Community pharmacy practice in India: past, present and future.

Today, community pharmacists play an important role in any country as they take responsibility for patient's medicine related needs for access to healthcare. However, in India only the supply of medicines remains the core activity of the community pharmacist. Most community pharmacists in the country still hardly offer patient-oriented service. The role of the pharmacists in the community, and with it their medicine management, may change in the wake of the rapid growth of domestic medicine output and national healthcare expenditure. This article seeks to discuss the genesis of Indian community pharmacy, the majority of which are privately owned, and sketches its education, training and future prospects.

Introduction

India is a developing nation that is home to over 1.1 billion people. Rapidly growing, the country accounts for 2.4% of the world’s surface but is home to 16.7% of the world’s population [1]. Throughout its 28 states and 7 union territories, 22 national languages have been recognized and upwards of 400 mother tongues and 800 different dialects is in common use. The genesis of community pharmacy practice in India can be traced back to British India when allopathic drugs were introduced and were made available through drug stores towards the end of the nineteenth century. During the colonial period, the pharmacy vocation remained business oriented and those trained to sell drugs were called drug sellers or sometimes dispensers. The pharmacy practice scenario and especially community pharmacy practice during pre‐independence era was highly unregulated and there were no restrictions on the practice of pharmacy in India. The practice of prescribing and dispensing was normally a fucntion performed by doctors. In addition, most doctors trained their clinic assistants to dispense medicines and assist in the compounding of medicinal preparations. The assistants were popularly knownas "compounders”, whose status, functions and duties were ill defined and improperly understood.

Who are Community Pharmacists?

A community pharmacy, often referred to as retail pharmacy or retail drug outlets, is places where medicines are stored and dispensed, supplied or sold. The general population usually calls community pharmacies "medical stores." Pharmacists working in the community practice setting are either diploma pharmacists or graduate pharmacists with B. Pharm degrees. Throughout this paper the word “Pharmacist” has been used to describe both types. Pharmacists are registered under the clause (i) and section (ii) of the Pharmacy Act [2] 1948, and their presence is legally required during the dispensing and selling of medicines according to Rule 65(15) of the Drugs and Cosmetics Rules [3] 1945.

Pharmacy Regulation

After the enforcement of provisions of the Pharmacy Act 1948, pharmacists working in India must have a pharmacist registration certificate issued by the state in which they wish to practice. To obtain a registration certificate, the prospective pharmacist must acquire the minimum diploma (D. Pharm.) from a pharmacy institute that is recognized by the Pharmacy Council of India [4] (PCI). Both D. Pharm. and B. Pharm. holders are allowed to practice in any sector of pharmacy. However, the B. Pharm. course was designed in such a way as to satisfy the requiremenst of the pharmaceutical industry, drug control laboratories and drug regulatory bodies. The D. Pharm. course was developed to satisfy the requirements of hospitals and medical stores. This is supported by the fact that diploma pharmacists are not considered appropriate for positions within the pharmaceutical industry and B. Pharm. (graduate) pharmacists are not in significant numbers in community pharmacies and in other practice settings, probably due to lower salary as compared with industrial positions.

The community pharmacists who actually manage pharmacies today are mostly D. Pharm. holders (diploma pharmacists). The D. Pharm. (Table 1) involves a minimum of 2 years of study besides practical training of 500 hours spread over a period of 3 months in a hospital or community pharmacy. Once qualified, most of these pharmacists receive little additional training and there is no exposure to up‐to‐date information. However, prior to 1984, persons without any pharmacy educational qualifications were able to register their names as pharmacists in the First Register of the pharmacy act, as long as they had five years of experience in the compounding and dispensing of drugs in a hospital or a clinic. However, section 32B provisions (related to displaced persons or repatriates) of the pharmacy act had been misused during 1980s and a large number of persons, without any recognized education or training, were reported to have registered their names as pharmacists (called non‐ diploma pharmacists). Many of these people, who did not succeed in placement in government hospitals, are currently working as community pharmacists in the private community pharmacies.

On paper, every community pharmacy must have a diploma pharmacist or B. Pharm pharmacist onsite. In practice, few pharmacists are onsite in community pharmacies and the dispensing is undertaken by the owner of pharmacy, a relative in case of the pharmacy being owned by a pharmacist, or other supporting person (assistant or attendant) with knowledge of selling medicines. A study conducted in 2005 found about 50% of thepharmacies function without pharmacists [5]. This study further observed that the majority of patients (70‐80%) seek advice about sexually transmitted diseases, menstrual disorders, contraceptive methods and minor illnesses from community pharmacists. A majority of pharmacy owners, who are not pharmacists, hire pharmacists on a token basis and as a result, pharmacists are never available to dispense medications. Pharmacists are underpaid in retail outlets owned by people having no health related education or training. There are relatively few studies articulating the situation with community pharmacy services in India. One study reported that pharmacists lack proper training to undertake patient counseling [6]. Two studies suggest that community pharmacy practice in India is only limited to the supply of “ready to dispense drug packages” [7, 8].

Image of Community Pharmacists

The public perception of community pharmacy and the pharmacist is very weak. The general population considers community pharmacists as drug traders and obviously not better than the general store owners. Consumers and patients consider a visit to the medical store to purchase drugs in much same way they consider a visit to a grocery to buy food items. The educated people consider the retail pharmacist as a person who has acquired a drug licence to supply the medicines or a grocer who deals in medicines. They think anyone in our country can open a stationary shop and a medical store (i.e. pharmacy) also.

The pharmacists are portrayed as poor compounders, who are assistants to doctors in mainstream films and dramas .This is not surprising because the national health policy 2002 [9], while declaring current levels of health care professionals, maintain a stoic silence about the pharmacists. The Indian Public Health Standards formulated recently under the National Rural Health Mission (NRHM) does not place much emphasis on the role of pharmacists as compared to other categories of personnel such as nurses and laboratory technicians. In the recently accepted union government’s sixth pay commission report, pharmacists have been placed in the lowest band and structure along with other non technical persons [10]. During the end of the twentieth century when the first author was a student, many hostel mates of engineering disciplines wanted to know, “What is the difference between the sales of medicines and the sale of common consumer goods?” They did not appear to be convinced by the explanation about the important role of pharmacists in making the right medicaments available to patients. The situation today has not changed.

Community Pharmacy and Availability of Medicines

The community (retail) pharmacy sector is the prime source of medicines for both ambulatory and hospitalized patients (minimum stock in many hospitals). The medicines manufactured by pharmaceutical companies are made available to the community pharmacy level through their distributor or clearing and forwarding agent. In many developing countries, private community pharmacies are often seen as a source of inexpensive medical care [11]. India is of no exception. Private pharmacies are often the first and only source of health care for a majority of patients in developing countries [12]. During the early period the diploma courses were mostly run by Government medical colleges. Since the 1980’s there has been phenomenal growth of private institutions offering D. Pharm. course s. However, most of these self‐ financing institutions that provide education in pharmacy are away from practice environment resulting in diploma pharmacists lacking the skills needed for the community practice setting.

Community pharmacy in India ‐ the way forward

According to unofficial estimates, there are over 600,000 licensed retail outlets for medicines sale and supply.

In India, consumers' (or patients) expectations from community pharmacists are that the medication should be effective, safe, and affordable. Other expectations from Indian pharmacists would be to dispense the drugs according to the rules with proper advice on how and when the medicines should be taken, and what to do in the case of adverse drug reactions as well as the provision of advice on common ailments. However, it is an undeniable fact that the community pharmacist has failed to provide all these patient oriented services. Perhaps our curriculum of D. Pharm., revised way back in 1991 has failed to change its focus from the preparative and compounding pharmacy towards a focus on patient care. Nonetheless, the introduction of the Doctor of Pharmacy (Pharm. D.) programme recently in India (Table 1) may not help the community pharmacy sector and apprehension has been raised regarding the utilization of this course for international status and a tool to serve the US pharmacist workforce shortage [13].

In nutshell, India faces massive challenges in providing health care for its vast and growing population. Despite many barriers, community pharmacy services are central to the safe and effective medicines management in advancing health. With rapidly occurring changes in the health care delivery and growing patient expectations, it is hoped that community pharmacy practice will change accordingly.

Table 1: Spectrum of Pharmacy Education in India

Course	Entry level	Duration	Regulation	Comment
D. Pharm	10+2	2¼	PCI	Last revised 1991
B. Pharm	10+2	4	AICTE, PCI	Curriculum is a decade old
M. Pharm	B. Pharm	2	AICTE	Many disciplines
M. Pharm (Clinical)	B. Pharm	2	AICTE	Started in 1997
Pharm. D.	10+2	6	PCI	Started in 2008
Pharm. D. (Post B.S.)	B. Pharm	3	PCI	Started in 2008

Note: AICTE‐All Indian Council for Technical Education, PCI‐ Pharmacy Council of India.