(Author is a  pharmacist currently registered and practicing in UK. In this article, he tries to manifest the value of pharmaceutical care (which is a totally new concept for Nepal) as an integral part of health care system and its advantages.

This article was originally written for Graduate Pharmaceutical Association of Nepal.)

"A disease management strategy must match the structure, skills, and culture of each organization in the health care system. Structure should support the strategy; skills will enable successful implementation of the strategy; and a receptive culture will encourage the systems approach of disease management needs to emerge and thrive in a practical reality1."

The sole aim of the health care system, I believe, is to ensure that people are in a state of complete physical, mental, and social well-being. For this purpose, all Health Care Professionals (HCPs) should work together with a customer-focused and outcome oriented policy with follow up procedures in place, which has already been widely accepted and proven beneficial in developed countries like UK. All HCPs should use their knowledge and skills to maximum potential. The government, Planning commission and relevant authorities should make sure that all health resources are in use for the maximum benefit.

The management of drug therapy is one of the most important challenges in health care management. Drug related problems are considered as indirect costs to health care systems, and according to a 1992 study in the United States exceeded the direct cost of prescription medication.

 
Drug related problems include:

- an untreated condition for which a drug was indicated
- an improper drug selection for a condition
- sub-therapeutic doses / overdose
- failure to receive the drug / non-compliance
- adverse drug reaction
- drug interactions
- drug use with no indication
 
One of the most widely accepted models for the management of drug therapy is "Pharmaceutical Care". This is defined by the American Pharmaceutical Association as "patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate and modify medication to assure that drug therapy regimens (diagnostic or therapeutic) are safe and effective. The goal of Pharmaceutical Care is to optimize the patient's health-related quality of life, and achieve positive outcomes, with realistic economic expenditures".

Dr. Peter Kielgast2, outgoing president of the International Pharmaceutical Federation, (FIP) once quoted “in spite of soundness of the concept and the enthusiasm of the pharmaceutical profession, it was still not an integral part of any health care system”. The pharmacy profession needs to be aware of the gab between the ideal and real practice in order to fully embrace the philosophy of pharmaceutical care.

Pharmacy is the health care profession that focuses on safe and appropriate medicines management. In order for pharmaceutical care to be appropriately developed and evaluated, we need to identify the effectiveness of the services provided and the potential benefits to both patients and professionals.

Known as the ‘Drug Experts’ in developed countries, pharmacists can contribute much more to health service users if they are fully integrated into health care systems and given an opportunity to apply their knowledge and skills for the benefit of patient care. This has already been realized in many developed countries like the US, Australia and UK, where pharmacists are already involved in:

- participation in the disease management team as the drug therapy manager

- monitoring for contraindications, adverse drug reaction, drug interactions, drug allergies, drug-food interactions and for drug interference with laboratory tests.

- monitoring drug profiles of patients

- antimicrobial therapy optimization

- pharmacokinetic dosing consultations for drugs with narrow therapeutic windows such as - antibiotics (e.g., aminoglycosides and vancomycin), digoxin, phenytoin, theophylline and other drugs when  appropriate.

- clinical pharmacist/physician rounds;

- drug information and medication inservices to other health care professionals.

- coordination and evaluation of new drug clinical research studies (phase I, II, and III drug trials) as well as post-marketing surveillance studies (phase IV);

- the conduct and documentation of pharmaco-epidemiology, pharmaco-economics and drug outcome studies;

- participation in continuous quality improvement  process teams, in the Pharmacy and Therapeutics Committee, and in other committees;

- drug formulary and clinical guidelines development and management.

- Research, education and training to other HCPs and patients. 

The pharmacist plays an integral role in the health care team as a pharmacotherapy expert. The pharmacist is responsible for accurate and efficient distribution of medications but is also responsible for the pharmacotherapy outcome of patients. Besides ensuring appropriate use of medicines, pharmacists also have the ability to reduce unnecessary use of medicines thereby minimizing drug related adverse events i.e. to save money, which can be used to provide health service for poor without discrimination. Is our Nepal government and Ministry of health still in doubt that pharmacists can contribute to boost the national economy? Let us explore some evidences from developed countries:

Financial Savings:

- In a recent study in the US 3, it cost up to $293 per month (29 percent) less to treat patients in a pharmacy-based disease management program than to treat comparable patients receiving traditional pharmacy services-------
Studies in general practices and nursing homes in UK4 have shown that every £1 spent on employing pharmacists to review patients' medication resulted in £2 cost savings.------

Risk Reduction:

- Adverse drug effects (ADEs) have a significant effect on the length of hospital stays and patient mortality. The rate of ADEs short-term hospitalized patients has been estimated to be approx. 6.5% in theUS, approx. one-half are potentially preventable.1 The hospital costs of preventable ADEs was estimated at $1 to $2 billion 5,6! ----

Optimising Drug Therapy:

The cost of noncompliance, where pharmacists can play crucial role by counseling and with compliance aids, with drug therapy in New York State1 in 1995 was: 

1. 8600 deaths per year

2. 1.4 million lost work-days corresponding to $100 million in income

3. 10% of all hospital admissions (25% among the elderly)

4.  23% of nursing home admissions

Other studies in the US8, estimate medication error (prescribing, dispensing, administration and monitoring of drug therapy) rate of 12% in a typical hospital many of which could have produced serious consequences without pharmacist intervention. A significant percentage of medical errors occurring in healthcare community are due to medication errors. Medication errors have imposed a serious threat to patient safety in the U.S., Australia and the United Kingdom, and have become a major public health issue in Canada7. Pharmacists are the vital role player to minimize medication errors by educating and training other HCPs and patients, and developing risk minimization procedures. These are only few examples.

If in developed countries like UK, Australia, Canada and the US, where hospital and community pharmacy have been established long ago and pharmacists have been well recognized for their clinical role, has such significant medication error  rate we, the government, the pharmacists and other HCPs should be worrying about the condition in Nepalese health care system where pharmaceutical care is still to  born.

The current situation in pharmacy practice is akin to that in UK in the 1960s when traditional compounding roles were being superseded by industry. Shortage and ineffective distribution of medicines throughout the country is well-known problem in Nepal. Other than affluent cities of Nepal, struggling economy made conventional medicines a luxury and out of reach of a population that struggles to access the basic essentials of life such as food.

Although WHO did not list the number of pharmacists in Nepal, in 1998 health professional statistical data list we know for sure that our country has now approx. 330 pharmacists2i.e. One pharmacist per 73 thousands population. Let see the distribution of pharmacy professionals:

(Graph 1: Pharmacy Manpower distribution in Nepal 10, 2001)
 
If you allow me, I would like to say that we are not only creating a boundary to limit the use of our own knowledge and skills that we (the pharmacists) have acquired during the undergraduate study program but also being left out of the whole health care system where patients come into contact.

Do we, as pharmacists, think we can make a difference for the healthcare service users? Question to ponder…..

As the then member of National Planning Commission of Nepal, Mr. Nirmal Pandey once quoted2: “expired, very low quality and duplicate medicines are commonly distributed in the country”, we, the pharmacists, should be given authority for the procurement and distribution of medicines to alleviate this problem. Although this is the provision of National Drug Policy we as professionals know that reality is totally different. While it is true that we do not have enough pharmacists (as the WHO, GMP demands at least 3 pharmacists in a pharmaceutical company), I believe that we should review the deployment of our professionals into different areas of health care particularly in hospitals & community pharmacy. This in turn, I believe, would result in the rising remuneration of pharmacists as a principle of the demand and supply theory.

The then president of Nepal Medical Association, Dr Kalyan Raj Pandey, accepted10 that doctors are too busy to counsel and monitor proper use of medicines in patients. If we deem ourselves as the drug expert, we should take this role.

"integration of pharmacists on medical teams and patient care units provides an effective method of promotic appropriate medication use"

Pharmacists have an essential role in health promotion. For example in UK, the role of pharmacists in the community for smoking cessation is a well-organized and extensively used service. This role has personal importance to me as I gave up smoking with the support of a pharmacist – without this help; I failed to give up many times. Looking at the statistics, there is a mortality rate9 (1998) of 1605 (age 45+) per 100,000 population from smoking related cancer and respiratory disease (cardiovascular disease not included) in Nepal. Back to statistics, Approx. 260% rise in per capita consumption in annual cigarette consumption from 1970 to 1997 and approx. 605% increase in total sticks of cigarette consumption during these 27 years. Shall we think about the service and propose to the government?

While we, pharmacy professionals need to expand our roles we also need to make sure that we are competent, and trained to give the best to the service users. The pharmacists must establish a caring, ethical professional relationship with the patient.

The pharmacists must use skills in medical informatics and in the evaluation of diagnostic information (laboratory test and medical imaging data). The pharmacist must be skilled in the use of clinical practice guidelines and protocols.

We can thrive in our profession with the inter-co-operation and liaising hand in hand with Ayurveda Doctors’ Associan of Nepal (ADAN), Nepal Medical Association (NMA), Association of Pharmaceutical Producers’ of Nepal (APPON), Paramedics’ Association of Nepal (PAN), Nepal Medical Sales Representative Association (NMSRA), Nepal Chemist & Drugist Association (NCDA), Nursing Council.

Although there is Frustration among pharmacists (as I come across) lots of good news are coming out as well such as recent establishment of pharmacy council and initiation of pharmacists’ registration process. It is quite good for pharmacy profession that Nepal is now in International Pharmaceutical Federation (FIP), which means we are now exposed to, and able to contribute to the international world of pharmacy.

Systems do not change over night but continuing dedication, enthusiasm and disciplined hard work do build ‘Rome’. Many issues require legislative changes, government interest and support, initiative & leadership from professional bodies, development of multi-disciplinary team approach culture and of course, individual motivation and dedication.

We have to adopt not only to change around us, but also to change ourselves; the biggest challenge of all – just as in developed countries.

I am thankful to Alex Hodgins, Principle Pharmacist, Mental health and Care of Elderly; Naomi Meadows, Endocrine Pharmacis:,Sotiris Antoniou,Principle Pharmacists, Clinical, Education and Trainin, all from Barts and The London NHS Trust for their time and valuable suggestions.