 98910-40938 Mr. Meghendra Banerjee Resource Person and Moderator Maternal and Child Health Community WHO-India Country Office Shri Ram Bharatiya Kala Kendra 5th Floor, 1-Copernicus Marg Near Mandi House New Delhi - 110 001 Tel: 011-42595600 Extn.: 23233 Dr. Deeksha Sharma Research Associate Maternal and Child Health Community WHO-India Country Office Shri Ram Bharatiya Kala Kendra 5th Floor, 1-Copernicus Marg Near Mandi House New Delhi - 110 001 Tel: 011-42595600 Ext: 23233 Fax: +91-11-23382252 Challenges and Opportunities for Pharmacists in Health Care in India

CONFERENCE PARTICIPANTS LIST

Mr. S. D. Joag Hon. Secretary Indian Pharmaceutical Association Kalina, Santa Cruz (East) Mumbai 400 098 Mobile: +91-93224-00902 Mr. A. K. Adhikari St. Stephen's Hospital Tis Hazari Delhi - 110 054 Tele: 011-2396 6021, Ext: 590 Mr. Vijay Roy Emmanuel Hospital Association Manager Pharmacy Services 808/902, Deepali Building Nehruplace New Delhi - 110019 Mobile: 99683-00007 Mr. P. P. Sharma LU / 56, Vishakla Enclave Pritam Pura Delhi 110 034 Dr. P. R. Pabrai C-568, Sarita Vihar New Delhi - 110 044 Mobile: +91-98104-95330 Dr. S. N. Sharma V/25 (FF) Eros Garden Surajkund FARIDABAD - 121 009 Phone: 95-129- 225 2322 Mobile: 98100-68443 Mr. Neelkanta Bhoi Central TB Division Room No.523, C-Wing Nirman Bhawan New Delhi-110011 Mob: (0) 9868612287 Dr. Shruti Sehgal Central TB Division Room No.523, C-Wing Nirman Bhawan New Delhi-110011 Mobile: 98102-21855 Mr. S. L. Nasa Registrar Delhi Pharmacy Council S-360, Double Storey, (1st Floor) New Rajinder Nagar New Delhi 110 060 Mob: 93132-94423

Dr. Farhan Jalees Ahmed Dept. of Pharmaceutics Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062 Mobile: 98105-08898 Dr. Sunil K. Jain A P 17-A, CD Block Pitampura New Delhi Tel: 27318094 / 27315125 Dr. N. K. Sethi Senior Advisor Planning Commission Yojana Bhavan, Sansad Marg New Delhi - 110 001 Telefax: 011-2309-6607 Mr. R. Srinivasan Former Health Secretary D-402, Kaveri Alaknanada New Delhi 110 019 Tel: 011-2602 9192 Prof. Ranjit Roy Chaudhury Chair, Inclen Y-85, Hauzkhaas New Delhi - 110 016 Tel: 011-2685-6524 Mr. Sunil Nandraj World Health Organization India 534, “A” Wing, Nirman Bhawan Maulana Azad Road New Delhi 110 011 Tel: 011-23061955, 23062179 Dr. G. P. Mohanta WHO-India Country Office Shri Ram Bharatiya Kala Kendra 5th Floor, 1-Copernicus Marg Near Mandi House New Delhi - 110 001 Tel: 011-42595600 Dr. Devesh Gupta CMO, TB Room No.523, C-Wing Nirman Bhawan New Delhi-110011 Dr. G. S. Sonal, Jt. Director N V B D Control Programme 22, SHAM NATH MARG Delhi - 110054 Tel: +91-11-2396-7745 (Ext. 117)

Challenges and Opportunities for Pharmacists in Health Care in India

CONFERENCE PARTICIPANTS LIST

Mr. T. S. Jaishakar Chairman Confederation of Indian Pharma. Industry Quest Life Sciences P. Ltd. SDF III, MEPZ Chennai - 600 045 Tel: 044-2262-2727 Dr. M. Venkateswarlu Drugs Controller General of India Nirman Bhawan, New Delhi 110 011 Tel: 011-2306-1806 Dr. B. D. Miglani R-566, New Rajinder Nagar New Delhi - 110 060 Mobile: 93138-54344 Mr. Nitin Maniyar 2, Amita, Hingwala Lane Ghatkopar (East) MUMBAI-400077 Tel.: 2513 2488 Mr. J. S. Shinde 201, Safalya Building Opp. Jai Gopal Industrial Estate Baburao Parulekar Marg, Dadar(W) Mumbai - 400 028 Mahrashtra Tel: 022 - 24306889 / 24306874 Mr. Kalhan Bazaz Editor, The Indian Pharmacist Bazaz Publications 507, Ashok Bhawan 93, Nehru Place New Delhi 110019 Tel: 011-2644-3169 Mr. Sameer Dhingra Sr. Lecturer & Chief Incharge Drug Information Centre Lord Shiva College of Pharmacy Near Civil Hospital Sirsa, Haryana Mr. Ajay Pal Gupta Yamuna Chemists 20, Main Market Lodhi Colony New Delhi 110003 Tel: 011 469 1583 Mr. M.S. Arya General Secretary Federation of Indian Pharmacists Organization N-2 Charak Palika Hospital Campus Moti Bagh New Delhi 110021

Dr. Shampa Nag Habitat World, Business Centre India Habitat World Lodhi Road New Delhi 110003 Mobile: 93125-50359 Mr. Satish Shah IPA-SMB, Mumbai E-mail: makvis@rediffmail.com Dr. P. K. Manna Professor of Pharmacy Annamalai University Annamalainagar - 608 002 T.N. Tel: +914144238432 (R), +914144239738 (O) Cell:919443957439,Fax:914144238080 Mr. Kuldeep Kumar Maharshi Dayanand Hospital Medical Store Shahadra, Delhi Mr. T. K. Sachdeva Confederation of Indian Pharma. Industry Quest Life Sciences P. Ltd. SDF III, MEPZ Chennai - 600 045 Tel: 044-2262-2727 Mr. K. K. Singh Indian Pharmacopoeia Commission Laboratory CIPL CAMPUS, SECTOR 23, RAJ NAGAR, GHAZIABAD - 201 002 Dr. S. K. Sikdar Assistant Commissioner Ministry of Health & Family Welfare Room No. 452-A, Nirman Bhawan New Delhi - 110011 Telefax: 011-2306-2427 Mobile: +91-99-114-22499 Ms. Ishita Shampa Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062 Ms. Mahak Humayun Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062 Mr. S. M. Abbas Zaidi Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062 Challenges and Opportunities for Pharmacists in Health Care in India

CONFERENCE PARTICIPANTS LIST

Mr. Abdul Wadood Siddiqui Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062 Mr. Nitin Saigal Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062 Ms. Shalini Dwivedi Faculty of Pharmacy Hamdard University Hamdard Nagar New Delhi 110 062

Mr. Prafull D. Sheth Professional Secretary SEARPharm Forum E-256, Greater Kailash - I New Delhi - 110048 Telefax: 011-4163-2089, 46566411 Mobile: +91-98103-35405 Mr. M. V. Siva Prasada Reddy Executive Secretary SEARPharm Forum E-256, Greater Kailash - I New Delhi - 110048 Telefax: 011-4163-2089, 46566411 Mobile: +91-98718-77117

Challenges and Opportunities for Pharmacists in Health Care in India

SEARPharm Forum

South East Asian FIP-WHO Forum of Pharmaceutical Associations

Promoting Pharmacists Role in WHOâ&#x20AC;&#x2122;s Health Agenda South East Asia Region of WHO SEARPharm Forum is FIP Forum of National Pharmaceutical Organisations in collaboration with WHO Regional Office for South East Asia. Its secretariat is based in Delhi. Our Objective is to encourage and support a dialogue and collaboration among national and regional pharmaceutical associations in the South-East Asia region of WHO and WHO SEARO by: l

Improving health in the South- East Asian region by development and enhancement of pharmacy practice (Good Pharmacy Practice) Encouraging the implementation of pharmacy service and pharmacy practice projects by national pharmaceutical associations

Supporting WHO- policies and goals

Integrating appropriate WHO policies into undergraduate, postgraduate, and continuing education programmes in pharmacy

Formulating policy statements on health issues

Combating the production and distribution of counterfeit medicine and sale of medicine by people who are not qualified.

SEARPharm Forum Secretariat E-256, Greater Kailash -I New Delhi 110 048, INDIA. Telefax: +91-11-4656 6411, 4163 2089 Email: searpharmforum@hotmail.com website: www.searpharmforum.org