Evaluation of the Perception of Community Pharmacists Regarding their Role in Pakistan ' s Healthcare System : A Qualitative Approach

Purpose: To explore the perception of community pharmacists regarding their role in Pakistan's healthcare system. Methods: A qualitative study design was adopted. A semi-structured interview guide was developed and face to face interviews were conducted. The participants were community pharmacists and were recruited through one of the researcher’s personal contacts in two cities of Pakistan (Islamabad and Lahore) from April to June 2008. The interviews were conducted at the pharmacists’ work-place. Arrangements for the time and place of interview were made during initial contacts. Written consent was obtained from the participants prior to the interview. Results: Among the respondents interviewed, seven were male and three female community pharmacists aged between 25 and 50 years. All the participants regularly dispensed > 50 prescriptions daily. Thematic content analysis yielded 5 major themes: (a) provision of pharmacy services to consumers, (b) counseling at pharmacy, (c) application of Good Pharmacy Practice (GPP), (d) Pakistan Pharmacy Association (PPA) contribution towards pharmacy profession, and (e) strategies to improve community pharmacies. Conclusion: Community pharmacies in Pakistan currently face shortage of pharmacists. This has resulted in non-provision of patient counseling; rather services are more focused more on the management of pharmacies than clients. As a result, there is little public awareness of the pharmacist’s role in health care.


INTRODUCTION
Pharmacists have been recognized globally as important healthcare practitioners especially with regard to the promotion of safe and rational use of medicines [1].Compared to the developed world, the pharmacy profession faces various barriers in developing countries, two of such major barriers being acute shortage of qualified pharmacists and lack of standard practice guidelines [2], [3].
Pakistan is the sixth most populous country in the world with a population of approximately 160 million [4].In Pakistan, the Ministry of Health is responsible for national planning and coordination in the health sector [5].It has been estimated that around 8102 qualified pharmacists are currently practicing in Pakistan, 2836 of which are in the public sector, 5023 in private setting and 243 in private not-for-profit organizations [6].Approximately 55 % of them are in engaged in pharmaceutical production, 15 % work in federal and provincial drug control, and hospital pharmacy set-up, 15 % in the sales and marketing of pharmaceuticals, 10 % in community pharmacy, and 5 % in teaching and research [7].As a result of progress in pharmaceutical industry and education, community pharmacy has grown significantly.With only 10 % of pharmacists engaged in community pharmacy practice, this sector has failed to focus on pharmaceutical care, health promotion and patient counseling as this small number is inadequate to meet optimum national requirements [8,9].This study has therefore been conducted to explore the perception of Pakistani community pharmacists with regard to their role in Pakistan's healthcare system. .

Study design
This was a qualitative study designed to explore the perception of community pharmacists.An interview guide was developed after extensively reviewing the literature and thereafter semistructured interviews were conducted to collect data.

Sample size and sampling technique
The participants were the community pharmacists recruited through the researcher's personal contacts in two cities of Pakistan, namely, Islamabad and Lahore, from April to June 2008.Arrangements for the time and place of interviews were agreed during the initial contact.All the interviews were conducted at the pharmacists' work-places.Written consent was obtained from the participants prior to the interview.

Interview implementation and data analysis
The interviews mainly focused on pharmacy practice in Pakistan and services provided to consumers by community pharmacists other than dispensing of drugs.Furthermore, information was gathered regarding the contribution of the pharmacy organization towards pharmacy profession.Probing questions were used where necessary and respondents were given freedom to express their views at the end of the interview session.Each interview lasted approximately 20 to 30 min, was conducted by one of the researcher (SA) at a place and time convenient to the pharmacist.All the interviews were conducted in English, audio taped and transcribed verbatim.Transcripts were verified by the researcher for accuracy by listening to the tapes.The researcher analyzed the transcripts line by line, read repeatedly by the experts and thematically analyzed for its content.From the analysis, saturation of data was reached after 10 interviews with no new themes emerging in the last two interviews.

Characteristics of participants
Among the respondents, seven were male and three female community pharmacists, and they were aged between 25 and 50 years.All the respondents regularly dispense more than 50 prescriptions per day.From the analysis, saturation of data was reached after 10 interviews with no new themes emerging in the last two interviews.Thematic content analysis yielded 5 major themes: 1) Provision of pharmacy services to consumers, 2) Counseling at pharmacy, 3) Application of Good Pharmacy Practice (GPP), 4) Pakistan Pharmacy Association (PPA) contribution to pharmacy profession, 5) Strategies to improve community pharmacies.

Theme 1: Provision of pharmacy service to consumers
The respondents gave mixed responses when they were asked about the services provided to customers other than dispensing.

 Non provision of other services to customers
"No, we do not provide any kind of services other than dispensing".(CP2)

Theme 5: Strategies to improve the community pharmacies
Suggestions were elicited from the respondents on how to improve the current practice and the status of pharmacy profession in the country.
A few of the respondents suggested that there is a need to create awareness programmes on the role of pharmacists.

"Only pharmacists should be allowed to run pharmacies and awareness about the importance of pharmacists should be created through seminars or media so as to inform the layman about the importance of the pharmacist." (CP2)
"Exactly, for the improvement I must say that government should take charge of the profession and create awareness through media and seminars.Only then the pharmacy profession may be evoked.At present, the situation is so bad that people even don't know who the pharmacist is." (CP3) Two of the respondents suggested that there is a need for more focused customer-based services.

"One thing that I want to share is that the owner of a pharmacy should not be the manager, instead, he should be the pharmacist. Although it's important to manage inventory and cash but our main focus should be on patient services. I think the government should make policies and pay special attention to the pharmacy profession." (CP5)
"There is still a lot to be done; rules and regulations must be strict, more pharmacies should be opened and run by pharmacists only, so that pharmacy students can be accommodated for training.In this way, the patients will benefit when medicines are dispensed by pharmacists."(CP8) Few of the respondents suggested the need for change in curriculum.
"The subjects that we cover in theory in the university is a lot, but not even 5 % of it is practiced in practical the field; our curriculum should be revised according to the practice requirements of the field.Pharmacy students need to experience practical aspects of the profession but our curriculum is theory-based."(CP1) "A lot of planning is required regarding pharmacy education in the country with regard to curriculum; the curriculum should be re-designed to focus more on practical approach.For the betterment of the profession, the pharmacist should be given proper training before entering into the field."(CP10)

DISCUSSION
Consumer satisfaction is one of the most important indicators of the quality of healthcare because it reflects whether or not a given service meets consumers' expectations [10].There were mixed opinions in terms of the provision of pharmacy services to customers in Pakistan's healthcare system.Few of the pharmacies did focus on rendering services to customers.All the respondents affirmed that pharmacists were providing patient counseling on dosages and side effects of medicines.These findings are consistent with the study of Bonnie [11], which showed that pharmacists have been encouraged to take more active roles in patient counseling and this can significantly reduce patients' nonadherence.
It is recognized and accepted that the conditions of pharmacy practice vary widely from country to country.When respondents were asked about the application of Good Pharmacy Practice (GPP) in the country, they totally denied the presence of it.The reason given was the shortage of pharmacists in pharmacies.This factor was consistent with the statement by FIP (International Pharmaceutical Federation) regarding the lack of pharmacists in developing countries [12].Apart from the shortage of qualified pharmacists there is also a preference among them to work in other practice areas such as industry.However, there are exceptions, as shown in the study conducted in Nepal, which were not consistent with the current study [13].In the Nepal study found that the community pharmacies were very often, the first and the only, source of healthcare outside their homes [13].
The main aim of the pharmacy professional bodies is to improve the professional standards of pharmacy and to enhance the status of the profession in public health.The respondents suggested that awareness programs should be carried out to enable the general public know who the pharmacist is.They felt that the expertise of the pharmacists should be recognized and that it is very important to establish a relationship between the pharmacists and the consumers.Another point of view which was put forward was that the main focus should be on services to patients rather than managerial tasks.The respondents emphasized that patients would obtain additional benefits if drugs were dispensed by pharmacists.These findings are consistent with those showing high public support for the advisory role of the pharmacist [14].
The respondents expressed dissatisfaction with current pharmacy practice and hoped that a lot would be done in the country with regard to the pharmacy curriculum.They further posited that the curriculum was not practice-oriented.These findings are consistent with with a report in an earlier paper which stated that the pharmacy curriculum in Pakistan had not been given due attention though this is very crucial to improving professional practice in Pakistan.

Limitation of the study
This study involved community pharmacists in two cities of Pakistan; however, dispensing practices were assumed to be consistent across Pakistan.Although it is probable that pharmacists in other parts of the country have a similar perception of their role in healthcare system, the findings of the present may not be generalizable to pharmacists working in other provinces of the country.

CONCLUSION
This study reported and addressed some issues that had not been previously discussed.This qualitative study showed that community pharmacies in Pakistan do have concerns about their present professional role in the health care system, is the main being the shortage of pharmacists in pharmacies.Pharmacists working in community pharmacies do not provide adequate patient counseling and their services are largely focused more on management of their outfits rather than patients.Consequently, the roles of pharmacists are not well known to the public.

Table 1 :
Demographic profile of respondents *'Pharmacy chain' refers to a group of community pharmacies owned by a business group.