At the heart of every healthcare system, the workforce is critical to advancing health. WHO defines health workers as all people whose main activities are aimed at enhancing health. They include the people who provide health services - such as doctors, nurses, pharmacists, laboratory technicians - and management and support workers. Without them, prevention and treatment of disease and advances in healthcare cannot reach those in need. Around the world, the health workforce is in crisis. There is a chronic global shortage of health workers, as a result of decades of underinvestment in their education, training, salaries, working environment and management. Many health systems have considered or implemented the introduction of new cadres or groups of health workers to fill a skills gap or improve the cost-effectiveness of the skill mix in the health workforce. In practice many persons in existing occupations or grades have additional skills and can fill an extended role, undergoing continuing training. For example in Kenya, initial diagnosis and care of AIDS patients is done at central level. Care for stable patients is then decentralized to satellite clinics in districts and even further down to the community.

The third largest healthcare professional group

Pharmacists represent the third largest healthcare professional group in the world. The majority of pharmacists practice in private retail pharmacies, few in public health facilities. There is very little published international data on the pharmacy workforce. In 2006 a survey by International Pharmaceutical Federation (FIP) revealed that the pharmacist to population ratios vary widely from less than 5 to over 200 pharmacists per 100’000 population. In Zimbabwe for instance, only 20% of the approved public sector positions in 1999 were filled with the majority of pharmacists opting to work in the private sector.

Medicinal therapy is the most frequently used form of treatment intervention in any health practice setting. In many countries, pharmacists are the most accessible of all healthcare workers and as such play a key role in the delivery of healthcare services at all levels. However, reports, maps and tables on health providers often exclusively focus on doctors and nurses. Pharmacists are hardly ever mentioned as key health professional. They tend to run under “others, associates, auxiliary, allied, support staff” etc.

The traditional role of pharmacists is to manufacture and supply medicines. More recently, pharmacists have been faced with increasing healthcare demands: an ever-growing and complex range of medicines and poor adherence to prescribed medicines have forced the evolution of the pharmacist’s role into a more patient centred approach.

Most often however, pharmacists operate behind counters and in store rooms. In low income countries, a majority of pharmacy graduates can be found in the private sector, more lucrative and even more rewarding in patient contact than supply chain activities in the public sector. The few pharmacists working in public health facilities are often invisible, engaged in activities of medicine supply logistics. Dispensing, a classical role of pharmacists is often done by non-pharmacists. Pharmacists are rarely represented in health facility committees and are often merely used as information sources about procurement and stock of medicines. In the private sector, much of the academically acquired knowledge disappears behind business and entrepreneurial activities.

Nonetheless, the importance of pharmacists in the healthcare sector is underestimated, particularly in developing countries. A large potential, a significant proportion of pharmacy knowledge and skills is wasted and remains untapped for public health and patient care.

Towards a provider of patient care

Over the past four decades there has been a trend for pharmacy practice to move away from its original focus on medicine supply to a more inclusive focus on patient care. India, for instance has 500,000 pharmacists and chemists/druggists working in retail outlets, hospitals and government dispensaries. In order for HIV/AIDS to be effectively addressed in India, the private health care sector is now actively engaged alongside the public health care sector. A national working group is training pharmacists in HIV prevention and information, counselling, diagnostic tests and safe use of antiretrovirals (ARVs).

The role of the pharmacist should be evolving from that of a compounder and supplier of pharmaceutical products towards that of a provider of services and information and ultimately that of a provider of patient care.

The scope of pharmacy practice can also include patient-centered care with all the cognitive functions of counseling, drug information and monitoring of drug treatment, next to technical aspects of medicines supply management. By taking direct responsibility for individual patients’ medicine-related needs, pharmacists can make a unique contribution to the outcome of drug therapy and to their patients’ quality of life. On the other hand, certain responsibilities of pharmaceutical operations such as stock control can be transferred to lower skilled technicians.

The WHO has previously called for greater involvement of pharmacists in the general healthcare system and wider use of their broad academic background. The movement towards the patient care approach has occurred to varying degrees in countries such as the UK and the USA. It encompasses the opportunity for pharmacists to change and improve patient outcomes as integral, active members of the patient care team.

However, pharmacists in practice today were mainly educated and trained according to the old paradigm of product focus. If they are to contribute to patient-centered pharmaceutical practice effectively, they need to be given the opportunity to acquire the new knowledge and skills required for their new role.

Examples of roles:

Clinical pharmacy: The term “clinical pharmacy” was coined to describe the work of pharmacists whose primary job is to interact with the healthcare team, interview and assess patients, make specific therapeutic recommendations, monitor patient responses to drug therapy and provide drug information. Clinical pharmacists work primarily in hospitals and clinical settings and provide patient- rather than product-oriented services. In certain countries, the pharmacy profession has evolved to the point that clinical pharmacy with patient-focused practice is no longer the exception but is carried out by most pharmacists. The impact, value and acceptance of clinical pharmacy services have been well documented.

Chronic patient care - HIV/AIDS: The world has never faced in its history a health challenge like the HIV/AIDS pandemic. Conventional healthcare systems especially in resource-limited settings have to respond adequately by shifting healthcare provision from acute healthcare services to chronic patient care. Financial resources available for the provision of antiretroviral (ARV) treatment are steadily increasing. Human resources are the most critical component of health systems and delivery. Successful strategies for ARV treatment have reduced dependence on highly skilled health professionals by sharing aspects of patient care and follow-up among different cadres of healthcare workers, the community and family members. To address the lack of highly skilled human resources, existing skills can be upgraded to cope with the demands of delivering ARV treatment and care services. One health professional that must imperatively be mobilized and involved is the pharmacist. Uninterrupted supply of ARVs and adherence to chronic HIV care and treatment is one of the key areas where pharmacists can be involved.

The value of professional pharmacists services

The World Health Report 2006 by WHO describes evidence that staff numbers and quality are positively associated with immunization coverage, outreach of primary care, and infant, child and maternal survival. The quality of doctors and the density of their distribution have been shown to correlate with positive outcomes in cardiovascular diseases. There is no mention of the value of pharmacists in patient care. But there is ample evidence:

A controlled study in Australia in 2003 investigated the value of community services and showed clear evidence of improved medication use and improved patient outcomes (1). A recent review in Turkey investigated the effectiveness of professional pharmacist services in terms of patient education. Its key findings illustrate that patients' adherence to TB treatment improved when a pharmacist provided patient education on medication use (2). Another study in Malaysia demonstrated significant cost savings with pharmacists interventions in ICU patients (3).

Hence, pharmacists’ services and involvement in patient-centered care have been associated with improved health and economic outcomes, reduced adverse drug events, improved quality of life, and reduced morbidity and mortality. These accomplishments have been achieved through gradual expansion of traditional roles and, in some cases, through the emergence of collaborative drug therapy management programs.

How can this potential be used?

"Pharmacists should move from behind the counter and start serving the public by providing care instead of pills only. There is no future in the mere act of dispensing. That activity can and will be taken over by the internet, machines, and/or hardly trained technicians. The fact that pharmacists have an academic training and act as healthcare professionals puts a burden upon them to better serve the community than they currently do."(4)

Pharmacists have the potential to improve therapeutic outcomes and patients’ quality of life within available resources, but they must be given a voice and must position themselves in the healthcare system.

Pharmacists have an important role to play in the healthcare team which consists of the patient and all the healthcare professionals who have responsibility for patient care. The added benefits which pharmacists can provide requires new roles, skills and attitudes which integrates traditional pharmaceutical science with supply management expertise, clinical aspects of patient care, communication skills, active collaboration with medical teams and solving of medicine-related problems. For them to be recognized as full members of the healthcare team, pharmacists will need to adopt the essential attitudes required by all health professionals: visibility, responsibility, accessibility in a practice aimed at the general population as well as commitment to confidentiality and patient orientation.

Approaches to engage private pharmacies include public-private partnerships. Possible interventions for example include certification of pharmacies that are willing to undergo quality assurance programs, continuing education and incentives to motivate collaboration.

A key to ensuring that pharmacists do move towards this goal is their proper reimbursement. Such a step can only occur if there is effective documentation of what pharmacists actually do to improve outcomes and if its economic value is recognized and acknowledged.

Then, pharmacists must assume greater responsibility and accountability than they do currently for the management of drug therapies in the patients they serve. Such responsibility goes well beyond the traditional dispensing activities that have been the mainstay of pharmacy practice for years. While supervision of the medicines distribution process must remain the responsibility of pharmacists, pharmacy practice requires commitment and willingness to share responsibility for the outcomes of pharmacotherapy. Thus, pharmacists' responsibilities must be expanded to include monitoring therapeutic progress, consulting with prescribers, and collaborating with other healthcare practitioners on behalf of patients.

Some pharmaceutical tasks now assigned to highly skilled pharmacists can be delegated to less or differently skilled workers able to deliver them competently.

A change in pharmacy education and a new learning approach is needed to produce graduates who are competent to render pharmaceutical care in practice. The emphasis should be on professional practice rather than only technical aspects of pharmacy.

Last but not least, more efficient use of the existing pharmacy workforce is proposed. Simple, inexpensive measures like improving management and supervision and writing clear job descriptions would help. Another helpful strategy is "piggy-backed" services -- meaning that pharmacists delivering one specific service, such as a dispensing ARVs, can simultaneously deliver others, such as adherence support.

The pharmacy profession has a responsibility to identify new practice opportunities in a changing health sector context and to demonstrate their potential to fulfill them successfully.

What you can do

"Pharmacists have an important role to play in healthcare, which is much more than selling medicines."(5)

Pharmacists have been a neglected healthcare workforce. They now need to be given a voice, be recognized, trained and integrated in the heath care team and patient care. Pharmacists themselves should move their focus from products to patients and health systems. The challenge may involve expansion of existing roles; in other cases they may require that pharmacists adopt new roles that were previously considered to be beyond the scope of traditional pharmacy practice. As roles change, competency and training requirement also change. An expertly skilled and competent, but also motivated and professionally fulfilled pharmacy workforce is of primary importance in the safe and effective delivery of healthcare and has a critical role to play and a gap to fill in the health workforce.

Nonetheless, the potential for pharmacists to effect dramatic improvements in public health still remains largely untapped. Pharmacists are an essential part of the health system and should be recognized as potential healthcare providers who need to be mobilized and integrated. Pharmacists are an existing workforce that needs to be given the opportunity to contribute to patient care.

Overall, there is considerable evidence to demonstrate the value of professional pharmacy services for improving patient outcomes and medication use in both the community and clinical settings.

As a project manager, district medical officer, hospital director or health manager - find your pharmacists! As a politician, raise awareness about public investment into a workforce that is not optimally used. As an educator, start reviewing your pharmacy curriculum. Find your pharmacists in medical depots and in private shops. Recognize their knowledge, skills and potential and integrate them into healthcare teams. Challenge them and give them the opportunity to expand their skills and responsibility. Train and supervise them, make pharmacists accountable and give them a voice. Use them and discuss models of integration, and remuneration and rewards. And you may be surprised at the added value and contribution your pharmacy colleagues can offer to patient care.

*Karin Wiedenmayer is a Clinical and Public Health Pharmacist and works at the Swiss Centre for International Health at the Swiss Tropical Institute. Contact: Karin.Wiedenmayer@unibas.ch.

Notes

1. Zaidi ST et al, Impact of pharmacists recommendations in ICU patients, Pharmacy World Science 25:299, 2003

2. Roughead L et al, Value of community services, Pharmacy Guild of Australia, 2003

3. Clark P et al, Effect of pharmacist-led patient education on adherence to TB treatment, AJHSP 2007

4. van Mil JW, Schulz M, Tromp TF, Pharmaceutical care, European developments in concepts, implementation, teaching, and research: a review. Pharmacy World Science 26:303, 2004

5. Dr Hans V. Hogerzeil, WHO Director of Medicines Policy and Standards

References

World Health Report 2006: Working together for health, WHO 2006

Developing pharmacy practice - A focus on patient care, WHO 2006

International Pharmaceutical Federation (FIP), www.fip.org