Postgraduate Pharmacy Education in Developing Countries

Mary J. Berg, PharmD

Disclosures

October 19, 2001

In This Article

Developing Clinical Pharmacy in India

In the 1990s, successful clinical pharmacy programs were developed in India with input from their Western neighbor, Australia. The Australians used consultancy income as the funding base for this project. The clinical pharmacy programs demonstrated that India still had to work within its own cultural framework. To think as Indian, not Western, was necessary in order to effectively apply the skills learned in the West to Indian hospitals.

The Indian program emphasized the new and ongoing program of Pharmabridge that is offered through FIP. Pharmabridge fosters intercommunication between pharmacists and the creation of institutional and personal links in support of schools of pharmacy, pharmacists associations, drug information centers, hospital pharmacies, and individual pharmacists in developing and transitional countries.

The Indian speakers were B. Suresh, MPharm, PhD, FICP, Principal and Professor of Pharmacology, and S.D. Rajendran, MPharm, PGDCP, FICP, Professor and Head of Department of Pharmacy Practice, both of the JSS (Jagadguru Sri Shivarathreeswara) College of Pharmacy in Ootacamund (referred to as Ooty), India. The third Indian colleague was G. Parthasarathi, MPharm, PhD, PG Dip Clin Pharm (Australia), Professor and Head of Department of Pharmacy Practice of the JSS College of Pharmacy in Mysore, India. The Western speaker was Frank May, Reader, Schools of Pharmacy at the University of Queensland and University of South Australia.

In order to understand the need for implementation of clinical pharmacy in India, one must understand the current state of pharmacy education and practice in that country. For the most part, these focal areas still exist according to the traditional Indian model. Historically, India has used a 3-tier educational approach. Since 1991, opportunities in pharmacy practice include a Diploma of Pharmacy (Dip. Pharmacy) that typically takes 2 years to complete; a Bachelor of Pharmacy (B. Pharmacy), 4 years; and a Masters of Pharmacy (M. Pharmacy), 1.5 to 2 years beyond the B. Pharmacy. No continuing education is required to maintain these 3 degrees once they are conferred. There are 20,000 diploma pharmacists that qualify each year and an additional one third, or 7600, with the B. Pharmacy per annum. Although there are 343 pharmacy educational institutions, only 143 offer the 4-year program. The government proposed the abolishment of the diploma in 1998, but action is still pending

Community pharmacy generally is served by more than 98% of pharmacists holding the diploma. There is 1 pharmacist with a diploma for every 2500 people. There are 700,000 community pharmacies, served by only 400,000 diploma pharmacists. In hospital pharmacy, the distribution is 75% diplomates, while B. Pharmacy degrees represent 20% and M. Pharmacy degrees, 5%. It has only been since 1986 that the government of India holds pharmacists responsible for pharmaceutical services in India through the "Consumer Protection Act."

India's per capita expenditure on healthcare is Indian rupee 15.20 (US $0.32). This compares unfavorably to Indian rupee 6876 (US $142.71) in the United States and Indian rupee 14,823 (US $307.66) in Japan. Less than 2% of the gross domestic product is spent on healthcare. An average Indian spends about 5% of annual income on curative care. There are a total of 810,538 beds in 13 governmental hospitals for a population of over a billion people. Healthcare is severely underserved to the Indian people.

As for healthcare delivery in India, rational drug use is still a dream. Problems include:

  1. Multidrug resistance to antituberculosis agents

  2. Increasing ineffectiveness of antimalarials

  3. Availability of prescription medicines over the counter

  4. Availability of more than 85,000 pharmaceutical formulations in the country

  5. High percentage of nosocomial infections (60%) caused by drug-resistant microbes

  6. Improper patient education, which leads to mismedication and noncompliance

  7. Use of herbal drugs

  8. Alarming rates of increased antibiotic resistance

  9. Lack of unbiased written information for healthcare professionals

Additionally, in India there has been a change in the healthcare scenario. This has included increased work pressure on doctors and has necessitated the involvement of pharmacists in patient care. Patients are becoming more aware of the uses of medications, while increased competition puts community pharmacists under pressure to provide more patient-oriented services.

This combination of Indian background begins to explain the need for clinical pharmacy in India. Proactive efforts of several faculty members from India were responsible for getting the West involved.

Clinical pharmacy services started in 1992, when 2 Indian hospital pharmacists, B. Suresh and B.G. Nagavi, of Ootacamund (Ooty) and Mysore, respectively, sought out clinical pharmacist Frank May in Australia. That same year, May visited their schools of pharmacy in India. Between 1993 and 1995, multiple attempts to gain funding for a joint educational project were thwarted. However, in mid-1995, the necessary financial support was provided, derived from money paid for consulting activities and donated by the hospital pharmacy staff of the Repatriation General Hospital (RGH), where May worked. Upon building sufficient equity, negotiations occurred and there was a signing of a "Memorandum of Understanding" between the institutions in both countries later that year. The education of 2 faculty members from India sent to Australia began in early 1996. In the spring of 1997, both received the postgraduate diploma in clinical pharmacy. Those 2 individuals, along with a senior clinical pharmacist from Australia, worked to establish clinical pharmacy practices in 2 hospitals, in Mysore and Ooty. Two other members from the faculty of those Indian schools of pharmacy received training in Australia during 1997 and 1998.

During 1997, the hospitals in Mysore and Ooty were the sites of clinical pharmacy practice programs developed in collaboration with a senior clinical pharmacist from RGH. The target approaches for the programs were developing competencies through academic curricula and establishing practice centers in hospitals. Curricular changes were targeted in undergraduate curriculum development, and a new branch in postgraduate courses was introduced.

Two model centers for the practice of clinical pharmacy were developed: the government sector model and the private sector model. In 1998, there was a review of the newly established clinical pharmacy programs in the 2 pilot-project hospitals. The clinical pharmacy activities at the government hospital in Ooty included:

  1. Poison management protocols

  2. IV administration guidelines

  3. Antibiotic and ranitidine usage guidelines

  4. Group counseling programs

  5. Clinical pharmacy newsletter to the medical staff

The research programs initiated included:

  1. Antibiotic resistance

  2. Drug usage evaluation

  3. Adverse drug events monitoring

  4. Patient counseling

Since these 2 schools of pharmacy now had established the beginning of clinical practice, it allowed for changes in their undergraduate and postgraduate curricula. They added applied therapeutics, practice-based teaching, drug information, documentation, and quality assurance methods for the services provided.

In late 1999, a national meeting was held in Mysore on "Hospital and Clinical Pharmacy" in India. There, the "Mysore Declaration on Clinical Pharmacy Practice and Education in India" was presented. This document discussed the standards for the practice of clinical pharmacy in India and included:

  1. Training and facilities

  2. Syllabus

  3. Patient-focused teaching

  4. Hospital infrastructure requirements

  5. Resources

  6. Interested and committed management

  7. Inspection and approval of institutions

The full text of that declaration is presented in Appendix A. It is the best summary written on clinical pharmacy to date and could be applied to other countries.

Because of the success of their clinical pharmacy activities in the 2 hospitals in Mysore and Ooty, activities have begun to occur in other Indian cities as well, including Bangalore, Belgaum, Chennai, Cochin, Coimbatore, Manipal, and Trichur.

The FIP Pharmabridge program is for individuals and organizations in the West that wish to help developing countries in many areas of pharmacy education and practice. Agathe Werhli, formerly with the World Health Organization, is the coordinator of the assistance program. The Pharmabridge program has been invaluable to the JSS College of Pharmacy in Ootacamund and in Mysore. To date, over 120 parties (pharmacists, pharmacy associations, and academic and hospital institutions) from over 30 countries are participating. Most of the assistance has originated in the United States, and the bulk of these coordinated efforts have been in Africa and India. The usual contribution involves current written material, such as journals and reference books. However, contacts have been established that have enabled a person from a developing country to visit the host country to learn more about pharmacy practice.

In conclusion, this presentation showed how this small project galvanized Indian pharmacy educators to start clinical pharmacy in several locations of the country by partnering with a Western contact in Australia. This bond gave the necessary tools for these Indian pharmacists to take back to their country and fit into their native culture. The success of the introduction of clinical pharmacy practices is now spreading to other cities of India. The goal of the innovators is to promote further partnerships with other Australian healthcare institutions and schools of pharmacy in India. It was the most impressive success story of the West helping a developing country, and hopefully this will serve as a basis for further help to those developing countries with the assistance of pharmacists from countries that have the resources to give back.

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