|Year : 2016 | Volume
| Issue : 2 | Page : 212-217
Hospital pharmacy services in teaching hospitals in Nepal: Challenges and the way forward
P Ravi Shankar1, Subish Palaian2, Harish S Thapa3, Mukhtar Ansari4, Bishnu Regmi5
1 Department of Pharmacology, Xavier University School of Medicine, Oranjestad, Aruba
2 Department of Pharmacy Practice, Gulf Medical University, Ajman, United Arab Emirates
3 Department of Clinical Pharmacology, School of Health Sciences, Council for Technical Education and Vocational Training, Bharatpur, Chitwan, Nepal
4 Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
5 Department of Hospital and Clinical Pharmacy, College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal
|Date of Web Publication||20-Dec-2016|
P Ravi Shankar
Xavier University School of Medicine, #23, Santa Helenastraat, Oranjestad
Source of Support: None, Conflict of Interest: None
In Nepal, a developing country in South Asia, hospital pharmacies in teaching hospitals faces a number of challenges. Design and location of the pharmacy is inadequate, the pharmacy is often rented out to private parties, there may be a lack of separation of outpatient and inpatient pharmacy services, medicines are not selected based on objective criteria, too many brands are stocked, pharmaceutical care services are not provided, and pharmaceutical promotion is not regulated within the hospital premises. Furthermore, there is often a lack of pharmacy management software to help dispensing, continuing pharmacy education is not provided, medicines are not compounded or packaged in house, there are problems with medicines availability and medicine quality, and drug utilization studies are not linked with initiatives to promote the rational use of medicines. In this article, the authors examine these challenges and put forward possible solutions.
Keywords: Hospital pharmacy, Nepal, pharmacy care, South Asia
|How to cite this article:|
Shankar P R, Palaian S, Thapa HS, Ansari M, Regmi B. Hospital pharmacy services in teaching hospitals in Nepal: Challenges and the way forward. Arch Med Health Sci 2016;4:212-7
|How to cite this URL:|
Shankar P R, Palaian S, Thapa HS, Ansari M, Regmi B. Hospital pharmacy services in teaching hospitals in Nepal: Challenges and the way forward. Arch Med Health Sci [serial online] 2016 [cited 2017 Aug 22];4:212-7. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/212/196212
| Introduction|| |
Nepal is a developing country in South Asia situated between two Asian giants, China and India. In 2016, the number of medical schools in Nepal has increased to 20 as per the list maintained by the Nepal Medical Council. A well-structured and functioning hospital pharmacy could play an important role in efficient drug supply and promoting the rational use of medicines (RUM). Although all teaching hospitals of Nepal have a pharmacy within their premises, the concept of “hospital pharmacy services” exists only in a few. In this article, the authors focus on challenges facing hospital pharmacy services in teaching hospitals and put forward suggestions for improvement. We believe many of these findings may also be applicable to teaching hospital pharmacies in other developing countries.
The authors have been involved with hospital pharmacies and pharmacy services in Nepalese teaching hospitals for many years. They were not able to come across articles providing an overview of various challenges faced by teaching hospital pharmacies in Nepal and suggestions to improve these services. With an increasing number of medical schools and associated teaching hospitals in the region, this is becoming an increasingly important issue.
The authors conducted a literature search using the keywords “hospital pharmacy services,” “teaching hospitals,” and “Nepal.” Articles published between the years from 2000 to present were included. The authors reviewed the published studies and included those which provided insights into the working of hospital pharmacies and associated pharmacy care services. They also searched for publications by various governmental and other organizations on this topic. Nepal also suffers from occasional shortage of medicines due to transport disruptions. We obtained articles dealing with this problem from the lay press using Google Search Engine. We also consulted articles dealing with hospital pharmacy services in teaching hospitals in Nepal from the Drug Information Bulletin published by the Drug Information Center (DIC) at Manipal Teaching Hospital (MTH) and also the Journal of Medicine use in developing countries published by the Discipline of Social and Administrative Pharmacy at Universiti Sains (University of Science) Malaysia, Penang, Malaysia. The authors have long experience with hospital pharmacies in Nepal, and their insights and experiences were also utilized while preparing the manuscript.
The present article aims to provide the reader with an overview of challenges facing hospital pharmacies in teaching hospitals in Nepal and also put forward possible solutions using studies from the scientific literature and personal observations and experiences of the authors.
| Design and Location of the Hospital Pharmacy|| |
A hospital pharmacy is a place where patients not only obtain medicines but also pertinent information about their proper use. An ideal pharmacy should be centrally located, well lighted, ergonomically designed, and capable of providing patients with information about the safe and effective use of medicines through pharmacist-provided counseling. The functions of billing, dispensing, and counseling should be separated. A nontechnical person can handle billing leaving the pharmacists free to carry out technical responsibilities. The pharmacy should have a dedicated area for dissemination of information about RUM to consumers.
Unfortunately, there are no specifications about the space and design of hospital pharmacies at present. Hospital administrators are aware of the revenue-generating potential of the pharmacy and would like to have the pharmacy at a central location. However, this location may not have adequate space and fulfill other requirements. Lack of proper space and ergonomic working environment can lead to an increased risk of medication errors. The Institute for Safe Medication Practices of the United States identifies improper communication such as bad handwriting, poor verbal communication, drugs with similar names, missing or misplaced zero and decimal points, use of nonstandard abbreviations, poor drug distribution practices, complex or poorly designed technology, access to drugs by nonpharmacy personnel, workplace, and environmental problems that lead to increased job stress, dose miscalculations, lack of patient information, and understanding of their therapy as possible reasons for medication errors. Many of these are likely to be present in Nepalese teaching hospital pharmacies also.,
The pharmacy at the MTH, Pokhara, has taken steps to reduce medication errors. Three computer bills are created for each prescription and are checked by three pharmacists before dispensing. Dispensing is done as per the batch number of preparations. There are multiple windows within the pharmacy with the prescription being received at one window, medications being dispensed at a second window, and instructions for use and cross-checking being carried out at a third window.
Although the Ministry of Health and Population (MoHP), Nepal, has already formulated “Hospital Pharmacy Guideline 2015” to ensure good quality hospital pharmacy services, most teaching hospitals do not run their own hospital pharmacy services and meet the required specifications. We feel that the Department of Drug Administration (DDA), the National Drug Regulatory Authority, should inspect hospital pharmacies to check compliance with specifications before granting license to operate the pharmacy.
| Running the Pharmacy by the Hospital under the Supervision of the Drug and Therapeutics Committee|| |
The authors of a recent article strongly recommend that teaching hospital pharmacies should directly run by the hospital under the supervision of the hospital Medicine (Drug) and Therapeutics Committee (MTC/DTC). Unethical promotion can be checked, service regulated, medicines selected using objective criteria, number of brands restricted, and pharmaceutical care services established.
“Hospital Pharmacy Guideline 2015” recommends all teaching hospitals and government hospitals at various levels run their own pharmacy under the supervision of the MTC/DTC. However, there are challenges in implementing the guidelines. Starting a MTC/DTC in all teaching hospitals is an important first step, and many national workshops have been held to promote the concept.
| Lack of Separation of Outpatient and Inpatient Pharmacy|| |
Separating the outpatient and inpatient pharmacy services has many advantages. Compounding services can be started in the inpatient pharmacy, and dosage forms and doses specific to individual patients dispensed. Patient-specific dispensing is the most favored mode of drug distribution in hospitals for inpatients and some teaching hospitals in Nepal, for example, Dhulikhel Teaching Hospital and MTH, have adopted the concept. This method of dispensing has several advantages such as reduced medication errors, costs, losses and theft, and improved productivity of health-care professionals and better quality of health care.
Pharmacists at the outpatient pharmacy can devote more time to patients who are not hospitalized and counsel them better regarding the use of medications. At MTH, there are three pharmacies, a bulk pharmacy, an inpatient pharmacy, and an outpatient pharmacy. At KIST Medical College (KISTMC), Lalitpur, Nepal, there are separate inpatient and outpatient pharmacies, and efforts are underway to establish a bulk pharmacy. DDA should develop guidelines specifying separate pharmacies for outpatients and inpatients depending on the number of hospital beds.
| Lack of Objective Criteria for Selecting Medicines and Too Many Brands in the Pharmacy|| |
In many hospitals, medicines are selected based on the recommendations of individual prescribers. This in turn may depend on promotion by medical representatives (MRs) during a particular time period. Furthermore, many brands of a particular medicine are stocked in the pharmacy creating problems with inventory management and ensuring the quality of medicines. Arranging medicines in a manner easily accessible to pharmacists is also difficult. An increasing number of medicines and brands can increase the risk of medication errors, especially with look-alike and sound-alike medicines.
In the MTH pharmacy, the number of brands is limited to a maximum of six, and medicines are arranged by therapeutic category. Prescribers can recommend new generic medicines or new brands of an existing medicine for inclusion in the hospital drug list. The resources of the DIC are used for evaluating the proposed medicine and comparing it to other brands and existing medicines. Patan Hospital (PH) also has a form for adding new medicines to the hospital medicines list. KISTMC pharmacy follows objective criteria for including medicines in the hospital medicines list. The criteria followed for selection are registration of the brand with DDA, possession of good manufacturing practice certification by the company, and cost. The pharmacy stocks a maximum of two national and two international brands for each generic medicine.
The recent draft guidelines of the MoHP and DDA recommend limiting the number of brands available in the hospital pharmacy to four. Central tendering and local procurement have also been suggested for government hospitals to select medicines at a competitive price. For private hospitals, pooled procurement can be considered.
| Lack of Pharmaceutical Care (Pharmacy Practice) Services|| |
Pharmaceutical care stipulates that all practitioners assume responsibility for the outcomes of drug therapy in their patients. In Nepal, MTH was one of the first hospitals to provide pharmaceutical care services. Medicines are dispensed only with a valid prescription except in the case of over-the-counter (OTC) medicines. The hospital has created an OTC drug list specifying the medicines and the quantities which can dispend without a prescription. The department also provides drug information services, operates a regional pharmacovigilance center, and provides medication counseling services. Drug information services are also provided at the Tribhuvan University Teaching Hospital (TUTH). Nepal Medical College Teaching Hospital operates a pharmacovigilance center. At KISTMC, medication counseling services are provided, and medicine information services are operating. The department runs a regional pharmacovigilance center under the national program.
Lack of access to objective, unbiased information about medicines and therapeutics is a major problem in developing countries  including Nepal. Certain DICs in Nepal have been closed while others are facing problems in their functioning. The DIC at MTH was functioning very well. The DIC besides providing information about medicines was involved in supporting medication counseling, pharmacovigilance activities, continuing pharmacy education (CPE) programs, teaching students about drugs and therapeutics, and supporting research. The center also published a drug information bulletin to disseminate objective, impartial information to prescribers. Recently, however, the activities of the center have been affected, and it has stopped publishing the bulletin.
Academic detailing (AD) has been defined as a form of continuing medical education, in which a trained health professional (physician or pharmacist) visits physicians in their offices to provide evidence-based information about medicines and therapeutics. AD is common in developed nations and has been associated with improvements in the use of medicines and reduction in cost., In Nepal, AD is in its infancy. At KISTMC, AD sessions had been conducted during 2008 using a large group format. Informal feedback obtained from the participants had been positive. The sessions and the medicine information services had been well received and accepted as a source of unbiased, objective information. Unfortunately, the initiative was not continued.
Thus, pharmaceutical care services are deficient or lacking in many teaching hospitals. Possible reasons could be a lack of MTC/DTC, renting the hospital pharmacy on contract to the highest bidder, lack of commitment of the departments of pharmacology and hospital pharmacy to RUM, and lack of interest and commitment on the part of the hospital management.
| Lack of Regulation of Pharmaceutical Promotion Within the Hospital Premises|| |
In Nepal, many urban areas are becoming booming markets for pharmaceuticals. Most teaching hospitals in Nepal allow free, unrestricted access of MRs to doctors and administrators. From our observations in different hospitals, we have noted that pens, posters, calendars, diaries, and pen stands are common gifts to doctors and residents.
PH in Lalitpur does not allow visits by MRs within the hospital premises. In MTH, MRs can freely visit doctors, but the DTC takes the final decision about inclusion of a particular brand in the hospital pharmacy. In KISTMC, MRs cannot visit prescribers individually. They can present their products to a group of doctors, other prescribers, and faculty members during a fixed time period each week.
The Government of Nepal, DDA formulated a guideline (Guidelines on Ethical Promotion of Medicine, 2007) to promote ethical pharmaceutical promotion in the country. However, unethical pharmaceutical promotion has become widespread and is a highly challenging issue in Nepal due to extensive competition among the manufacturers and problems with implementation of the guideline.
The departments of pharmacology and hospital Pharmacy should work on regulating pharmaceutical promotion under the guidance of the hospital MTC/DTC. Prescribers in developing countries lack access to objective, unbiased information about medicines which can be provided by these departments.
| Lack of Dispensing Software|| |
In Nepal, indigenously developed pharmacy software is available to help in controlling inventory and billing functions of the pharmacy. Dispensing software that can assist the dispensing process and point out possible errors, and drug–drug interactions are not yet widely available. Globally, numerous pharmacy-related software have been developed for maintaining inventory, dispensing, calculating proper drug dose, and checking for possible drug–drug interactions. Dispensing software would be a major step toward reducing dispensing errors and can contribute significantly toward the safer use of medicines. A time and resource intensive activity is customizing the software for individual hospitals in accordance with MTC/DTC decisions.
| Continuing Pharmacy Education|| |
In Nepal, the majority of pharmacists in teaching hospitals are diploma level pharmacists who have completed a 3-year course in pharmacy after passing their tenth standard or matriculation. CPE programs are essential for pharmacists to maintain and upgrade their knowledge about medicines. CPE programs are conducted regularly at MTH for all hospital pharmacists. At KISTMC, a short course was conducted during the initial days of operation of the pharmacy, but it has not been possible to conduct further courses due to various reasons.
The department of hospital pharmacy should formulate a CPE program for all hospital pharmacists, which can be periodically restructured in the light of comments and suggestions from the participants and assessment of its usefulness in improving professional knowledge and practice. Inputs could also be obtained from the department of pharmacology.
| Lack of Compounding and in House Production Facilities|| |
Many medicine preparations, especially pediatric doses of medicines and topical preparations can be compounded and produced inside teaching hospital pharmacies. Production of personalized medicine packs can lead to savings in cost and reduce wastage of medicines. Pharmacies at TUTH, Dhulikhel Hospital, and PH are compounding certain medicines. Personalized medicine packs are, however, not being used in Nepalese hospitals. The high cost of clean room facilities and laminar air flow may be a hindering factor. Teaching hospitals could come together to pool resources to construct these facilities.
| Problems With Medicine Availability|| |
Shortage and nonavailability of essential and lifesaving medicines has been a major problem in Nepal. An often-cited reason has been nonrenewal of license by DDA and consequent inability to import the medicine into Nepal. Medicines with low profit margin are manufactured by few companies only and are especially prone to availability problems. These problems should be discussed and sorted out with DDA. Nepal recently has drafted a new constitution, and some ethnic groups are unhappy citing their rights or demands have not been significantly addressed. Therefore, these groups and some political organizations have been adopting repeated blockades and strikes to express their dissatisfaction. This has affected not only the day-to-day life of the people but also the health-care system. In the recent past, a long strike in the Terai (plain) region adjoining the Northern Indian boarder led to a huge shortage of medicines and medicinal products.
| Problems With Medicines' Quality|| |
Counterfeit products include drugs with the correct ingredients in inadequate amounts or with the wrong ingredients, without active ingredients, with insufficient active ingredient, or with fake packaging and are a major problem in developing countries. In 2001, it was reported that China had 1500 illegal medicine factories. A 2002 study by government officials showed that 9% of all drugs tested in India were substandard. Because of its proximity to counterfeit medicine producers, Nepal may be at high risk.
Information on the extent of these medicines in the Nepalese market is lacking. There are only a few laboratories testing medicine quality. MoHP and DDA are proposing that 3% of the total profit from medicine sales should be invested back in quality assurance initiatives and imported medicines are distributed through a single distributor only. A functioning pharmacovigilance program will help in early identification of adverse effects and nonresponse or inadequate response to a particular medicine. A study by Gyanwali et al. pointed out the availability of substandard medicines in Nepal.
| Linking Drug Utilization Studies With Measures to Promote Rational Use of Medicines|| |
Drug utilization studies help to obtain information on the prescribing, dispensing, and use of medicines in the particular teaching hospital and/or region. The data obtained can be compared with international figures and problems in medicine use identified. These problems can be addressed through educational, managerial, and/or regulatory interventions. The impact of these interventions can be measured through further studies.
In Nepalese teaching hospitals, many drug utilization studies have been carried out. However, linking the data obtained from these studies to interventions to improve drug use has been a challenge. The lack of a MTC/DTC or inadequate functioning of an existing committee could be a possible reason. Furthermore, it is challenging to convince clinicians that use of medicines is below standard and can be improved. Formation of a MTC/DTC and carrying out interventions through the MTC/DTC can ensure greater acceptability and success of interventions.
| Hospital Pharmacies in Medical Colleges in Other Countries|| |
The authors have no personal experience about the situation in teaching hospital pharmacies in other countries in the region. A review of literature was done to obtain more information about this topic. A study conducted in a private medical college in India showed patients were not satisfied with the waiting time at the hospital pharmacy. In a teaching hospital in South India, clinical pharmacy services have been provided and have been assisting clinicians to improve drug therapy and patient care. The services were well received by the health-care providers. In a teaching hospital in the People's Republic of China, a mobile pharmacy service system was used to deliver individual pharmaceutical care through text messages to patients' mobile phones. These messages dealt with reminders about medications, practical information about medicines, and information about adverse drug reactions. In Pakistan, pharmacists were concerned about their present professional role in the health-care system and their role in improving patient outcomes. A shortage of pharmacists in pharmacies was also noted.
| Implications for Patient Care|| |
As mentioned throughout the manuscript, pharmacists, hospital pharmacies, and pharmacy care services have an important role to play in improving drug therapy, patient care, and patient-related outcomes in teaching hospitals. There have been many studies exploring the role of pharmacists in improving patient outcomes. Medication review by pharmacists, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADRs. With the increasing prevalence of chronic diseases, pharmacists with training in clinical and behavioral skills will play an important role in disease management. Thus, knowing about the current status of hospital pharmacies and of pharmacy care services will be of importance to all clinicians and other health-care professionals in Nepal and in other countries in the region.
| Conclusion|| |
Various challenges are noted with the functioning of hospital pharmacies in Nepalese Teaching Hospitals. Among these were issues with the design and location of the hospital pharmacy, leasing the pharmacy to the highest bidder, not running the pharmacy under the supervision of the hospital DTC/MTC, lack of separation of outpatient and inpatient pharmacy, lack of objective criteria to select medicines, problems with pharmaceutical care services, lack of regulation of pharmaceutical promotion, problems with dispensing software, and lack of CPE. There are problems with medicines availability, issues with the quality of medicines, and with using data obtained from drug utilization studies to improve the use of medicines. The problems are multifactorial and are linked with unethical drug promotion and lack of administrative commitments. The authors have mentioned various measures that may help in overcoming these problems. At present, scientific studies about the challenges facing hospital pharmacies in teaching hospitals are lacking. A questionnaire study can be considered among senior pharmacists and hospital administrators in Nepalese teaching hospital pharmacies to obtain objective information about this topic. Closer cooperation among teaching hospitals and with the national regulatory authority is required.
The authors would like to acknowledge Daya Ram Parajuli, B. Pharm, M. Pharm (Molecular Pharmacology), PhD Fellow (Cardiovascular Research), Faculty of Medicine, Nursing and Health Sciences, Flinders University, Australia, for reviewing the initial versions of the manuscript and suggesting modifications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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