Pharmacy Education in Bangladesh

Introduction

In Bangladesh, a relatively small South Asian country, the pharmacy profession has been in existence for the last 4 decades. However, the profession is still preserving the status quo to support pharmaceutical industries. Until now the dispensing and patient care roles of Bachelor of Pharmacy (BPharm) graduate (A-grade) pharmacists have been non-existent in the healthcare system of Bangladesh¹. In hospital pharmacy settings, B-grade diploma pharmacists dispense, procure, and distribute medicines. A C-grade pharmacist with a 3-month pharmacy certification following a secondary school diploma can own and run a retail pharmacy and dispense medications.²

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Pharmacy education in Bangladesh has been traditionally industry based with 95% of the entry-level BPharm curriculum focusing on pharmaceutical science and industry-based courses, generating pharmacists with expertise in the areas of pharmaceutical production, quality control and assurance, pharmaceutical marketing, and regulatory affairs. With the global upsurge aimed at reforming pharmacy education, several south Asian countries including India, Nepal, and Pakistan have launched clinically-oriented PharmD programs to integrate the pharmacist into the healthcare system.^3-7 Following the same trend, pharmacy schools in Bangladesh have been restructuring their curricula to include patient-care components of pharmacy education including exploring the possibility of introducing PharmD programs.^{2, 8}

In a recent article, we discussed the status of current pharmacy education and the opportunities and challenges associated with incorporating PharmD or clinical programs in Bangladesh⁸. One of the major barriers we identified is the lack of knowledge and awareness of the importance of the pharmacy profession among healthcare stakeholders and the government. Physicians and other healthcare stakeholders of the country fail to recognize the important roles of pharmacists in comprehensive healthcare. Physicians’ recognition of the evolving pharmacy profession and development of a pharmacist-physician professional relationship are critical in order to integrate the pharmacy profession into patient care. Studies conducted in several countries have shown that physicians are receptive to pharmacists-provided dispensing as well as patient care services^9-11. There is increasing evidence that pharmacists can play a role in improved and cost-effective approach of patient care and reduction in total drug-related morbidity and mortality^{12, 13}.

As Bangladeshi pharmacy schools are reforming their curricula to include clinical components, it is the right time to set the stage for future inter-professional collaboration. The changing face of today’s healthcare and increasing complexity of drug therapy underscores the need for strong working relationships between pharmacists and physicians in order to provide optimal patient care. Thus, it is important to assess the knowledge and attitudes of physicians regarding pharmacists’ roles and responsibilities in healthcare. The objective of this study is to determine physicians’ knowledge and perceptions of the pharmacists’ roles in patient care and pharmacy services. The survey results will assist in initiating a fruitful dialogue with different stakeholders in healthcare regarding the evolving changes in the pharmacy profession in Bangladesh.

Methods

A survey instrument was developed by the investigators, based on previous literature reports^{9, 14, 15} of physician-pharmacist collaboration. The survey instrument was reviewed by all investigators and revisions were made on feedback. Two investigators of this study are registered pharmacists with experiences in hospital and/or community pharmacy settings. Since, the researchers graduated in pharmacy from Bangladesh, they are abreast of the past and present healthcare systems of the country. The study received exempt status from the institutional review board of West Coast University and Lake Erie College of Osteopathic Medicine. The survey collected data on 3 domains: physicians’ current awareness of pharmacy education and profession in the country; their perceptions of the future roles of pharmacists in patient care and, finally, interprofessional collaboration with pharmacists. The survey instrument also collected demographic information of the respondents including age, gender, affiliation and duration of practice.

The participant physicians (n=160) were randomly selected from Dhaka, the capital city of Bangladesh. The survey was administered by two methods: 1) electronically (n=110) and 2) distributing hardcopies of the survey (n=50) by a volunteer in selected clinics and hospitals. The online survey instrument was sent through email that contained a link of the survey instrument (Survey Monkey). Email addresses of physicians were obtained from websites of government and private teaching hospitals and professional organizations. Ninety percent of the email information was collected from 3 government and 10 private hospitals of Dhaka.

A cover letter accompanied the survey which explained the purpose of the survey along with the assurance that participation will be voluntary and identity will remain anonymous. Also included in the cover letter, was information on current trends in global pharmacy education and physician-pharmacist collaborative practice to provide optimal patient care. Physicians were also informed that clinical pharmacy courses are being introduced in Bangladeshi pharmacy curricula to prepare pharmacy graduates to work in clinical settings with physicians and other healthcare professionals.

The survey instrument included 13 questions divided into two sections: i) understanding physicians’ knowledge of pharmacy education and profession (5 items) and ii) physicians’ perceptions of the future roles and responsibilities of pharmacists in comprehensive patient care (8 survey items). Items on the current understandingof the physicians about the pharmacy profession and education were self-reported as “yes” or “no”. Items on the perception of pharmacists’ future roles in patient care and interprofessional collaboration were self-reported on a five-point Likert scale with 1-very uncomfortable to 5-very comfortable. At the end of the questionnaires, there was a section for individual comments. Data obtained from manually distributed survey were submitted online by one of the investigators. Results from the two arms of the survey were aggregated and analyzed. The Fisher Exact test was used to test the significance of association between the independent variables (gender and length of medical practice) and the dependent variables (respondents’ level of comfort). Statistical significance was accepted at a p value of <0.05. At the end of the survey, physicians were asked to provide overall comments about the anticipated roles of pharmacists in patient care and physician-pharmacists collaborations/relationships. Text-based comments were collated and thematic analysis of the content was performed.

Results:

Of the 160 questionnaires distributed, 103 participants completed the survey (response rate 67%). The demographic profiles for the participants are given in Table 1. Greater than two third of the participants were male. More than 50% of the participating physicians were under 30 years of age with 1-3 years of experience in medical practice. About 75% of the respondents work primarily for private hospitals/ clinics and 25% in government hospitals. Interestingly, 95% of the responding physicians are concurrently engaged in private practice.

When asked to indicate their awareness about pharmacy education and profession, nearly all the physician participants (96%) are aware of pharmacy as a healthcare profession. Seventy nine percent of the participants are aware that pharmacy education in Bangladesh has been significantly expanded. But only 60% of the respondents knew that pharmacists obtain an A-grade license after successful completion of a 4-5 year BPharm degree program from an accredited university. The participants recognize that pharmacists are knowledgeable about drugs (80%) and serve as reliable sources of drug information (91%).

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Responses regarding physicians’ perceptions towards the anticipated patient care roles of pharmacists in Bangladesh and interprofessional collaboration among healthcare providers are shown in Table 2. Physicians exhibited a high level of comfort with most of the roles of pharmacists as members of Interprofessional healthcare team. They felt very comfortable/comfortable with pharmacists procuring, distributing, and dispensing medications in hospital and community pharmacies (81%); providing education to patients/caregivers about the safe and appropriate use of prescription medications (85%); and educating patients about health and wellness, nutrition, and use of OTC medications and dietary supplements (65%). Physicians are comfortable/very comfortable with pharmacists detecting and preventing prescription errors (56%), designing pharmacotherapeutic regimens (78%) and monitoring patient safety (80%) and therapeutic outcomes at in-patient settings (62%). Physicians’ comfort level was found to be the lowest with pharmacists recommending physicians alternative drug therapy or modified drug-therapy regimen when therapeutic outcomes were not satisfactory (comfortable/very comfortable, 51% versus uncomfortable/very uncomfortable, 49%).

A total of 41 open-ended comments were recorded from a total of 102 respondents and were subjected to thematic analysis (Table 3). Most of the comments (26/41) reflected upon positive attitudes towards pharmacists’ future roles in patient care. Physicians were supportive to the pharmacists’ roles in dispensing and other clinical pharmacy services. Several physicians commented on the challenges of integrating pharmacists into patient care and focused on the proper training and education of pharmacists. They also commented on the importance of an interprofessional dialogue between physicians and pharmacists. A few comments pertained to the reservations of physicians about pharmacists’ recommendations to change prescriptions or drug therapy regimen.

Discussion:

Pharmacy education is evolving from it’s original “product-oriented” focus towards an inclusive “patient-oriented” focus.^{16, 17} In developed countries, the emphasis on clinical pharmacy education has enabled pharmacists to provide optimal patient care as members of interprofessional teams.¹⁶ With the evolution of pharmacy profession, especially in the developed nations, pharmacists now provide direct patient care as a part of interprofessional team in a variety of practice settings.

Although Bangladeshi physicians are aware of pharmacy as a healthcare profession, over 50% did not know that 4-5 years of study towards BPharm degree are required for pharmacist licensure. It is noteworthy that the number of private universities offering BPharm degrees is increasing in the country. Out of 27 pharmacy schools, 22 are in the capital city. Pharmacy schools are also restructuring their curricula to include clinical pharmacy.^2,18 The introduction of a clinically-oriented PharmD program in developing countries is a challenging undertaking^{3, 4} In Bangladesh, the current status of pharmacy practice and the fact that the profession is not well recognized among government and other stakeholders in the healthcare arena constitute major barriers to initiation of patient-oriented clinical programs. Other challenges associated with healthcare policy, physical infrastructure, financial resources, establishment of a framework of inter-professional collaboration, and physicians’ recognition of the pharmacists’ roles in patient care need to be addressed.

It is encouraging that physicians in Bangladesh appeared to be comfortable with pharmacists dispensing prescription orders, detecting and preventing prescription errors, checking adverse effects and drug-drug interactions, and providing patient education. There is documented evidence that the integration of pharmacists to interdisciplinary healthcare teams improves health and safety outcomes for patients, decreases morbidity and mortality due to medication-related problems, decreases healthcare costs, and improves quality of care.^{11-13, 19} In a recent pharmacy-based controlled trial, Vinks et. al. showed that community pharmacists play critical roles in reducing the occurrence of drug-related problems in elderly patients.^{20, 21}

Irrational prescribing, medication errors, and poly pharmacy have become a major health problem globally.^22-25 Similarly, in Bangladesh, irrational prescribing of medications and medication errors are common in every healthcare setting. Superfluous prescribing of antimicrobials is widespread and leads to emergence of antibiotic-resistant strains and treatment failure²⁶. In a recent study, Paul et al. have reported highly prevalent prescription errors in a private hospital in Bangladesh.²⁷ A number of factors such as lack of medical professionalism²⁸, curricular gap²⁹ and inadequate training in pharmacology and therapeutics^30-34, aggressive promotion of pharmaceutical products, and unlawful contract between doctors and pharmaceutical industries ³⁵ contribute to the continuing crisis of irrational prescribing trends in the country. In addition, Bangladeshi healthcare delivery systems seriously suffer from corruption, poor management, shortage of properly trained health professionals, and lack of accountability³⁶. There is little or no strategy for collecting statistics on medication errors and its prevention to ensure patient safety. In the last decade there has been an upsurge of private hospitals including several world-class corporate hospitals which, for the first time, are emphasizing quality control, patient safety standards, and privacy practices ³⁶. The systemic strategies for medication management, including integration of pharmacists into healthcare team by the Apollo Hospitals Dhaka, the most prominent hospital in Dhaka, are noteworthy. The hospital claims that the current rate of medication error has dropped to 2.45%, where the US benchmark is 5%.³⁷It is expected that the Apollo Hospitals can be a model for other hospitals in the country in the recognition of pharmacists’ roles in patient care and safety.

Bangladeshi physicians are comfortable with upcoming pharmacists’ monitoring and optimization of drug therapy. This is consistent with a survey study in the United Arab Emirates which showed that the majority of participating physicians (92%) supported the clinical pharmacists’ roles⁹. However, physicians in Qatar¹⁴, Kuwait³⁸, Pakistan¹⁵, and Sudan³⁹ were found to be more comfortable with pharmacists’ roles closely linked with drug products than responsibilities associated with monitoring and optimization of patient outcomes or recommending drug therapy for patients. In Montreal, Canada, a physician-pharmacist collaborative care model showed better patient-care outcomes where pharmacists ordered diagnostic tests and optimized medication dosages. However, the perception of physicians was unfavorable to the success of this model as they felt unsecured and threatened by the expanding roles of pharmacists.⁴⁰

Integrating pharmacists into dispensing and clinical pharmacy services in Bangladesh will represent a milestone. Therefore, it is time for Bangladeshi pharmacy community to start building interprofessional relationships with physicians, establishing communication channels, developing mutual respect, and understanding each other’s responsibilities. The results of the current study can serve as a foundational approach towards the interprofessional relationship between pharmacists and physicians. Physicians’ perceptions and knowledge of pharmacy profession have direct implications on the current pharmacy education reform in Bangladesh. Physicians demonstrated positive attitude towards future pharmacists’ involvement in patient care. They emphasized the optimal level of clinical education and training for the pharmacists to perform clinical services. Moreover, several physicians recognized that communication and dialogue between them and pharmacists are inevitable for better patient care. In this context, we propose curricular and non-curricular approaches to develop the culture of interprofessional collaboration (Figure 1). As we have discussed in our previous article⁸, Bangladeshi pharmacy educators need to revisit the curriculum to incorporate optimal didactic and experiential clinical courses, incorporate effective communication, professionalism, and ethics into curriculum. In addition, the concept of interprofessional education and practice needs to be incorporated early in the curriculum. A number of strategies can be utilized through extra-curricular activities at different levels involving professional associations, institutions, and students. At professional association level, a channel of communication must be developed to initiate professional dialogue. Upon establishment of communication, physicians and pharmacists can be invited as speakers in each other’s professional meetings. These initiatives will offer the opportunity of recognizing each other’s experiences, expertise and competence in patient care. At institution level, collaboration between medical and pharmacy school faculties in teaching and research, and joint seminars/workshops on clinical areas of interest will increase appreciation and recognition of the roles of interdisciplinary colleagues. In addition, opportunities may be created for organizing health fairs, workshops, seminars, and community outreach activities involving both pharmacy and medical students. Since the government controls the major health benefits for its citizen, educating the government officials about the positive impacts of pharmacists on overall healthcare should be an important consideration for leaders of the profession.

In summary, Bangladeshi physicians possess favorable attitudes towards accepting pharmacists in the healthcare arena. It is crucial for pharmacy educators and leaders to begin a dialog with the government in order to expand the roles of pharmacists, adopt relevant changes in health policy, and establish inter-professional healthcare teams.