Implementing Hospital Pharmacy Service Guideline in Nepal: A Critical Analysis

Introduction

The Ministry of Health and Population, Government of Nepal, has endorsed the “Hospital Pharmacy Service Guideline, 2015” to promote good hospital pharmacy practice (HPP) in Nepal. ¹ The guideline covers most of the important domains of HPP. ² It encourages to form of a multidisciplinary drug and therapeutic committee (DTC)/pharmacy and therapeutic committee (PTC) in the hospitals with the objectives of rational drug therapy (RDT). ³ The DTC has a key role in the drug therapy management (DTM) process. ³ It guides the supply chain management (SCM) system of appropriate medicines and related items for the hospitals. It also works on hospital formulary and standard treatment guidelines (STGs) or protocol development, effective procurement practice, pharmacovigilance activity, and drug utilization evaluation (DUE) process. The guideline has also defined the minimum number of pharmacists and pharmacy-related workers required in healthcare settings based on the number of beds. However, the proper consideration and implementation of such guidelines is a major challenge in Low-and Middle-Income Countries (LMICs) like Nepal. After the endorsement of the guideline, the hospital pharmacy has developed as a substantial department of health care setting like other medical departments as far as the set-up is concerned, however, there is a need for proper implementation of the guideline.

Current Scenario in Nepal

In Nepal, many hospitals lack their own hospital pharmacies as a department but run a medical shop as a pharmacy on a tender basis. Most government hospitals have adopted the guideline and started their own hospital pharmacies whereas the implementation in private hospitals is comparatively less. However, many hospitals do not have proper set-ups for pharmacy as well as the required expertise for practice. Separate inpatient and outpatient pharmacies and satellite pharmacies are also not so common. Most of the settings where these facilities are available also only run outlets as dispensaries. Most of the hospitals in Nepal lack DTCs and hence the existence of hospital formulary and RDT are still questionable. The quality of medicine is not up to the mark in Nepal as the current procurement practice of medicine seems to prioritize cost-saving rather than cost-effective in many places. ⁴ The procurement plan and quality policy are direly needed. The HPP can be assumed at a sub-optimal level. ⁵

However, efforts are being made by experts in many places. Currently, BPharm, MPharm in Pharmaceutical Care/Hospital Pharmacy, and even PharmD graduates are making places in hospitals as pharmacists. The DTC exists in some hospitals including Shree Birendra Hospital (SBH), Patan Academy of Health Sciences (PAHS), Tribhuvan University Teaching Hospital, Norvic International Hospital (NIH), Dhulikhel Hospital, KIST Medical College, Bharatpur Hospital, and Manipal College of Medical Sciences (MCOMS). Hospital formularies are in place in some different hospitals such as SBH, PAHS, NIH, Bharatpur Hospital, and Tikapur Hospital. ⁶ Separate patient counseling units are in operation at SBH, Dhulikhel Hospital, and MCOMS. Similarly, regional pharmacovigilance centers are established in 15 healthcare institutes including SBH, PAHS, KIST Medical College, BP Koirala Institute of Health Sciences, and Dhulikhel Hospital. ⁷ Appointment of clinical pharmacists in SBH, NIH, and Nepal Medical College Teaching Hospital is another big step in the pharmacy practice. Tender-based procurement system has been practiced in government hospitals as well as in some non-government hospitals. These all signify the importance of pharmacists and hence pharmacy practice for a better healthcare system. However proper practice of DTC, hospital formulary, pharmacovigilance, scientific procurement, and overall hospital and clinical pharmacy in most of the hospitals are still not up to the mark. Pharmacists are still not considered core healthcare team members in most healthcare settings. The lack of – proper inter- as well as intra-professional coordination (IPC) of pharmacists and other healthcare professionals, delegation of responsibility of the individual based on expertise, continuous professional development (CPD) training, and the sense of ownership of healthcare professionals are the factors behind mistrust of people toward the pharmacists as competent healthcare professionals system in many places.

Merits

This is the first endorsed guideline on HPP in Nepal. In LMICs like Nepal, it is a good initiative for uplifting the pharmacy service that ultimately provides patient care focusing on the RDT. ¹

• The guideline talks about the formation of DTC and having a pharmacy with separate in-patients and out-patients units.

• It demands making indent of medicines and related items in the hospital, checking the qualification of the manufacturer and supplier of medicine, effective procurement system, preparing formulary and standard treatment protocol, using formulary drugs, generic prescribing, setting appropriate prices, and pharmacovigilance activities.

• The provision of seed money to start a pharmacy is also a noteworthy step.

All these promote good pharmacy practice (GPP) in a hospital and improve patient care.

Shortcomings and a Way Forward

Though the guideline has covered most of the facets of HPP, some important realms are not touched upon. The guideline doesn’t give an outline of the organizational structure of the hospital pharmacy as an independent department. It would have been comprehensive if the different sub-units such as compounding/manufacturing, procurement, storage, academic and research, clinical, and administrative including account and IT units are covered under a single pharmacy department. The guideline doesn’t focus on patient counseling, which is one of the most important areas of HPP by which pharmacists assure the rational use of drugs. The different set-ups of hospital pharmacies such as satellite pharmacies for bigger hospitals are equally important.

The number of pharmacists and pharmacy-related manpower set by the guideline does not cater to the need of all types of hospitals, especially in the tertiary care hospitals providing multi-specialty services. The minimum number of clinical pharmacists in more than a 100 bedded hospitals is not sufficient for adequate clinical pharmacy practice (CPP). Also, the provision of only assistant pharmacists in 15 to 25 bedded hospitals and a lack of clinical pharmacists in 50-bedded or small hospitals may not justify RDT. The guideline gives a controversial statement regarding clinical pharmacists. It states that PharmD following BPharm degree holders are clinical pharmacists. However, PharmD graduates as first professional degree holders are also entitled clinical pharmacists.^8-11 Though the guideline elaborates on setting appropriate prices for therapeutic agents, there is a need for a uniform pricing policy for people so that patients can bear out-of-pocket expenses for the regular use of medicines. The continuous availability of medicines that are freely obtainable from the Government of Nepal must be assured by all government hospitals at any cost. The provision of essential medicines to all patients must also be assured by the hospital pharmacy.

There has been a paradigm shift in pharmacy practice since the 1960s after the concept of a patient-focused approach. ¹² There must be proper inter-as well as intra-professional coordination among the healthcare professionals with the common goal of proper patient care. The attitude and knowledge, evidence-based practice, and CPD are musts for pharmacists as well. It is high time to implement pharmacy services in hospitals; HPP and CPP focusing on clinical and managerial roles. In LMICs like Nepal, proper CPP is a far cry. ¹ However, efforts can be made to establish and enhance such practices. Empowering pharmacists for patient-oriented roles in healthcare set-up has led to improvement in patient outcomes in the developed world as well as in LMICs.^13-15 Regular DTC meetings, updating and strict use of HFS, consistent ward rounds and DTM, research activities, pharmacovigilance activities, and effective patient counseling and follow-up service along with proper dispensing of quality medicines and related items must be assured to justify GPP. The hospital pharmacy service guideline can be made more efficient and inclusive by incorporating other important aspects that are missing in current guidelines.

Conclusion

Endorsement of hospital pharmacy service guideline is a cornerstone in strengthening HPP and thus ensuring rational drug therapy. Implementation of the guideline is the foremost priority. Though it has covered most aspects of HPP, some prominent areas are not accommodated. It has been about 8 years since the endorsement of the guideline and many hospitals have somehow implemented it. It is suggested to get feedback from the implementing bodies and review the guideline at the national level and make necessary amendments to make it more adoptable and efficient.