Challenges in the management of community pharmacies in Malaysia.

BACKGROUND: The provision of professional pharmacy services by community pharmacists continues to be limited, particularly in low and middle income countries. It was postulated that multiple management challenges faced by community pharmacists contribute to this situation.
OBJECTIVE: The primary aim of the research was to determine the challenges faced in the management of community pharmacies in Sarawak (the largest state in Malaysia), and practical strategies to cope and overcome the challenges.
METHODS: Semi-structured interviews were carried out with community pharmacists practising in Sarawak. Purposive and snowball sampling were employed to ensure a diverse group of informants. The interviews were audio-recorded and transcribed verbatim, with the resultant data analysed using thematic analysis. Data collection, coding, interpretation were carried out iteratively until theoretical saturation.
RESULTS: Twenty respondents from different demographic characteristics were recruited. Six major themes were identified. Management challenges faced by community pharmacists traverse five major domains: market competition, legislative issues, customers' knowledge and expectations, macroeconomic impacts and operational challenges. Most of these challenges require government intervention to be resolved. In the meantime, improving customer service and expanding the range of professional services were seen as the most viable strategies to cope with existing challenges. The main concern is that current legislative and economic landscape may hinder these strategies. Enactment of dispensing separation and more protective measures against market competition were suggested to alleviate the challenges faced.
CONCLUSION: Numerous management challenges faced by community pharmacists that distract them from delivering professional pharmacy services have been highlighted. Urgent affirmative actions by the government are warranted in supporting community pharmacists to realise and maximise their potentials.

INTRODUCTION

The management of community pharmacies is fraught with numerous operational and strategic challenges. Pharmacy managers are expected to be proficient in managing human resources, finances, marketing, store inventory, information systems and physical space of the pharmacy.1 The skills set required for this function include, but not limited to, the ability to lead, manage interpersonal relationship and being well-organised, as well as having the strategic foresight to detect changes in the environment and tailor sustainable responses from time to time.2,3,4

However, unlike most commercial enterprises, the key roles of community pharmacists are supposed to safeguard the health of the population they serve, providing a myriad of professional services that commensurate with their knowledge and expertise.5 This dual business person-professional healthcare provider role has existed since antiquity, necessitating community pharmacists to oscillate between both persona, which may be contradictory in certain situations.6 This had resulted in numerous debates whether these two roles can coexist, to the extent that community pharmacists were branded as pseudo-professionals.7,8

The clash of roles gained further prominence after the pharmaceutical care concept was introduced by Hepler and Strand.9 Policymakers and academia identified this philosophy as the perfect opportunity to cement the professional status of community pharmacists.10,11 A slew of services, ranging from medicines use review, disease state management to health promotion activities were earmarked and impinged upon community pharmacists to develop and deliver. Unfortunately, the implementation of these services in many countries was far from smooth.12,13 Challenges faced by community pharmacists in this context had been examined, with numerous barriers and facilitators noted for further actions.14,15,16 Generally, community pharmacists lacked adequate time and confidence levels to provide them.16,17 Change management issues were also faced, with pharmacy staff trapped in the comfort of current practice and hence reluctant to shift their roles.18

Additional challenges are faced by community pharmacies in low and middle income countries (LMICs) in their quest to be more professional services oriented. This stemmed from an underdeveloped health system and legislations that did not facilitate proper development of pharmacy practice.19,20,21 As a result, quality of even basic pharmacy services such as dispensing and counselling are much poorer compared to developed nations.19 Transgressions of pharmacy legislations, primarily dispensing by pharmacy assistants and without authorised prescriptions are rampant.19 Lack of recognition from the government, peers in the medical lines and even customers are also common, as well as workforce issues.22 All these difficulties were similarly experienced by community pharmacists in Malaysia.23

In Malaysia, documented maladaptive practices amongst community pharmacies include selling medications without prescriptions, offering excess medications to customers and procuring cheaper medicines with questionable origins.24,25 This happen despite increased enforcement activities and the existence of Community Pharmacy Benchmarking Guidelines (CPBG) as a professional practice guide to promote better adherence to the existing laws.26 As the community pharmacy market in Malaysia is competitive, this may be indicative of community pharmacists buckling under the strain of the challenges. However, professional pharmacy services are also routinely provided, suggesting that not all coping strategies are negative.23 Indeed, community pharmacies in some competitive localities were found to be more inclined towards offering professional services, in an effort to differentiate themselves and gain competitive advantage.27,28

The aims of this study were to explore the management challenges faced by community pharmacists, existing strategies employed by them to cope and potential solutions to further resolve these problems. Challenges faced by community pharmacists are multifaceted and the coping strategies employed to counter them varied. Therefore, a holistic view of the management challenges faced is warranted to capture the interplay between the diverse barriers and coping strategies, which influences community pharmacy practice and professional services provision. As observed in several recent studies, this context provides more insights compared to studies focusing on barriers faced in the provision of specific pharmacy services per se.8,29,30 In the Malaysian context, the various challenges resulted in under-utilisation of community pharmacists’ clinical skills and knowledge.31 As the country’s healthcare system is in the precipice of a major overhaul, with a national health insurance scheme being considered to replace the current two-tiered public and private healthcare system, this study is timely to explore potential solutions to maximise the utilisation of their knowledge and skills for this purpose.31,32

METHODS

Participants

Participants were community pharmacists practicing in the state of Sarawak (i.e., the largest state in Malaysia). Respondents were selected using purposive sampling to ensure that the final cohort differed in terms of gender, age, position in the pharmacy, as well as the location and organizational structure of their pharmacy, in order to achieve more well-rounded perspective. Snowball sampling was employed in the later stages of participant recruitment to approach individuals needed to be introduced through existing respondents.

The study was focused on a single state in Malaysia as a model. This is believed to suffice based on the assumption that the challenges faced by community pharmacists throughout Malaysia are similar, as they are exposed to the same legislations and macroeconomic conditions.

Instruments

A semi-structured interview guide developed from extensive literature search and consultations with subject matter experts was used (Table 1). The guide was developed in English and translated to Mandarin. As the majority of community pharmacists in Sarawak are Chinese, with Mandarin being their mother tongue, this step was taken to prevent expression of their views being constrained by language impediments. A back-translation of the guide to English was carried out to ensure the accuracy of the translation. Periodic interim analyses of data collected were performed, leading to revisions of the semi-structured interview guide to facilitate the subsequent interviews and enhance the richness of the data.

Table 1

Semi-structured interview guide

No.	Key questions
1.	Can you provide me with a general idea, how challenging is it now to manage a community pharmacy?
2.	What are the specific challenges experienced by you in managing your community pharmacy?
3.	Are there any other notable challenges that you can think of?
4.	What factors do you think contribute to these challenges?
5.	What would you say is the most pressing challenge? Why is that?
6.	What are the impacts of these challenges on your community pharmacy business?
7.	What kind of constraints you face in providing professional pharmacy services due to the challenges faced?
8.	If customers are willing to pay for the services rendered, will you consider offering more professional pharmacy services?
9.	How is your pharmacy currently coping with all these challenges?
10.	What strategies are in place to further strengthen your pharmacy services due to the challenges faced?
11.	Are these coping strategies successful in overcoming the challenges?
12.	Are there any policies that you would like to see being established or changed by the government, that you think can help in overcoming some of the challenges faced?

Procedures

Interviews with respondents were carried out solely by the main author from February until April 2016 on a face to face basis. They took place either in the workplace of the respondents or a public venue, and were between 10 to 50 minutes long. English or Mandarin was used based on the preference of the respondents. All interviews were audio-recorded and subsequently transcribed verbatim by the main author. A random selection (20 percent) of transcripts were checked for accuracy by another researcher. No significant discrepancy was detected. Transcripts were subsequently returned to respondents for comments and corrections. Slight corrections were requested for three of the transcripts, with the changes made bracketed in the final transcripts.

Ethical considerations

Approval was obtained from the Malaysian Ministry of Health Medical Research and Ethics Committee for the conduct of this research. All respondents signed an informed consent form prior to the start of interviews. No financial incentive was provided for respondents.

Data analysis

Transcribed data were coded and analysed for emergent themes using thematic analysis, as per approach and steps recommended by Braun and Clarke.33 Constant comparison was done by having the data collection, coding and interpretation carried out in an iterative manner. Two authors carried out this process in an independent manner for triangulation purposes, with differences in opinions resolved via consensus. As both authors are bilingual, transcripts in Mandarin were directly coded using English terms without being translated. Only quotes selected to represent the themes and sub-themes were translated to English to enable discussion with other co-authors. This step was taken to minimise distortion in meaning which could happen during the translation process. The data was managed using NVivo (version 10, QSR International).

RESULTS

A total of 20 interviews were successfully conducted with community pharmacists in Sarawak. 3 other community pharmacists approached were reluctant to be interviewed and declined to participate. Data collection was terminated after all authors were satisfied that data saturation had been reached, as no new information were forthcoming in the last two interviews. Demographic characteristics of the respondents were also sufficiently heterogeneous (Table 2).

Table 2

Demographic characteristics of respondents

Characteristics	N	%
Gender
Male	8	40
Female	12	60
Age range
21 – 30 years old	7	35
31 – 40 years old	7	35
41 years old and above	6	30
Location of pharmacy
Urban	15	75
Rural	5	25
Type of pharmacy
Single outlet independent	14	70
Multi-outlet independent	4	20
Chain pharmacy	2	10
Position in pharmacy
Owner	9	45
Part owner	7	35
Employee	4	20

A total of 6 themes were identified from the data collected.

Theme 1: Market competition

1.1 New entrants

The increasing number of new community pharmacies, especially those opened by young, inexperienced pharmacists was a major concern. The common sentiment was that these pharmacists are likely to indulge in price war and undercut the market in order to gain a foothold in the sector, especially those with adequate financial backing. Another worrying trend was them overloading customers with products to maximise their profit margin.

“The price throwing had thrown a lot of the margin off so it’s actually quite bad. More pharmacists coming up and opening new shops around the area… they want to compete with the older pharmacies. Therefore price is the only thing they can compete on, cause experience wise they can’t.”

Some respondents suggested that the number of new pharmacy undergraduate intakes should be closely monitored and planned, and the scope/area of job opportunities for pharmacy graduates expanded to solve the perceived over-population of pharmacists in the community sector, particularly in the absence of dispensing separation. They also advocated for the enactment of zoning rules to prevent new community pharmacies opening in close proximity to an existing pharmacy.

“We are hoping that in an area they probably need to limit [number] of pharmacy that can be established within a [certain] distance… there are more and more pharmacies being opened that it can be next to you.”

1.2 Emergence of government supported competitors

The consent given by the government to set up community pharmacies in the vicinity of public hospitals was another source of consternation. The location offered an unfair privilege in accessing prescriptions written by government doctors intended for purchase in the private sector. In Sarawak, these pharmacies are owned by the Hospital Workers’ Cooperative, and it was deemed unethical for government officials to have direct commercial interest in the community pharmacy business.

“At the moment the Kop-Sihat (Hospital Workers’ Cooperative) are launching a retail pharmacy in the general hospitals, and these pharmacies will be a bigger threat to all the retail pharmacies in the near future… they are getting a much more lower pricing compared to the majority of the retail pharmacies.”

Theme 2: Legislative issues

2.1 Absence of dispensing separation

The majority of the respondents lamented the continued absence of dispensing separation in Malaysia, which resulted in a lack of prescriptions for them to dispense. They felt that the situation is detrimental to the health of the population by depriving them from getting medicine use and safety counselling. Respondents also had to face daily dilemmas regarding the sale of controlled medicines without prescriptions; their desire to be ethical clashing with their altruism to fulfil the needs of customers and ensuring business survival.

“We have a lot of rural customers requesting for urgent supply of Poison B (Prescription Only Medicines)… sometimes we really need to juggle how we want to swing between [following] the law and breaching the law. So what should we do? We really, at the moment, we really don’t know.”

The respondents hoped that the government can be a fairer referee in the on-going deliberation regarding dispensing separation, as they seemed to favour the medical doctor profession.

“We had been talking for so many years, and now, before we want to implement it (dispensing separation), medical profession come in with a lot of condition and so on… government must come in because there’s a commercial interest involved.”

They also advocated for an increased range of pharmacy only medicines (known as Poison C), perceiving the current list as being too limited. Suggestions include maintenance medicines for customers whose disease and medicine dosage had been stabilised. The creation of an emergency supply category, enabling them to legally dispense a limited supply to customers who ran out of their medications was also suggested.

2.2 Rules and regulations without empowerment

Additional restrictions, including the outlaw of sponsored signboards and sale of items not related to the profession were proposed by the government in an effort to maintain the professional image of community pharmacies. Inspections and covert operations by pharmacy enforcement officers are also held frequently to ensure compliance with prevailing laws. Respondents felt that these restrictions may be unwarranted without the provision of corresponding compensatory concessions to sustain their livelihood.

“They say in the near future pharmacy will be barred from selling items that are not related to health… if cannot sell how can we do business?… We didn’t sell any illegal things, unless like if we sell cigarettes, that they can say pharmacy can’t sell.”

Dissatisfactions were also raised regarding the inability of the government to act against pharmaceutical suppliers who offer unfair bonus schemes. General practitioners in Malaysia enjoy better purchase discounts and exclusivity for selected items compared to community pharmacies, and thus they can sell medicines at cheaper prices. This discriminatory practice still exists despite the distribution of Good Pharmaceutical Trading Practice Guidelines to all stakeholders by the Pharmaceutical Services Division that prohibit this practice.

“What we know, some big company, they are biased. They give certain items only special for doctors and then we pharmacy, we couldn’t sell it… and then also doctors or certain big players of pharmacy they can enjoy special bonus. It’s very, very unfair, especially for us independent small pharmacies.”

Theme 3: Customers’ knowledge and expectations

3.1 Distorted expectations on pharmacists’ roles and jurisdiction

There are still confusion among customers regarding the exact roles of community pharmacists in the Malaysian healthcare system. Some of them cannot differentiate between the distinct roles and jurisdiction of doctors and pharmacists.

“There are so many times where patients just come in, have their blood pressure tested, and they just ask for medications like that.”

Customers also often demand prescription medicines from community pharmacists without a prescription. This expectation is caused by the fact that there are numerous community pharmacists who actively supply them even though it is against the law. The situation is so entrenched that pharmacists who did not concede to the requests of their customers have their pharmacies branded as not being a ‘proper’ pharmacy.

“Customers with no prescriptions… they will say this is not a proper pharmacy, and then they say ‘your shop so big [how come] this thing never sell’, and then they say other people sell to me.”

3.2 Poor knowledge on medicine use

Lack of knowledge among customers visiting community pharmacies about health and medicine use was also an important challenge faced. Very often, customers fail to differentiate between symptoms and illness, and grasp that for certain illness numerous medications are needed for successful treatment.

“Usually they thought that taking a single type of medicine will be sufficient, but sometimes when there are a lot of problems, a lot of symptoms, they actually need more than one type of medicines… They always thought that they will be okay after only taking one or two types of medicines.”

Customers are also prone to identify their medicines based on the shape and packaging rather than the active ingredient. They often cannot accept substitutions (ie generic medicines) offered by pharmacists, even though the substitute contains similar active ingredient.

“Most of the people they still used to this pre-packed type of [extemporaneously prepared] cream. So they demand it, even though we give them the same ingredient type of the [commercially] ready made tube cream, they still refuse to use.”

Theme 4: Macroeconomic impacts

4.1 Increasing costs

Many community pharmacies experienced a slowdown in business due to the introduction of Goods and Services Tax (GST), high foreign exchange rate and economic uncertainties. When the GST was first introduced in April 2015, the prices of most items sold in community pharmacies increased, as a lot of medicines were initially taxed. The concurrent weakening of the Malaysian currency resulted in further price increases, as most medicines are imported.

“The challenge that we face for this year, very obvious, actually started end of last year and this year is increase of cost of medication. Not just medication, also supplement, basically everything, due to the drop of the Malaysian currency, and the economy is not very good, the GST.”

4.2 Decreasing sales

The negative economic sentiments also reduced the spending power of customers, rendering them being more price conscious. An increased tendency of customers telephoning or dropping in just to enquire about prices was observed. Community pharmacists were generally unhappy with this emphasis on price, as it distracted the customers from learning more about proper use of medications.

“They even go on the telephone and just ‘how much do you sell this? How much do you sell that?’ They do telephone shopping. So as a result when they come in only talking about price, they divert us from our role as a professional.”

The respondents were also worried that the economic slowdown impacts their customers’ optimisation of health. Instances of customers not being able to afford the medicines needed, delaying treatment and stopping their consumption of health supplements and vitamins were noticed.

“You see them come in with 5, 10 [MYR] (1 MYR = 0.23 USD, February 2017) to get a medication. They have cough, flu, fever, everything but with 5 or 10 [MYR]… so it’s quite hard sometimes to dispense so we select the more urgent treatment.”

Theme 5: Operational challenges

5.1 Financial capital and cash flow

A large financial capital is required to operate and manage a community pharmacy. Prudent financial and cash flow management is also essential to ensure business survival. In particular, a lot of considerations are involved in stock purchases, as community pharmacists need to order based on customer demand patterns to reduce wastage.

“Especially financial aspects…need a lot of funds to manage a shop… sometimes we can’t afford to buy certain items, due to lack of funds. As a consequence we can’t fulfil the requests of the customers.”

They also need to juggle between buying large enough quantity to enjoy cheaper prices without tying too much of their capital in the stock and thus affecting cash flow. For those operating in rural areas or independent pharmacies, this is a more pronounced problem as pharmaceutical companies and suppliers preferred community pharmacies to take larger stock quantities to offset transportation costs.

“Some company, because we are further away [in a rural area], they will tend to encourage us to take a bigger load, so when we want to take on a bigger [load], our company will need more funds to pay for this stock.”

5.2 Staffing problems

Most respondents work as the sole pharmacist in their community pharmacies. The long hours (some works for over 55 hours a week) led to them being mentally tired and having less time to spend with their families. The recent move enabling government employed pharmacists to be locums at their pharmacy was a welcome respite and positively received. They also wished that private sector pharmacists have the choice to be a full-time locum, whom they can hire as needed on a short notice. It is currently not possible due to the pharmacy specific nature of Malaysian practicing license.

“It’s another idea as well to actually not fix a pharmacist at a pharmacy. It’s better off to make sure that there is pharmacist at the pharmacy at all times, but it doesn’t have to be one pharmacist at one place.”

A lot of respondents faced difficulties in recruiting and retaining competent auxiliary staff. Pharmacy assistants in community pharmacies are often trained up from scratch by the community pharmacists themselves. It took approximately six months of training for them to be competent. Unfortunately, it is hard to find candidates with sufficient basic education and skills, especially in the rural areas. Retaining pharmacy assistants also proved to be hard, and most community pharmacies have high staff turnover rate.

“Staff do come and go and sometimes after we trained up like 4 or 5 months, they probably want to switch job…and that’s why we do get quite a high turnover rate, like I would say maybe every 6 to 18 months.”

5.3 Non-professional responsibilities

Independent community pharmacists reported spending a significant amount of their time dealing with non-professional work. They have to do stock management, ensure proper recordings of controlled substances, renew their licenses and dealing with the provident funds and social security contributions of their staff. The amount of paperwork increased substantially after GST implementation due to the fillings needed to be done for rebates.

“Major issue will be paperwork and red tape…currently the major thing is customs. Most of them will be GST registered because we want to get the [rebate] back. So that adds on a lot of work… we have corporate body that we need to registered… a lot of paperwork compared as to before.”

Theme 6: Coping strategies

6.1 Lack of concrete coping strategies

Most community pharmacists did not have concrete strategies to counter the challenges faced by them in managing their community pharmacies. Some of them felt that current challenges are still manageable. In contrast, the majority of respondents claimed they were overwhelmed with the day-to-day management of their pharmacies to the extent of not having the time and energy to actually plan a strategy.

“If I managed to recruit staff then I will. Without staff I cannot do anything, even cleaning the store I already feel [tired].”

6.2 Improving service provision as a coping strategy

For community pharmacists with a strategy in mind, most of them centred on improving customer services or increasing the range of professional pharmacy services provided. Developing a closer relationship with customers by being attentive to their needs was seen as important to attract customers.

“My best strategy at the moment is to provide a good service to my customers. When I provide them with the knowledge, then they usually tend to come back again.”

Hiring pre-registration pharmacists (PRPs) was integrated by some community pharmacists to be part of this strategy, as having another pharmacist is particularly helpful in service expansion. This is possible as PRPs in Malaysia can conduct professional activities independently as long as their preceptors are satisfied with their competence. Some respondents also sought to increase public awareness about their pharmacy by conducting road-shows and free health screenings; however, this move was only taken by a few pharmacies and offered for a short duration.

“It (free screenings) will help them open up more, come and seek for advice, details on these medicines like there’s any certain condition they cannot control… they will feel welcomed.”

6.3 Operationalisation of strategy

The intention of some community pharmacists to operationalise their strategies was however, curtailed by the current negative economic outlook. Due to narrowing profit margins, they do not have the time to focus on service provision/expansion nor making major changes like renovating the pharmacy and purchasing equipment for a new service. For example unique services like asthma management require additional physical space and a nebulizer machine.

“Not at the moment, based on the present economic situation. I think times are pretty [tough], though even we might have the ideas, but we wouldn’t be able to do it yet.”

The lack of an adequate healthcare system, particularly dispensing separation and a national health insurance financing system, also limits their options to make changes. Community pharmacies currently exist at the periphery of the system, with their roles and potential contributions unfamiliar to many.

“Actually the biggest problem still stemmed from the overall government system… so if there are no changes in the system, I think it’s difficult for us to make any major changes.”

“With a proper health system in the country, where people can get the medications from the pharmacy at a reduced prices, and the government tops up on that, that will also help.”

DISCUSSION

The need to manage business oriented challenges continues to preoccupy community pharmacists, inhibiting formation and operationalisation of strategies to further improve their service delivery. Legislative changes are urgently needed to facilitate transition of community pharmacies in Malaysia towards being professional services oriented entities. This study delved into the rarely researched area of community pharmacy management challenges, and the insights unearthed is believed to be useful to chart future policies in the country and act as a reference point for other LMICs.

The lack of mechanisms to control the price of medicines and regulate market competition are still major challenges for community pharmacists in Malaysia, despite being highlighted in previous research.25,29 The government’s response so far were to produce best practice guidelines regarding indiscriminate bonus schemes34 and pharmacy location zoning.26 It had yet to be seen how these guidelines are law-binding or voluntarily abided by all involved parties. The recent approval for government-linked agencies to own community pharmacies muddled the situation.35,36 It gives rise to ethical concerns, as they may be provided unfair competitive advantage like the opportunity to establish premises in the vicinity of government hospitals.36

The resultant erosion of community pharmacies’ profit margins will likely reinforce the attention on commercial viability at the expense of professionalism. This may explain why dispensing of controlled medicines without prescriptions continued to be practiced in Malaysia.24 Despite increased pharmacy enforcement activities, the lack of effective deterrents particularly heavy punitive actions may embolden pharmacists to take the risk. Pharmacists seemed to concede that accommodating customers’ demands is the only pragmatic choice for survival.37 The widespread nature of this practice in developing countries suggests an inherent systemic flaw in prevailing pharmacy legislations, particularly the lack of dispensing separation.19,21,24 The need to constantly exercise professional judgment and conscience before dispensing may also be detrimental to the pharmacists, resulting in a mental toll that affect their enthusiasm for the profession.38

Protective measures that insulate community pharmacists from excessive market competition are mooted to reduce the pressures faced in community pharmacy management. Suggestions from overseas practice include restricting the ownership for community pharmacies to registered pharmacists39, curbing the establishment of chain pharmacies40, fixing the margins of controlled medicines41 and requiring pharmacy to operate at a location with enough inhabitants and a set distance from the nearest pharmacy by law.40 Even though these moves run contrary to the growing trend of liberalisation in community pharmacy governance of developed countries, the greater need to improve the health awareness and outcomes of the general population should be given precedence.42

The dispute over dispensing separation continues to dominate the Malaysian community pharmacy landscape, stifling further growth of existing pharmacy practice.43 Malaysian community pharmacists currently have exclusive jurisdiction over only a narrow range of pharmacy only medicine, which does not provide them sufficient competitive edge. Professional pharmacy organisations in Malaysia including the Malaysian Pharmaceutical Society (MPS) and Malaysian Community Pharmacy Guild (MCPG) are continuously fighting for dispensing separation. Unfortunately, recent development suggests that the current arrangement is still favoured by the Malaysian authority.44 Therefore, another option is to enlarge this range of medicines, which besides affording them better financial returns, also acknowledges their professional expertise and provides a sense of empowerment. Furthermore, if the current legislative situation remains unchanged, their restricted roles will create a surplus of pharmacists in the community pharmacy sector. Local universities in Malaysia produce approximately 1,200 new pharmacists annually, a rate that will double the current number of pharmacists within a decade.45 Thus it is pertinent for the government to create more job opportunities for pharmacists or scale back the intake of pharmacy undergraduates to mitigate this impending problem.

Mandating dispensing separation will also increase the opportunities for patients to be provided with professional drug counselling, as well as their recognition towards the skills and expertise of Malaysian community pharmacists. Current attempts to educate them are constantly frustrated by impatience and lack of interest. This is particularly important as research have found out that about half of the Malaysian population did not know the name of the medicines they were using nor how to use them properly.46 Besides, activities to increase medicines related knowledge amongst the Malaysian public, especially the ‘Know Your Medicines’ campaign, can be intensified with closer collaboration with community pharmacies.47

A high percentage of over-the-counter medicines in Malaysia were found to be dispensed by pharmacy assistants.48 Green-lighting to the hiring of pharmacist locums is part of the solution, as they can step in when the permanent pharmacist is unavailable. Allowing a pharmacist to work exclusively as a locum, filling in at different premises on a as-needed basis can be next considered by the government, as it promotes greater flexibility and fluidity in the workforce planning of pharmacies.49 Besides, as most pharmacy assistants employed in community pharmacies do not possess any related qualifications, regulating their competency should be considered. Establishing a standard learning module and competency examination for them is an option. As colleges in Malaysia do offer pharmacy assistant diplomas, avenues to make graduates more affordable to be hired by community pharmacies can also be explored. At the moment nearly all of these diploma holders are employed in the government sector, most likely due to better remunerations offered.50

Respondents regarded offering more professional-oriented services as a viable option to confer their pharmacy a competitive advantage, which dovetailed with the increasing focus on professional services delivery. Health screening tests and to a lesser extent health promotion activities and medication management services are offered.23 Unfortunately, further innovations and offerings proved a step too far, due to a lack of time and basic resources needed to support a new service.16,51 These limitations may be more pronounced as most community pharmacies in Sarawak are still independently-owned and operated by sole pharmacists who have to personally manage every aspect of the entity. Remunerating professional services which had been proven to improve patient’s health outcomes, such as medicines use review may incentivise them to consider hiring additional pharmacists to run these services.52 Most of the challenges raised are external in nature, with issues related to legislative policies predominate. This was also reflected by the suggested solutions provided by respondents, with all of them pleading governmental interventions to take effect. Some Malaysian consumers do approach community pharmacists for health screening tests and consultations regarding their chronic illnesses.53 Unfortunately, the government seems to be ambivalent and still unsure about the immense potential of community pharmacies in preventing and managing illnesses as well as promoting health. The challenges raised demonstrated similarities with extra-organisational factors identified by Rangchian et al.30 This indicates the importance of laying a strong legislative foundation to facilitate conducive community pharmacy practice, particularly in LMICs. The limited internal challenges and coping strategies raised may indicate that these problems are less prominent, or reflect the passive culture of pharmacists which predisposed them to blame external circumstances for their predicaments.54 Professional pharmacy organisations need to rally community pharmacists into a vocal and cohesive voice to push for affirmative changes, for the betterment of community pharmacies and more importantly the healthcare of the general public.

Limitations

Being a qualitative study, generalising the findings is a path that should be threaded with caution. However, some of the findings are consistent with the results of previous research conducted in another state in Malaysia, suggesting a certain extent of generalisability.29 As the research only involved community pharmacists, findings may lack balance and might be biased towards other parties involved. Similar studies focusing on the viewpoints of policymakers and pharmacy customers are plausible directions for future research.

CONCLUSIONS

Numerous management challenges faced by community pharmacists, which affect their enthusiasm towards the profession and capabilities to extent the professional services have been highlighted in this study. They are too exposed to national economic vagaries and local market competition, besides needing to contend with customers lacking in medicine use knowledge. Unfortunately in Malaysia, most of these challenges faced require substantive changes in the health care system to be resolved. A paradigm shift amongst legislators and the public towards perceiving community pharmacies as professional service firms, rather than conventional business entities is needed to start the ball rolling.