The changing roles of pharmacists in community pharmacies: perception of reality in India
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Aim of the review To summarise the state of community pharmacy in India including: the provision of patient care, pharmacy education, the pharmaceutical market, healthcare delivery, community pharmacy services, the professional role of community pharmacists, and future developments. Method Medline, Scirus, and Google Scholar databases and the journals “Indian Journal of Pharmaceutical Sciences” and “Indian Journal of Hospital Pharmacy” were searched up to the end of December 2008. In addition to these, other available sources were used to identify relevant articles. Results India has a fast growing pharmaceutical industry sector and a need for well educated pharmacists. Domestic sale of medicines is estimated to be $5 billion during 2006 and increasing. The supply of medicines to the population is undertaken by privately owned community pharmacies and sometimes also by hospital pharmacies. Community pharmacists are involved only in dispensing medicines. Community pharmacists have an opportunity to improve healthcare of the population, particularly of the disadvantaged section of the society that does not have the resources to visit clinics (both the poor and rural population). However, important barriers to the provision of pharmaceutical care exists, including lack of proper education and training of pharmacists, weak implementation of existing laws, and lack of recognition of the pharmacy as a profession by the other healthcare professionals. Conclusion The healthcare services in community pharmacies, currently insignificant, must undergo reforms to meet the changing needs of modern medicines users. The pharmacist’s role in patient care is expected to grow as professional and educational standards develop. Although pharmacists’ contributions to health care are not yet recognized, there is every reason to be optimistic toward making patient care in community pharmacy setting a success. For this, the educational system for pharmacists has to be adapted.
KeywordsCommunity pharmacy Community pharmacists India Pharmacies Pharmacy Pharmacy education
Impact of findings on practice
The healthcare services in community pharmacies, currently insignificant, must undergo reform
Community pharmacists in India need revamped curriculum to educate and participate in training
Development of educational standards can facilitate patient care role of the pharmacists
India, with its capital New Delhi, is a vast country with a population of 1.028 billion (2001) and a growth rate of 1.93% per year. It is a multicultural society and consists of 28 states and 7 union territories with a total area of 32, 287,263 km2. India accounts for only 2.4% of the world surface and yet, it supports 16.7% of the world population . There are 22 national languages which have been recognized by the constitution of India, with more than 400 mother tongues and approximately 844 dialects. The aggregate expenditure in the healthcare sector in 2004 was 5% of gross domestic products (GDP), with the government responsible for only 17.3% of this expenditure . The annual per capita public health expenditure in 2002 was no more than $4.20 . The life expectancy at birth in 2003 was 63.9 years for men and 66.9 years for women. The Human Development Report (HDR) for 2007/2008 of the United Nations Development Programme (UNDP) measured the human development index for India is 0.619, which gives the country a rank of 128 out of 177 countries . The status of education in the country as calculated by UNESCO education development index is low. India is positioned as 100 out of 121 countries .
Aim of the review
In many countries, including India, community pharmacists are an important part of the overall healthcare delivery services. This paper seeks to sketch the position of community pharmacy in India, and discusses its need and potential for new opportunities and growth. In advance of methods an exploratory study was made to report the background on pharmacy education including pharmacist licensing, pharmaceutical market and healthcare delivery.
Pharmacy education in India
The demand for graduates with a pharmacy education is growing steadily with the simultaneous rapid growth of pharmaceutical industries in India and outsourcing of drug clinical trial and bioequivalence studies of generics from abroad. The pharmacy education in India has three levels: 2 year Diploma in Pharmacy (DPharm), 4 year Bachelor of Pharmacy (BPharm) and 2 year Master of Pharmacy (MPharm) courses. The language for all pharmacy teaching in India is English. The entry point, for both diploma and bachelor programs, is 12 years of formal school education in the science (starting students are approximately 18 years of age). The DPharm involves a minimum of 2 years of study besides practical training of 500 h spread over a period of 3 months in a hospital or community pharmacy.
The BPharm involves 4 years of study which may include 2 months’ practical training in a drug manufacturing unit or hospital pharmacy. The BPharm curriculum is based on industrial pharmacy, and consists of chemistry, pharmacology, and pharmacognosy. There is not much attention for the biomedical, clinical and social sciences.
The Master of Pharmacy (MPharm) degree program requires an additional 2 years of study and involves completing a research project of 1 year in any pharmaceutical discipline, for instance pharmaceutics, pharmacology or pharmacy practice. About 60% of MPharm graduates go to work in drug manufacturing while 20% opt for overseas assignments mainly in the United States, and 20% go to academic and/or public sector.
The Pharmacy Council of India (PCI),  a statutory body established by an act of parliament (The Pharmacy Act 1948),  has sole responsibility for the regulation of practice of pharmacy. The PCI makes regulations prescribing the minimum standard of education required for qualification as a pharmacist. It dictates the curriculum norms, among others for institutions and takes care of the registration of pharmacists. The All India Council for Technical Education (AICTE)  is primarily responsible for planning, formulating and maintaining of norms and standards, quality assurance through accreditation and funding in priority sectors of technical education which also include pharmacy.
In March 2008, the Indian Health Ministry has approved the 6-year PharmD course, to be regulated by the PCI. Nonetheless, questions have been raised regarding the utilization of this course for international status and as a tool to serve the US pharmacists workforce shortage . Another opinion reported  that existing postgraduates with an M.Pharm in clinical pharmacy cannot opt to work as a clinical pharmacist in Indian hospitals, as the value of clinical pharmacy services is not recognized, and current regulatory framework does not yet recognize the need for clinical pharmacist at the national level.
The minimum qualification for registration as a pharmacist is a DPharm from an institution approved by the Pharmacy Council of India. These registered pharmacists primarily work in hospitals or community pharmacies. Unlike other countries, the current regulations do not require registered pharmacists to periodically to update their knowledge and skills. In addition, pharmacists in all states of India do not have any laid down norms or competencies and quality services.
The number of registered pharmacists in India is estimated to be 5.6 per 10,000 persons or 1 pharmacist per 1,785 persons: the world average is around 1 pharmacist per 2,941 persons . Although the ratio of pharmacists to population compares favorably with world average, the real number of practicing pharmacists is probably lower due migration and early retirement. In 2000, the real ratio of pharmacies to population was 1:2049 in Tamilnadu, 1:3684 in Uttar Pradesh and 1:4082 in Karnataka . Moreover this ratio is relatively high in urban areas and cities due to liberal granting of Chemists and Druggists licenses but extremely low in rural areas and almost nil in remote areas.
Indian pharmaceutical market
The pharmaceutical industry is one of the fastest growing industries in India; pharmaceutical production is 4th largest in volumes (about 8% of global trade) and 13th largest in health value (about 1.3% of global trade) . India exports about 20% of total pharmaceutical production and 33.7% of total exports to industrialized nations . Although 20,000 pharmaceutical manufacturers are registered for the production of drugs and pharmaceuticals in India, only 250 of these are registered under the Factories Act 1948. These 250 units constitute the core of the industry and account for 70% of country’s total output of branded generics .
Healthcare delivery and medicine supply in India
In India there are three types of institutions that provide health care to patients and supply medications. First, there are state-run primary health centers for ambulatory patients and state-run hospitals in subdivision towns and districts for hospitalized patients. In most hospitals, the medicines dispensing counter facilities are under the charge of a medical officer of a hospital . The status is the same in primary health centers and sub-centers as in the state-run hospitals, but in general, these primary centers are the cornerstone of the rural health care system. A vast majority of the lower income groups uses these state services. Second, privately owned multi-specialty well established hospitals provide care to more affluent people. Patients must pay for all medications. Finally, numerous privately owned independent clinics provide health care, counseling (mostly by doctors) and medications to ambulatory patients, which all need to be paid by the patient.
The expenditure on health care in India is borne mainly by the individual directly. Indian public healthcare expenditures are low, around 0.9% of GDP in the past decade. India ranks among the top 20 countries, in terms of private expenditure on health, at around 4.5% of GDP . The private expenditure consists of out-of-pocket expenses only. The private sector is dominant with 50% of the population seeking institutional care and around 60-70% seeking ambulatory care from private facilities.
Government employment is the main source of reimbursement for medical expenses. The existing government schemes are mandatory for government employees with explicit benefits in return for payment and voluntary private schemes offered by both public and private agencies. Health insurance is very limited covering currently about 10% of the total population . Medical insurance scheme (mediclaim) policies, a product of the public sector General Insurance Corporation, are utilized by a small part of urban population, specifically in the high income group .
A literature review was carried out using the keyword search ‘Indian community pharmacy’, ‘Indian community pharmacists’, ‘Role of community pharmacists’ and ‘views on community pharmacists’ in the Medline, Scirus, and Google Scholar databases up to the end of December 2008. A direct search was made in primary sources, specifically in the journals “Indian Journal of Pharmaceutical Sciences” and “Indian Journal of Hospital Pharmacy”. In addition to these, other available sources were used to identify relevant articles.
We present the results as a narrative description of the various aspects of community pharmacy in Indian context.
Community pharmacy services
Licensed retail outlet of drugs (community pharmacy)
Licensees who do not engage the services of a registered pharmacist
Chemists and Druggists
Licensees who employ the services of a registered pharmacist to dispense readymade manufactured medicines but who do not maintain a ‘Pharmacy’ for compounding against prescriptions
Licensees who employ the services of a registered pharmacist and maintain a ‘Pharmacy’ for compounding against prescriptions
Specified minimum area and equipment
Compounding of prescription medicines should be done by a pharmacist
Sale of prescription medicines should be done under direct supervision of pharmacist
Sale of prescription medicine should be recorded in a prescription register, and in a cash or a credit memo for other medicines
No prescription medicines should be sold without a prescription
Prescription medicines belonging to schedule X need duplicate prescription
Supervisor of a community pharmacy
Registered pharmacist whose presence is legally required
People who actually manage a pharmacy when no pharmacist is present.
Both community pharmacist (i.e. registered pharmacist) and drug retailers (i.e. not registered pharmacists) as both play an important and equal role in the pharmacies
Anyone can own a pharmacy, including physicians or chain-store companies. A large majority of pharmacies are owned by non-pharmacists and the proportion of chain-store pharmacies has risen significantly in the last decade due to the entry of major corporate sector in retail sale of drugs.
Community pharmacies and pharmacists
The staff of a pharmacy typically consists of one retail pharmacist (a pharmacist or a drug retailer) and a few assistants. A majority of pharmacy owners, who are not pharmacists, hire pharmacists on a part time basis and as a result pharmacists are available sometimes to dispense medications. The monthly salary of pharmacists who work 48 h a week is usually between $100 and $200, and pharmacists on part-time basis receive on an average $40 a month. Due to this low salary, many community pharmacists have to take on other jobs. The drug retailers’ margin is fixed at 16% for the price controlled scheduled drugs as per the Drugs (Prices Control) Order 1995 . For non-scheduled formulations the companies are at liberty to decide the margin. The prevailing normal trade margin is 20% for retailers and 10% for wholesalers. There is no provision in the law for collecting any professional fee by the pharmacists. Pharmacy owners generate revenue based on a markup on medicines without any dispensing fee. When there are many pharmacies in close proximity to each other, they compete with each other to offer more discounts. Many pharmacies are able to sell medicines with large discounts for products from a non reputed small company.
Professional role of community pharmacists
Dispensing of prescriptions is the primary duty of community pharmacists. The Drugs and Cosmetics Act describes dispensing as follows: “dispensing and compounding against a prescription shall be effected only by or under personal supervision of pharmacist. The supply of a drug should be recorded with particulars such as prescriber’s name, patient’s name, name and quantity of the drug and its expiry date among others. The prescription must not be dispensed more than once unless the prescriber has stated thereon that it may be dispensed more than once. Duplicate prescription is needed to dispense opium and narcotics. Physicians are allowed to purchase, store and dispense medicines for their own patients” . Compounding is done in a very few community pharmacies. The dispensing activity, for most pharmacies, mainly consists of sales of the medicines with or without prescription, and is mostly performed by non pharmacists. The dispensing is almost instantaneous and therefore a patient or a consumer receives a medicine within minutes, if in stock. Retail pharmacists count and pack tablets and capsules, and distribute these to consumers without counseling. In most chain-store pharmacies, over-the-counter sales are undertaken by pharmacists and they supply prescription medicines against a prescription. The patient, due to financial constraints, sometimes ask for a day’s supply—that means blister packs are cut, and often dispensed with no identifying marks or label. The drug retailers dispense tablets or capsules from bulk container in a paper envelope without proper labelling and written instruction. In India, physicians always prescribe medicines by the brand name (over 60,000 branded formulations) rather than the generic drug name. Patients expect exactly the medicine that has been prescribed.
Pharmacy practice based research
There have been reports of research being conducted on community pharmacy practice [22, 23, 24]. Only a few studies have focused specifically on the role of community pharmacists’ behavior in medications counseling, including disease control and management issues [25, 26]. A survey on pharmacists’ knowledge has affirmed that 95% of the pharmacists were not aware of the existence of tuberculosis control program in India . Another similar study of medicine dispensing behavior reiterated this trend: the majority of individuals presenting with asthma symptoms did not receive appropriate advice or medications from pharmacy attendants . A survey conducted with healthcare professionals in an Indian state revealed that 99% of the patients and doctors do not trust community pharmacists on health and prescription related issues  and this poor social status, pharmacists agree, is due their inability to take up counseling .
In this review, the analysis of literature and limited data allowed us to provide a snapshot of the current position of Indian community pharmacy. This enables us to look at the following facets, along with results, governing community pharmacy:
Status of community pharmacists
In 2002, the position on the professional role of the pharmacist received a setback when a Government committee suggested that there is no requirement for pharmacists in distribution and sale of drugs . The Indian Public Health Standards recently formulated under the National Rural Health Mission do not put as much emphasis on the role of pharmacists as on other categories of personnel such as nurses and laboratory technicians . Most drugs are dispensed illegally without prescription by drug sellers with little or no knowledge of laws governing sale of medicines . The potential contributions of Indian community pharmacist toward the provisions of pharmaceutical services have only been recently recognized resulting in an all round focus on community pharmacy practice [33, 34, 35, 36]. There is knowledgeable information in the Indian journals [37, 38, 39, 40] and in an international journal  dealing with various aspects of Indian community pharmacy. These studies focused on the present situation with regard to community pharmacy in India, future roles, opportunities and responsibilities for pharmacists to assuming patient centered role.
Opportunities and challenges
Like in other countries, community pharmacy practice in India also offers endless options to interact with patients and help them to achieve good outcomes from pharmacotherapy, including a better quality of life. Opportunities for pharmacy practice are based on three aspects of medicine use that are of concern to the patient: cost, safety and access. Improving access to medicines, ensuring proper procurement, advising on treatment of common ailments, dispensing prescriptions with proper advice, and delivering pharmaceutical care, all offer huge opportunities for community pharmacists in India.
assessing expectations of health professionals, community pharmacists and patients; revising the curriculum for community pharmacists to ensure its clinical and community orientation;
investing in improving the quality of pharmaceutical education and training;
overhauling drug regulation and implementation;
developing guidelines for competence in pre-service education and continuing education for in-service training;
developing norms for pharmacy assistants; and
developing and promoting benchmarks to ensure standards of ethical and professional practice.
The government of India has recently proposed to implement Good Pharmacy Practice  and a system of accreditation in drug retail outlets in accordance with Good Pharmacy Practice (GPP) guidelines drafted by the Indian Pharmaceutical Association . The project is planned to be implemented on a pilot scale initially with guidelines for space, environment, display of drugs, patient counseling, documentation among others. This Government move, with professional support, can play a decisive role in changing the face of Indian community pharmacy. In the 1990s, the Pharmacy Council of India has realized the need to upgrade the minimum qualification for registration from DPharm to BPharm and proposed amendments in the Pharmacy Act. In addition, it has also proposed inclusion of pharmacy practice regulations in the Pharmacy Act. The 6-year Pharm D program has begun from the academic year 2008; the major highlight of the course is practical training in practice sites that include pharmacists’ participation in monitoring prescription, running drug information centres, contributing to drugs and therapeutic committees.
All of these developments aim to uplift the standard of pharmacy practice with a focus on community pharmacy’s contribution to healthcare. Further, there is a need to interlink pharmacy institutions, practice and regulation.
In many countries including India, community pharmacists are the most accessible of all health care workers and as such play a key role of health care services at all levels . Pharmacists as members of the health care team should play a role in ensuring affordable access to quality essential medicines, dissemination of appropriate information to patients, the general public and other health professionals, and participating in health promotion and health education programs. This review showed that currently very little of this is happening in India.
Although in India, as in other south Asian countries, patient care in community pharmacies is in its infancy, professional education and legislation are undergoing reforms to meet changing needs of modern medicine procurement, dispensing and use. Despite a few initiatives, this study suggests that community pharmacy practice still has many barriers to overcome. But it seems that pharmacists in India are not yet educated for their future roles. Pharmacy in the world is changing towards patient/pharmaceutical care, but it seems that in India the profession, professional organisations, legislators and universities/colleges do not yet recognise this important change. This is partially due to the facts that practising pharmacists seem to be ‘invisible’, partially due to the legislation and partially due to the fact that pharmacy schools also educate a totally different type of pharmacists for industry; the latter being probably the most financially rewarding.
We are grateful to two anonymous referees for critical comments on an earlier version of this paper. Thanks are also due to the Department of Pharmacy, Annamalai University for providing all possible assistances for this paper.
Conflict of interest
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