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Is there a link between the growing drug selling outlets, licensure type, and rising OTC antibiotics utilization in Pakistan?
Research in Social and Administrative Pharmacy j (2016) j–j
Letter to the Editor
Is there a link between the growing drug selling outlets, licensure type, and the rising OTC antibiotics utilization in Pakistan? Ahsan Saleem, Pharm.D.*, Mehwish Nawaz, Pharm.D., M.Phil. (c), Jahangir Khan, Pharm.D. Department of Pharmacy, The Islamia University of Bahawalpur, Pakistan
We read with great interest the letter to the editor by Khalid et al,1 wherein the authors shed light on the public health problems associated with the OTC use of antibiotics in developing countries with a special focus on Pakistan. The authors mainly associated public health problems of OTC antibiotics with the lack of control over antibiotics sales without prescription, poor performance of drug regulatory authorities, and the lack qualified pharmacists.1 We applaud them for making this valuable contribution, however, we would like to input additional details to further emphasize this important issue. Pharmacy is generally acknowledged as the most reliable, respected, and highly paid profession worldwide.2 People prefer seeking help and medicinerelated information from practicing pharmacists due to their expertise in medicines. However, the situation seems entirely opposite in Pakistan, as the majority of the population is lacking knowledge about the role of the pharmacist.3,4 The lack of knowledge and confusion about the pharmacist’s role in the community can be attributed to the lack of confidence and acceptance of pharmacists toward community practice due to several psychosocial barriers.5 The poor pharmacist–community interaction yields a perception of pharmacy owners as having insufficient knowledge. This is exacerbated by sheer numbers, as there are approximately 63,000 retail/community drug selling outlets in Pakistan for a population of nearly 199 million.6 The U.S. also has
approximately 67,000 pharmacies,7 but for a comparatively higher population of close to 319 million. This clearly shows that Pakistan has too many drug selling outlets as compared to most developed countries, and therefore indicates the risk of transformation of such a valuable port of several public health services toward profit making business enterprises due to the lack of adequately trained staff.8 Additionally, there are a few areas in Pakistan where pharmacies/medical stores are located without regard to the area or population served.9 Thus, the ultimate goals of such pharmacies seems to be focused toward capturing more and more customers and increasing the sales of medicines for the sake of gaining more profit.8 Moreover, the provincial pharmacy councils in Pakistan are responsible to some extent for the lack of acknowledgment pharmacists’ roles, higher number of drug selling outlets, and higher number of Category-B pharmacists throughout the country. For instance, the provincial pharmacy councils issue two types of registrations: Category-A, and Category-B. The Category-A license is issued solely to persons holding degree (16–17-years of education) titled bachelor in, or a doctor of pharmacy by adding their names in Register A. In contrast, the Category-B license is issued to persons holding a lower level qualification (12–14-years of education) such as a diploma of pharmacy assistant, and diploma of pharmacy technician by adding their
* Corresponding author. Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, P.O. Box 63100, Pakistan. E-mail address: [email protected] (A. Saleem). 1551-7411/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2016.03.008
Letter to the Editor / Research in Social and Administrative Pharmacy j (2016) 1–2
2
Table 1 Types of licensure, drug selling outlets, and the registration prerequisites in Pakistan Outlet type
Pharmacy
License type Qualification Duration of study Prior qualification
Category-A PharmD, B-Pharm 5-years, 4-years degree 12th grade (equivalent to UK A-level) Restricted medicines None (all registered medicines are allowed to store and sell).
Medical store Category-B Pharmacy technician, or pharmacy assistant diploma 1–2-years diploma 10th or 12th grade (equivalent to UK O-level or A-level) Immunological products, vaccines, sera/anti sera, prostaglandins, alpha blocker, biotechnological products, narcotics, psychotropic/tri cyclic anti-depressant, antivirals, anti-leprosy drugs, products related with malignant diseases and immunosuppression, and broad spectrum antibiotics (vancomycin, imipenem etc.)
This table was adapted and developed from Punjab Drug Rules 2007 & Pharmacy Act 1967 in Pakistan.
names in Register B. However, despite these significant differences, The Pharmacy Act 1967 states that a pharmacist means “a person who is registered under section 24 in Register A and Register B,”10 giving both category holders an equal right to open or run a drug sale outlet and enjoy equal worth. This discrepancy significantly affects the dignity of pharmacists in Pakistan. Later on, The Punjab Drugs Rules 2007 were introduced,11 that minimally differentiated the scope of both category holders and stated that “the Category-A holders can run a full fledge pharmacy and Category-B holders can run a limited medical store.” This means that Category-A holders can sell any kind of medicines, while Category-B holders are prohibited from storing or selling a few medicines. Further details are given in Table 1. However, despite these changes, Category-B holders are still potentially impacting the rational use of medicines due to the weakness of drug regulatory authorities in Pakistan. Due to such discrepancies, drugs are easily being accessed, purchased, and misused. It is suspected that medical stores registered with Category-B pharmacists are selling these restricted drugs, including antibiotics, for financial gain. Overall, the scope and survival of pharmacists appear to be at stake due to a significantly high number of Category-B pharmacists. Moreover, the phenomena of growing number of drug selling outlets, licensure type, and rising OTC antibiotics utilization appear linked. Therefore, to ensure the rational access and use of medicines, the appropriate authorities should take adequate steps by either reducing the unnecessarily high number of drug selling outlets and reinforcing strict laws to prevent such discrepancies. Acknowledgment No source of funding.
All authors declared that they have no conflicts of interest. References 1. Khalid L, Mahsood N, Ali I. The public health problem of OTC antibiotics in developing nations. Res Soc Adm Pharm; 2016, http://dx.doi.org/10.1016/j. sapharm.2016.03.003. 2. Traulsen JM, Almarsdo´ttir AB. Pharmaceutical policy and the pharmacy profession. Pharm World Sci 2005;27:359–363. 3. Azhar S, Hassali MA, Ibrahim MIM, Ahmad M, Masood I, Shafie AA. The role of pharmacists in developing countries: the current scenario in Pakistan. Hum Resour Health 2009;7:1–6. 4. Khan MU, Khan AN, Ahmed FR, et al. Patients’ opinion of pharmacists and their roles in health care system in Pakistan. J Young Pharm 2013;5:90–94. 5. Saleem A. Barriers to accepting community practice by pharmacists in Pakistan. Res Soc Adm Pharm 2016;12:364–365. 6. Ali I, Khan TM. Potential for community pharmacies to promote rational drug use in Pakistan. Res Soc Adm Pharm 2016;12:L167–L168. 7. InterNations US Pharmacies: facts and figures 2016 [cited 2016 31 March]. Available from: https://www. internations.org/usa-expats/guide/16304-health-insur ance/us-pharmacies-16307. 8. Butt ZA, Gilani AH, Nanan D, Sheikh AL, White F. Quality of pharmacies in Pakistan: cross-sectional survey. Int J Qual Health Care 2005;17:307–313. 9. Hussain A, Ibrahim MIM, Baber ZUD. Compliance with legal requirements at community pharmacies: a cross sectional study from Pakistan. Intl J Pharm Pract 2012;20:183–190. 10. Pharmacy act 1967 [cited 2016 31 March]. Available from: http://apps.who.int/medicinedocs/documents/ s17127e/s17127e.pdf. 11. Punjab Drugs Rules, 2007 [cited 2015 31 March 2016]. Available from: http://www.pcdapakistan.com/ wp-content/uploads/2013/04/PUNJAB-DRUGS-RUL ES-2007.pdf.
Letter to the Editor
Is there a link between the growing drug selling outlets, licensure type, and the rising OTC antibiotics utilization in Pakistan? Ahsan Saleem, Pharm.D.*, Mehwish Nawaz, Pharm.D., M.Phil. (c), Jahangir Khan, Pharm.D. Department of Pharmacy, The Islamia University of Bahawalpur, Pakistan
We read with great interest the letter to the editor by Khalid et al,1 wherein the authors shed light on the public health problems associated with the OTC use of antibiotics in developing countries with a special focus on Pakistan. The authors mainly associated public health problems of OTC antibiotics with the lack of control over antibiotics sales without prescription, poor performance of drug regulatory authorities, and the lack qualified pharmacists.1 We applaud them for making this valuable contribution, however, we would like to input additional details to further emphasize this important issue. Pharmacy is generally acknowledged as the most reliable, respected, and highly paid profession worldwide.2 People prefer seeking help and medicinerelated information from practicing pharmacists due to their expertise in medicines. However, the situation seems entirely opposite in Pakistan, as the majority of the population is lacking knowledge about the role of the pharmacist.3,4 The lack of knowledge and confusion about the pharmacist’s role in the community can be attributed to the lack of confidence and acceptance of pharmacists toward community practice due to several psychosocial barriers.5 The poor pharmacist–community interaction yields a perception of pharmacy owners as having insufficient knowledge. This is exacerbated by sheer numbers, as there are approximately 63,000 retail/community drug selling outlets in Pakistan for a population of nearly 199 million.6 The U.S. also has
approximately 67,000 pharmacies,7 but for a comparatively higher population of close to 319 million. This clearly shows that Pakistan has too many drug selling outlets as compared to most developed countries, and therefore indicates the risk of transformation of such a valuable port of several public health services toward profit making business enterprises due to the lack of adequately trained staff.8 Additionally, there are a few areas in Pakistan where pharmacies/medical stores are located without regard to the area or population served.9 Thus, the ultimate goals of such pharmacies seems to be focused toward capturing more and more customers and increasing the sales of medicines for the sake of gaining more profit.8 Moreover, the provincial pharmacy councils in Pakistan are responsible to some extent for the lack of acknowledgment pharmacists’ roles, higher number of drug selling outlets, and higher number of Category-B pharmacists throughout the country. For instance, the provincial pharmacy councils issue two types of registrations: Category-A, and Category-B. The Category-A license is issued solely to persons holding degree (16–17-years of education) titled bachelor in, or a doctor of pharmacy by adding their names in Register A. In contrast, the Category-B license is issued to persons holding a lower level qualification (12–14-years of education) such as a diploma of pharmacy assistant, and diploma of pharmacy technician by adding their
* Corresponding author. Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, P.O. Box 63100, Pakistan. E-mail address: [email protected] (A. Saleem). 1551-7411/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2016.03.008
Letter to the Editor / Research in Social and Administrative Pharmacy j (2016) 1–2
2
Table 1 Types of licensure, drug selling outlets, and the registration prerequisites in Pakistan Outlet type
Pharmacy
License type Qualification Duration of study Prior qualification
Category-A PharmD, B-Pharm 5-years, 4-years degree 12th grade (equivalent to UK A-level) Restricted medicines None (all registered medicines are allowed to store and sell).
Medical store Category-B Pharmacy technician, or pharmacy assistant diploma 1–2-years diploma 10th or 12th grade (equivalent to UK O-level or A-level) Immunological products, vaccines, sera/anti sera, prostaglandins, alpha blocker, biotechnological products, narcotics, psychotropic/tri cyclic anti-depressant, antivirals, anti-leprosy drugs, products related with malignant diseases and immunosuppression, and broad spectrum antibiotics (vancomycin, imipenem etc.)
This table was adapted and developed from Punjab Drug Rules 2007 & Pharmacy Act 1967 in Pakistan.
names in Register B. However, despite these significant differences, The Pharmacy Act 1967 states that a pharmacist means “a person who is registered under section 24 in Register A and Register B,”10 giving both category holders an equal right to open or run a drug sale outlet and enjoy equal worth. This discrepancy significantly affects the dignity of pharmacists in Pakistan. Later on, The Punjab Drugs Rules 2007 were introduced,11 that minimally differentiated the scope of both category holders and stated that “the Category-A holders can run a full fledge pharmacy and Category-B holders can run a limited medical store.” This means that Category-A holders can sell any kind of medicines, while Category-B holders are prohibited from storing or selling a few medicines. Further details are given in Table 1. However, despite these changes, Category-B holders are still potentially impacting the rational use of medicines due to the weakness of drug regulatory authorities in Pakistan. Due to such discrepancies, drugs are easily being accessed, purchased, and misused. It is suspected that medical stores registered with Category-B pharmacists are selling these restricted drugs, including antibiotics, for financial gain. Overall, the scope and survival of pharmacists appear to be at stake due to a significantly high number of Category-B pharmacists. Moreover, the phenomena of growing number of drug selling outlets, licensure type, and rising OTC antibiotics utilization appear linked. Therefore, to ensure the rational access and use of medicines, the appropriate authorities should take adequate steps by either reducing the unnecessarily high number of drug selling outlets and reinforcing strict laws to prevent such discrepancies. Acknowledgment No source of funding.
All authors declared that they have no conflicts of interest. References 1. Khalid L, Mahsood N, Ali I. The public health problem of OTC antibiotics in developing nations. Res Soc Adm Pharm; 2016, http://dx.doi.org/10.1016/j. sapharm.2016.03.003. 2. Traulsen JM, Almarsdo´ttir AB. Pharmaceutical policy and the pharmacy profession. Pharm World Sci 2005;27:359–363. 3. Azhar S, Hassali MA, Ibrahim MIM, Ahmad M, Masood I, Shafie AA. The role of pharmacists in developing countries: the current scenario in Pakistan. Hum Resour Health 2009;7:1–6. 4. Khan MU, Khan AN, Ahmed FR, et al. Patients’ opinion of pharmacists and their roles in health care system in Pakistan. J Young Pharm 2013;5:90–94. 5. Saleem A. Barriers to accepting community practice by pharmacists in Pakistan. Res Soc Adm Pharm 2016;12:364–365. 6. Ali I, Khan TM. Potential for community pharmacies to promote rational drug use in Pakistan. Res Soc Adm Pharm 2016;12:L167–L168. 7. InterNations US Pharmacies: facts and figures 2016 [cited 2016 31 March]. Available from: https://www. internations.org/usa-expats/guide/16304-health-insur ance/us-pharmacies-16307. 8. Butt ZA, Gilani AH, Nanan D, Sheikh AL, White F. Quality of pharmacies in Pakistan: cross-sectional survey. Int J Qual Health Care 2005;17:307–313. 9. Hussain A, Ibrahim MIM, Baber ZUD. Compliance with legal requirements at community pharmacies: a cross sectional study from Pakistan. Intl J Pharm Pract 2012;20:183–190. 10. Pharmacy act 1967 [cited 2016 31 March]. Available from: http://apps.who.int/medicinedocs/documents/ s17127e/s17127e.pdf. 11. Punjab Drugs Rules, 2007 [cited 2015 31 March 2016]. Available from: http://www.pcdapakistan.com/ wp-content/uploads/2013/04/PUNJAB-DRUGS-RUL ES-2007.pdf.