Defining Opportunities for Pharmacists in Global Public Health
in Resource Limited Countries
by David Steeb
A Master’s Paper submitted to the faculty of the University of North Carolina at Chapel Hill
in partial fulfillment of the requirements for the degree of Master of Public Health in
the Public Health Leadership Program
Chapel Hill
Fall 2017
ABSTRACT
With the profession of pharmacy globally shifting towards more patient-centered
services than product-centered services, there still remains the question of what the role of the
pharmacist can be as not only a patient care provider, but also a public health practitioner. As
one of the most accessible healthcare providers, pharmacists worldwide are exploring how they
can better protect and promote the health of their communities. While high-income countries
have more established patient-centered services with public health implications, such as
vaccinations, disease state management, and lifestyle counseling among others, poor countries
lack recognition of these services, which can hinder their adoption and spread throughout this
part of the world. Low to middle-income countries though often are in the greatest need of
these services where they often face the double burden of both communicable and
non-communicable diseases. Compounding this issue is that not only do poor nations have a higher
disease burden, but also have a greater shortage of health care workers including pharmacists.
There are several areas of need and opportunity for pharmacists in resource-limited
countries to engage in public health services. With the global health care worker shortage,
pharmacists can help fulfil roles in primary care and extend their responsibilities to increase
coverage in gaps of care. Supply chain management is another essential opportunity given the
unique medication knowledge pharmacists have in combination with their familiarity with
workflow and operations of a pharmacy. Additionally, medication safety and adherence
continues to be a significant issue as low to middle-income countries address falsified and
substandard medications. In order for pharmacists to be engaged in these and other services
better be recognized and integrated within the public health infrastructure and systems within
resource-limited areas.
INTRODUCTION
The role of the pharmacist in global public health continues to evolve. Pharmacists
throughout the world have traditionally been involved in product-oriented services such as
dispensing or compounding medications. However, there is a global shift that is occurring from
product-centered to patient-centered and preventative services including disease state
management, family planning, immunizations, lifestyle counseling, health screenings, and
health education among others.1 Many of the patient-centered services that pharmacists are
involved with have public health implications. While these services are more established in
high-income countries such as the United States, Canada, and the United Kingdom, low and
middle income countries are beginning to explore and recognize the contributions of
pharmacists to public health. From health screenings for diabetes and osteoporosis to
immunizations and health education, pharmacists are positioned to have an impact on the
health of both patients and communities. Beyond patient-centered services with public health
implications, pharmacists in both rich and poor countries are also engaged in broader essential
public health services such as community partnership mobilization and innovative research in
order to discover and implement new practice models that advance the profession.2
In limited resource communities throughout the world there is a need and opportunity
for pharmacists to be utilized across key global health areas over and above what is currently
pharmacists can apply their medication expertise to contribute to gaps in care that align with
major global health efforts and programs. The role of pharmacists in these global health areas is
yet to be defined and presents an opportunity to move the profession forward globally in
establishing pharmacists as health care providers who also serve as public health practitioners.
EVOLVING ROLE OF THE PHARMACIST IN PUBLIC HEALTH IN HIGH INCOME COUNTRIES
Traditionally, the role of the pharmacist has focused around product-centered services
such as compounding and dispending medications. As technological advances in manufacturing
occurred along with increased consumer demand for medication information, there was a need
for pharmacists to focus more on patient-centered services as well. As the profession has
shifted its attention over to patients, more attention has been given to what the role of the
pharmacist could be within public health. Pharmacists can vaccinate in the United States,
United Kingdom, and Canada highlighting their role in primary prevention. In Canada, nearly a
third of patients surveyed stated that they would not have been vaccinated against influenza if
it was not provided at their local community pharmacy.3 Tobacco cessation and lifestyle change
recommendations are often services provided by pharmacists across the world. In a systematic
review of public health pharmacy services, 83% of participants stated that pharmacists were
appropriate providers of tobacco cessation services.4 It has been shown that community
pharmacists had a higher success rate of tobacco cessation counseling compared to general
practitioners (physicians) and that they were effective in medication adherence for key diseases
states such as diabetes and cardiovascular disease.5 Additionally, pharmacists and student
chronic disease states such as cardiovascular disease and diabetes as well as emerging health
issues such as pain management and medication disposal.6
Many of the patient-centered services that pharmacists provide mentioned above are
considered to be micro-level public health activities that are part of the responsibilities of a
pharmacist. Currently, there is a lack of participation in macro level engagement such as the
coordination and planning of a community health program and other high level activities within
community organizations or government agencies.7 In 2008, the American Society of
Health-System Pharmacists put out a position paper outlining the activities of health-system
pharmacists that contribute towards public health. These include providing population-based
care, developing disease prevention and control programs, developing health education policies
and programs, collaborating with state and local authorities to address emergencies, engaging
in population-based research, and disseminating new knowledge.8 As part of medication
reconciliation efforts upon patient admission, pharmacists can design screening programs to
detect gaps in immunizations as well as collaborate with social workers to detect barriers to
care. Pharmacists in this setting can also contribute towards the detection and management of
infectious diseases outbreaks. In addition to health system roles, pharmacists are also
employed in government agencies. Careers for pharmacists with defined roles in public health
in the United States are mostly within the U.S Public Health Service (USPHS). Within USPHS, the
most pharmacists work within the Indian Health Service (47%), followed by the Food and Drug
Administration (26%), Bureaus of Prisons (14%), and the National Institutes of Health (13%).9
Pharmacists are capable of being engaged at a higher level within the top ten essential
is because pharmacists are one of the most accessible health care providers.10 A study by the
Royal Pharmaceutical Society of Great Britain estimated that 94% of the population visits a
pharmacy at least once a year.11 Patients can walk into pharmacies often at any time of the day
or night and receive professional advice without an appointment or paying a fee. With reduced
barriers to care, vulnerable populations are able to find quality health services that they
otherwise may not be able to have. There are often behavioral as well as financial barriers that
prevent patients from picking up and adhering to their medications. The National Coalition for
Prescription Information Education found that 50-60% of medications to treat chronic
conditions are not taken as prescribed.12 These issues are often not assessed at the point of
physician diagnosis and can be addressed by community pharmacists who often refer patients
to medication assistance programs or help patients adhere to their medications through
techniques such as motivational interviewing.13
In 2012, the CDC published a program guide on how health care professionals should
collaborate with pharmacists for the control and prevention of chronic diseases.14 Just as
pharmacists are part of team-based care plans, pharmacists should be part of program planning
teams given the fact that nearly 45% of Americans take at least one prescription medication
and that people with chronic conditions account for 91% of all prescriptions filled.15 To help
facilitate these collaborative efforts, the CDC guide recommends using the Community Tool
Box, a free online resource for community health development, as well as the CDC’s Framework
for Program Evaluation.16 In a commissioned report by Public Health England, it too
recommends that community organizations and other healthcare professionals partner with
ROLE OF THE PHARMACIST IN PUBLIC HEALTH – LOW INCOME COUNTRIES
The role of the pharmacist in public health activities is not limited to those in wealthier
nations. The WHO currently recommends 1 pharmacist per 2000 population recognizing the
contributions pharmacists can make to public health worldwide.17 Although the role of the
pharmacist in global public health is not as established as it is for other health disciplines such
as medicine and nursing, pharmacists are positioned to make a difference in global health.18 As
in the United States, pharmacists in developing countries are often one of the most accessible
health care professionals in communities and are positioned to advise on chronic disease state
and lifestyle management. Low income countries are increasingly facing the double burden of
both communicable and communicable diseases where over 75% of deaths due to
non-communicable diseases are attributed to developing countries.19 Although non-communicable
diseases are recognized by the WHO and others as a global health priority, less than 2% of
global health funding currently goes towards NCDs.20 In 2013 the WHO developed the Global
Action Plan for Noncommunicable Diseases with one of the goals having each country achieve
at least 80% access to essential medications for NCDs.21 There has also been the development
of the Non-Communicable Disease Alliance which pharmacists can be part of. Pharmacy
services such as disease state management and patient wellness programs have been shown to
be cost effective in several developed countries with the potential for this to be translated to
limited resource environments.22
The most evident forms of public health participation by pharmacists in LMICs are
occurring in community pharmacy settings. Community pharmacists in Sudan are actively
cessation, contraception, and obesity and weight reduction.23 In Zimbabwe, supply chain
management, health information provision, and chronic disease state management were cited
as public health activities pharmacists are engaged in.24 Zimbabwe pharmacists also view the
provision of medications to vulnerable populations as a public health activity associated with
their ability to manage the supply change and procure the right medications for the right
patients.24 Based on interviews of pharmacists in Zimbabwe though, there are concerns
regarding the quality and consistency of these services. In Nigeria, 94% of surveyed pharmacists
felt that it was acceptable to be engaged in public health activities.25 In Ethiopia, community
pharmacists stated that the public health services they were involved with most were
management and screening of infectious diseases, STD partner counseling, and antimicrobial
stewardship.26 These increased efforts by pharmacists in developing countries to expand into
public health is supported by the WHO concept of a 7 star pharmacist of which one of the stars
is “being a lifelong learner reinforcing the complementary aspects between the fields of
pharmacy and public health”.27
In addition to these opportunities that are common to both high and low income
countries, there are some areas unique to LMICs in which pharmacists can play an important
role. Some of these are mentioned below.
WORKFORCE DEVELOPMENT
Workforce capacity has been identified as one of several factors that enable the
implementation of pharmacy services in resource-limited settings.28 By 2035 it is projected that
pharmacists.29 This translates into nearly 1 billion people not having access to a trained health
worker.30 While much focus is put on physicians, nurses, and community health workers in
filling the gap of the health workforce shortage, there is little effort to recognize pharmacists as
a contributor towards the solution given their training and accessibility. Eighty five percent of
WHO member states report having less than 1 pharmaceutical personnel per 1000
population.31 Developing countries are impacted the most by this shortage of qualified
pharmaceutical personnel across both community and health system sectors.32 Countries such
as Zambia, Uganda, and Ethiopia report having less than 3 pharmacists per 100,000 people
compared to 88 pharmacists per 100,000 in the US.28 A study assessing the necessary human
resources required for scaling up highly active antiretroviral therapy in Malawi identified
pharmacists as the health profession cadre needed the most for the program to be effective.33
Another key issue in attaining an equitable and sustainable workforce is the appropriate
distribution of health care workers in both urban and rural settings. A systematic review of the
pharmacy workforce found that there is a lack of pharmacists in rural compared to urban
settings.34 Retention strategies are needed to place pharmacists in rural areas so that patients
have equitable access to care.
One of the focus areas within the Global Strategy on Human Resource for Health is the
need for more and higher quality education.35 To help facilitate the discussion of advancing
pharmacy education across sub-Saharan Africa, a UNESCO-Unitwin grant supported the
development of the African Centre of Excellence in Pharmacy Education consisting of Ghana,
Nigeria, Namibia, Uganda, and Zambia.36 In 2016 the pharmaceutical workforce development
address the critical shortage of pharmacists and expand their use across the health sector. The
13 different PWDGs focus on a locally-needs based, outcomes-focused approach that span
across the areas of academia, professional development, and systems to fulfil the vision of
advancing the pharmaceutical workforce globally. The PWDGs are intended to be utilized by
each country independent of socioeconomic status.
The first of the 13 PWDGs focused on increasing the academic capacity of training
institutions for both students and the existing workforce. To increase the quality of pharmacy
education, governments can introduce higher education standards that are appropriately
assessed through accreditation mechanisms. The Pharmacy Council of India created the
National Taskforce for Quality Assurance in Pharmacy Education in order to address the
increasing number of pharmacy institutions with a decreasing number of student applicants.36
There is also a need to ensure that the training of health workers not only meets higher quality
standards, but is also relevant for the local needs of the population.37 If pharmacists are
over-qualified for their responsibilities, this could lead to decreased job satisfaction and eventually
attrition. With gaps in care that span beyond individual disciplines, pharmacists can be trained
and utilized to help provide public health services in collaboration with other health care
professionals to provide better care and coverage for patients.
Case Study: UNC Project-Malawi
Malawi currently has only one school of pharmacy in Blantyre that trains 40-50 students
each year. This is not enough to meet the needs of the country. Since 2014, the UNC Eshelman
Project-Malawi . UNC pharmacy students facilitate the outpatient operations and workflow of
Kamuzu Central Hospital (KCH) and have the opportunity to help with diabetes and
cardiovascular screenings in the outpatient clinic. Prior to increased UNC pharmacy
involvement, KCH had employed only one pharmacist. As of 2017, KCH has now employed a
total of four pharmacists working in both inpatient and outpatient settings. While most of the
work focuses on dispensing supervision and supply chain management, there is interest in
pharmacy expanding into more clinical patient-centered services that have public health
implications after better understanding how pharmacists could be utilized in this capacity.
MEDICATION SAFETY & ADHERENCE
Improper medication use is a $500 billion problem worldwide with pharmacists
positioned to be part of the solution given their medication expertise.38 Having an adequate
pharmaceutical workforce helps ensure patient safety which is important in the discussion of
quality being part of the larger global health agenda.39 Substandard and falsified medications
pose a significant health risk worldwide with poor quality medications often having the wrong
amount or lack of active ingredient leading to increased morbidity and mortality. Developing
countries are impacted the most by falsified and substandard medications where life-saving
treatments for communicable diseases such as malaria, tuberculosis, and HIV are often the
targets. A 2012 Lancet study found that up to 35% of antimalarials tested in southeast Asia
were falsified and that 35% of samples from sub-Saharan Africa failed chemical analysis.40,41
consumption of poor quality antimalarials.40 Several factors known to contribute towards poor
quality medications in which pharmacists can have an impact include self-prescribing behaviors,
lack of pharmaceutical quality assurance, limited patient knowledge regarding medication
authenticity, supply chain management, and a lack of regulations to ensure quality control.41
Pharmacists also have the opportunity to participate in the WHO Prequalification Team which
helps government agencies ensure the procurement of quality essential medicines.
Not only are there individual patient issues such as treatment failure, but also public
health issues including increased incidence and development of drug resistance. A recent WHO
report indicated that there are too few drugs being developed to address to growing burden of
multiple drug resistant tuberculosis.42 In addition, a recent meta-analysis of self-medication use
in developing countries estimates that over 38% of patients self-diagnose and treat which can
contribute to the growing global burden of antimicrobial resistance.43 Pharmacists are also
essential to antibiotic stewardship programs which help ensure the rationale use of antibiotics.
In addition to falsified and substandard medications, medication errors is another global
medication safety issue that costs $42 billion annually worldwide.44 While automation and
sophisticated software systems have been in place for quite some time in developed countries
to mitigate errors, developing countries lack the infrastructure and resources to implement
such systems. Instead, more basic procedures and paper-based checklists and protocols are
utilized. In 2007, the WHO launched the High 5’s Patient Safety Initiative aimed at
implementing and evaluating standardized operating procedures for priority areas such as
medication reconciliation which can reduce the number of medication errors for patients in
launched the third patient safety challenge focusing on the topic of ‘medicines without harm’
with an ultimate goal of reducing medication-related harm by 50% over the course of five
years.46 Pharmacists are again positioned to uniquely contribute to the global health effort of
patient safety.
Even if medications are of high quality, they are of limited utility and benefit if patients
are not adherent. A review of factors positively associated with antimalarial adherence in
developing countries including individuals with higher household income, higher education,
provision of information on how to take drugs, and knowledge about malaria and
antimalarials.43 While pharmacists cannot influence the first two factors, they are critical in
influencing the latter two. In Malawi and other parts of sub-Saharan Africa, some patients have
made their own assumptions about the strength or weakness of antimalarial medications and
adjust the dosage according to their beliefs.47 Educational implementation strategies have
been integral in addressing antimicrobial resistance and pharmacists can play a larger role in
helping shape health behavior.48
Medication safety is also an influential factor in the recently launched Global Health
Security Agenda which is a consortium of 31 countries seeking to combat infectious disease
outbreaks and threats.49. In addition to combatting antimicrobial resistance and falsified drugs,
the Global Health Security Agenda seeks to restrict the spread of zoonotic diseases through a
One Health approach, which includes pharmacists. Pharmacists can also be part of biosafety
and biosecurity efforts by ensuring the proper procurement and administration of medications
SUPPLY CHAIN MANAGEMENT
Supply chain management is an area that pharmacists in developing countries as well as
those working in humanitarian efforts are engaged with in order to help improve access to
essential medications for both communicable and non-communicable diseases. Each country is
encouraged by the WHO to develop and use a National Medicines Policy (NMP) which should
outline strategies and approaches for procuring and using certain medications drawn from the
Essential Medicines List. Despite 71% of countries having a NMP, less than half of developing
countries have revised their plan within the past 5 years.50 It is estimated that fewer than 30%
of patients in the WHO Africa region have public access to essential medications.51 While
technology and software solutions have helped develop robust supply chain systems in
developed countries, pharmacists in developing countries such as Haiti are exploring how to
utilize and implement web-based platforms to mitigate supply chain issues so that more time
can be spent on patient interaction.52
Several successful initiatives have been implemented to address shortages of essential
medications. In 2003, Tanzania with the assistance of Management Sciences for Health (MSH)
started the Accredited Drug Dispensing Outlet (ADDO) program with the goal of improving
access to affordable, essential medications. The ADDO program had targeted interventions that
improved the capabilities of pharmaceutical personnel that worked at the drug outlets and
imposed new regulations designed to improve medication quality. Evaluation of the ADDO
program has shown increased adoption of treatment guidelines, significantly higher availability
success of the ADDO program has been replicated in other sub-Saharan countries including
Uganda and Liberia.
Case Study: Zambia Health Shops Project
Currently the Zambia Ministry of Health through the Zambia Medicines Regulatory
Authority (ZAMRA) is looking to implement the Health Shops Project modeled after the ADDO
program. While the urban population in Zambia (35%) has access to over 150 pharmacies,
several rural areas where most of the population lives do not have any access to a pharmacy.54
This gap in care is filled by illegal drug outlets in which unregulated medications of unknown
quality are sold and distributed on a transactional basis. The Health Shops Project seeks to
enforce new regulations and pharmacy training requirements to provide access to key WHO
essential medications. The program will be a key example of a public-private partnership in
order to extend access to care for a larger population that couldn’t be done so by either entity.
The Health Shops Project will address several of the objectives of the Zambia Health Sector
Supply Chain Strategy and Implementation Plan (2015-2017) by helping ensure the
procurement of quality medications as well as their rationale use.55
Before rolling out country-wide efforts such as the Health Shops Project, it is imperative
that one assess readiness before doing so. It is estimated that over half of large scale initiatives
fail due to a lack of planning and readiness assessment.56 Current work is ongoing to help assess
the readiness of ZAMRA as well as health shop owners to determine what gaps may exists that
should be addressed as the Health Shops Project is piloted across several rural districts.
to facilitate the scale-up of health shops across districts and eventually the country. This case
study is a collaboration between the UNC Eshelman School of Pharmacy, UNC Gillings School of
Global Public Health, and the University of Zambia (UNZA).
IMMUNIZATIONS
The launch of the Global Alliance for Vaccine Initiative (GAVI) in 2000 promoted the
adoption and utilization of vaccines in developing countries at scale. A recent study evaluating
10 vaccine preventable diseases across 73 low to middle income countries showed that
vaccination for these diseases could prevent 20 million deaths and over 500 million cases of
illness between 2001-2020.57 Despite vaccinations being shown to be one of the most
cost-effective public health interventions, developing countries face numerous challenges in
adopting and sustaining acceptable immunization rates. The WHO Initiative for Vaccine
Research (IVR) seeks to increases the use of implementation research in order to increase
adoption of vaccinations in the developing world. Complimenting this effort is the recent launch
of the Ottawa statement which focuses on population health implementation research with a
focus on primary prevention programs including immunizations.58
According to a 2017 assessment report of the WHO Global Vaccine Action Plan, a key
recommendation moving forward is to broaden the dialogue with other organizations and
partners, and pharmacists are excellent candidates.59 Over the years policies and regulations in
the US and other countries have helped pharmacists in other countries gain the necessary
support to provide key immunizations to promote health and well-being. There is an
is needed to understand how current immunization implementation plans in developed
countries, such as the US Department of Health and Human Services National Adult
Immunization Plan, might be translated to developing countries with the utilization of
pharmacists. With continued progress towards the development of vaccines against malaria,
Ebola, and Zika, pharmacists can be positioned to assist with new immunization efforts and
programs.
The 2016-2020 GAVI five-year strategy includes four overarching goals including
increasing the effectiveness and efficiency of immunization delivery.60 Pharmacists are
positioned to actively contribute towards this effort given their accessibility, therapeutic
knowledge, and operations management experience. The CDC’s Strategic Framework for Global
Immunization describes the essential role of the health workforce in ensuring the delivery of
vaccinations to those who need it.61 Based on the accessibility of pharmacies in developing
countries where coverage rates for key immunizations are lower, pharmacists can be part of
immunization screening programs when patients are there to seek medical advice or procure a
medication.
MOBILE HEALTH
Pharmacists can play a significant role in the constantly evolving field of mobile health.
Over 90% of the world has access to a mobile phone signal which is often much higher than
access to other services such as sanitation, water, and electricity.62 Combining the accessibility
of pharmacists with the wide-spectrum coverage of mobile phones presents an emerging
The WHO has recognized the importance of determining ways to utilize mobile health
for non-communicable diseases with the launch of the Be He@lthy, Be Mobile campaign in
which each WHO Region started a pilot project around one of several disease state areas
including cervical cancer, diabetes, and tobacco cessation. Pharmacists can be integrated within
this initiative as they have been with other mHealth programs such as the SMS for Life program
which has increased access to medications by improving inventory management systems.63 In
this program pharmacists manage medication inventory by sending SMS text messages to
district warehouses to indicate supply levels so as to ensure that these medications are
available to the public. With increased training, pharmacists can extend their role in mHealth by
using SMS text messages to participate in disease surveillance activities since pharmacists are
often the first health care professional patients will see. Additionally, pharmacists can utilize
mHealth to assist with medication safety and adherence issues by sending reminders and
educational or motivational messages. Known implementation determinants of mHealth
programs in sub-Saharan Africa include adequate incentives for participation, government
support and engagement, and appropriate training for clinical staff.64 These determinants can
help shape future studies as to what are the determinants of participation are of pharmacists in
these initiatives to combat non-communicable diseases.
Due to the rapid growth of mHealth, there has been inconsistent terminology use, a
multitude of new modes and frameworks, and a lack of understanding of what actually
constitutes mHealth. These challenges make it difficult to compare and synthesize the findings
of the limited studies being conducted in developing countries around non-communicable
and programs, there could be more effective monitoring and evaluation strategies for the scale
up of mHealth programs in sub-Saharan African countries.65 Provided that most mHealth
studies are looking at improving medication adherence, making lifestyle recommendations, or
changing medication therapy regimens, pharmacists can play a significant role in advancing
mHealth for non-communicable diseases.
CHALLENGES FOR PARTICIPATION OF PHARMACISTS IN PUBLIC HEALTH
Despite the enormous potential for pharmacists to contribute to public health in both
high and low resource settings, there is still little formal recognition of the ability of pharmacists
to serve as public health practitioners. In 2006, the American Public Health Association (APHA)
created a policy statement formally recognizing the role of pharmacists within public health.7
One of the key insights within the statement was that although pharmacists are performing
public health activities, their role in public health is not recognized unlike physicians and nurses.
To strengthen the focus of pharmacists as public health practitioners, the Joint Commission of
Pharmacy Practitioners, a group of CEOs from the leading US pharmacy associations, developed
a 2015 vision statement that stated that pharmacists will be prepared for both patient-centered
and population based care.66 This aligns with the increased training focus on public health
within the pharmacy curricula. Even with formal recognition, there also appears to be a lack of
confidence in how pharmacists view their services. In Scotland, only slightly more than half
either agreed or strongly agreed that they considered themselves as public health practitioners
Also, while organizations within and outside of pharmacy have declared the importance
of pharmacists in public health, their still needs to be increased awareness and recognition by
patients of this role. A 2016 report by the Royal Society of Public Health and Public Health
England stated that a key challenge in establishing the role of the pharmacist in public health
was that the public lacked awareness of the services pharmacists provide. Only half of the
public in the United Kingdom knew that pharmacists provided immunizations, family planning,
and general health checks.67 Although 80% of pharmacy customers in Sweden expected to
received drug related information from the pharmacist, less than a quarter expected to receive
information on diet, smoking cessation, or disease management.4 In summary, while
pharmacists are viewed upon favorably in other countries because of their accessibility and
convenience, their role impacting public health is not as widely known or understood.68 In
addition to patient stakeholders, health insurance companies and payers need to recognize
pharmacists as well so that they can be compensated and incentivized to provide these services
on a more consistent basis.
These barriers to recognition are also present in more acute forms in low resource
settings. Factors known to hinder public health services offered by pharmacists in developing
countries include a lack of knowledge and skills, lack of confidence, limited policies and
regulations, poor recognition within the healthcare system, inadequate workforce capacity, and
patient reluctance to use pharmacy services.26 In Ethiopia nearly 80% and 90% of pharmacy
personnel were “not at all involved” or “a little involved” in tobacco cessation and diabetes
management, respectively.26 Often in developing countries there are physical space restrictions
30% of pharmacies lack a counseling area.11 Another barrier is perceived competency in
assuming a more public health oriented role. Although aspects of public health are being
incorporated into training curricula, graduating pharmacists and the existing workforce feel
insufficiently prepared to delivery such services.11 Additional barriers to advancing the role of
pharmacist in global public health is a lack of distinct separation from medication prescribing
and dispensing as well as a critical shortage of pharmacists.17 Even when services are provided,
there is a high degree of variation concerning the type and the quality of the service.
RECOMMENDATIONS
In summary, while several areas across LMICs progressive growth of pharmacy-based
public health services, this is not universal. Overall, pharmacists are underutilized within public
health worldwide and can make an even larger impact on the health of the communities if
appropriately positioned and recognized. The following policy recommendations are to be
considered by governments in developing countries in order to enhance the impact that
existing and future pharmacists can have on global public health.
1) Recognize pharmacists as part of the public health workforce
As done in developed countries, formal recognition of pharmacists by associations and the
governments as part of the public health workforce can provide the confidence needed for
pharmacists to act as public health practitioners. Further, enhanced recognition at district and
national levels can increase the visibility of the profession and attract future applicants and
2) Establish pharmacists’ roles in immunization and medication safety programs that promote well-being
Immunizations are one of the most cost effective interventions, but remain underutilized.
Pharmacists have been shown to provide safe and effective delivery of immunizations and
positively influence the behavior of patients receiving the.3 Governments can push for
pharmacists to be trained as immunizers so as to reduce the already high workload of
physicians and nurses. A review of training outcomes for healthcare professionals in low to
middle income countries revealed a number of effective short-term training strategies including
using train-the-trainer programs in order to upskill the existing workforce.69
3) Integrate mHealth interventions in community pharmacies
The accessibility of pharmacists complement the vast accessibility of phones within limited
resource settings. With the right training, pharmacists can be utilized in mHealth interventions
that address both communicable and non-communicable diseases. It has already been shown
how pharmacists can help with supply chain management as in the SMS for Life program and
this technology can be extended to engage pharmacists in disease surveillance activities as well
as medication safety and adherence programs. According to the Global Strategy on Human
Resources for Health, mHealth tools should be utilized to enhance global public activities such
as supply chain management and patient safety.35 Government leaders should invest in the
infrastructure necessary to support the implementation and scale-up of mHealth services which
can help mitigate the unequal distribute of health workers in rural areas by leveraging
4) Utilize implementation science methods in pharmacy across limited resource settings
Many of the above mentioned global health areas have success stories and evidence based
practices that have been utilized in high income countries. However, it is unknown how
evidence based practices from the global north translate to the global south. Implementation
science is the field of understanding how to translate evidence into everyday practice and can
be utilized across public health issues from medication safety to mobile health. While
implementation science is stimulating research opportunities in the community and primary
care settings for pharmacy in the United States, there is a lack of research regarding the
effective implementation and evaluation of pharmacy services within developing countries.
There is a need for the appropriate monitoring and evaluation of pharmacy provided public
health services so that these can be adopted and scaled up accordingly. Implementation
research for pharmacy in low to middle income countries can help provide the data needed for
government leaders to support the integration of pharmacists into public health services. As
pharmacists develop their niche within global public health, there will be the need to
understand how and why pharmacy services can improve the health and well-being of
communities throughout the world in resource-limited settings.
5) Incorporate public health principles in pharmacy education
There is growing demand by students and pharmacists in developing countries to have
further instruction and engagement with public health activities so that they can more
effectively contribute towards the broader health of the community.70 In order to implement
competencies to be able to understand how patients fit into populations and how to manage
the health of these populations. Beyond key principles of pharmacoepidemiology and health
policy management, pharmacy students in developing countries should take a primer on
implementation science that introduces them to the basics of program planning, quality
improvement, and monitoring and evaluation. This skill set will equip graduates with the
capability to putting research into practice. Additionally, continuing professional development
should be offered for those in the workforce to elevate the training of the whole profession.
This is a need that is also important in high income countries. More schools and colleges
of pharmacy are developing PharmD/MPH dual degree programs to help prepare individuals
with the skill sets necessary to be effective in public health programs. The most recent
accreditation standards for schools and colleges of pharmacy included public health as one of
the key competencies required for students upon graduation so they can effectively utilize
population health management strategies and implement public health activities and
programs.71 Others have called for increased competence across the broader core
competencies in public health in order for pharmacists to make a larger difference on
population health.72
CONCLUSIONS
Despite the challenges pharmacists face in limited resource settings, the role of the
pharmacists in global public health in low to middle-income countries will continue to evolve as
pharmacists become better recognized and engaged in the above mentioned areas. The shift
services with public health implications took decades to achieve. The shift for pharmacists in
low to middle-income countries will also take time. More studies are required to further
demonstrate the impact pharmacists can have in resource-limited areas within certain areas of
global public health. The accumulation of more evidence and data can help drive the
development of new policies and advocacy efforts to recognize pharmacists not only as patient
REFERENCES
1. Burns A. Medication therapy management in pharmacy practice: Core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008.
2. Centers for Diseases Control and Prevention. The public health system & the 10 essential public health services.
https://www.cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices.html. Accessed September 10, 2017.
3. Papastergiou J, Folkins C, Li W, et al. Community pharmacist-administered influenza
immunization improves patient access to vaccination. Can Pharm J (Ott). 2014 Nov;147(6):359-65.
4. Eades CE, Ferguson JS, O’Carroll RE. Public health in community pharmacy: A Systematic review of pharmacist and consumer views. BMC Public Health. 2011 Jul 21;11:582.
5. Consolidating and developing the evidence base and research for community pharmacy’s contribution to public health: a progress report from Task Group 3 of the Pharmacy and Public Health Forum. Public Health England.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/271682/2014
0110-Community_pharmacy_contribution_to_public_health.pdf. Accessed November 19, 2017.
6. Abrons J, Vadala T, Miller S, et al. Encouraging safe medication disposal through student pharmacist intervention. J Am Pharm Assoc. 2010 Mar-Apr 1;50(2):169-73
7. The Role of the Pharmacist in Public Health. American Public Health Association.
https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/07/13/05/the-role-of-the-pharmacist-in-public-health. Accessed September 17, 2017.
8. ASHP statement of the role of health-system pharmacists in public health. AM J Health Syst Pharm. 2008 Mar 1;65(5):462-7.
9. Cater J, Slack M. Public Health at the Local, State, National, and Global Levels. In: Pharmacy in Public Health – Basics and Beyond. Bethesda, MD. American Society of Health-System
Pharmacists.
11. Mathialagan A, Nagalinggam P, Mathialagan S, et al. Relationship between performance barriers and pharmacist competency towards the implementation of an expanded public health pharmacy role. Int J Pharm Pract. 2015 Oct;23(5):320-6
12. Smith M. Pharmacists’ Role in Public and Population Health. Ann Pub Health Res. 2014.
13. Taitel M, Jiang J, Rudkin K, et al. Impact of pharmacist face-to-face counseling to improve medication adherence among patients initiating statin therapy. Patient Prefer Adherence. 2012;6:323-9
14. A program guide for public health. Partnering with pharmacists in the preention and control of chronic diseases. National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention.
https://www.cdc.gov/dhdsp/programs/spha/docs/pharmacist_guide.pdf. Accessed November
17, 2017.
15. Hughes A. Williams MR, Liparia RN, et al. Prescription Drug Use and Misuse in the United States:Results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Service Association. https://www.samhsa.gov/data/sites/default/files/NSDUH-TrendBreak-2015.pdf. Accessed November 18, 2017.
16. Community tool box. Center for Community Health and Development, University of Kansas.
http://ctb.ku.edu/en. Accessed November 18, 2017.
17. Azhar S, Hassali MA, Ibrahim MI, et al. The role of pharmacists in developing countries: the current scenario in Pakistan. Hum Resour Health. 2009 Jul 13;7:54
18. Steeb DR, Joyner PU, Thakker DR. Exploring the role of the pharmacist in global health. J Am Pharm Assoc. 2014. Sep-Oct;54(5):552-5.
19. Noncommunicable diseases. World Health Organization. Accessed at
http://www.who.int/mediacentre/factsheets/fs355/en/. August 1, 2017.
20. Allen L. Non-communicable disease funding. Lancet Diabetes Endocrinol. 2017 Feb;5(2):92.
21. World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020. http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1
Accessed September 1, 2017.
22. Touchette DR, Doloresco F, Suda KJ, et al. Economic evaluations of clinical pharmacy services: 20067-2010. Pharmacotherapy. 2014 Aug;34(8):771-93.
23. Mohamed SS, Mahmoud AA, Ali AA. Involvement of Sudanese community pharmacists in public health activities. Int J Clin Pharm. 2013 Jun;35(3):393-400.
24. Mdege ND, Chevo T, Toner P, et al. Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe. Res Social Adm Pharm. 2016 Nov - Dec;12(6):876-884.
26. Erku DA, Mersha AG. Involvement of community pharmacists in public health priorities: A multi-center descriptive survey in Ethiopia. PLoS One. 2017 Jul 13;12(7)
27. Thamby SA, Subramani P. Seven-star pharmacist concept by World Health Organization. J Young Pharm. Apr-Jun 2014.
28. Systems for Improves Access to Pharmaceuticals and Services (SIAPS). Enhancing health outcomes for chronic diseases in resource-limited setting by improving the use of medicines: the role of pharmaceutical care. Submitted to the US Agency for International Development by the SIAPS Program. Arlington, VA: Management Sciences for Health. May 2014.
29. World Health Organization. A universal truth: no health without a workforce.
http://www.who.int/workforcealliance/knowledge/resources/GHWA-a_universal_truth_report.pdf?ua=1. Accessed September 15, 2017.
30. Crisp N, Chen L. Global supply of health professionals. N ENgl J Med 2014;370:950-7.
31. World Health Organization. Density of pharmaceutical personnel.
http://www.who.int/gho/health_workforce/pharmaceutical_density/en/. Accessed October 1,
2017.
32. Bates I, John C, Bruno A, et al. An analysis of the global pharmacy workforce capacity. Hum Resour Health. 2016 Oct 10;14(1):61.
33. Muula AS, Chipeta J, Siziya S, et al. Human resources requirements for highly active antiretroviral therapy scale-up in Malawi. BMC Health Serv Res. 2007 Dec 19;7:208.
34. Hawthorne N, Anderson C. The global pharmacy workforce: a systematic review of the literature. Hum Resour Health. 2009 Jun 19;7:48.
35. World Health Organization. Global strategy on human resources for health: Workforce 2030. http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/. Accessed November 19, 2017.
36. International Pharmaceutical Federation. Transforming our workforce – Workforce development and education: Systems, tools and navigation. 2016.
http://www.fip.org/files/fip/PharmacyEducation/2016_report/FIPEd_Transform_2016_online_ version.pdf. Accessed November 18, 2017.
37. McPake B, Squires A, Mahat A, Araujo EC, editors. The economics of health professional education and careers: insights from a literature review. Washington DC: World Bank; 2015
38. IMS Health. Responsible Use of Medicines Report. 2012.
39. Scott KW, Jha AK. Putting quality on the global health agenda. N Engl J Med. 2014 Jul 3;371(1):3-5.
40. Renschler JP, Walters KM, Newton PN. Estimated under-five deaths associated with poor-quality antimalarials in sub-Saharan Africa. Am J Trop Med Hyg. 2015 Jun;92(6 Suppl):119-26.
42. World Health Organization. Medicines Shortage.
http://www.who.int/medicines/publications/druginformation/WHO_DI_30-2_Medicines.pdf.
Accessed November 17, 2017.
43. Ocan M, Obuku EA, Bwanga F, et al. Household antimicrobial self-medication: a systematic review and meta-analysis of the burden, risk factors and outcomes in developing countries. BMC Public Health. 2015. 15:742.
44. World Health Organization. Medication without harm: WHO’s third global patient safety challenge. http://www.who.int/patientsafety/medication-safety/en/. Accessed October 1, 2017.
45. Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: The WHO High 5s project. Int J Qual Health Care. 2014 Apr;26(2):109-16.
46. Sheikh A, Dhingra-Kumar N, Kelley E, et al. The third global patient safety challenge: tackling medication-related harm. Bull World Health Organ 2017;95:546-546A.
47. Ewing VL, Terlouw DJ, Kapinda A, et al. Perceptions and utilization of the anti-malarials artemether-lumefantrine and dihydroartemisinin-piperaquine in young children in the Chikhwawa District of Malawi: a mixed methods study. Malar J. 2015 Jan 21;14:13.
48. Okeke IN, Klugman KP, Bhutta ZA, et al. Antimicrobial resistance in developing countries. Part II: strategies for containment. Lancet Infect Dis. 2005 Sep;5(9):568-80.
49. Centers for Disease Control and Prevention. Global Health – CDC and the Global Health Security Agenda. https://www.cdc.gov/globalhealth/security/index.htm. Accessed November 20, 2017.
50. World Health Organization. Equitable access to essential medicines: a framework for collective action, Policy Perspectives on Medicines. 2004, vol. 8 (pg. 1-6)
51. Lubinga SA, Jenny AM, Larsen-Cooper E, et al. mpact of pharmacy worker training and deployment on access to essential medicines and health outcomes in Malawi: protocol for a cluster quasi-experimental evaluation. Implement Sci. 2014 Oct 11;9:156.
52. Holm MR, Rudis MI, Wilson JW. Medication supply chain management through
implementation of a hospital pharmacy computerized inventory program in Haiti. Glob Health Action. 2015 Jan 22;8:26546.
53. Rutta E, Liana J, Embrey M, et al. Accrediting retail drug shops to strengthen Tanzania’s public health system: an ADDO case study. J Pharm Policy Pract. 2015 Sep 25;8:23.
54. Zambia Medicines Regulatory Authority. Health Shops Project Promotional Leaflet. 2016.
55. Zambia Ministry of Health. Health sector supply chain strategy and implementation plan (2015-2017). http://www.moh.gov.zm/docs/impplanncss.pdf. Accessed November 20, 2017.
56. Shea CM, Jacobs SR, Esserman DA, et al. (2014). Organizational readiness for implementing change: a psychometric assessment of a new measure. Implementation Science. 9:7.
58. Ottawa statement from the sparking solutions summit on population health intervention research
59. 2017 Assessment Report of the Global Vaccine Action Plan Strategic Advisory Group of Experts on Immunization. Geneva: World Health Organization; 2017.
60. Global Alliance for Vaccines and Immunizations. 2016-2020 five-year strategy.
http://www.gavi.org/about/strategy/phase-iv-2016-20/. Accessed September 28, 2017.
61. Centers for Diseases Control and Prevention. 2016-2020 Strategic framework for global immunization.
https://www.cdc.gov/globalhealth/immunization/docs/global-immunization-framework-508.pdf. Accessed November 20, 2017.
62. Stephani V, Opoku D, Quentin W. A systematic review of randomized controlled trials of mHealth interventions against non-communicable diseases in developing countries. BMC Public
Health. 2016; 16:572.
63. Barrington J, Wereko-Brobby O, Ward P, et al. SMS for Life: a pilot project to improve anti-malarial drug supply management in rural Tanzania using standard technology. Malar J. 2010 Oct 27;9:298.
64. Aranda-Jan CB, Mohutsiwa-Dibe N, Loukanova S. Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa. BMC Public health. 2014 Feb 21;14:188.
65. Tomlinson M, Rotheram-Borus MJ, Swartz L, et al. Scaling up mHealth: where is the evidence? PLoS Med. 2013;10(2):e1001382.
66. Vision Statement. Joint Commission of Pharmacy Practitioners.
https://www.accp.com/docs/positions/misc/JCPPVisionStatement.pdf. Accessed November 18,
2017.
67. Building capacity: realizing the potential of community pharmacy assets for improving the public’s health. Royal Society for Public Health.
https://www.rsph.org.uk/asset/45AD864A-F61A-4E3E-917F3E22C0BDFD8F/. Accessed November 19, 2017.
68. Saramunee K, Krska J, Mackridge A, et al. How to enhance public health service utilization in community pharmacy?: General public and health providers’ perspectives. Res Social Adm Pharm. 2014 Mar-Apr;10(2):272-84.
69. Dawson AZ, Walker RJ, Campbell JA, et al. Effective strategies for global health training programs: a systematic review of training outcomes in low and middle income countries. Glob J Health Sci. 2016.
70. Law M, Maposa P, Steeb DR, et al. Addressing the global need for public health clinical pharmacists through student pharmacist education: a focus on developing nations. Int J Clin Pharm. 2017 Oct 31.
Education. https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Accessed November 18, 2017.
