Pharmacists are the most skilled personnel to deals with the innovation, research and development, manufacturing, storing, dispensing of medicines along with required information’s regarding medicines and it’s usage wherever applicable. To be able to perform all of these responsibilities a pharmacist must have appropriate knowledge on pharmaceutics, pharmacology, pharmacotherapeutic, toxicology information’s of medicines as well as to detailing of their usage, side effects, adverse effects, drug interactions, warnings, precautions to the relevant healthcare professionals and more importantly to the patients. In my previous articles “Prospects and Importance of Hospital, Clinical and Community Pharmacy Practice in Bangladesh” and “An overview on the Hospital Pharmacy Set-up with the Roles & Responsibilities of Hospital Pharmacist” I have mentioned in details of the importance and requirements of Pharmacists in the healthcare system of a country. In this particular article I am actually going to details on the scopes of Pharmacists in the public healthcare system of a country and then I will try to benchmark these scopes with the current public healthcare system of Bangladesh to see how more opportunities can be created for the Pharmacists in the public sector.
For us to have a better understanding of these scopes we must first of all have an in-depth understanding of overall public healthcare system of a country. For the sake of a minimum appropriate structure I am going to highlight structures from the development or developed countries that are of course doing better in this sector comparing Bangladesh. First of all let us then understand public healthcare system of a country in brief.
How Does Public Healthcare System Works:
Health is one of the five basic needs of life for any individual in this world and as a basic requirement the overall responsibility goes to the government of any country to ensure that each and every citizen of the country has an easy access to the healthcare service in the public sector with minimum cost expenses or in some instances completely for free. Developed countries manage to provide such service of their own where else development and least developed countries seek help and/or donations, technical assistances from non-government organizations (NGO’s), World Health Organization (WHO), Different UN agencies and other developed countries as well especially for primary healthcare services. Basically government runs these services under their ministry of health which has a structure in place to determine the roles and responsibilities of different healthcare service providers within different departments and units starting from the top level of government to the downstream of healthcare centers. Basically the structure is full of different health professionals along with other administrative personnel. Pharmacists have a huge scope within this structure to contribute which will ensure all the pharmaceutical aspects and requirements have been established to ensure quality healthcare service in every point of the system. Usually state head is the supreme authority of the entire system that coordinates through the minister of health but ministry secretary is actually the chief executive and accountable officer to ensure that the entire system is functioning well.
Below model structure can give us an idea how the structure should be to meet the entire requirement to establish an effective healthcare system in the public sector. Remember this structure is also responsible for the regulatory and compliance in the private sector but our concentration is public sector this time.
Figure 1: High Level Structure of Ministry of Health
This structure is very high level and basic, a further break down at department level is shown below to have a clear idea of these above various departments’ roles and responsibilities towards the public healthcare system along with the scopes for pharmacists in the system. Wherever there is green color indicates scope for the pharmacists. A Brief description on their scopes also has been elaborated under each area.
Department of Pharmaceutical Services:
Basically this is the department that represents pharmacists at the ministry level and provides required services within its policy and mandates. This department also works along with other departments in the ministry and stakeholders from home and abroad whenever there is a need arises. Below is a basic structure of such department along with a brief description of scopes for the pharmacists under different areas.
Figure 2: Department of Pharmaceutical Service, MoH (Green color indicates area of scope)
Department of Health Service:
This is the department responsible for the direct provision of health care services at public health facilities and also indirectly to ensure quality health service at private settings. Health service provides regulatory assistance & guidelines in both public & private sector regarding health care provision and private practice licensing. Green colors highlighting scopes for the pharmacists in different settings under health service.
Figure 3: Department of Health Service, MoH (Green color indicates area of scope)
Department of Health Policy, Planning, Monitoring & Evaluation:
This department deals with the high level policies and planning of health related strategies at national level with its proper implementation. Monitoring and evaluation of existing health sector against the policy is also their responsibilities. Though pharmacists doesn’t have a direct role to play but pharmacists from the department of pharmaceutical services are always involved during any health related policy drafting and planning. Monitoring and Evaluation (M&E) is a authentic source of morbidity data information regarding diseases pattern in the country and Logistics Management Information System (LMIS) at central medical stores (CMS) are always depended on them for such morbidity data to make firm decision during national forecast and quantification of certain pharmaceuticals for a particular period of time.
Department of Regulatory & Health Inspectorate:
This department deals with all kinds of regulatory aspects except drug regulation that required by the overall healthcare system in both public and private sector. Drug related regulation is deals by Drug Regulatory Administration under department of pharmaceutical services. As drug regulation and health regulation has impact to each other it is always very important to engage pharmacists especially from drug regulatory administration during regulatory processes starting from the drafting to inspection at health facilities whenever necessary. Health care premises licensing and approval are given by this department.
Health Professionals practicing license are also issued by this department through a council run by selected board members for different cadres e.g. Doctors, Pharmacists, Nurses etc. Pharmacists have a scope in such professional council to deals with pharmacist’s registration and licensing as a pharmacy board member who is directly appointed by the minister of health for a particular time of period.
Figure 4: Department of Regulatory & Health Inspectorate (Green color indicates area of scope)
Department of Public Health:
This department is the back bone of national public health of the country. Usually this department deals with certain selective programs and campaigns depending on the country’s epidemiological, geographical disease pattern and needs which has a health related impact on the majority proportion of the nation. Some public health issues are very common within the whole world, some are common within the same continent and some are very common within same region. That’s why it is very important to have direct partnerships with international NGO’s and organizations like WHO, UNFPA, UNHCR etc to fight these common public health issues in the country. Some very common public health issues around the world are HIV/AIDS, Malaria, TB, Maternal Health, Vaccination, Sexual Reproductive Health (SRH), Cervical Cancer, Breast Cancer, Polio, Leprosy, Hypertension, Diabetes etc. To be able to achieve desire goals on such related issues need a proper team work from all kinds of health professionals including pharmacists. Pharmacists play a very important role especially for chronic disease management by providing right information and counseling to the patient to get maximum outcome of the treatment. Beside that pharmacists with a public health post graduation does better than other public health professionals due to their immense knowledge on medicines and its proper use. Department of public health get direct support from pharmacists from different health care settings and also recruit some pharmacists especially with public health skills to forecast and quantify national demand to tackle such issues and also to counsel public on health matters especially on the use of medications properly. Public health department is the main source of morbidity data regarding public health issues which can be used by other entities like CMS to forecast and quantify national demand for a particular period of time to maintain smooth national supply chain of medicines and related commodities round the year in the whole country.
Beside these public health department also deals with the sudden onset of epidemic or pandemic like H1N1 Virus, Swine Flu, Ebola, Zika Virus etc. In such cases national committee being formed along with pharmacists from different settings to make firm decision to tackle such situations. Recent pandemic of Ebola in West Africa shows how pharmacists can contribute directly to fight such situations; most of the retail, community pharmacies was one the main point of diagnosis at very early stage which had saved life through early hospitalization and care. Remember most of the healthy patients always go to pharmacies to get their refill and any new implications or complains are being identified by pharmacists which helps for early diagnosis of any kind of disease. Below structure shows the scopes of pharmacist in the public health management;
Figure 5: Department of Public Health (Green color indicates area of scope)
Department of Clinical Services:
Basically most of the developing and under developed countries put pharmaceutical services within clinical services but ideally pharmaceutical service is a broad area which involves with so many aspects of the overall health care system that’s why I have shown it here as separated which is widely followed by most of the developed and some few developing countries. Other than this clinical services department is involves with all kinds of allied care in health system e.g. nursing service, radiology service, biomedical service, laboratory service, clinical psychology, nutrition and diet, physiotherapy service, occupational health & safety etc. Pharmacists play a role here by keeping smooth supply of pharmaceuticals and relevant commodities within the health facilities to maintain standard care as expected.
Department of Health sector Relations and Partnerships:
This is the department which maintains international and local relationships with health sector NGO’s, WHO & other UN agencies and relevant stakeholders that work for the development of health system in a country. Health is a common issue around the world and is a one of the five basic needs for human life. That is why it is very much important and needful that a country to should work hand to hand with other countries and global organizations to strengthen health care system as well as to contribute in the international arena through providing trainings, knowledge’s, experience, expertise, donations, man power etc. Pharmacists plays a role here by collaborating with these kinds of partners and ensure that global standard has been maintains within the national pharmaceutical care as well contribute to the international arena. Department of Pharmaceutical service works directly with this department for local and international relations with various partners working in health sector.
Figure 6: Department of Health sector Relations and Partnerships (Green color indicates area of scope)
Department of Research and Development:
This department deals with all kinds of research and development process that held in the health sector of a country. Any research that needs to be conducted shall get approval before implementation. Various pharmaceutical researches that involves evaluation of current pharmaceutical care, review of drug utilization review, rational uses of medicines etc can be conducted throughout the whole country or in a particular health facility wherever applicable. Pharmacists are the overall lead person in such kinds of research and also to work on the outcomes so that necessary development can take place with proper recommendations. Besides that pharmacists along with the local and international NGO’s, academic institutions may also conduct various research on specific pharmaceutical components or commodities, supply chain processes, logistics information systems to gather quality data which may help in the decision making for national supply chain policy, forecast to strengthen the supply chain system.
Figure 7: Department of Research and Development (Green color indicates area of scope)
Department of Corporate Services:
This department deals with the administration, human resource, finance & accounts, IT etc to support ministry to perform its mandate without interruption. Usually pharmacist has a role here to assist human resource to develop effective job descriptions (JED’s) of pharmacists in various settings as well as to get involves in the interview board during recruitment of pharmacists in the public healthcare system. Pharmacists also play a very important role during budget planning especially for overall pharmaceutical care for the whole country along with finance unit. IT is a core area which has direct relation with pharmaceutical supply chain, warehouse and distribution process, pharmacists has a important role to play here by providing required demand necessary and assistance to come up with a suitable IT system for a smooth operation for the whole country. As an end user of IT systems for pharmaceutical care, pharmacists are responsible for continuous maintenance of systems by direct support from IT.
Figure 8: Department of Corporate Services (Green color indicates area of scopes)
Public healthcare system of a country is the back bone of overall health component. Majority population and their health status depend on the quality and service of public healthcare system. As healthcare system comprises of various healthcare professionals including vital role of pharmacists, it is very important to define and engage pharmacists in the different areas of the system. Still so many countries in the world especially developing and under developed where pharmacists are not involved in the direct patient care both in public and private sector has a serious impact on the quality of healthcare service as pharmacists are the right person to deal with any kind of medicines & related health commodities starting from innovation, manufacturing, warehousing, distribution and dispensing to the patient. Pharmacists are the most skilled person to detail on the usage of medicines and related commodities along with their other necessary information on mechanism of action, pharmacokinetics, pharmacodynamics, side effects, adverse effects, warnings, dosage and administrations etc. It’s also very important to engage pharmacists in the drug selection process for a country along with the necessary treatment guidelines and protocols to ensure rational use of medicines in the public healthcare system. Regulatory aspects for medicines and related commodities is also a very vital component for the overall healthcare system of a country and pharmacists are the legal person to deals with all kinds of regulatory policy, guidelines, drug registrations, inspections of pharmaceutical premises to ensure quality standard medicines are available throughout the whole system as well as to control counterfeit medicines in the country. Pharmacists are the right personnel to work hand to hand with other relevant health professionals in the system to assist in decision making for prescribing of medicines & treatment management, dose calculation, screening prescriptions for possible prescribing error, transcribing error, dispensing error, patient counseling to reduce risk and increase best outcomes of treatment as well as to ensure rational use of medicines, medicines utilization review, national formulary, national treatment guidelines etc.
One of the key components in the public healthcare system is the smooth supply chain of medicines and related commodities in the country and to be able to ensure that it’s very important to forecast country’s need and plan necessary budget on time. Pharmacists are the right person to conduct annual forecast and quantification using quality dispensed to user data, consumption data, issue data, morbidity data through logistics management information system (LMIS) throughout the country. As country’s disease conditions and trends has a direct impact on the nature of consumption it’s crucial to analyze morbidity data and disease pattern of the country which pharmacists can lead along with other relevant professionals like prescribers, public health specialists, logisticians and other stakeholders from local and international health organizations, NGO’s etc. Not only supply chain management but also maintain proper storage conditions and inventory management of medicines throughout the country is a vital role of pharmacists to ensure accuracy and efficacy of medicines and related commodities till end use. As medicines and related commodities has a defined shelf life within which it shall be used, there is a high risk of expiring medicines which can cause unintended cost of the government as well as destruction of expired medicines has also a expenditure value. Though it is very difficult to avoid expires of pharmaceuticals due to several factors like disease conditions, sudden drop of consumption, over forecast but still it’s possible to reduce expiry rate through several initiatives and actions throughout the system. WHO standard expiry rate at any given time is 3% of overall inventory and pharmacist can play a very vital role here to remain with such standard though expiry management. How it can be done I have explained in another article regarding the role of pharmacists in the hospital and community pharmacy practice in “Pharmabook”- a pharmaceutical blog by me for continuing pharmacy education. Medicines are poison and have serious impact on the environment during destruction of expired medicines and a related commodity, that’s why it is very important to engage pharmacists to ensure expired medicines are properly destroyed maintaining local and international policy and guidelines as per WHO recommendations to control environmental pollution.
In this short summary I tried to explain how important it is to engage pharmacists in the public healthcare system of a country to ensure quality health service maintained throughout the system and reduced risk associated with the management of pharmaceuticals & related commodities. Engaging right people in right areas of healthcare system will also ensure rational employment of different healthcare professionals in the country. That’s why it’s important to understand need of pharmacists in the public healthcare system and then come up with national policies and regulations which will ensure areas of scopes for pharmacists has been defined by the government of a country. Especially in our country Bangladesh still pharmacists has not been engaged properly in the relevant areas of public healthcare system which is a serious threat for the overall health status of the country. Also day by day number of pharmacists graduating in quite good numbers from different institutions in the country and industrial Pharma sector is almost saturated which is an alert for the government to have more unemployment rate especially for pharmacists that can have a negative effect on the national economy and GDP growth. In a nut shell I would like to mention few risks factor below that may already exists or happen in future due to lack of pharmacists in the public healthcare system of country;
Risk Factors associated in the public healthcare system due to lack of pharmacists:
- Increased number of substandard and/or counterfeit medicines & related commodities due to lack of regulatory enforcement
- Less and/or no control on prescribing pattern due to lack of proper medicine act & policies, national essential medicine list, national formulary, national treatment guideline etc
- Over and/or under forecast of commodities which can cost extra money and unstable supply chain with frequent stock out
- Increased number of damages due to lack of improper storage conditions
- Increased number of irrational prescriptions
- Increased number of prescribing, transcribing and dispensing error
- Increased number of adverse drug reactions (ADR’s)
- Increased number of death due to ADRs, improper administration of medicines, substandard or counterfeit medicines
- Increased number of antibiotic resistance due to irrational prescribing of antibiotics, improper use by the patients
- Increased treatment cost for a particular disease condition due to these above mentioned factors
- Increased pharmaceutical budget cost due to above factors
- Increased pilferage rate and abuse of medicines due to lack of proper inventory management and control
- Increased expiry rate that causes unintended financial loss to the government
- Increased cost associated with destruction of expires due to high expiry rate
- Increased environmental pollution due to improper destruction of pharmaceuticals
- Increased unemployment rate of pharmacists due to lack of scopes in the public sector
- Increased mortality rate and decreased other health related indicators of the country
Hope these above risks factors are enough to prove that why we must engage pharmacists in the public healthcare system of a country and I believe this article will help us to understand scopes for pharmacists how important it is to engage them in the national healthcare system.I wish if Bangladesh government take these issues in considerations and have some quick intervention to resolve existing gaps in the public healthcare systems as soon as possible which will help to achieve a healthy nation through quality healthcare delivery as well as employment of pharmacists in the country.
Mohammed Younus, R.Ph.
Ministry of Health
Republic of Botswana