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Physicians are often highlighted as the final pathway for nearly all professional decisions about the use of health resources. Yet with respect to drugs, pharmacists and other dispensers are in many cases the final link between the medication and the patient. Community pharmacies have always been a major location for health care worldwide. Pharmacy employees are consulted for health advice on problems of all kinds, and remedies are sold or dispensed with almost every transaction. Some of the remedies are safe and effective when used correctly but otherwise can be dangerous; others are ineffective no matter how they are used.
The purpose of this session is to identify important factors that influence the dispenser's behavior and consequently, his or her impact on a patient's compliance with drug therapy.
To develop your ability to:
Read Session Notes and Trainers Guide and review visual aids.
Read Chapter 32 of Managing Drug Supply, "Ensuring Good Dispensing Practices."
Note: This module has been developed by a number of people including Drs. Kumud Kafle, Farai Chinyanganya and Sri Suryawati. Photographs have been provided by Dr. Edelisa Carandang (Philippines), Fatima Suleman (South Africa), Prof. Willy Anockobongo (Uganda), and Dr. Farai Chinyanganya (Zimbabwe).
Inappropriate or incorrect dispensing can undo many of the benefits of the health care system. Regardless of the modern facilities, extensive education, and careful diagnosis, the proper medication must be dispensed to the patient and the patient must comply with therapy for the health system to have accomplished its task.
Dispensing is often overlooked by health planners during the development of health care delivery. It is usually considered of secondary importance to diagnosis, procurement, inventory control, and distribution. This oversight is unfortunate, because poor or uncontrolled dispensing practices can have a very detrimental impact on the health care delivery system. All of the resources required to bring a drug to the patient may be wasted if dispensing does not ensure that the correct drug is given to the right patient in an effective dosage and amount, with clear instruction, and in packaging that maintains the integrity of the drug. Since the dispenser is often the last person to see the patient before the drug is used, it is important that the dispensing process be understood as it affects drug use.
This session outlines specific considerations of dispensing that are not only factors in rational drug use, but are also essential to the overall functioning of a health care delivery system.
A. WHO IS A DISPENSER?
Most of this session will discuss dispensing as if it were only performed by trained pharmacists, pharmacy auxiliaries or other qualified health workers. In many, if not most countries, dispensing is performed by a wide variety of personnel, not all of whom have had formal training.
In the real world, a prescriber is anyone with a recommendation for treatment; a dispenser is anyone that gives out the treatment.
Formally, we think of a dispenser as a person who has had special training in the art of preparing and giving out medicines. In a global sense, however, a dispenser can literally be any person who prepares and gives out remedies, regardless of training. Thus, dispensers include not only the qualified health workers (pharmacists, physicians, nurses, basic health workers, even veterinarians), but also self-appointed health workers who have access to any substance that they believe can cure. These dispensers would include friends, relatives, store keepers, taxi drivers, etc.
Consider the scenario in most countries. The qualified pharmacist's role is often suggested by the advertisement: "Drugs - Retail and Wholesale." In their retail role, druggists, or their employees, will provide medicines and advice on any number of health conditions. On the wholesale side, they provide drugs to the entire private, and often to the public, health care system. Many drugs are sold to small local village shops, where they might be sold to anyone who can buy them. The buyer, in turn, might resell the drugs to someone else who might possibly resell them again, ... and so on. The informal private drug distribution and trade network remains a mystery. But one thing is certain: where there is a demand for drugs, there will be a supply - and "dispensers" will dispense them, hopefully in accordance with good dispensing practices that will enhance rational drug use.
In many health care institutions, especially in the developed countries, the role of the pharmacist in patient care, especially in dispensing drugs to patients, becomes more and more important. [Link to Picture] Pharmacists contribute the safe and effective use of pharmaceuticals at times when drugs are dispensed. They also play a significant role in promoting rational use of drugs, e.g. providing drug information to patient, and carrying out drug utilization studies.
A safe dispenser needs knowledge about different drugs, the specific product being dispensed and to have communication/consultation skills. This person needs to be aware of promotional and marketing techniques that may be used. To be an effective dispenser he/she needs an adequate drug supply, dispensing equipment, a relationship with the prescriber and status in the community.
B. THE DISPENSING PROCESS
As shown below, there are eight important steps to assure the proper delivery of drugs to the patient from the dispenser. Notice that each step carries with it a number of important responsibilities and/or considerations. For our purposes, we make the assumption that (1) the prescriber has made the correct diagnosis and has selected the correct drug, dosage and quantity, and (2) the patient has access to the dispensary (pharmacy).
5. The dispenser communicates the correct way to take the medication to the patient.
6. The patient understands the instructions from the dispenser.
7. The patient complies with the instructions for therapy.
8. The dispenser keeps accurate records of operations.
POTENTIAL FOR ERROR PROBLEMS
During any of the above activities there is potential for errors to be made and problems to occur. A few of these have been identified below. See if you can think of others.
Wrong interpretation of the prescription (or diagnosis)
Retrieval of the wrong drug from stock
Inadequate packaging/labeling of proprietary drugs
Inaccurate counting, compounding
Inadequate or nonexistent labeling
No knowledge of proper drug compliance
Insufficient knowledge of the disease process
Insufficient time to talk with patients about their drugs
Inability to communicate to patients about therapy
As can be seen from the above, there are many potential areas in which the dispenser can make mistakes. Dispensing requires trained, conscientious, responsible individuals. Proper policies, practices, and incentives must be provided to attract such personnel.
There are many factors that influence dispenser behavior:
C. DISPENSING PRACTICES TO ENHANCE RATIONAL DRUG USE
Below are a series of questions designed to help assess dispensing practices in a drug delivery system.
What conditions exist at dispensing points? How are drugs handled? How accurately and cleanly are drugs dispensed? How concerned are health officials and health workers about the quality of compounding and dispensing practices?
How long is normally spent for dispensing? How do dispensers communicate with patients?
How often are patients improperly treated because their medicines have been improperly compounded or dispensed, or because drugs have deteriorated in inadequate packaging?
At each level in the health care system, who is responsible for the compounding and dispensing of drugs? What training do these individuals have in the principles and practices of drug compounding and dispensing? How much supervision do these individuals receive?
What types of pharmaceutical training are available in the country? Are there standardized education curricula for pharmacy personnel? Are training requirements for dispensers spelled out and reasonable, given the numbers and geographical distribution of individuals meeting, or eligible for meeting, these requirements?
What resources exist to attract individuals to pursue dispenser training and to what extent can these individuals expect satisfactory remuneration for the services they provide?
Are wages and salaries adequate to effectively discourage dispensers from engaging in the illegal sale and distribution of pharmaceuticals?
What kinds of packaging are used to dispense drugs to patients? Is there any mechanized repackaging into course-of-therapy packets? In light of losses from poor packaging and the costs of proper packaging, are there cost-effective alternatives to present packaging methods? Could more expensive containers be recycled?
D. ROLE OF PRESCRIBER AND DISPENSERS IN PROMOTING CORRECT DISPENSING
Diagnosis - By ensuring a correct diagnosis which is explained to the patient, compliance is improved.
Prescribing - By prescribing as few drugs possible and explaining to the patient which drugs are for which condition, patient understanding is enhanced.
Drug information - The prescriber should explain how each drug should be taken, what side effects may occur and what to do if there is an unexpected effect, or no response to the drug.
The pharmacist/dispenser has a crucial function in the health care system in:
Drug Procurement - Ensuring that good quality drugs are available when needed.
Drug Distribution - Moving the drugs safely to wherever they will be dispensed; making sure that storage and transport conditions do not adversely affect the drugs.
Drug Prescribing - Pharmacists and dispensers are often asked to prescribe 'Over The Counter' (OTC) preparations. In some countries there may be no distinction between OTC and prescription only products.
Drug Monitoring - In some settings pharmacists/dispensers are being called on to monitor long term treatment for chronic conditions such as hypertension, diabetes, asthma, etc.
Additional roles which a pharmacist/dispenser may be called on to fill include:
Communication with physician -- this may be to check a prescription or respond to a question.
Ensure compliance with treatment guidelines, particularly in institutional settings. Hospital pharmacists may be given the responsibility of ensuring that prescriptions comply with treatment guidelines. This is particularly true of complex regimens such as cancer treatment.
METHODS TO IMPROVE COMPLIANCE WITH THERAPY
Dispenser-patient communication - Dispensers play a significant role in communicating with patients on how to take the drugs, and ensuring compliance with drug therapy. This can be done during dispenser-patient contact.
Packaging for Patient Use - Drugs are usually dispensed to patients in some form of container. The type of container can affect the quality of the drug at the time it is consumed. It can also have an important impact on the patient's image of the health system, and his faith in the medicine. Shoddy containers can give the indication of an unreliable system and ineffective medicine. It also might affect the patient's compliance with therapy.
Labeling - Do patients read labels? How much influence does a label have on dispenser effectiveness and patient compliance? In countries where the illiteracy rate is high, how can labeling communicate therapy protocol effectively? These are questions in search of answers. We do know, however, that some forms of printed communication to patients do enhance therapy.
In the United States, labels are typed and are often accompanied by auxiliary labels [picture of computer label with stickers] which provide such information as "do not drink alcohol while taking this medication" or "shake well". However useful, this type of labeling requires high literacy and might be too expensive or inappropriate for use in other cultures. The use of pictorial labeling is gaining favor in health programs. One of the most ingenious labeling schemes for both dispensers and patients uses symbols to match drugs with conditions, and instructions when to take the medications.
Whether public or private sector, the dispenser is usually considered to be available and is sought after for "free" advice. It is rare that a dispenser will charge a consulting fee.
F. PUBLIC vs. PRIVATE SECTOR DISPENSING: A PATIENT'S CHOICE
The Public Sector Option: Health care and drugs are often "free", being provided by the government. However, the public health clinic is frequently located some distance from the patient's home or work. Granted, it is within 3 kilometers, but that is a long distance to walk, especially since the clinic is only open certain hours. Once there, our patient knows he will encounter long lines. After being seen by the doctor, there is another line to get the prescription -- if it is in stock. This is not a pleasant situation for someone who is feeling ill to begin with.
The Private Sector Option:
Private pharmacies or chemists' shops are located in high traffic areas, right around the corner, or they are on the way to work. It takes less time to get service and the vendors provide friendly advice on the products they sell. True, the medication is more expensive, but it is there, and the patient feels he is getting his "money's worth" with the slick, commercial packaging.
Which would you choose? Estimates are that in some countries as much as 80-90% of the money spent on drugs is in the private sector. If we want to truly make a global impact on rational drug use, dispensing in the private sector must be addressed.
There have been a number of interventions aimed at improving dispensing. In Ghana, View locally or access on the web at http://www.who.int/dap-icium/posters/2b1_txt1.html researchers tested three different educational interventions. The results of this study showed that posters were effective in improving dispensing time, adequate labeling and patient understanding, albeit at a low level.
In Uganda View locally or access on the web at http://www.who.int/dap-icium/posters/2f3_text.html a large study showed that it was possible to improve dispensing.
In Kenya and Indonesia View locally or access on the web at http://www.who.int/dap-icium/posters/3C3_1.html studies were undertaken in commercial pharmacies to improve diarrhea treatment. In both of these countries, improvements in treatment occurred. (See Ross-Degnan, et al - "The Impact on Face to Face Educational Outreach on Diarrhea Treatment in Pharmacies," Health Policy and Planning, Vol. 11, No. 3, Sept 1996, p. 308-318.
In the Philippines View locally or access on the web at http://www.who.int/dap-icium/posters/3C4_TXTF.html an intervention was focused at drug selling store keepers. Through a series of discussions with these store keepers changes were made in their selling behaviors related to antibiotics.
All of these interventions were aimed at improving dispensing at local levels. Major improvements occurred. What is not clear is whether regulatory or policy changes would have similar effects.
Dispensing is a critical and integral part of the drug use process. Up to now, the importance of dispensing has been neglected in training and in essential drugs programs. The incredibly short dispensing times seen in many of the country indicator surveys reflects the serious situation that exists. Of all the areas open to intervention, improving dispensing is among the easiest. Whether regulatory, managerial, or educational methods are used, the patient benefits and the health system benefits.
Country Situation Review
Think about who is responsible for dispensing in your own country. Review what training dispensers have, formal or informal, and for how long they have been trained. Finally, discuss how the dispensing process is monitored. How do we know that drugs are being dispensed correctly?
Each group member should fill in Worksheet 1 below for his/her own country. Then the group should discuss their country situations together. If group members are from the same country they can discuss the same questions.
Worksheet 1: Who Dispenses in Your Country?
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