Chapter 1. Introduction to Pharmacy Practice
Chapter 2. Bangladesh Pharmaceutical Industry
Chapter 3. Bangladesh Health System Review
Chapter 4. Clinical Pharmacy Practice
Chapter 5. Pharmacists in Hospital Management
Chapter 6. Pharmacists in Community Care
Chapter 7. Prescription Pharmacy
Chapter 8. Rational Use of Drugs
Chapter 9. Patient Education and Compliance
Chapter 10. Pharmacoeconomics
Chapter 11. Pharmacovigilance and ADR Management
Chapter 12. Clinical Pharmacists in Chronic Care
Chapter 13. Managerial Role of a Pharmacist
Chapter 14. Basic Marketing Concept
Chapter 15. Professional Communication
Chapter 16. Pharmaceutical Regulatory Affairs
Chapter 17. Pharmaceutical Marketing Practice
Chapter 18. Tablet: Formulation & Manufacturing
Chapter 19. Pharmaceutical Pre-formulation
Chapter 20. Dispersed System
Chapter 21. Mixing & Separation Techniques
Chapter 22. Pharmaceutical Analysis
Chapter 23. QC and Method Validation
Chapter 24. Advanced Drug Delivery System
Chapter 25. Topical Inorganic Preparations
Chapter 26. Major Electrolytes
Chapter 27. Pharmaceutical Excipients
Chapter 28. Pharmacology Review
Chapter 29. Pharmaceutical Microbiology
Chapter 30. Medicinal Plants of Bangladesh
Annexure 1. Sample Questions on Pharmaceutical Technology
Annexure 2. Sample Question for the Post of Executive, PMD/Training
The expanded role of pharmacists uplifts them to patient care, industrial marketing, regulatory affairs from dispensing and manufacturing of drugs. The sector is emerging in both developed and under-developed countries. Furthermore, pharmacy teaching institutions need to revise and up-date their curricula to accommodate the progressively increasing development in the pharmaceutical education and the evolving new roles of practicing pharmacists in healthcare arena. The study aid highlights the pharmacists’ roles and responsibilities along with basic pharmacy education, with the most recent information obtained from publications in several journals, books, bulletins, newsletters, magazines, etc. Also, many of the prospective viva and interview questions are solved along with a few chapter outlines, covering many of the pharmacy courses. However, it is very important to remember that no study aid can help do well in a viva session or job interview unless a knowledge base is kept sharpen. Therefore, authors of this study aid do not claim any superiority over textbooks and current knowledge from quality pharmacy magazines and other similar sources, as the world is changing every day. The sole of this book is to support a pharmacy student or professional to give an accelerated mental support when books are not feasible to carry before an interview and viva session.
Chapter 1. Introduction to Pharmacy Practice
As a profession pharmacy was recognized in Bangladesh after the promulgation of Bangladesh Pharmacy Ordinance-1976. Although, the pharmacy education started its journey by the hand of the Department of Pharmacy, Dhaka University in 1964. Major work field for pharmacist in hospital as hospital, clinical pharmacist and community pharmacist in a specific community. In Bangladesh, pharmacy practice areas for graduate pharmacist is limited in industry i.e., industrial pharmacy practices or in the marketing sections. A few numbers of pharmacists are involved in administrative positions. In the area of industry or marketing sections graduate pharmacists involved in production, research & development, quality control, quality assurance and product marketing, etc. But graduate from other disciplines like biochemistry, microbiology, biotechnology, chemistry can also work in these sections. The educational system of pharmacy is one of the major reasons for bounded pharmacy practices because the courses included in bachelor degree principally emphasize on industrial practices. The government and pharmacy regulatory authority should take sufficient initiative to develop the pharmacy sector in Bangladesh.
Practice for Pharmacists' Care Imposed by American Pharmacists Association (APhA)
1. Serves patients by preparing medications, giving pharmacological information to multidisciplinary health care team, and monitoring patient drug therapies.
2. Prepares medications by reviewing and interpreting physician orders and detecting therapeutic incompatibilities.
3. Dispenses medications by compounding, packaging, and labeling pharmaceuticals.
4. Controls medications by monitoring drug therapies; advising interventions.
5. Completes pharmacy operational requirements by organizing and directing the workflow of technologists, evaluating their pharmaceutical preparation and labeling, and validating order entries, fees and safety checks.
6. Provides pharmacological information by answering questions and requests of health care professionals and counseling patients on drug therapies.
7. Develops hospital staff’s pharmacological knowledge by participating in clinical programs and training pharmacy staff, students, interns, externs, residents, and health care professionals.
8. Complies with state and federal drug laws as regulated by the pharmacy board, drug enforcement administration and FDA by checking of nursing units.
9. Maintains records for controlled substances and removes outdated and damaged drugs from the pharmacy inventory.
10. Supervises the work results of support personnel.
11. Maintains current registration, studies existing and new legislation, anticipates legislation, and advises management on needed actions.
12. Protects patients and technicians by adhering to infection-control protocols.
13. Maintains safe and clean working environment by complying with procedures, rules, and regulations.
14. Contributes to team effort by accomplishing related results as needed 1.
Pharmacy Code of Ethics
1. A pharmacist respects the covenantal relationship between the patient and pharmacist.
2. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.
3. A pharmacist respects the autonomy and dignity of each patient.
4. A pharmacist acts with honesty and integrity in professional relationships.
5. A pharmacist maintains professional competence.
6. A pharmacist respects the values and abilities of colleagues and other health professionals.
7. A pharmacist serves individual, community, and societal needs.
8. A pharmacist seeks justice in the distribution of health resources 2.
Scope of Pharmacists in Bangladesh
1. Pharmacy Education: Pharmacy is taught in about 100 public and private universities in Bangladesh and about 8000 pharmacy students graduate every year. Nearly a thousand of pharmacists are engaged in pharmacy education and several other training projects.
2. Pharmaceutical Marketing: Medical Services Department (MSD), Product Management Department (PMD), Clinical Services, Training field forces, Sales Promotion/Medical Promotion and International Marketing (IM) departments.
3. Pharmaceutical industries (Finished medicines, Active Pharmaceutical Ingredients/APIs, and Excipients Manufacturing industries): In Production, Quality Control (QC), Quality Assurance (QA), Product Development (PD), cGMP Training, Warehouse, Drug Research and Invention, and Technical Services Department (TSD).
4. Hospital Pharmacy: Hospital pharmacy practice in Bangladesh is confined to selling drugs till today. Nearly 75% of pharmacists around the world work in patient care but an opposite scenario is found in Bangladesh. The practice has just begun in some modern private hospitals in Bangladesh like Apollo hospital, Square hospital, United hospital and Gastro liver hospital etc. and showing a huge prospect in future.
5. Drug Testing Laboratories (Dhaka and Chittagong)
6. Research & Development in Pharma industries, educational and research institutes (Research for new drug molecules, Novel Drug Delivery Systems, Improved Healthcare, Clinical aspects, etc.)
7. Drug Regulation: To register pharmaceutical products in regulated markets it requires highly standardized documents. Currently pharmacists are working in BPS, PCB and DGDA (affiliated with Commonwealth Pharmaceutical Association and International Pharmaceutical Federation), watching standard of both pharmacy education and standard of manufacturing procedure of pharmaceutical companies of the country [3,4].
Prospect of Pharmacists in Abroad
Pharmacists acquire medical and medicinal history, check medication errors including prescription, dispensing and administration errors, identify drug interactions, monitor ADR, suggest dosage regimen individualization, provide patient counseling, etc. in many developed countries like:
1. In the USA: US National Center for Health Workforce Analysis projected that, between 2012 and 2025 the pharmacist supply, would increase by 16%. Pharmacy graduates are employed in hospitals, health systems and ambulatory clinics at a greater rate than in the traditional community chain or independent pharmacy settings. It is a good time to be a pharmacist in the US, but how good it is will depend on the ability of the profession to foster and strengthen autonomy in practice and to continue to expand their scope of practice and impact on patient outcomes 5.
2. In UK: Around 30% of GP accomplices have declared not having the capacity to fill a GP opening in their training. There are currently over 1000 Full Time Equivalent clinical pharmacists working across the country through the NHS England Clinical Pharmacists in General Practice Program since it started in 2015 6.
3. In UAE: There is still a clear shortage of pharmacists in UAE and it is expected to be even worse by the year 2020. Pharmacy education was first established in the UAE in the year 1992 by Dubai Pharmacy College. However, majority of students enrolled in UAE College of pharmacy were nonnational residents, and a large number of graduates leave the country after graduation 7.
4. In Malaysia: Pharmacy practice in public health clinics and community pharmacies are very different. Pharmacists in the public health clinics possess complete control over the supply of medicines. A pharmacy practice reform that integrates pharmacists into primary healthcare clinics can be a potential initiative to deliver comprehensive primary healthcare services to the public 8.
5. In Australia: The community pharmacies looking to recruit permanent pharmacists have to wait for months. Government is trying to attract more pharmacists to rural, regional and remote areas. Pharmacist salaries in rural and remote areas are on the rise as the demand for professionals in community and hospital roles increases 9.
6. In New Zealand: Demand for healthcare is increasing because the population is ageing and because new technology means more health problems can now be treated. As a result, employment prospects for hospital pharmacists, industrial pharmacists and retail pharmacists are good 10.
Challenges of Pharmacy Profession in Bangladesh
1. Education System: The graduates who pass out do not get employment easily due to their inadequate training, lack of thorough knowledge of fundamental concepts and practical skills. Universities in Bangladesh should formulate curricula based on market demand and real-life situation as 36% of employers in the country are now facing the shortage of skilled manpower.
2. Job Environment: At present, industrial jobs are apparently saturated. Therefore, getting entrance of new Pharmacists to Pharmaceutical Industries become quite tough or have narrow scope for new Pharmacists. On the contrary, companies are seeking experienced pharmacists with higher skill, professionalism and exposure for top management/new ventures.
3. Eligibility in Abroad: The present Pharmacy education system of Bangladesh does not comply with the international requirements for jobs and higher studies in many developed countries.
4. Underutilization of Hospital Pharmacists: Though hospital pharmacists are recognized in many developed nations for their importance as a healthcare professional, in Bangladesh it is still underutilized or underestimated.
5. Lack of R&D Activities and Backward Linkage: Due to lack of financial and technological support as well as collaboration between local manufacturers and researchers, research practice among pharmacy profession is very limited in Bangladesh. Also, the country lacks a strong backward linkage industry including the APIs and machinery. All these things narrowed down the job scopes further [11-14].
Table 1. International Pharmacist Organizations 15
Abbildung in dieser Leseprobe nicht enthalten
List of Pharmacy Networks/Blogs (in brief)
The Pharmacist, Innovative community pharmacy services in the UK, FiercePharma, PharmaTimes, Pharmaphorum, PharmaTutor, PharmTech Talk, Patent Docs, PharmaVOICE, APhA DrugInfoLine, In-Pharma Technologist , Reddit - Pharma, The Catalyst - A PhRMA Blog, Royal Pharmaceutical Society Blog, Eye For Pharmacy, NY Times - Drugs (Pharmaceuticals), Science Magazine - In The Pipeline, Certara Blog, Optymyze OutSourcing Pharma, European Pharmaceutical Review, Pharma Focus Asia Blog/Ochre Media Pvt. Ltd., Pharmacy Checker Blog, Tosc Pharma Blog, WellSpring Pharma, FDA Law Blog
List of Pharmacy Magazines (in brief)
Pharmacy Times, Monthly Prescribing Reference, Drug Topics, Pharmacy Today, U.S. Pharmacist, The Medical Letter on Drugs & Therapeutics, Pharmaceutical Representative, BioSupply Trends Quarterly, Pharma Mirror, Pharma world, Pharmacy Practice News, American Journal of Health-System Pharmacy
List of Pharmacy journals (in brief)
Expert Opinion on Therapeutic Patents, Indian Journal of Pharmaceutical Sciences, International Journal of Clinical Pharmacy, International Journal of Pharmaceutics, Journal of Controlled Release, Journal of Pharmacy and Pharmaceutical Sciences, Journal of Pharmacy Practice and Research, Molecular Pharmaceutics, The Pharmaceutical Journal, European Journal of Pharmaceutics and Biopharmaceutics, The Annals of pharmacotherapy, The Western journal of medicine, Health Expectations, BioMed Central, American Journal of Pharmaceutical Education, American Health & Drug Benefits, British Journal of Clinical Pharmacology
List of Pharmacy Recruiting Agencies (in Brief)
- UK: Spencer Clarke Group, Flow care services limited, Health Care Recruits, HRSS Recruitment Specialists, Kaleidoscope Consultants Ltd, Team 24, Pearls International etc.
- US: UnitedTM Pharmacy Staffing, Cameron and Company Inc., CareerStaf Unlimited®, Empire Pharmacy Consultants, Rx relief (Fresno, California) etc.
- Canada: Kelly Services, MNM Medical Recruiters, TAL Group Inc., RPI Consulting Group, Health Match BC, Grapevine Executive Recruiters Inc. etc.
- Australia: LocumCo, Raven's Recruitment, Wavelength International, Career Medical Recruitment, Frontline Retail Recruitment etc.
- UAE: Robert Half, Adecco Middle East, TASC Outsourcing, Hays UAE (Dubai), Mindfield FZ LLC, Parker Connect Consultants (Crowne Plaza Dubai) etc.
- New Zealand: Medacs Healthcare (Auckland), Horizon, Alpha Recruitment, Michael Page (Auckland), Life Plus etc.
- Denmark: Compass HR Group, UniqueConsult, Hartmanns, StepStone, CBP Network, Stanton Chase, JKS Vikar & Recruitment etc.
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2. “Code of Ethics for Pharmacists - ASHP.” Accessed July 9, 2020. https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/code-of-ethics-for-pharmacists.ashx.
3. Mohiuddin AK. Prospect of Tele-Pharmacists in Pandemic Situations: Bangladesh Perspective. Journal of Health Care and Research. 2020;1(2):72-77. doi:10.36502/2020/hcr.6164.
4. Mazid MA, Rashid MA. Bangladesh Pharmaceutical Journal, Vol. 14, No. 1, January. Pharmacy Education and Career Opportunities for Pharmacists in Bangladesh. Bangladesh Pharmaceutical Journal. 2011;14(1):1-9.
5. Walton SM, Manasse HR Jr. Is It a Good Time to Be a Pharmacist in the US?. Pharmacy (Basel). 2018;6(3):61. Published 2018 Jul 3. doi:10.3390/pharmacy6030061
6. Mohiuddin AK. Pharmacists in Public Health: Scope in Home and Abroad. SOJ Pharmacy & Pharmaceutical Sciences. 2019;6(1):1-23. doi: 10.15226/2374-6866/6/1/00196
7. Dameh M. Pharmacy in the United arab emirates. South Med Rev. 2009;2(1):15-18.
8. Saw PS, Nissen LM, Freeman C, Wong PS, Mak V. Health care consumers' perspectives on pharmacist integration into private general practitioner clinics in Malaysia: a qualitative study. Patient Prefer Adherence. 2015;9:467-477. Published 2015 Mar 19. doi:10.2147/PPA.S73953.
9. Cooper R. Pharmacists’ demand highest in rural and remote areas. Australian Pharmacy/Industry, November 13, 2019.
10. New Zealand Pharmacist Salaries. Available in: https://www.enz.org/salary-pharmacist.html
11. The Daily Star. '36pc BD employers facing skilled manpower shortage'. National, May 04, 2019.
12. Mohiuddin A. An A-Z Pharmaceutical Industry: Bangladesh Perspective. Asian Journal of Research in Pharmaceutical Science. 2019;9(1):17. doi:10.5958/2231-5659.2019.00004.3
13. Alam G, Shahjamal M, Al-Amin A, Azam M. State of Pharmacy Education in Bangladesh. Tropical Journal of Pharmaceutical Research. 2014;12(6):1106. doi:10.4314/tjpr.v12i6.36
14. Mohiuddin AK, Nasirullah M. Scope of Tele-Pharmacists in Pandemic Situations of Bangladesh. Curr Tr Clin & Med Sci. 1(5): 2020. CTCMS.MS.ID.000525.
15. Chapter 1. Pharmacy Practice at a Glance. In: Abdul kader Mohiuddin. The Role of the Pharmacist in Patient Care, published by Universal Publishers, 2020. ISBN-13: 9781627343084, Page 14.
1. Kenneth W. Schafermeyer. McCarthy's Introduction to Health Care Delivery: A Primer for Pharmacists, published by Jones & Bartlett Publishers, 2016. ISBN 1284094103, 9781284094107
2. Bruce Lubotsky Levin, Ardis Hanson, Peter D. Hurd. Introduction to Public Health in Pharmacy, published by Oxford University Press, 2018. ISBN 0190238305, 9780190238308
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4. Federal Pharmacists: Leading Through APhA. Journal of the American Pharmacists Association. 2003;43(5). doi:10.1331/154434503322612302
5. Zweber A. Pharmacy: An Introduction to the Profession. Am J Pharm Educ. 2009;73(8):140.
6. Jommi C. An Introduction to Economic Evaluation of Health Care Programs. Economic Evaluation of Pharmacy Services. 2017:1-9. doi:10.1016/b978-0-12-803659-4.00001-1
7. Kahaleh AA. Chapter 3: Pharmacy Reborn: From Clinical Services to Pharmacists’ Patient Care Services. Pharmacy: An Introduction to the Profession, 3rd Edition. 2016. doi:10.21019/9781582122779.ch3
8. Burrows J. Becoming pharmacists: exploring professional development of pharmacists following graduation. doi:10.14264/uql.2019.291
Chapter 2. Bangladesh Pharmaceutical Industry
Pharma market is now a days one of the fastest growing sector of Bangladesh. Considering 1950 to present, significant changes taken place. After liberation, Bangladesh pharma industry was largely dominated by the import dependent MNCs. On or before 1982 ordinance, 75% of the market was dominated by the MNCs and the rest share was with the other 133 local companies 1. After NDP formulation and the Drug Control Ordinance, there was a dramatic change of reverse. By 1994, a few pharma companies achieved a tremendous growth and they reinvest their profit for faster return. In 2015, the WTO extended patent waivers for pharmaceuticals products for its members in the least developed countries category to January 2033. In 2018, the country's domestic pharmaceutical market size stood at BDT 205 billion with 15.6% compound annual growth rate (CAGR) for the last five years. Over the last three years, approximately $250 million was invested in the sector and market is expected to be worth between BDT 400 billion and 500 billion by the year 2022-23 [2-4]. Reasons behind its growth are economic development, population blast, investment scopes, FDIs along with many other unexplained matters. The annual growth of the sector was estimated to be more than 24% in 2018-2019, which is nearly 7% by now due to Covid-19 pandemic 5.
Products of The Industry
The Directorate General of Drug Administration under the Ministry of Health & Family Welfare, Govt. of Bangladesh, is the Drug Regulatory Authority of the country. This Directorate supervises and implements all prevailing Drug Regulations in the country and regulates all activities related to import and procurement of raw and packing materials, production and import of finished drugs, export, sale, pricing, etc. of all kinds of medicine including those of Ayurvedic, Unani, Homoeopathic and Herbal systems 6. Among complementary medicine arena, at present there are 295 Unani, 201 Ayurvedic, 15 Herbal, 79 Homeopathic and nearly 300 allopathic companies operating in Bangladesh. The industry has 3,657 generics of allopathic medicine, 2,400 registered Homeopathic drugs, 6,389 registered Unani Drugs and 4,025 registered Ayurvedic drug 3, 7.
Local Market Overview
It’s predominantly a branded generic marketplace. They can either sell to the private sector pharmacies, to the government and its public health care establishments (HCEs), or to international organizations like UNICEF. The top 20 companies Pharma are having a combined market share of near 80% of the total pharmaceutical market of the country 8. Bangladesh Association of Pharmaceutical Industries (BAPI) was instituted in 1972, since then BAPI playing a pivotal role in shape up of the industry.
1. The primary layer of R&D Activities. This is often a very costly and high-risk business, and for many of global Pharmaceutical firms, represent the majority of costs. However, to continue to develop export capacity, sector specialists strongly emphasize the need for increased investment in R&D.
2. The second layer is manufacture of ingredients for finished formulations. These activities cover production of API, solvents and excipients used as raw material for drug formulations. Historically, Bangladesh is an import dependent country for API and others. The local manufacturers arrange raw materials from China, India, Japan, Germany, France, Holland, Italy, Switzerland, Austria, Hungary, Ireland etc.
3. The final layer concerns producing final products, finished formulations. In this layer, there are both patented and generic products. However, in Bangladesh, only generic products are produced. Formulations represent the mainstream business in pharmaceuticals industry of Bangladesh. Presently, the market consists of approximately 8000 generic products and 258 firms with manufacturing capability, along with some imported patented products [9-12].
1. High-End Biotech Products (Anti-Cancer, Insulin, Vaccines etc.): These are essentially products specific to market niches, i.e. Anti-cancer, Diabatic products, Vaccines etc. these products are usually high priced and represent a small portion of the market. Profit margin in such products is very high. Recently, domestic firms have been entering into this field, and competition is expected to drive prices and import dependency down.
2. Branded generics (Anti-Ulcer, Antibiotic etc.): This represents broadest segment of the market, comprising products with relatively stable margin and Brand orientation. This segment is dominated by local manufacturers, and due to high brand loyalty observed in our market, market share of manufacturers is usually moving rarely.
3. Low End generics: This segment is small, often for products with low branding possibility, and price war is most evident here. The number of competitors is very high, and market share of each competitor depends on success of marketing strategy.
4. Contract manufacturing (Domestic and export): Locally, this segment is small as almost every firm manufactures its own products. The business usually comes from Health organizations like SMC (Social Marketing Company), UNICEF etc. to provide products such as saline, contraceptives etc. Presently, a number of top firms engage in contract manufacturing. Competition is very low, as each firm engages based on foreign counterpart relations 1.
A number of companies have already obtained or in the process of obtaining UKMHRA, EU, TGA, Australia and GCC certifications. At the beginning it was exporting pharmaceutical products to Vietnam, Singapore, Myanmar, Bhutan, Nepal, Sri Lanka, Pakistan, Yemen, Oman, Thailand, and some countries of Central Asia and Africa. The industry today exports, besides a large spectrum of generic drugs, high-tech specialized products like HFA inhalers, suppositories, nasal sprays, IV infusions, etc., to nearly 15 countries. It also has a large market in European countries. However, it remains to be said that in view of the highly regulated markets of the advanced countries, most of the exports are confined to the less regulated markets in the developing world. Approximately 1,200 pharmaceutical products received registration for export since 2018 [13,14].
The import is mostly from nearby countries, especially from India and China. Almost 95% of the BDT 5,000 crore worth of raw materials required by the pharmaceutical sector are imported 15. Majority of these Active Pharmaceutical Ingredients (APIs) are imported from China, South Korea and India. Approximately 75-80% of the imported APIs are generic and 20-25% is patented 16. Novo Nordisk and Medimpex are importing maximum amount of these types of products. Other organizations are engaging to import the pharmaceuticals products. They are- Sanofi, Aventis, GSK (now closing operation), Sandoz, Novartis, Roche, UniMed UniHealth, Servier etc. Certain vaccines, anticancer products, hematological products and other biotech products are imported [17,18].
The industry had to import about 97% of API every year for pharmaceutical goods production. Although banned in domestic market, Ranitidine tablet was exported to dozens of countries but it had to stop due to API shortage. The government initiated a high-tech park for API production in 2008 and expected to launch in early 2023. However, The API park built at Gazaria in Munshiganj (a 38 million BDT project on 200 acres land) does have space to accommodate more than 40 API producers. This delay has been a major hurdle for the pharmaceutical industry to gain better control over the inputs and improve operational efficiencies. India, the major generic drug player, has more than 3500 Drug Master File (DMF) approval for APIs whereas Bangladesh has none. While the industry is achieving self-sufficiency, it yet procures 90% of raw materials from 98 indenters around the world as only one company (Active Fine Chemicals) produces raw materials independently. Currently, the company produces 25 active pharmaceutical ingredients and three types of laboratory reagents. There are 3000 valid sources of raw materials including countries like China, India, Taiwan, Italy, Germany, Spain, Switzerland, France, the UK and the US. API consists a significant percent of total cost in medicine which can run up to 30-40%. At present, only a few companies – Square, Beximco, Ganasastha Pharmaceuticals, Globe and Active Fine – are manufacturing raw materials for drugs like paracetamol, amoxicillin, flucloxacillin, ampicillin and metformin, on a limited scale [19-22].
Domestic Drug Distribution
Bangladesh’s drug market place is composed of small independent pharmacies. Pharmaceutical firms can sell their products to private sector pharmacies, the government and its public health care facilities, or to international organizations operating in Bangladesh (e.g., UNICEF). About 70% of prescribed drugs is distributed through wholesalers to hospitals, health maintenance organizations (HMOs), and retail pharmacies. There are approximately 200,000 unregistered and around 150,000 of registered drug stores in Bangladesh. Consumers purchase one to ten tablets or capsules at a time. The quantity of drugs purchased often depends more on the consumer’s finances of than on the required dose. The unscrupulous drug sellers sell almost 90% of the stocked drugs without prescription and also date expired drugs are sold in more than 90% drug stores [23-25].
Access to Essential Drugs
Although officially 80% of population has access to affordable essential drugs, there is plenty of evidence of a scarcity of essential drugs in government healthcare facilities. A study conducted in four district hospitals and one medical college hospital showed that less than 10% of patients received the prescribed medicines from these facilities. In most such cases, government officials and health professionals are responsible for the shortage as they often sell government-supplied drugs to local drug stores instead of dispensing them to poor patients [26-28].
Quality of Available Drugs
According to the WHO, falsified medicines, including contaminated, or contain the wrong or no active ingredient, or may be out-of-date, is worth more than $30bn in LMICs. Only 20 to 25 top pharmaceutical companies among the 300 produce drugs of standard quality. An estimated Tk 600 crore of counterfeit medicines are traded in the Tk 18,000 crore medicine market in Bangladesh each year 29. It is widely alleged that adulteration flourishes in the country because of poor government vigilance and supervision over drug manufacturers and sellers. Also, quality of alternative medicines still lags behind due to various bottlenecks as well as lack of goodwill on the part of the stakeholders. However, Bangladesh is capable of producing high-quality products as the industry employs state-of-the-art manufacturing facilities, sophisticated quality control equipment and skilled human resources. To achieve the goals of marketing, especially in high-value overseas markets, it has to fulfil the compliance norms which are often market-specific.
Medical representatives, who are given annual drug sales targets, offer various gifts, from stationery items to sample drugs to air tickets for overseas trips, while using persuasion. Acceptance of these gifts, especially the expensive ones, obliges the physicians to return the favor by changing established prescription norms and increasing drug sale. Pharmaceutical companies in Bangladesh spend more than Tk 6,000 crore on marketing a year, around 30% of their turnover in 2018. A study shows that the companies employ 65% of the work force in marketing — medical representatives 45% and sales representatives 20%. Accordingly, the costs of drugs increase because of the huge expenditure on marketing [30,31].
On May 28, 1992, a policy guideline for fixation of prices of drugs has been framed, which is still followed by the pharmaceuticals industries. But due to an amendment brought to the drug policy in 1994, the onus of fixing medicine prices outside essential drugs' list went back to the producers. The VAT rate applicable to production of medicines is 15% and to sales of the products is 2.4% cent under the new VAT and Supplementary Duty Act-2012 that came into effect from July 1, 2019. That means, for a unit of medicine with trade price at production stage at Tk 100, VAT will be Tk 17.78. And the price is fixed including 16% commission the manufacturers give to chemist or pharmacy [32-34].
Import of innovator drugs without valid licenses was prohibited and punishable under the Drugs & Cosmetics Act, 1940. Many of these spurious and unlicensed drugs are imported by luggage parties in an extremely clandestine and surreptitious manner. This surreptitious trade channel witnesses supply of these drugs without maintaining cash memos, demanding prescriptions or issuing invoices, and only against cash payments. Some of these imported medicines are sold in the country market at a much higher price than Bangladeshi medicines. This creates the barrier to capture the market share by Bangladeshi pharmaceutical industries. There are also entities which are manufacturing spurious and unlicensed drugs with a fictitious address and contact details to escape any possibility of being detected. Many spurious and unlicensed drugs are also advertised and supplied through media or by a doctor himself [35,36].
It is largely protected from external competition by the restriction regarding import of similar drugs manufactured locally. But our industry is not afraid of this foreign competition. There are many multinational pharmaceutical organizations which have established their plants in Bangladesh and importing their raw materials from abroad. Among these competitors, Roche, Novartis are leading. In export market, the Novartis is playing the dominant role. GSK, Organon, ICI, Pfizer closed their operation at different time periods [37,38].
MNCs facing a lot of problems:
In pharmaceutical sector, multinational corporations are more concerned about research and development than locally owned companies. In Bangladesh, they are facing a lot of difficulties as none of them are to market their products without their own factory in Bangladesh. No foreign brands are allowed to be manufactured under third party license. Imports are also prohibited if similar products are manufactured locally. And if the International patented trade name of the brands is allowed if their raw materials are brought from the patented companies, which make MNCs to price their products higher than the national companies in this generic market. As NDP 1982 implemented, most multinational companies sold their business to local pharmaceutical. This fueled to the evolution of the local pharmaceutical sectors. MNCs were dissatisfied with this development, already. However, Under the 1982 Ordinance, the Government determines Maximum Retail Prices (MRP) of essential drug chemical substances. This is applicable for the local companies and still now the MNCs are determining their price by their own way 1.
Pharmaceutical companies are increasingly engaging in toll or contract manufacturing, a development that allows them to utilize unused capacities and reduce the need for fresh investment. Toll manufacturing, ushered in by the government in the National Drug Policy 2005, is an arrangement in which a company with specialized equipment processes raw materials or semi-finished goods for another company. As potential hub for global contract manufacturing, key advantages of Bangladesh were: Patent waiver up to 2032; reverse engineering of new molecules for API synthesis (already stopped in India and China); and overhead cost (manpower+ utility cost) per unit conversion cost of product is 30% less. Contract manufacturing is mainly used for specialized or high-tech products, the facilities for which require considerable capital investment. It is unfeasible for a firm to develop facilities to make a single product. However, Bangladesh pharma companies can only contract manufacture for domestic distribution with MNCs that already have a manufacturing facility in Bangladesh. For example: Beximco contract manufactures Ventolin, which is an inhaler for GSK. More than 30 local companies including Renata, Beximco and Popular are currently engaged in toll manufacturing for their local counterparts or MNCs 39.
Emerging Business of Herbal Medicines
According to the WHO, about 80% of the population in developing countries including Bangladesh depends on traditional healing for their primary healthcare needs. The market size for herbal medicines including Ayurvedic and Unani is expected to be BDT 250 billion in Bangladesh, which was BDT 100 billion in 2010. The government termed herbs and herbal medicine as one of the five priority sectors to diversify the country's export basket. Industry people observed that Bangladesh has prospect in making footsteps on the global market for medicinal plant and products as nearly 650 medicinal plant species have been identified to be in use in Bangladesh with around 25 plants having high value. Over 30 companies have lined up for licenses from the drug administration to manufacture such medicines to exploit business potentials in the sector, still almost untapped.
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8. Report on Pharmaceutical Sector of Bangladesh: Prospects and Challenges. Available in: http://dspace.bracu.ac.bd:8080/xmlui/bitstream/handle/10361/3220/13274025.pdf?sequence=1&isAllowed=y
9. Chowdhury MAA. TRIPS and Innovative Capacity of Bangladesh’s Pharmaceutical Industry: Promotion of Access to Essential Medicine. IIUC Studies. 2016:111-126. doi:10.3329/iiucs.v10i0.27430
10. Karim R. Cut dependence on pharma raw materials' import. The Financial Express/Trade, January 27, 2018.
11. Nadin M. Growth Of Pharmaceutical Company In Bangladesh. Available in: http://dspace.daffodilvarsity.edu.bd:8080/bitstream/handle/20.500.11948/1866/P05743.pdf?sequence=2&isAllowed=y
12. Rahman MF. Window of opportunity for the pharma industry. The Daily Star/ 25th anniversary special part-2, February 02, 2016.
13. UK Trade & Investment. Sector briefing: Pharmaceutical opportunities in Bangladesh. Available in: https://s3.amazonaws.com/StagingContentBucket/pdf/20110926121243121.pdf
14. Sheel SK. Problems of Export of Pharmaceutical Products from Bangladesh : An Analysis . Journal of Business Studies. 2015;36(3):23-37. https://www.fbs-du.com/news_event/15053071512. Dr.pdf. Accessed July 9, 2020.
15. DataBD.CO. Pharmaceuticals. Available in: https://databd.co/profiles/industries/profile-pharmaceuticals
16. Pharmaceutical Processing World. Pharma in Bangladesh. April 29, 2015. Available in: https://www.pharmaceuticalprocessingworld.com/pharma-in-bangladesh/
17. Rahman S. GSK shuts factory after six decades. The Daily Star/Back Page, July 27, 2018.
18. Mirdha RU. Sanofi to leave Bangladesh. The Daily Star/Business, September 15, 2019.
19. Khan S. Expediting completion of API industrial park. The Financial Express/Opinion, August 28, 2019.
20. Haider S. A prescription for growth. DhakaTribune, February 12, 2015.
21. Uddin J. Government discourages API export amid China supply snag. NEWAGE/Business, March 08,2020.
22. Noyon A. Pharma industry spending a fortune on importing raw materials. The Business Standard/ Pharma, 02 November, 2019.
23. Moniruzzaman M. Supply Chain Management in Pharmaceutical Industries: A Study on Eskayef Bangladesh Ltd. Available in: https://core.ac.uk/reader/74352570
24. Ahmed SM, Naher N, Hossain T, Rawal LB. Exploring the status of retail private drug shops in Bangladesh and action points for developing an accredited drug shop model: a facility based cross-sectional study. Journal of Pharmaceutical Policy and Practice. 2017;10(1). doi:10.1186/s40545-017-0108-8
25. Hossain MA, Amran MS. A Cross-Sectional Pilot Study on Pharmacovigilance to Improve the Drug Safety in Bangladesh. Biomedical & Pharmacology Journal. 2019;12(3):1039-1049. doi:10.13005/bpj/1733
26. Akter SF, Rashid MA, Mazumder SK, Jabbar SA, Sultana F, Rahman MH, et al. Essential drugs in Bangladesh and role of different stake holders – A qualitative study. Int J Sci Environ Technol. 2012;1:506–18.
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28. Mannan MA. Access to Public Health Facilities in Bangladesh: A Study on Facility Utilisation and Burden of Treatment. Bangladesh Development Studies. 2013;36(4):25-80. https://bids.org.bd/uploads/publication/BDS/36/36-4/2_Mannan.pdf.
29. Mohiuddin AK. Patient Satisfaction: A Healthcare Services Scenario In Bangladesh. The American Journal of Medical Sciences and Pharmaceutical Research. 2020;02(05):15-37. doi:10.37547/tajmspr.v2i05.344
30. Maswood MH. Tk 6,000cr spent on drug marketing a year. NEWAGE/Bangladesh, Dec 09, 2019.
31. Mohiuddin M, Rashid SF, Shuvro MI, Nahar N, Ahmed SM. Qualitative insights into promotion of pharmaceutical products in Bangladesh: how ethical are the practices?. BMC Med Ethics. 2015;16(1):80. Published 2015 Dec 1. doi:10.1186/s12910-015-0075-z
32. Staff Correspondent. VAT on pharma items included in retail prices: NBR says. NEWAGE/Business, July 24, 2019.
33. Mala DA. Industry frets about possible drug price hike. The financial Express/Trade, August 25, 2019.
34. Star Business Report. VAT on medicine sales unchanged at 2.4pc: NBR. The daily Star/Business, July 24, 2019.
35. Khan SI, Reza MM, Crowe SM, et al. People who inject drugs in Bangladesh - The untold burden!. Int J Infect Dis. 2019;83:109-115. doi:10.1016/j.ijid.2019.03.009
36. Rabbi AR. Drugs, smuggled goods worth Tk14.94cr seized by BGB in April. DhakaTribune/Bangladesh, May 1, 2020.
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Chapter 3. Bangladesh Health System Review
Bangladesh is the seventh most populous country in the world and population of the country is expected to be nearly double by 2050. According to the 2018 Country Environmental Analysis (CEA) report of the World Bank, air pollution causes the deaths of 46,000 people in Bangladesh per year 1. Less than 10% hospitals of this country follow the Medical Waste Management Policies. In 2017, 26 incidents of disease outbreak were investigated by IEDCR 2. The rising burden of communicable diseases in Bangladesh can be related to rapid urbanization, and nearly 50% of the country's slum dwellers live in Dhaka 3. There is little assessment of the quality of provider care, low levels of professional knowledge and poor application of skills. Bangladesh does not have a formal body for arbitration of complaints against health providers. Hospital or clinic authorities address complaints and disputes independently, without involving the government or legal entities. Bangladesh's post-disaster management is inadequate due to a lack of adequate compensation, inadequate or inaccessible health care facilities and the slow rehabilitation process to accommodate disaster survivors within the mainstream society.
Implication of Medical Law and Ethics
Unsurprisingly, death due to oversight of physicians or medical laxity and doctors' incompetence have been reported in the media all the year-round. Laws such as the Penal Code 1860, Code of Criminal Procedure 1898, Consumer Rights Protection Act, 2009 under which cases can be filed for legal remedies 4. In the event of death due to medical laxity, cases may be filed under the penal code, 1860, as death by laxity is a criminal offence and is punishable under section 304A of the penal code 5. There are also provisions for imprisonment and fine which are equally applicable to both the doctors and the complainants. Doctors usually give little time, often less than one minute, to examine patients and mistreat them; fixated mind-set of hospital staff who overestimate their own performance, care little about the patients’ experiences and don’t know that patients’ satisfaction index is related to clinical outcome [6,7].
Present Healthcare Situation
According to WHO, the current doctor-patient ratio in Bangladesh is only 5.26 to 10,000, which places the country second from the bottom, among the countries of South Asia 8. According to the Bangladesh Medical and Dental Council, there were 25,739 registered male doctors in the country between 2006 and 2018 (47%) and 28,425 female doctors (53%) 9. Average consultation length is used as an outcome indicator in the primary care monitoring tool which was found was found a less than a minute to an outdoor patient. An average 1.5 hours is to spend to see a doctor in Dhaka Medical College and other public hospital outdoors, sometimes there are no doctors due to post vacancy 10. Patients’ struggle for essential services during any disease outbreak in hospital indoor and outdoor is common. The country has just 127,000 hospital beds, 91,000 of them in government-run hospitals. Overall, 67% of the healthcare cost is being paid by people, whereas global standard is below 32% [11,12]. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. Unnecessary diagnostic tests and caesarean sections are also common and impose a substantial economic burden on the poor. Bangladesh Health Facility Survey (BFHS), 2017 reveals that over 70% of rural health facilities do not have all six basic supplies (thermometers, stethoscopes, blood pressure gages, infant and adult weighing scales, and torch lights) 13. Only about half of doctors employed in district-to-union sub-center public hospitals are satisfied with the availability of medicines in their facilities, suggesting a widespread lack of stocks of medications in public amenities. In 2013/2014, the infant mortality rate, which is 34 per 1000 live births in urban areas overall, and 40 in rural communities, rises to nearly 70 in urban slum areas. More than 80% of the population seeks care from untrained or poorly trained village doctors and drug shop retailers. ‘Oversight of Physicians’ and ‘Inappropriate Treatment’ have become commonly-used phrases in print and electronic media of Bangladesh. The 2019 Dengue outbreak in August 2019 alone caused more than 50,000 hospital admissions and around 100,000 hospitalizations and claimed 112 deaths from January to October 2019, where hospitals had been unable to cope with the huge number of patients flooding the hospitals 14. The country is hosting 1.1 million Rohingya refugees, who are posing serious threat of diphtheria, HIV and other STDs transmission along with Covid-19.
System Collision with Traditional Medicine
There are around 86,000 villages in the country and almost every village has one or two traditional practitioners 15. More than 65% of Bangladesh's population receive first-line healthcare services primarily from village doctors. An estimated 75% of the country's people use traditional medicine for their health care 16. 70% of females also used at least one herbal product during their last pregnancy, mostly without a qualified medical care practitioner's consultation. Again, alternative/traditional medicine are not included in the medical school curriculum except in Ayurvedic Medical College of Bangladesh. Illiteracy, poor financial status, social context, uncertain diagnosis and treatment costs, physician absenteeism in rural health complexes, divergent medical opinions, unhealthy competition between healthcare professionals and their tendency to linger on treatment, negative impression of expensive medical tests and unnecessary food supplements, as well as easy accessibility and accessibility of alternative medicine diverted the patients to seek help from orthodox to alternative medicine 17.
Drug Cost Vs OOP Expenditures
Out-of-pocket (OOP) treatment cost raised nearly 70% in the last decade. About 2/3rd of the total health expenditure is from OOP, and of this, 65% is spent at the private drug retail shops [18,19]. Very often, medical representatives rush at peak hours and aggressively pulls patient prescriptions in the name of survey. Prescribing antibiotics in 44% consultations, prescribing of 3 or more drugs in 46% in urban centers and 33% in local health centers clearly raise OOP expenditure and create strong repulsion towards modern medicine where nearly 22% of the population is below poverty line 20. Moreover, doctors are more often accused to take 30% to 50% commission on a test from hospitals/diagnostic centers. Neither the regulatory authority nor the professional or consumer rights bodies has any role to control or rectify the process. 'Global Monitoring Report on Financial Protection in Health 2019' estimates that around 7% households are pushed into poverty due to OOP outlays wherein chronic non-communicable diseases are the principle contributor 21. Middle class families spend 11% of their total budget on healthcare, with 9% of households facing financial disaster, with 16.5% of the lowest paid and 9.2% of the richest households facing catastrophic health expenditure 22.
Prescription patterns of drugs
Despite legal prohibitions, numerous drugs with similar or no significant benefits are available in the market. As a specific example, there are seven members of the Angiotensin-Converting Enzyme (ACE) inhibitors available in the country 23. The efficacies and chemical structures of these molecules are more or less similar, but their prices vary. The drug policy clearly prohibits the production of multi-ingredient preparations of vitamins and minerals with the exception of B-complex vitamins, but a mixture of 32 vitamins and minerals including selenium, vanadium, molybdenum, tin and many other unnecessary ingredients has been marketed in the country for a few years, violating the principles of the NDP 24. The need for these trace elements in Bangladesh is not established whereas nutritional deficiencies are mainly related to vitamins A and B-complex, iron, calcium, iodine and zinc. Irrational prescription and use of antibiotics are rampant throughout the country, with an estimated half of all antibiotics being sold without prescriptions 25.
Downgrading Image of Supplied Medicines
Fake drugs kill more than 250,000 children a year worldwide. Rural people, who are believed to be unaware of the situation are generally the victims of the adulterated medicines. "People are taking poison without knowing it," according to the Dean, faculty of Pharmacy at the University of Dhaka, who noted sales of counterfeit or sub-standard medication are most common in rural areas due to the lower levels of health awareness and formal education there 26. According to a survey by BSMMU, as many as 2,700 children died due to renal failure after taking toxic syrup from 1982 to 1992 27. Recently, a lot of people are being cheated in buying adulterated insulin. The government revoked licenses of 20 pharmaceutical companies for producing adulterated and low-quality medicine back in 2016. Besides those, licenses of 14 companies to manufacture antibiotics (penicillin, non-penicillin and cephalosporin groups) are revoked and permission of 22 companies to produce medicine of penicillin and cephalosporin groups be suspended 28. Around 370 cases of fake medicines had been filed in the first 6 months of 2019, according to the DGDA 29. Even hospitals like Apollo and United, were accused for keeping and selling of substandard reagents and drugs. Drug Testing Laboratories in the country, are fully-equipped with modern machines and other testing facilities but their performance is much lower than (5% of the total produce) present demand where more than 25,000 brands that produce more than 100,000 batches of medicines by nearly 300 pharmaceutical companies.
Quality of Medical Education
In a parliamentary session June 2019, the Health Minister informed that close to 50% teaching positions are vacant in public medical and dental colleges, where most of the vacant posts are of the basic subjects. The disappointing poor performance of the private medical colleges noted from the honorable prime minister in a seminar on critical disease treatment in Bangladesh. A deficit in 65% teaching staffs in both public and private medical colleges has also been reported. Generally, 80% of medical education should be provided to students through practical classes—the rest is theoretical knowledge. But in some private medical colleges, students do not get to see patients even in their fourth year 30. Doctors without adequate practical and field-based applied knowledge are increasingly become risk factors to the patients they happen to treat. If a degree-holding doctor fails to find the vein for just a saline push-in and then takes the professional help of an experienced nurse it is a shame not only for the doctor in question but also for the whole nation. Definitely all these facts have deep connections to progression of medical studies and quality of future doctors in Bangladesh.
Debasement of Health Providers’ Image
Surprisingly, more than 40% of private hospitals, clinics, blood banks and diagnostic centers are not registered with the relevant government agency 31. The number of hospitals of international or regional standard is quite a few and located only in Dhaka. Taking hostage of dead bodies for not clearing the hospitalization costs by some of the hospitals is becoming quite common. Other allegations also include such as: swapping of a deceased child with a new born baby, abducting or stealing newborn baby, staff not attending to patients in coma, high ICU, keeping clinically dead patients in ICU and raising hospital bill, wrong diagnosis and treatment, absence of human touch and care from the hospital staff, not maintaining proper medical history or lack of electronic health record (EHR) or illegible prescription writing etc. [32-34]. Hospital acquired infection rates in Bangladesh may exceed 30% in some hospitals. Also, rural practitioners routinely made errors in death certification practices (more than 95%) and medical record quality was poor (more than 70%) 35. The country has still not introduced the subject of Emergency and Critical care medicine in the curriculum 1 for graduate medical students.
Present Trend of Medical Tourism
In a press briefing, former health minister of Bangladesh revealed four reasons of Bangladeshi patients seeking medical treatment in abroad (economic solvency, love for treatment abroad, health tourism, and in some cases, for the lack of suitable treatment facilities in the country). However, public health experts, health economists, agents of foreign specialized hospitals and patients reported that Bangladeshis seeking treatment abroad is on an upward trend since patients are unwilling to gamble with their life and health. A low confidence on local doctors and flawed diagnosis are forcing a large number of Bangladeshis to travel abroad for treatment of medical conditions such as cancer, cardiac ailment, autism, infertility, as well as medical check-ups. In fiscal year 2015-16, 165,000 patients from Bangladesh visited different hospitals of India but only around 58,000 medical visas were issued to Bangladeshi nationals. Some 63,000-65,000 patients went to Thailand in 2015. On an average 1,000 Bangladeshis go to India daily and some 10,000 in Malaysia (in a year) to take treatment, as reported by 2 directors of Indian and Malaysian consultancy firms [36-38]. India, Thailand, Singapore and Malaysia are the most visited countries by Bangladeshis medical tourists. For Bangladesh’s economy, increasing medical tourism means the country economy is losing the amount of money Bangladeshis are spending abroad. About 700,000 people go to abroad every year for treatment spending US$ 3.5-4.0 billion during the period 2018-2019 which was $ 2.0 billion in 2012, due to lack of confidence on the local physicians and poor diagnosis system [39,40]. To cash in on the growing demand from Bangladesh's rising mid-income people, some hospitals of India, Thailand, Singapore and Malaysia have either opened their liaison offices or hooked clients through their consultants in Bangladesh. Doctors and nurses are also demotivated by poor working conditions, unfair treatment, and lack of career progression; private and unqualified practitioners sought to please patients instead of giving medically appropriate care.
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6. FE Online Desk. Doctors in Bangladesh see patients for merely 48 seconds on average, reveals study. The Financial Express/Health, November 10, 2017.
7. Hasan MI, Hassan MZ, Bulbul MMI, Joarder T, Chisti MJ. Iceberg of workplace violence in health sector of Bangladesh. BMC Res Notes. 2018;11(1):702. Published 2018 Oct 4. doi:10.1186/s13104-018-3795-6
8. UNDP, Bangladesh. Covid-19: A reality check for Bangladesh's healthcare system. Stories, May 3, 2020.
9. Palma P. Uphill battle of female doctors. The Daily Star/Back Page, May 07, 2019.
10. Irving G, Neves AL, Dambha-Miller H, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open. 2017;7(10). doi:10.1136/bmjopen-2017-017902
11. Mostafa N. Critical Care Medicine: Bangladesh Perspective. Adv J Emerg Med. 2018;2(3):e27. Published 2018 Jan 9. doi:10.22114/AJEM.v0i0.79
12. Fahim SM, Bhuayan TA, Hassan MZ, et al. Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage. Int J Health Plann Manage. 2019;34(1):e11-e20. doi:10.1002/hpm.2666
13. Molla MAM. Govt Hospital: Most lacking even basic equipment. The Daily Star/Front Page, June 30, 2019.
14. Mohiuddin AK. Dengue Protection and Cure: Bangladesh Perspective. European Journal of Sustainable Development Research. 2019;4(1). doi:10.29333/ejosdr/6260
15. Yoshida Y, Harun-Or-Rashid M, Yoshida Y, Alim MA. Perceptions of Ayurvedic medicine by citizens in Dhaka, Bangladesh. Nagoya J Med Sci. 2016;78(1):99-107.
16. Haque MI, Chowdhury ABMA, Shahjahan M, Harun MGD. Traditional healing practices in rural Bangladesh: a qualitative investigation. BMC Complement Altern Med. 2018;18(1):62. Published 2018 Feb 15. doi:10.1186/s12906-018-2129-5
17. Abdul Kader M. An Extensive Review of Patient Satisfaction with Healthcare Services in Bangladesh. Res & Rev Health Care Open Acc J 5(2)- 2020. RRHOAJ.MS.ID.000206. DOI: 10.32474/RRHOAJ.2020.05.000206
18. Mohiuddin AK. Pharmaco-economics: Essential but merely practiced in Bangladesh. Academia Journal of Scientific Research 7(3): 182-187, March 2019. DOI: 10.15413/ajsr.2018.0195
19. WHO, Country Office for Bangladesh. Bangladesh National Health Accounts, an overview on the public and private expenditures in health sector. Available in: http://origin.searo.who.int/bangladesh/bnha/en/
20. Rousham EK, Islam MA, Nahar P, et al. Pathways of antibiotic use in Bangladesh: qualitative protocol for the PAUSE study. BMJ Open. 2019;9(1):e028215. Published 2019 Jan 25. doi:10.1136/bmjopen-2018-028215
21. Tembon M. A larger health budget essential. The Financial Express/Views, December 11, 2019.
22. Khan JAM, Ahmed S, Evans TG. Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh—an estimation of financial risk protection of universal health coverage. Health Policy and Planning. 2017;32(8):1102-1110. doi:10.1093/heapol/czx048
23. Islam MS. Therapeutic drug use in Bangladesh: policy versus practice. Indian Journal of Medical Ethics. 2008. doi:10.20529/ijme.2008.009
24. Nasir M, Paul PC, Sinha SK. Multi-Centre Study on Practitioner’s Knowledge about Sources of Drug Information and Rational Prescribing Practice in Bangladesh . Advance Research Journal of Medical and Clinical Sciences. 2016;2(1):1-5.
25. Laizu J, Parvin R, Sultana N, Ahmed M, Sharmin R, Sharmin ZR, et al. Prescribing Practice of Antibiotics for Outpatients in Bangladesh: Rationality Analysis. Am J Pharmacol. 2018; 1(1): 1008.
26. Mohiuddin AK. Patient satisfaction with healthcare services: Bangladesh perspective. International Journal of Public Health Science (IJPHS). 2020;9(1):34. doi:10.11591/ijphs.v9i1.20386
27. Hossain E, Halder CC. A regret for life: Mother still laments for trusting a medicine; verdict on toxic syrup today, 27 yrs after death of her 2 kids. The Daily Star/Front Page, August 13, 2015.
28. Shaon AI. HC orders 20 pharmas to shut down, bans antibiotics of 14 more. DhakaTribune/Bangladesh, February 13th, 2017.
29. Rabbi AR. 22 pharmacy owners fined for selling expired, fake medicine. DhakaTribune/Bangladesh, June 20th, 2019.
30. Hasan S. Medical education in Bangladesh and its impact on doctors and patients. The Independent/Editorial, 8 June, 2018.
31. Khan S. Anarchy rules healthcare system, Financial Express, July 09, 2017.
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33. Staff Correspondent. Hospitals cannot refuse to hand over dead patients to relatives for unpaid bills: High Court. Bdnews24.com, November 20, 2017.
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Chapter 4. Clinical Pharmacy Practice
Clinical pharmacy took over an aspect of medical care that had been partially abandoned by physicians. Overburdened by patient loads and the explosion of new drugs, physicians turned to pharmacists more and more for drug information, especially within institutional settings. Once relegated to counting and pouring, pharmacists headed institutional reviews of drug utilization and served as consultants to all types of health-care facilities. In addition, when clinical pharmacists are active members of the care team, they enhance efficiency by both providing critical input on medication use/dosing and working with patients to solve problems with their medications and improve adherence.
Figure 1. Benefits of clinical pharmacists 1.
Abbildung in dieser Leseprobe nicht enthalten
Accountabilities of a Clinical Pharmacist
1. Develop clinical pharmacy programs according to policies and regulations
2. Review records of patients to determine the appropriateness of medication therapy
3. Evaluate patient’s condition to ensure all issues are being treated
4. Identify untreated health problems and refer patients to appropriate physicians
5. Develop effective medication plans that minimize the risk of adverse side-effects
6. Consult on dosages, medication substances etc.
7. Advise on the correct administration of drugs
8. Assess the results of pharmaceutical treatments
9. Collaborate with healthcare professionals to ensure optimal patient care
10. Keep accurate documentation of medication plans and patient progress 2
Evolution of Clinical Pharmacy
Its development began in the early 1950s, primarily as a result of the efforts of Harry Gold. Pharmacist rounding with inpatient hospital services has been traced to the University of Kentucky in 1957. Drug therapy was becoming much more complex. Graham Calder pioneered a new role for pharmacists on hospital wards in Aberdeen, Washington. The role of clinical pharmacists underwent important changes from the 1960s through 1990s as their participation in direct patient care increased. In the early 1970s, federal funding assisted with greatly expanding clinical pharmacy faculty in Colleges of Pharmacy. Pharmacy education debated where clinical pharmacy fit within pharmacy training. The AACP spearheaded an effort to examine this issue. Till then, two full generations of pharmacists have been educated and trained after the general adoption of the aims of clinical pharmacy. ACPE has revised the standards for colleges and schools of pharmacy several times since 2000. ACPE Standards 2016 go into effect July 1, 2016 [3-5].
The Clinical Care Pharmacists
Clinical pharmacists assume responsibility and accountability for managing medication therapy in direct patient care settings, whether practicing independently or in consultation or collaboration with other health care professionals. Clinical pharmacist researchers generate, disseminate, and apply new knowledge that contributes to improved health and quality of life 6. Within the system of health care, clinical pharmacists are experts in the therapeutic use of medications. They routinely provide medication therapy evaluations and recommendations to patients and health care professionals. Clinical pharmacists are a primary source of scientifically valid information and advice regarding the safe, appropriate, and cost-effective use of medications. At present, pharmacists must demonstrate their economic value through cost avoidance (either through direct drug cost savings or prevention of adverse events) 7.
Role Within the Healthcare Systems
Clinical pharmacists can contribute their efficiencies in medication review, identification of drug related problems, therapeutic recommendations and promotion of medication compliance. They obtain medical and medication history, check medication errors including prescription, dispensing and administration errors, identify drug interactions, monitor ADR, suggest individualization of dosage regimen, provide patient counseling, etc. They also provide information about the use of drugs and medical devices like inhaler, insulin pen, eye drops, nasal sprays, etc. Participation of a clinical pharmacist in ward/ICU rounds and clinical discussions helps to identify, prevent or reduce drug interactions and ADRs [8,9].
Abbildung in dieser Leseprobe nicht enthalten
Figure 2. Effects of pharmacist’s intervention on humanistic, clinical and economic outcomes in patients with CVD 10.
A. Prescribing Decisions and Prescription Monitoring
The prescription is reviewed for medication dosing errors, appropriateness of administration route, drug interactions, prescription ambiguities, inappropriate prescribing and many other potential problems. Formal assessments of prescription charts in hospitals have shown that there are wide variations in the quality of prescribing and pharmacists are able to identify and resolve many clinical problems. Patients can be questioned on their medication histories, including allergies and intolerances, efficacy of prescribed treatment, side-effects and ADRs 11.
Figure 3. Prescribing Decisions. After assessing a patient, a pharmacist prescriber may find it is appropriate to prescribe, to de-prescribe, or not to prescribe 12.
B. Medication Errors and ADR reporting
The role of a ward based clinical pharmacist with a hospital multidisciplinary committee is effective in recognizing, designing and implementing tailored interventions for reduction of medication errors. Computerizing the whole medication process and improving the pharmacological education of physicians and nurses may help to reduce medication errors. In addition, the adoption of clinical pharmacists on critical wards may also lower the medication error rate. For lowering the frequency of adverse drug reactions, medication errors should be avoided and the dosage of the drugs should be adapted strictly to the function of the eliminating organs. Risk factors such as drug allergies and familiar diseases should be screened for and drug therapies adapted accordingly. Severe ADRs have to be reported to the regional pharmacovigilance centers [13-15].
C. Prescribing Advice to Medical and Nursing Staff
Pharmacists must bridge the observed gap and use a more strategic and consistent approach to build a more positive image in line with other healthcare professionals and in providing patient-centered pharmaceutical care. Studies have shown that clinical pharmacists have a significant impact on patient safety in intensive care units and inpatient wards. Doctors and nurses in this US academic medical center/trauma center overwhelmingly support the presence of an emergency pharmacist (Eph), regularly seek their advice, and feel that they improve patient safety and quality of care. However, the advice given can include help with choice of medicine, dose, method of administration, side-effects, interactions, monitoring requirements and many other aspects of medicines use [16,17].