Pharmacy is a health profession

Chapter 1

The word is derived from the Greek word ‘pharmakon’ meaning “drug” or “medicine” and has been used since the 15th and 17th centuries 1. Pharmacy is a health profession that combines the health sciences with the chemical sciences. It ensures the safe and effective use of pharmaceutical drugs.

Pharmacy practice includes modern services that are related to health care: clinical services, providing drug information and reviewing medications for safety and efficacy purposes 1.

1.1.1 The various disciplines of Pharmacy

Pharmacy can be divided into three major disciplines:

a) Pharmaceutics

b) Medicinal Chemistry and Pharmacognosy

c) Pharmacy Practice

Pharmacology is often considered to be a fourth discipline but is not specific to pharmacy, even though it is essential. The boundaries between the different disciplines and other sciences like biochemistry are not clear cut. Hence, research work from the various disciplines is often done concurrently 2.

1 The Hormone Shop LLC. The History of Pharmaceutical Compunding. [home page on the Internet]. 2010 [cited 2010 Oct 10]. Available from: http://www.thehormoneshop.com/historyofcompoundingpharmacy.htm

2 Dayanada Sagar College of Pharmacy, Bangalore, India. History of Pharmacy. [home page on the Internet]. 2008 [cited 2010 Oct 10]. Available from: http://www.dscpharmacy.org/pharmacy.php

1.1.2 The Pharmacist and Community Pharmacy

Pharmacists are skilled and highly-trained health care professionals who ensure optimal health outcomes for their patients. In the community pharmacy, the pharmacist has various roles and these include amongst others (Azzopardi, 2010):

a) the procurement of medications that are suitable for human consumption

b) ensuring the appropriate conditions for the storage of medicines

c) ensuring the appropriate and safe disposal of expired medicines

d) dispensing of medications that are either on a prescription, or pharmacist-recommended or asked for directly by the patient

e) point-of-care testing

f) offering general medical advice without the need of a prior appointment.

The practice of community pharmacy varies between countries. Nevertheless, the basic functions and responsibilities are the same.

A community pharmacist builds a special relationship with the clients, especially the regular ones. Hence, communication skills are of major importance. The pharmacist finds him / herself comforting and hearing out the patient when necessary, and is expected to be understanding and also a good listener.

1.2 History of Pharmacy

The first pharmacies, apothecaries as they were formerly known, were founded in the Middle Ages in Baghdad. The first one was founded in the year 754 AD by Muslim pharmacists during the Islamic Golden Age 2. During the 11th century, community pharmacies were established in southern France and southern Italy. In 1240, Emperor Frederick II issued a decree – the medical profession was to be separated from the pharmacy profession. Pharmacy practice was to be supervised so that drugs of a suitable quality would be prepared and produced (Azzopardi, 2010).

The history of pharmacy can be classified into three stages:

a) compounding and dispensing

b) clinical pharmacy

c) pharmaceutical care.

Originally, the pharmacists had to prepare and dispense medicines so they had to excel at compounding. The community pharmacist was therefore highly esteemed because the preparation of medicines was greatly valued in society.

In fact, at that time, the pharmacists and other professionals such as lawyers, medical doctors and parish priests were the leaders in the community. As time passed, newly discovered drugs became more dangerous and potent so they started being prepared by manufacturing companies. The pharmacists’ role was only to dispense these drugs (Al-Shaqha, Zairi, 2001).

2 Dayanada Sagar College of Pharmacy, Bangalore, India. History of Pharmacy. [home page on the Internet]. 2008 [cited 2010 Oct 10]. Available from: http://www.dscpharmacy.org/pharmacy.php

Pharmacists moved to clinical practice about 25 years ago. The original concept of clinical pharmacy services was based on the fact that pharmacists ought to use their professional knowledge to ensure the appropriate and safe use of drugs in patients. As a result, several pharmacists nowadays work in hospitals, nursing homes and some ambulatory clinics. Problems remained within the drug-use-system despite the advances made in clinical pharmacy and documenting and recognising these problems has led to the concept of pharmaceutical care becoming the new basis for pharmacy practice (Al-Shaqha, Zairi, 2001).

1.2.1 History of pharmacy in Malta

1.2.1.1 History of pharmacy in Malta from the late 15th century until the arrival of the Knights of the Order of St. John of Jerusalem in 1530

Before 1500, the pharmacists in Malta were almost all Sicilian. In the early 15th century, pharmacists were employed either by the Universita’ or by the Hospital of Santo Spirito.

Mastru Salvatore Passa is the first documented pharmacist in Malta who practised in Mdina and the Hospital of Santo Spirito in Rabat from 1450 to 1475. The medicines prescribed in those days were mainly herbal. During this period, Passa often travelled to Sicily due to his work, presumably to import medicinal herbs as many herbs did not form part of the local flora (Borg, 1998).

1.2.1.2 Pharmacy under the Knights of the Order of St. John of Jerusalem

The Knights of the Order of St. John of Jerusalem arrived in Malta on the 26th October, 1530 and they applied their knowledge of pharmacy to the practice in Malta. A Holy Infirmary in Birgu was built and the Greek pharmacist, Giacomo Gualterio, who had accompanied the Order to Malta was the apothecary (Borg, 1998).

Grand Master Nicholas Cottoner established the School of Anatomy and Surgery at the Holy Infirmary in 1676. It is very probable that a Pharmacy course was established in the school (Borg, 1998).

Under the Knights, the practice of pharmacy in Malta changed gradually, but continuously, occurring in a similar way to that in Europe. However, extemporaneous preparations remained the same from the times of Mastru Salvatore Passa because the enlargement of the pharmaceutical industry still had to occur (Borg, 1998).

1.2.1.3 Pharmacy under the French and British colonies

The French arrived in Malta in 1798. There were no more than 32 pharmacies under their dominion, each one having an average clientele of 3,000 patients. No changes were made to the laws governing the practice of pharmacy under the French. Hence, the daily activities of the pharmacists were identical to those of under the Knights. The laws established by the Knights of the Order of St. John remained in force until 1900. In their stay in Malta, which lasted for about one hundred years, the British left their mark on the pharmacy profession. The use of the English language, the names of pharmacies pertaining to Britain or England and the consulting room in the pharmacy are all such examples (Borg, 1998).

1.2.1.4 Pharmacy in the 20th century

“The Medical and Kindred Professions Ordinance” of the Laws of Malta, governs pharmacy laws. This was enacted in 1900 as the laws governing the profession at that time had become outdated and needed restructuring. A legislation that allowed pharmacists to dispense certain medicaments without a prescription was enacted in October 1955 and on the 12th October 1955, a list of these substances was published in the Malta Government Gazette (Borg, 1998).

The Malta Chamber of Pharmacists was founded in 1900 in order to protect the common interests of the pharmacists and also to maintain the profession’s dignity. Hence, the profession’s standards were raised by enabling the profession to keep abreast of the changes that were occurring internationally (Borg, 1998).

In April 1961, an Extraordinary General Meeting was held by the Chamber to discuss the issue of forming a Trade Union that would represent pharmacists; all 33 pharmacists present agreed that this was necessary. One of the Union’s objectives, among others, was to improve the conditions under which the profession was exercised and to promote the interests of pharmacists. The Pharmacy Board was set up in 1968 and this was the greatest achievement of the Chamber and Union. The Union worked very closely with the Chamber and in 1979 they formed one association, i.e. the Chamber of Pharmacists – Trade Union. This association worked very hard and it affected the current state of the profession and also the legislation governing the practice of pharmacy (Borg, 1998).

In 1984, after several meetings with the Chamber, it was finally decided that new pharmacies ought to be owned by pharmacists and that before granting new permits, the population ratio has to be taken into consideration (Borg, 1998).

Patients could get their free medications from the Central Hospital Dispensary and Government Dispensaries throughout the first fifty years of the 20th century. The latter could be found in most villages around Malta. In 1954, the Central Hospital at Floriana was turned into the Headquarters of The Malta Police Force as by the late 1940s, St. Luke’s Hospital became Malta’s General Hospital. Hence, the Out-Patient Dispensary of St. Luke’s Hospital became the Central Government Dispensary (Borg, 1998).

Pharmamed, the first local pharmaceutical enterprise, was founded in 1974. This gave rise to several job opportunities in the industrial field, besides enhancing Malta’s image abroad.

In 1995, as a result of strong and consistent negotiations and representations by the Maltese Chamber of Pharmacists, there was the appointment of the first director of the Government Pharmaceutical Services (GPS). This was part of the reform of the GPS and the career progression of pharmacists in Government service. It was concluded in 1998 in agreement with the Ministry of Health on the full implementation of the GPS reform.

1.2.1.5 Pharmacy in the 21st century

In June 2007, Mater Dei Hospital replaced St. Luke’s Hospital as the national hospital of Malta. The last of the personnel migrated to Mater Dei by November of that year. Hence, the main Government Dispensary was moved to Mater Dei as well 3.

In 2008, the much awaited and debated Scheme of the Pharmacy of Your Choice (POYC) was introduced. This Scheme enables the people to have an easier and more comfortable access to the medicaments that are given for free by the Government.

3 Mater Dei Hospital Malta. [homepage on the Internet]. 2009 [cited 2010 Oct 23]. Available from: http://malta.cc/health-care/mater-dei-hospital-malta/

Thus the service that was previously provided for by the village Health Centre Dispensaries was transferred to the community pharmacies. The patients chose the pharmacy of their choice. The initial stages of the POYC Scheme do not envisage any changes in the reimbursement system. Therefore, patients who are entitled to take free medication will continue to do so; there is no co-payment (Grima IC). Until January 2011, the POYC Scheme had spread to 96 Maltese community pharmacies and to 17 community pharmacies in Gozo. Following the introduction of the Scheme, the village Health Centre Dispensaries where the Scheme was initiated, were closed down after sufficient time had elapsed.

Over the past few years, the number of local pharmaceutical manufacturing companies has dramatically increased. So has the number of locally licensed pharmaceutical wholesalers who import medications from EU countries. There are more pharmaceutical products registered with the local Medicines Authority. This has had a positive impact on both the private and public pharmaceutical sectors due to the availability of more different therapeutic classes of medicines and more medicines that fall within the same therapeutic class (Grima IC).

Recently, the number of generic medicinals in the private sector has also increased considerably. Nowadays, a pharmacist can substitute a branded prescribed medicinal with a generic product that is cheaper for the patient (Bugeja, 2007).

Accession into the European Union in May 2004 had a great impact on the medicines in Malta, especially with regards to their availability. Some medicines that were previously available were not registered due to the high registration costs. Hence, EU accession improved the quality of medicines. On the other hand, it had a negative impact on their availability and affordability (Bugeja, 2008).

The prices of medicines in Malta increased considerably after EU accession in 2004. In fact, according to studies carried out, the Maltese are paying about 40% more than the average price for medicinal products in the European Union 4. In July 2010, the Parliamentary Secretary, Chris Said, announced reductions in prices of 62 medicines. Some of these reductions were to be implemented immediately whereas with others, when stocks were sold out. Many medicines in Malta are overpriced when compared to other EU countries, so this was a step in the right direction 5,6.

1.3 Pharmaceutical Care

In 1990, Hepler and Strand looked at the responsibilities of the pharmacist and at pharmacy services in a new way. They applied the term “pharmaceutical care” and over the years pharmacists have endeavoured to develop pharmaceutical care practices (Foppe, Schulz 2006). According to Hepler and Strand (1990):

4 Maltastar. The price of medicines in Malta under European Commission scrutiny. [homepage on the Internet]. 2010 [cited 2010 Oct 27]. Available from: http://www.maltastar.com/pages/rl/ms10dart.asp?a=11804

5 Xuereb M. Makers cut prices of 62 medicines. Times of Malta [serial on the Internet]. 2010 [cited 2010 Oct 27]. Available from: http://www.timesofmalta.com/articles/view/20100703/local/makers-cut-prices-of-62-medicines

6 Vella Matthew. Medicine importers agree to cuts in prices of up to 67%. MaltaToday [serial on the Internet]. 2010 [cited 2010 Oct 27]. Available from: http://www.maltatoday.com.mt/news/medicines/medicine-importers-agree-to-cuts-in-prices-of-up-to-6

“Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. These outcomes are (1) cure of a disease, (2) elimination or reduction of a patient’s symptomatology, (3) arresting or slowing of a disease process, or (4) preventing a disease or symptomatology.”

In their definition of pharmaceutical care, Hepler and Strand looked at the patient’s quality of life (Strand et al, 1991). Pharmaceutical care involves a pharmacist cooperating with the patient and members of other health care professions 7. This interprofessional relationship allows the implementation, design and monitoring of a therapeutic plan that will have specific therapeutic outcomes for the patient to benefit from (Ford, Jones, 1995). Pharmacists are the last health care professionals to come in contact with the patients. They thus have a major role in educating them regarding drug use. For this reason, pharmacists must be adequately trained and have excellent communication skills in order to provide this service in an effective manner (Alkhawajah, 1992). Pharmaceutical care can therefore be seen as the component of pharmacy practice that has to be performed by a competent pharmacist who must be committed, honest, accountable and loyal to the patient (Strand et al, 1991).

1.4 The Health Care System in Malta

Malta’s health care system is divided into the public / national health care system and the private health care system in which pharmaceutical services are provided for by 211 pharmacies that are distributed around Malta and Gozo. The public / national health system is based on a model that is founded on the principles of Equity, Solidarity and Justice.

7 American Pharmacists Association. Principles of practice for pharmaceutical care. [homepage on the Internet]. 2005 [cited 2010 Oct 12]. Available from: https://www.caremark.com/portal/assset/Principles_of_Practice_for_Pharmaceutical_Care.pdf

1.4.1 The Public Health Care System

The Maltese Government consists of different Ministries, one of these being the Ministry of Health, Elderly and Community Care. This deals with the healthcare needs of the people and ensures that adequate services are provided for 8.

The main goals of the Government for the public health services include 9:

The concern of the patient, which is a constant issue

The provision of health care and its management

The value for money

The sustainability of public health care.

The Maltese Medicines Authority controls and ensures the quality, safety and efficacy of the pharmaceuticals that are available locally. It also authorizes the medicines that are to be placed on the local market.

The Government Health Procurement Services (GHPS) is responsible for the purchasing, storage and distribution of all the pharmaceuticals that are required by the Government Health Services (GHS) in Malta. This entity operates with the funds that are allocated annually by the Government. Procurement of pharmaceuticals is done via tendering procedures that are regulated by the Public Service (Procurement) and Public Contracts regulations.

8 Government of Malta. The health care system in Malta. [homepage on the Internet]. No date [cited 2010 Oct 25]. Available from: The Government of Malta, Web site: http://www.sahha.gov.mt/pages.aspx?page=156

9 Integrated health information system phase 2. [homepage on the Internet]. 2010 [cited 2010 Oct 24]. Available from: The Government of Malta, The Malta Information Technology Agency Web site: https://www.mita.gov.mt/TenderFile.aspx?tfid=727

1.4.1.1 Primary Health Care

The Government delivers primary health care via the Health Centres that are distributed around various villages in Malta and Gozo. These centres were set up in 1980 in order to provide free health care services 9. Besides providing the free services of general practitioners, these centres also provide a vast range of other services, including:

Specialist clinics eg: gynaecological clinics and diabetes clinics

Laboratory diagnostic facilities

Radiology.

Many people choose to have the services of private general practitioners and / or specialists who work in the primary health care sector. In the private scenario, their services are against payment.

1.4.1.2 Secondary and Tertiary Health Care

These are provided for by public and private hospitals, found in different locations in Malta. The main public hospital is Mater Dei Hospital and it provides a wide range of services, including transplant surgery, open heart surgery, emergency care and diagnostic services. Sir Paul Boffa Hospital, another public hospital, has an oncology and dermatology unit. Mount Carmel Hospital is the island’s public psychiatric hospital.

There are a number of private hospitals in Malta, amongst which is Saint James Capua Hospital.

9 Integrated health information system phase 2. [homepage on the Internet]. 2010 [cited 2010 Oct 24]. Available from: The Government of Malta, The Malta Information Technology Agency Web site: https://www.mita.gov.mt/TenderFile.aspx?tfid=727

1.5 Free health services provided by the government

The Government provides free health services; free at the point of delivery, as these are directly funded from general taxation. In Malta, the boundary between the private and public sectors can be seen from two different aspects: medical and pharmaceutical (Wismayer, 2010).

1.5.1 The Medical Aspect

The healthcare is available to ALL Maltese citizens, irrespective of the social and financial background of the patient. Anybody can turn up at a Health Centre or public hospital and be given the necessary treatment. Hence, up to a certain extent there is a holistic attitude as no distinction is made between citizens and whoever requires a healthcare service is provided with what is needed (Wismayer, 2010).

The seams start to show up when the services available in the public health system are not accessible. That sector of society who can afford to pay, will therefore have to seek the services from the private sector. A case in point is the long waiting lists for certain required procedures at Mater Dei Hospital.

1.5.2 The Pharmaceutical Aspect

One of the major tools to achieve good healthcare is to provide good pharmaceutical care. From this aspect, there is a clearer distinction between the private and public sectors.

The Government offers free medications to a number of people who fall under different categories:

The Schedule II Patients (Pink Card Holders)

These cards are issued from the Department of Social Security. They are accompanied by a pink form which bears the name of the pink card holder. The total household income is assessed and the entitlement is based on this. Each household has one pink form that lists all members. However, every member of the household has his / her pink card. The pink form and pink card entitle their holders to free medication that is listed on the Government Formulary. Diabetics also have a pink card issued in their name.

There are several faults in the administration of this system, as there does not seem to be a distinction between the strata of society, as is the case with some affluent people who are also in possession of a pink card. Also, no distinction is made between hospital in-patients and out-patients; there is only one formulary for all. 10.

The Schedule V Patients (Yellow Card Holders)

If a person suffers from a medical condition that is listed under the fifth schedule of the Social Security Act, then he / she can benefit from this free service, irrespective of the financial position. Examples of these conditions include:

Respiratory conditions

Cardiovascular diseases

Malignant diseases

Schizophrenia

Liver diseases

CNS diseases 10.

10 Ministry for Health, the Elderly and Community Care. Free medicinals. [homepage on the Internet]. No date [cited 2010 Oct 12]. Available from: The Government of Malta, Web site: http://www.sahha.gov.mt/pages.aspx?page=8

When a patient is diagnosed with such a condition, he / she is referred to a Consultant by the General Practitioner. The Consultant applies for a Schedule V Card for the patient listing the required medications. Subsequently, the patient is issued with the Card from the Almoner Section at St. Luke’s Hospital. People who possess a yellow card are only entitled to take the medications that are listed on the card for free. The list must be amended if the treatment is changed.

The Government Hospital In-Patients

Any patient resident in the Government Hospitals is entitled to free medication. To date, there is only one Government formulary for all public hospitals. It would make more sense if each hospital had its own formulary due to the specialisation of the hospitals that varies accordingly. These formularies ought to be put together by the doctors who work at the hospitals and by the pharmacists who know what medications are available and which are best suited for the patients.

Other people entitled to free medicines include amongst others:

Members of certain religious orders

Inmates of charitable institutions

Refuse collection employees

Prisoners

People who are injured on duty

Members of the Police Forces below the grade of Sub – Inspector

AFM personnel 11.

11 Ministry for Health, the Elderly and Community Care. Free medicinals. [homepage on the Internet]. No date [cited 2010 Oct 12]. Available from: The Government of Malta, Web site: http://www.sahha.gov.mt/pages.aspx?page=172

1.6 The Pharmacy of Your Choice Scheme

The Pharmacy of your choice Scheme (POYC) falls under the umbrella of the Health Division in Malta. The latter is under the portfolio of the Ministry of Health, the Elderly and Community Care. POYC is under the direct responsibility of the Permanent Secretary of Health. The Scheme started in 2008 after several years of discussions and debates. It enables the people to have an easier and more comfortable access to the medicaments that they are entitled to take for free from the Government.

The Scheme started in 2008 with an estimate budget of €460,000 and the actual expenditure for that year amounted to €366,000. In 2009, the estimate budget was of €400,000 and that for 2010 was of €1.5 million. The 2011 budget allocated €1 million to the Scheme apart from the additional €400,000 which had to be injected to strengthen the electronic system.

The POYC pilot study started in December 2007 in two pharmacies in the Ghargur area. About 550 patients were registered in these pharmacies. Mgarr was next (one community pharmacy having approximately 600 patients), followed by Mellieha (three pharmacies having approximately 1500 pateints) in January 2008 and Naxxar in February 2008 ( Sant Fournier, 2008).

Most community pharmacies enrolled in the POYC when the Scheme was introduced in their villages. For example, in the Mosta area, which includes Naxxar, St. Paul’s Bay, Xemxija, Gharghur, Mgarr, Mellieha and Mosta, only one out of the 24 community pharmacies did not join in the Scheme due to lack of space (Zahra, 2007).

With the introduction of the POYC Scheme, the village Health Centre Dispensaries were closed down after sufficient time had elapsed to allow for a seamless transition.

1.6.1 Advantages associated with the POYC Scheme

The main scope of the POYC Scheme was to reduce the long queues at the Health Centre Government Dispensaries. Also, patients are monitored better by the community pharmacists who ensure that the medicines are taken in the correct way as more patient advice is given on a one-to-one basis when compared to the previous system (Zahra, 2007). Pharmacy practice in the community has always focussed on the establishment of an excellent patient-pharmacist relationship (Sant Fournier, 2007). This advice is lacking in the public sector as the patients are given the medicines they require with haste, due to the large number of people waiting to collect their medications. Dosage regimen advice is usually the only advice given. Many people used to turn to their community pharmacists anyway to seek advice and to solve any queries they may have had.

With this Scheme, there is also a decrease in wastage because patients are not given the medicines if these are not required, despite the fact that they are entitled to them. Sant Fournier, the President of the Malta Chamber of Pharmacists, claimed that most patients have become more educated and as a result acknowledge the fact that medicines are not to be taken as a for granted privilege but must be used rationally (Borg, Bonello, 2009). The patients find it easier to confide in their habitual pharmacist rather than talk to someone who they do not know.

1.6.2 Problems associated with The POYC Scheme

According to Mario Debono, the then General Retailers Trade Union (GRTU) Pharmacy and Health Division President, this system has been a success even though it would improve if more money is allocated by the Government and if it receives more attention (Borg, Bonello, 2009).

As with any other recently introduced systems, there are flaws. Nevertheless, several efforts are being made to sort them out. The main problem that is associated with the POYC Scheme is the large number of medicines that are out of stock. This is causing unnecessary stress on the pharmacists and patients. The latter have to go to a Government Health Centre Dispensary that is still open or to Mater Dei Out-Patients Pharmacy to get the medications that are not available from the Scheme. However, this out of stock problem is not the fault of the POYC Department but it has got to do with the purchasing system of the Government. In October 2009, Debono stated that a possible reason why such a large number of medicines is out of stock is that some suppliers have not been paid for their services. Shortages of certain medicines abroad could also lead to decreased stock levels (Borg, Bonello, 2009).

The Government did not organise any educational campaigns for the general public regarding the implementation of the POYC Scheme, even though it was advised to do so (Sant Fournier, 2009). Hence, pharmacists were faced with several problems, including sometimes, heated arguments with their patients. It was recommended to have the campaign based on the one used for the introduction of the Euro in Malta, the Malta Euro Changeover Campaign.

In October 2009. Reginald Fava, the then President of the Malta Chamber of Commerce, Enterprise and Industry, made new proposals to upgrade the POYC system which were “estimated to cut at least a third of present consumption and abuse”. He described the current POYC system as being “obscene” because according to him medicines were being collected even when they were not required by the patients. Fava suggested that patients ought to pay for the medicines they require and will be reimbursed by the Government at a later stage. With this proposed system, the patients would also have the option to go for more advanced or more expensive medications as compared to their entitlement, and will only have to pay the difference in price. Hence, with this proposal, the POYC Scheme would be allowing superior medicines to be taken for free. It would also make the Scheme more sustainable as it would reduce the out of stock problem, be more cost-effective for the Government, reduce wastage and abuse. The Government would thus be saving on costs and would be in a better position to widen the National Formulary with more recent and advanced medications (Borg, 2009). At the moment, this is not possible due to financial constraints.

The POYC Scheme affected the daily running of the community pharmacies. Due to the increased work load, some pharmacy owners had to employ further staff. The owners had to purchase a computer and a printer for labels to be issued with every dispensed prescription. They also had to apply for internet service at the pharmacy. Also, some pharmacies had to make the necessary arrangements to increase shelving space to accommodate the weekly delivery of medicines from the POYC Department. Some pharmacies even needed to install another air-conditioning unit. Admittedly, the Government subsidized these expenses to a maximum capital expenditure of €6,990 (Lm 3,000). After the Memorandum of Understanding was signed, negotiations were held and the amount was capped at €9,000.

According to an article on the The Malta Business Weekly that was published in November 2009, only the pharmacists who own the pharmacy are happy with this new system. The employed pharmacists have had their work load doubled, if not trebled. Hence, they do not give their patients the service that they used to give before the implementation of the Scheme (Attard, 2009).

1.6.3 The Memorandum of Understanding

The very first document on the POYC Scheme was submitted to the Government by the Malta Chamber of Pharmacis