Two weeks ago, there were news reported on Malaysian GPs expressing their views pertinent to pharmacies “taking business away” from their clinics – further iterating many pharmacies are now “assuming the jobs of doctors” by diagnosing patients. There were also GPs who claimed that pharmacies are recommending alternatives to prescription medicines and dispensing prescription-needed medicines – without a doctor’s approval. This has caused “lacklustre business” and financial losses, as thousands are spent every month stocking up on medicines, whilst catering to less patients.

In an exclusive interview with Tn Haji Amrahi Buang, President of the Malaysian Pharmaceutical Society (MPS), MIMS hears the other side of the story, including the flaws of the Pharmacy Bill and the urgency to fix the national healthcare system—to provide better services, geared towards a healthy society and community.

Firstly, addressing the comment that pharmacist dispense medication without prescriptions, Amrahi states that “we must be clear that only group B poisons require prescriptions. However, the general public will concur that these are hard to come by because most doctors in the primary care setting refuse to release prescriptions. This puts the patient at a cost disadvantage – and leaves the pharmacist in a situation of having to decline service to patients with chronic disease on long term medication.”

He adds, “There are strict rules to the supply of medicines in clinics and pharmacies. Only Pharmacists with a Type A license are allowed to sell medicines – by retail – to patients. As per Malaysian law, only board registered pharmacists can apply for the Poison A license which gives them the right to provide medicine by retail.”

The evolving role of a community pharmacist

Responding to the statement of pharmacists are seen to be playing the doctor’s role, Amrahi disagrees. “This is incorrect. We have to correct this mindset,” he emphasises. “Consumers come in with symptoms only. For instance, a patient comes in with a cold. Under the law, if you have a cold, I can provide you with an antihistamine, which is a Group C item. It’s not wrong.”

In addition, the role of a community pharmacist has since evolved. Today, they assist patients in self-monitoring of their blood glucose levels and blood pressure levels. Medication counselling for non-communicable diseases (NCDs) and aiding in patient compliance as well as adherence to medication therapy are also part of their role.

“A pharmacist has three roles: They are drug experts, guardian of medicines and a healthcare provider,” iterates Amrahi. No longer are pharmacists mere dispensers of medication—they are also synergistic partners in healthcare and providers of care for consumers and patients.

In an exclusive interview with Tn Haji Amrahi Buang, President of the Malaysian Pharmaceutical Society (MPS), MIMS hears the other side of the story, including the flaws of the Pharmacy Bill and the urgency to fix the national healthcare system. Photo credit: MPS
In an exclusive interview with Tn Haji Amrahi Buang, President of the Malaysian Pharmaceutical Society (MPS), MIMS hears the other side of the story, including the flaws of the Pharmacy Bill and the urgency to fix the national healthcare system. Photo credit: MPS

“On this issue (referring to GPs blaming pharmacists for the lack of business), it is never our intention to fight with anybody,” says Amrahi, adding that “this is nothing new”—and that the supposedly “turf war” has been going on for years.

“Why is there a need to compete? GPs and pharmacists must be part of the system – so that healthcare is universal and patients can go anywhere,” he highlights.

“I think the most important thing is that we are talking about an environment where we have created in the private sector. If you look into the actual healthcare system, it is made up of the public and private sector. And each sector is made up of levels. There is primary care, secondary care and tertiary care. In a nutshell (if you can visualise), there are six parts,” explains Amrahi.

“Under the public sector, because it is all governed under one roof, there is no issue of dispensing separation,” he elaborates. “As for the private sector, there is no issue of dispensing separation in the secondary and tertiary care levels.”

“The only sector that does not have the separation system is the private primary health care. Why is that?” asks Amrahi.

To solve the problem entirely, Amrahi urges substantial steps to re-assess the healthcare system.

“We have to be more integrated. Instead of separating it into the public and private sector, we should base it on levels – primary, secondary and tertiary care – so, everybody can have access to healthcare,” he suggests.

Nonetheless, that is a goal that requires many steps and actions to see through fruition. In terms of immediate action, the proposed Pharmacy Bill is hoped to address the situation.

The Pharmacy Bill: An inconclusive debate between doctors and pharmacists

On 26 September, Malaysia’s Ministry of Health (MOH) announced that the Pharmacy Bill would be tabled soon. This would see doctors being restricted to only diagnosing medicine, and pharmacies dispensing them.

Doctors have argued that Malaysia is not ready for the dispensing separation system; especially in rural areas where patients could be inconvenienced if they could only purchase medicine at pharmacies – in which the nearest one sometimes being located 30km away.

The President of the Consumers Association of Penang (CAP), SM Mohamed Idris disagreed – finding it unjustifiable to say that the decision not to have dispensing separation is to cater to the needs of patients especially in rural areas – since countries like India and Indonesia which have a large rural population have been practising dispensing separation (DS) for years. CAP was also appalled that the MOH is denying pharmacists their fundamental role.

Amrahi agrees with CAP, stating that the building blocks must be built and “the government MUST decide,” as there was no issue with the public or some parts of the private sector.

“If they decide, a time-frame must be given as well as a grace period, because the GPs will have existing contracts with the Managed Care Organisations (MCOs) and third party-players,” he explains.

“There is nothing to rationale about it. A decision has to be made – form a committee, create a masterplan and address the other things, such as national healthcare financing, medicine prices and zoning,” suggests Amrahi. “A calculation must be made too – how many pharmacists and doctors are to serve a certain community. All this must be done properly,” he adds.

Bowing down to the pressure of powerful medical lobby

The Pharmacy Bill is also far from perfect and has been rejected by the MPS. “The big problem with the Pharmacy Bill is that it is supposed to address the issue of separation, but it doesn’t,” echoes Amrahi. “Rather than promoting a separation of roles – it appears to benefit private medical practices at the expense of consumers.”

Amrahi then points out five major flaws in the bill:
1. It doesn’t make it mandatory for doctors to issue prescriptions to their patients.
2. It doesn’t make it mandatory for a diagnosis or indication to be written on approved prescription paper.
3. It allows pharmacy assistants to work for non-pharmacists.
4. It allows doctors to prepare personalised medications, a practice known in the trade as “compounding”.
5. It allows doctors to dispense psychotropic drugs.

Pharmacists claimed that the bill insufficiently protects both consumer rights and patients.

“When we go into a clinic, more often than not, after the consultation, you are not given anything – no prescription slip, nothing,” explains Amrahi.

“Afterwards, you are being called to the counter to collect the medicines. But, who actually dispenses the medicine to you? Not a pharmacist. So, it is dangerous for the patient,” he says.

Amrahi also points out that patients often do not know the cost of what they are being prescribed, as there is no itemised billing.

“Why are the consumers not demanding?” he asks.

An Ask for your Prescription campaign was launched since 2016 – to encourage patients to demand for prescriptions. Photo credit: MPS
An Ask for your Prescription campaign was launched since 2016 – to encourage patients to demand for prescriptions. Photo credit: MPS

Since 2016, an Ask for your Prescription campaign was launched to address the issue. However, “it is easier to educate a doctor to provide a complete prescription than to educate a whole nation to ask for a complete prescription,” expresses Amrahi.

As such, “we have advised to make it mandatory for primary care doctors to provide a complete prescription, as this will benefit the patient,” asserts Amrahi.

He also highlights that the prescription slip could serve as a medico-legal document.

In current practice, if a doctor makes an error, nobody is capable of checking.

“The staff who dispense the medicine in clinics are not capable of checking whether the doctor is committing an error or not,” highlights Amrahi, adding that best dispensing practice dictates that one person cannot prescribe and dispense as well.

However, “if the government chooses to maintain the status quo, we can only do our part by voicing out the need for a “safety net” in the private primary care setting. We are not at war with the doctors, and that must be clear. We are advocating medication and patient safety as well as demanding the right to practice what we have been educated for,” iterates Amrahi.

Finally, Amrahi hopes that certain quarters would stop using pharmacists as the “punching bag” for their problems – as he puts forward the key message, as well as the ultimate mission of MPS: "Service towards a healthy society". MIMS

Sources:
http://www.themalaymailonline.com/what-you-think/article/proposed-pharmacy-bill-is-unjustified-sm-mohamed-idris#sFT8XBeYt4FC3TX2.97
http://www.freemalaysiatoday.com/category/nation/2017/09/26/pharmacy-bill-to-be-tabled-soon-says-subra/
http://www.freemalaysiatoday.com/category/nation/2017/09/21/fomca-give-patients-choice-on-where-to-get-medication/
http://www.freemalaysiatoday.com/category/nation/2017/09/19/pharmacy-group-sees-flaws-in-proposed-law/
http://www.mps.org.my/newsmaster.cfm?&menuid=37&action=view&retrieveid=7582