Pharmacists in IPHS – a missed opportunity!

Guru Prasad Mohanta and P. RavikrishnanWednesday, July 6, 2022, 08:00 Hrs  [IST]

The Government of India has recently released the Indian Public Health Standards (IPHS) 2022. IPHS are set of uniform standards to provide norms and benchmarks for quality of infrastructure, human resources, and services to be delivered from public health facilities at all levels. It prescribes the minimum standards to be adhered by the public health facilities at rural and urban areas. Standards once developed need to be periodically revised to make it relevant. The IPHS 2022 is the revised version of IPHS 2012. There have been several new initiatives since the last revision of IPHS made 2012: New Health Policy 2017, Merging of National Rural Health Mission and National Urban Health Mission, and Ayushman Bharat.  Norms for human resources are important. Always there is scarcity of human resources in health with long working hours and stress for those who chose to stay with public health facilities. The Member Secretary, Dr Himanshu Bhushan who coordinated the development of IPHS 2022, writes “The inspiration behind the IPHS 2022 is the conviction that build the health facilities that give rich treatment to poor people”.

The IPHS standards are described in four volumes. The volume I is for District Hospitals (DH) and Sub District Hospitals (SDH); the volume II is for Community Health Centres (CHC) – Rural and Urban; the volume III is for Primary Health Centres (PHC) and Health and Wellness Centres for Rural and Urban including multi-speciality urban PHC (polyclinic); and the volume IV is for Health and Wellness Centre – Sub Health Centre. The scanning of these four volumes of documents gives the idea on pharmacists’ roles and responsibilities. Minimum performance standard is defined as dispensing of 120 prescriptions per day. In addition, the pharmacist may be assigned the duties such as maintaining stock registers, and looking after the store and inventory management. In district hospital, the senior most pharmacist will oversee the management of store. Volume III and volume IV documents give additional responsibility of citizen charter with respect to drugs. All these activities belong the traditional role of pharmacists.  

The role of pharmacists has undergone big transformation worldwide. There has been paradigm shift from product oriented approach to clinical and patient oriented approach. Even in India, the clinical oriented pharmacy education, Doctor of Pharmacy programme, has been introduced since 2008. The Pharmacy Council of India, with approval of Government of India, notified the Pharmacy Practice Regulation 2015. The Pharmacy Council of India is the statutory authority governing all levels of pharmaceutical education in the country. Two areas suggested by the Pharmacy Practice Regulation are ignored in IPHS. They are: Provision of Drug Information Service and Clinical Pharmacy Service. Pharmacy Practice Regulation specified the roles and responsibilities of Drug Information Pharmacist and Clinical Pharmacist.

The use drugs are the most significant medical intervention. With increasing number of drugs and their brands, it is practically impossible to keep track of all drugs. Drug information service is a solution and drug information service is utilised throughout the world to promote appropriate use of drugs in the health set up. Many hospitals or health facilities have established the drug information centres. The duties of drug information pharmacist of drug information centre of the hospital are to provide information and advice regarding drug interactions, side effects, dosage and proper medication storage to patients, physicians, dentists and other healthcare professionals. Drug and medicine terminologies are used interchangeably.

The clinical pharmacy service is common in hospitals aboard. The pharmacy practice regulation advocates the utilization of clinical pharmacy service for promoting pharmaceutical care. Pharmaceutical care is part of the quality of healthcare. The pharmacy practice regulation has outlined the purpose, duties and responsibilities of clinical pharmacist as: providing patient care which optimises the use of medication and promotes health, wellness and disease prevention in collaboration with physicians and other health care professionals; evaluating all medicare coverage requirement requests; ensuring compliance to all clinical procedures; coordinating with pharmacy and medical staff to perform regular interventions according to present drugs; performing regular evaluation on all usage and dosage of drugs; ensuring absence of all reactions; assisting all patients with assessment of patient orders; assisting prescription infusion and ensure adherence to all laws and regulations; gathering, maintaining and analysing all laboratory data; recording all required patient information; making recommendations to change dosage if required; administering and completing all pharmacy care plans; performing reconciliation of all medications and supervising all sterile mixing processes; reviewing all medications and equipment and ensuring accuracy and effective functioning; managing all communications with physicians and patients; assisting to resolve all patients within required time frame; maintaining record of all medications for patients; ensuring absence of all discrepancies; analysing all side effects and drug interactions; retrieving clinical information for monitoring; revising of the medication use process; coordinating with all medical case managers; evaluating all high risk members to prevent all risks; participating in all patient associated meetings; preparing all clinical documents; participating in all on call activities for pharmacy; evaluating all pharmacy claim data and identify all clinical savings; attending all therapeutic and pharmacy committee meetings; coordinating with all clinical team members to ensure optimal services; providing support to all clinical programs; ensuring compliance to all medication process; evaluating all data to administer all drug utilization patterns; monitoring all departmental activities; analysing all quality improvement activities; presenting all annual studies for management; serving as a drug information resource; contributing to drug use management activities; and attending all major and national pharmacy meeting etc. In short, clinical pharmacist optimises the use of medicines and provide pharmaceutical care. There is no mention of pharmaceutical care nor the clinical pharmacy services even in district hospitals.

Another important area ignored is the labelling on medicine. Though medicines have already been labelled by the manufacturers, the font sizes are too small to be read and understood by average person leave about the elderly persons. The labelling of medicines promotes appropriate use of medicines. More the patient know about the medicines, better would be the adherence and outcome. The studies have reported that about half the patients do not take the medicines as advised. The pharmacist needs to provide patient centric labelling. But it requires resources in terms of cost of the labels and time required during dispensing. The benchmark specified for a pharmacist to dispense 120 prescriptions per day. It is really a time constraint situation.

Realising the shortage of doctors, the Odisha government has authorised prescribing powers to pharmacists in a limited way. The list of minor ailments and list of medicines for which the pharmacists can provide treatment are released by the Government. There are few other state Governments too who have similar policies.  

India has committed to achieve universal health coverage (UHC) by 2030. UHC envisages that all Indians will have access to quality healthcare services without facing financial hardship or out pocket expenditure. The human resources are crucial to quality healthcare. The expanded role of pharmacists as defined in pharmacy practice regulation should be explored and be made part of IPHS. Pharmacists did not find a place in earlier National Health Policy and for the first time entered into National Health Policy 2017 recognising them as one of human resources for health. All pharmacy professionals, their associations and statutory bodies concerned with the pharmacists should impress the government to make the pharmacists as a part of IPHS with expanded role beyond dispenser and store keeper. This is not only in the interest of the profession but also in the interest of the people.

(Guru Prasad Mohanta is former Professor and Head, Department of Pharmacy, Annamalai University, Annamalai Nagar – 608 002, and P. Ravikrishnan is member of Tamil Nadu State Pharmacy Council)