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Community pharmacy and emerging public health initiatives in developing Southeast Asian countries: A systematic review

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The development of health and healthcare systems in South-East Asia has influenced the practice of community pharmacy. Over the years, community pharmacy in the region has striven to expand services beyond dispensing to encompass more involvement in public health issues. Searches were conducted in Scopus, EMBASE, MEDLINE and PubMed for articles published between January 2000 and December 2014, with 21 studies in five countries meeting the inclusion criteria. The findings showed increasing interest in research into the delivery of pharmacy services and public health initiatives. Overall, the review found that provision of some health services in pharmacies was common; however, most public health initiatives appeared to be poorly implemented, had limited evidence and were not demonstrated to be sustainable across the sector. This indicates that the practice of community pharmacy in the region has not significantly changed over the past 14 years with respect to the scope and quality of pharmacy services provided, and fundamental policy changes are necessary to improve this situation.
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Review
Community pharmacy and emerging public health initiatives in developing
Southeast Asian countries: a systematic review
Andi Hermansyah MSc
1,2
, Erica Sainsbury PhD
1
and Ines Krass PhD
1
1
Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia and
2
Faculty of Pharmacy,
Airlangga University, Surabaya, Indonesia
Accepted for publication 30 July 2015
Correspondence
Andi Hermansyah
Faculty of Pharmacy
The University of Sydney
Sydney, New South Wales 2006,
Australia
E-mail: aher7258@uni.sydney.edu.au
What is known about this topic
Community pharmacies have both
the opportunity and the potential
to play a role in public health.
Earlier research has shown that
despite their potential, community
pharmacies have been
underutilised in the provision of
public healthcare services.
What this paper adds
Community pharmacies in South-
East Asia have attempted to
expand practice in public health.
However, the pace of the
expansion has been slow and
lacking evidence for its
sustainability in everyday practice.
Fundamental policy change is
needed to overcome the ongoing
barriers which have limited
progress.
Abstract
The development of health and healthcare systems in South-East Asia has
inuenced the practice of community pharmacy. Over the years,
community pharmacy in the region has striven to expand services
beyond dispensing to encompass more involvement in public health
issues. Searches were conducted in Scopus, EMBASE, MEDLINE and
PubMed for articles published between January 2000 and December 2014,
with 21 studies in ve countries meeting the inclusion criteria. The
ndings showed increasing interest in research into the delivery of
pharmacy services and public health initiatives. Overall, the review found
that provision of some health services in pharmacies was common;
however, most public health initiatives appeared to be poorly
implemented, had limited evidence and were not demonstrated to be
sustainable across the sector. This indicates that the practice of
community pharmacy in the region has not signicantly changed over
the past 14 years with respect to the scope and quality of pharmacy
services provided, and fundamental policy changes are necessary to
improve this situation.
Keywords: community pharmacy services, public health initiatives,
South-East Asia
Introduction
Healthcare systems in South-East Asia have dramati-
cally changed over past decades as a result of rapid
social and economic development and considerable
population growth (Chongsuvivatwong et al. 2011).
Healthcare in the region is at a crossroads, having to
deal concurrently with both a rising tide of chronic
conditions and ongoing issues with infectious
diseases. Moreover, the diversity of cultures, lan-
guages and geographical landscapes continues to be
daunting challenges to providing equitable access to
healthcare services (Acuin et al. 2011). While lack
of healthcare facilities and ongoing shortages of
providers, especially doctors and nurses, have
remained intractable problems over many years (Kan-
chanachitra et al. 2011), the increasing number of
community pharmacies in the region creates unex-
©2015 John Wiley & Sons Ltd e11
Health and Social Care in the Community (2016) 24(5), e11–e22 doi: 10.1111/hsc.12289
plored opportunities for delivering public health ser-
vices. In Vietnam, pharmacist numbers have nearly
doubled from 7800 to 13,900 between 2000 and 2008
(Le et al. 2010). In Malaysia and Indonesia, pharma-
cist numbers have exponentially increased over the
last decade as universities have graduated more phar-
macists annually (Chee et al. 2009, Shaeet al. 2012).
With strategic location in the heart of the commu-
nity, extended opening hours and no appointment
required for seeking healthcare advice, community
pharmacy has great potential as a setting in public
health. Moreover, pharmacy in the region has often
become patientsrst point of healthcare contact
(Chalker et al. 2005, Ngorsuraches et al. 2008, Chua et al.
2013). These benets provide a platform for more proac-
tive involvement of community pharmacy in address-
ing gaps in public health services and programmes.
As elsewhere, community pharmacy practice in
South-East Asia has evolved in response to the chang-
ing healthcare environment. Signicantly, provision of
a range of healthcare services beyond traditional dis-
pensing has been trialled in community pharmacies
across the region. Although relatively new, such ser-
vices include blood pressure monitoring, chronic dis-
ease screening, smoking cessation and weight
management programmes (Nimpitakpong et al. 2010,
Dhippayom et al. 2013, Chua et al. 2013, Phimarn et al.
2013). However, there is a dearth of evidence on the
extent of implementation of these services in everyday
practice and their impact on public health.
In this paper, we report the ndings of a system-
atic review of the published literature on pharmacy
services and public health initiatives in ve South-
East Asian countries: Indonesia, Malaysia, The Philip-
pines, Thailand and Vietnam. These countries were
selected because they are the most populous coun-
tries of the region, they are representative of develop-
ing countries, and they have introduced privatisation
in healthcare which provides an avenue for commu-
nity pharmacy partnership in public health (Ramesh
& Wu 2008, Lowe & Montagu 2009). This review is
guided by the research question: What is known about
the role of community pharmacy of this region in public
health services? To address this question, this paper
briey reviews the scope of practice and services pro-
vided in community pharmacy, then evaluates the
evidence for the provision of community pharmacy
public healthcare services, and nally identies barri-
ers to their provision.
Method
The literature search was conducted in Scopus,
EMBASE, MEDLINE and PubMed. The database
search was also supplemented with electronic
searches in relevant journals and/or publications.
Search terms included keywords such as commu-
nity pharmacy§, pharmacy service§, pharmaceutical
care, cognitive service§, pharmacy practice§in combi-
nation with South-East Asia or country name (In-
donesia, Malaysia, Thailand, Vietnam, Philippines).
The period covered 1 January 2000 to 31 December
2014. This review was based upon full-text original
research articles written in English.
The screening used three inclusion criteria: stud-
ies that (i) reported services provided including pub-
lic health activities in community pharmacy; (ii)
were conducted in at least one of the ve selected
countries; and (iii) involved community pharmacists
and/or pharmacy workers. Studies were excluded if
they: (i) were not conducted in a community phar-
macy setting or (ii) were investigations of patient/
students perceptions, attitude, knowledge or satis-
faction, etc. conducted in community pharmacy.
Details of literature search and screening process are
shown in Figure 1.
Community pharmacy in this paper was dened
as a healthcare facility that operates under the full
responsibility of a registered pharmacist and pro-
vides pharmacy services to the community. These
services may include, but are not limited to, dispens-
ing of prescribed medicines, self-medication advice
and other roles providing consumer assistance in the
use of pharmaceutical products. In relation to the
public health role of pharmacy, this paper adopted
Walkersdenition of pharmaceutical public health
described as:
The application of pharmaceutical knowledge, skills and
resources to the science and art of preventing disease, pro-
longing life, promoting, protecting and improving health
for all through organised efforts of society. (Walker 2000,
p.340)
Selected studies were evaluated for the scope and
quality of pharmacy services and public health initia-
tives. The evaluation also classied the level of evi-
dence of each study using a grading system adapted
from the public health literature (Anderson et al.
2004, Agomo 2012, Neville et al. 2015):
Level A: Evidence from meta-analysis or systematic reviews
Level B: Evidence from randomised controlled trials (RCTs)
Level C: Evidence from quasi-experimental studies
Level D: Evidence from observational studies or quantita-
tive surveys
Level E: Expert opinion, case reports, focus groups or quali-
tative studies
©2015 John Wiley & Sons Ltde12
A. Hermansyah et al.
Results
A total of 796 articles were identied through the
search process. After eliminating duplicates, titles and
abstract screening and reviewing full-text articles
meeting the inclusion and exclusion criteria, 21 stud-
ies were included for analysis. Details of the 21 stud-
ies are presented in Table 1.
Scope and quality of services
The studies covered a range of topics related to pub-
lic health services.
Management of minor ailments
Two studies examined the role of community phar-
macy in managing minor ailments such as back pain
(Chua et al. 2006) and migraine (Saengcharoen &
Lerkiatbundit 2013). Both employed simulated patient
methods to investigate pharmacy responses when pre-
sented with a patientwith specic symptoms. The
Malaysian study (Chua et al. 2006) did not distinguish
between responses given by pharmacists or other phar-
macy staff, while the Thai study (Saengcharoen &
Lerkiatbundit 2013) compared the responses of phar-
macists and non-pharmacists. In general, the majority
of simulated patientswere actively asked by phar-
macy staff members about their symptoms, especially
in the Thai study where pharmacists asked more ques-
tions than non-pharmacists in relation to migraine.
However, the services provided in both studies were
considered suboptimal and inappropriate. The Malay-
sian study found that the pharmacists assessment and
counselling activities only covered three to ve ele-
ments of a total of 13 elements which constituted
appropriate service. Likewise, only 30% of 142 phar-
macists in the Thai study had given appropriate advice
to the migraine patients.
Provision of smoking cessation services
Two Thai studies highlighted the role of pharmacy in
smoking cessation programmes. A mail survey was
Figure 1 Flow diagram of paper selection process using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analy-
ses) (Moher et al. 2009). RSAP, Research in Social and Administrative Pharmacy; IJPP, International Journal of Pharmacy Practice;
IJCP, International Journal of Clinical Pharmacy.
©2015 John Wiley & Sons Ltd e13
Community pharmacy and emerging public health initiatives
Table 1 Details of eligible studies
Author and country
Level of
evidence Aims/objective Study design Primary findings/conclusions
Management of minor ailments
Chua et al. (2006)
Malaysia
Level D Assessment of community
pharmacy response to patient
with back pain symptoms
Simulated patient; 100 randomly
selected pharmacies in Klang
Valley, Malaysia
Pharmacist’s assessment and counselling were considered
suboptimal. Only 3 and 5 of 13 elements for assessment and
counselling were addressed by pharmacists respectively
Saengcharoen and
Lerkiatbundit (2013)
Thailand
Level D Management of migraine in
community pharmacy
Simulated patient and interview;
142 randomly selected
pharmacies in South Thailand
33% and 53% of pharmacy staff appropriately dispensed
medication for patients presenting with mild and moderate
migraine respectively. Pharmacists showed higher knowledge
than non-pharmacists in history taking, yet their level of
knowledge was still not sufficient as on average they only
achieved half of the full score. Fewer than 30% of pharmacists
gave the appropriate advice to the ‘patients’
Provision of smoking cessation services
Thananithisak et al.
(2008) Thailand
Level D Assessment of pharmacists’
involvement, their perception
and barriers in smoking
cessation services
Mail survey and interview; 83
pharmacists participated in
the survey, 13 early adopter
pharmacists interviewed in
Bangkok, Thailand
51% of surveyed pharmacists provided smoking cessation
services. Their perception of the services was positive yet
barriers such as lack of demand, lack of educational materials,
lack of smoking cessation products, lack of knowledge and skills
and lack of follow-up visits have hindered their services. Only 4 of
13 early adopters still delivered the services by the third month
due to these barriers
Nimpitakpong et al.
(2010) Thailand
Level D Evaluation of smoking
cessation services and training
in community pharmacy
Mail survey; 1001 randomly
selected pharmacies
nationwide
71% of pharmacists provided smoking cessation services but only
15% provided comprehensive services. 29% of pharmacists
attended cessation training and they were more likely to provide
comprehensive services than those who were not trained
Provision of weight management programme
Phimarn et al.
(2013) Thailand
Level B Involvement of community
pharmacists in weight
management programme
Randomised controlled trial; 66
patients, 1 selected pharmacy
Although there is a potential role for pharmacist involvement in
weight management programmes, particularly in influencing
eating behaviours and knowledge of obese patients, there was no
significant improvement in clinical outcomes such as weight, waist
circumference and body mass index in the experimental group
Prevention and management of infectious diseases
L
onnroth et al.
(2000) Vietnam
Level E Assessment of knowledge and
dispensing practice of anti-
tuberculosis drugs
Interview; 147 randomly selected
pharmacies in Hanoi, Vietnam
The majority of the pharmacy staff members had adequate
knowledge about tuberculosis and National Tuberculosis
Programme. Of pharmacies, 58% dispensed
anti-tuberculosis drugs and 24% had sold them without
prescription in the previous 4 weeks
Chuc et al.
(2001) Vietnam
Level D Management of childhood acute
respiratory infections
Interview and simulated patients;
60 randomly selected
pharmacies in Hanoi, Vietnam
In actual practice, 83% of pharmacy dispensed antibiotics at the
first encounter while only 20% of them stated in the interview that
they would dispense antibiotics. Only 36% of pharmacy
encounters were managed according to the guidelines
©2015 John Wiley & Sons Ltde14
A. Hermansyah et al.
Table 1 (continued)
Author and country
Level of
evidence Aims/objective Study design Primary findings/conclusions
Chuc et al. (2002)
Vietnam
Level B Evaluation of multiple
interventions in the case of
acute respiratory infection,
sexually transmitted disease,
prednisolone and cephalexin
request
Randomised controlled trial; 68
randomly selected pharmacies
in Hanoi, Vietnam
Multiple interventions comprised of regulatory enforcement,
education and peer influence significantly improved the practice
of community pharmacy in terms of reducing dispensing of
antibiotics and steroids without prescription, increasing history
taking and advice to patients and increasing consultation with
physicians
Saengcharoen and
Lerkiatbundit (2010)
Thailand
Level D Management of childhood
diarrhoea in pharmacy
Simulated patient and
questionnaire; 115 randomly
selected pharmacies in South
Thailand
Only 5% of pharmacies correctly dispensed ORS for ‘simulated
patients’ and 52% of pharmacies responded inappropriately by
dispensing antibiotics as the first-line therapy. In contrast, the
majority of pharmacies stated they would dispense ORS as the
first-line therapy in the questionnaire
Vu et al. (2012)
Vietnam
Level D Detection of suspected TB
patients in pharmacy
Simulated patient and interview;
138 randomly selected
pharmacies in Hanoi, Vietnam
Almost half of the pharmacists were dispensing drugs for
suspected TB patients and did not directly refer patients to
healthcare facilities. No differences were found between
accredited and non-accredited pharmacies in the case study
Minh et al. (2013)
Vietnam
Level D Evaluation of training and
supervision in childhood
diarrhoea and emergency
contraceptive provision
Questionnaire and simulated
patient; 734 randomly selected
pharmacies in five provinces in
Vietnam
Pharmacists’ knowledge and practice in terms of providing more
information about drugs and offering ORS for diarrhoea were
significantly increased after a sequence of training and supportive
supervision
Screening for chronic diseases
Pongwecharak and
Treeranurat (2010)
Thailand
Level C Screening for pre-hypertension
and cardiovascular risk
Screening programme; 350
people in 1 selected pharmacy
in Songkla, Thailand
Community pharmacy can play a role to identify people at risk of
hypertension and cardiovascular disease
Sookaneknun et al.
(2010) Thailand
Level C Comparison of screening
programmes for diabetes
and hypertension
Screening programme; 457
people in 2 selected pharmacies
in Maha Sarakham, Thailand
Community pharmacy screening programme resulted in a higher
rate of detection of new patients and higher success rate for
referral, with reasonable cost compared to same services
provided by primary care unit. However, the study had a high
dropout rate (98%) as only 6 of 457 clients came back for follow-
up meaning that only these 6 patients were actually referred to
doctors. No particular reason was described for the low uptake
Pongwecharak and
Treeranurat (2011)
Thailand
Level C Screening pre-hypertension
and cardiovascular risk
Screening programme; 400
people in 1 selected pharmacy
in Hat Yai, Thailand
Community pharmacy can detect patients at risk of hypertension,
diabetes and/or dyslipidaemia
Dhippayom et al.
(2013) Thailand
Level C Opportunistic screening of
diabetes in community
pharmacy
Screening programme; 397
people in 7 selected pharmacies
in Bangkok, Thailand
The programme was effective in detecting half of the participants
who were at high risk of diabetes. However, 91% of the
participants (11 people) with suspected diabetes refused to see
physicians despite frequent reminders. The main reason was that
it was not convenient to visit a medical practice in a hospital
setting
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Community pharmacy and emerging public health initiatives
Table 1 (continued)
Author and country
Level of
evidence Aims/objective Study design Primary findings/conclusions
Harm reduction activities
Pankonin et al. (2008)
Vietnam
Level E Exploration of pharmacy harm
reduction activities
Interviews; 5 conveniently
selected pharmacies in Hanoi
Community pharmacists could contribute to harm reduction
programmes and prevent the spread of HIV infections by
providing sterile syringes and health education to injecting drug
users
Other identified studies
Chalker et al. (2005)
Thailand and Vietnam
Level B Effectiveness of multi-component
intervention on dispensing
steroids and antibiotics
Randomised controlled trial; 68
randomly selected pharmacies
in Hanoi, 78 pharmacies in
Bangkok
Multi-faceted intervention improved dispensing behaviour of
pharmacies in Hanoi but only improved it slightly in Bangkok
Babar and Awaisu
(2008) Malaysia
Level E Investigation of generic drugs
supply and substitution practice
in pharmacy
Interview; 40 randomly selected
pharmacies in West Malaysia
Branded drugs were more widely available at community
pharmacies and only 40%60% of pharmacy stock was generic
drugs. 73% of pharmacists agreed with the concept of
compulsory generic substitution. Generic substitution was more
driven by consumer demand than pharmacist initiative
Ping et al. (2008)
Malaysia
Level D Evaluation of generic substitution
practice by community
pharmacist
Self-completed questionnaire; 34
randomly selected pharmacies in
Penang, Malaysia
47% of pharmacies discussed the substitution with prescribers and
a majority of doctors (84%) contacted agreed to substitution. 88%
of consumers accepted the substitution and this could save 61%
of their expenditure on drugs
Chong et al. (2011)
Malaysia
Level D Assessment of generic
substitution practice among
community pharmacists
Mail survey; 157 randomly
selected pharmacies nationwide
85% of pharmacists recommended generic substitution, yet only
13% consulted about this practice with physicians. According to
pharmacists, 89% of patients accepted the recommendation for
substitution, which could save 57% of patients’ expenditure on
drugs
Puspitasari et al.
(2011) Indonesia
Level D Evaluation of community
pharmacy workers’ response
to antibiotic request
Simulated patient; 88 randomly
selected pharmacies in
Surabaya, Indonesia
Antibiotics were dispensed without prescription in the majority
(91%) of pharmacies. Few (2%8%) pharmacies assessed
patients’ suitability for antibiotics, and information about the
medicines was mostly given when requested by the ‘patients’.
The most frequent information provided were indication, dosing,
duration and direction for use
©2015 John Wiley & Sons Ltde16
A. Hermansyah et al.
employed in both studies to assess pharmacistsper-
ceptions and practice in providing smoking cessation
services. The rst study (Thananithisak et al. 2008)
also included an interview to gather the opinion of
early adopter pharmacists about smoking cessation
services, while the second study (Nimpitakpong et al.
2010) was more focused on a nationwide survey to
evaluate the programme and the effectiveness of ces-
sation training.
The studies found that more than half (51% and
71% respectively) of the pharmacies surveyed were
actively providing smoking cessation services. How-
ever, in the rst study, only 4 of 13 early adopters
consistently provided the services after the third
month. Barriers to continuation included insufcient
demand, educational materials, smoking cessation
products, knowledge and skills, and follow-up visits.
Although the provision of the services was higher
in the second study, only 15% of 1001 participating
pharmacies provided comprehensive services which
covered the standard 5As (ask, advise, assess, assist
and arrange follow-up). Almost half of the pharma-
cists only provided brief interactions such as advice
about the risks of smoking, giving leaets or suggest-
ing smoking cessation products. This nding was
associated with the fact that only 29% of surveyed
pharmacists had received smoking cessation training,
and it was this group which was more likely to pro-
vide comprehensive services.
Provision of weight management programme
One study from Thailand (Phimarn et al. 2013) exam-
ined pharmacistsrole in weight management. An
RCT with 66 obese patients investigated clinical out-
comes such as weight loss, waist circumference and
body mass index between a control group (attended
1 hour advisory session every 4 weeks) and an exper-
imental group (received comprehensive treatment
including routine monitoring) for 16 weeks after the
initial advisory session. Even though pharmacist
interventions were observed to improve patients
healthy eating behaviours and knowledge, the nd-
ings showed no signicant improvement in clinical
outcomes in the experimental group.
Prevention and management of infectious diseases
The region has long struggled with communicable
diseases, prevention and management of infectious
diseases, and this was reected in six studies, ve
from Vietnam and one from Thailand, which
addressed different types of infectious diseases
including tuberculosis (TB) (L
onnroth et al. 2000, Vu
et al. 2012), acute respiratory infections (Chuc et al.
2001, 2002) and diarrhoea (Saengcharoen & Lerkiat-
bundit 2010, Minh et al. 2013). Four studies (L
onnroth
et al. 2000, Chuc et al. 2001, Saengcharoen & Lerkiat-
bundit 2010, Vu et al. 2012) explored services pro-
vided in pharmacy associated with the diseases,
while two studies (Chuc et al. 2002, Minh et al. 2013)
were aimed at improving practice by introducing
multiple interventions.
Overall, the four studies which explored pharmacy
services targeted to management of infectious dis-
eases showed negative outcomes. In the case of TB,
both studies conducted in Hanoi (Vietnam) showed
that pharmacists dispensed drugs for suspected TB
patients without a prescription. In the earlier study
(L
onnroth et al. 2000), 58% of 147 pharmacies had
dispensed anti-TB drugs in the last 4-week period,
and 24% of this number without prescription. In the
more recent study (Vu et al. 2012), almost half of 138
pharmacists dispensed anti-TB drugs without pre-
scription and did not refer patients to doctors or
healthcare facilities, thus delaying appropriate diag-
nosis and treatment. In the management of childhood
diarrhoea, only 5% of 115 pharmacies correctly
responded to symptom presentations by simulated
patients (Saengcharoen & Lerkiatbundit 2010). A
mystery shopper studyusing an acute respiratory
infection scenario revealed that community pharma-
cies in Vietnam commonly dispensed antibiotics with-
out prescription, and only 36% of 60 pharmacies
managed the case appropriately according to the
guidelines (Chuc et al. 2001).
Two Vietnamese studies reported attempts to
improve practice in pharmacy by introducing multi-
ple interventions such as regulatory enforcemented-
ucationpeer inuence (Chuc et al. 2002) and
training-supportive supervision (Minh et al. 2013).
Both studies concluded that multiple interventions
signicantly improved the practice of community
pharmacy in managing infectious diseases. Chuc et al.
(2002) demonstrated that these interventions could
reduce the frequency of dispensing of antibiotics and
steroids without prescription in the management of
acute respiratory infection and sexually transmitted
diseases, while Minh et al. (2013) concluded that
training and supportive supervision improved phar-
macistsknowledge, and their dispensing patterns
became more appropriate according to the guidelines
for presentation of patientswith diarrhoea.
Screening for chronic diseases
The escalating rates of chronic disease have focused
attention on the need for early detection of those at
risk. Four studies in Thailand investigated screening
programmes conducted in community pharmacy.
Two focused on hypertension and the risk of other
©2015 John Wiley & Sons Ltd e17
Community pharmacy and emerging public health initiatives
cardiovascular diseases (Pongwecharak & Treeranurat
2010, 2011), one investigated diabetes screening
(Dhippayom et al. 2013) and one compared a screen-
ing programme conducted by pharmacy and a pri-
mary care unit (Sookaneknun et al. 2010).
All studies demonstrated a potential role for com-
munity pharmacy in the detection of people at risk of
hypertension, diabetes and predisposing factors such
as dyslipidaemia. In addition, community pharmacy
screening programmes generated higher detection
and referral rates compared to similar services pro-
vided by the primary care unit (Sookaneknun et al.
2010). However, two studies reported a poor uptake
of referral by customers detected as at high risk of
chronic disease (Sookaneknun et al. 2010, Dhippayom
et al. 2013). Reasons for the poor uptake were that
customers felt healthy (Sookaneknun et al. 2010), and
that it was not convenient to visit a hospital for fol-
low-up (Dhippayom et al. 2013).
Harm reduction activities
One Vietnamese study (Pankonin et al. 2008) investi-
gated the role of community pharmacy in the supply
of sterile syringes for Injecting Drug Users (IDU). The
ve pharmacies in the study sold on average 93 syr-
inges per pharmacy to IDU in a 1-week period. The
study demonstrated that the participating pharma-
cists had a solid understanding and strong commit-
ment to taking part in HIV prevention activities
through selling sterile syringes and providing educa-
tional materials for IDU. Therefore, the authors sug-
gested that pharmacists might potentially play a role
in the provision of harm reduction services.
Other identied studies
Five studies related to the safe supply and distribu-
tion of medicine, namely the role of pharmacists in
dispensing antibiotics and steroids, and the practice
of generic substitution in pharmacy. Three studies
carried out in Malaysia (Babar & Awaisu 2008, Ping
et al. 2008, Chong et al. 2011) focused on generic sub-
stitution practice and drew similar conclusions that
the majority of pharmacies were engaged in generic
substitution; however, fewer than half of the pharma-
cists discussed this practice with prescribers. Interest-
ingly, these studies revealed that generic substitution
was driven more by patients than by pharmacists.
However, since doctors in Malaysia have dispensing
rights, the number of prescriptions actually dispensed
in pharmacy represented only a fraction of the total.
In the other two studies, in Indonesia (Puspitasari
et al. 2011) and in both Thailand and Vietnam
(Chalker et al. 2005), dispensing antibiotics and ster-
oids without prescription was commonly found. In
Indonesia, inappropriate dispensing was com-
pounded by a lack of adequate patient assessment
and counselling. Chalker et al. (2005) found that a
multi-faceted intervention which comprised regula-
tory enforcement, education and peer review was
able to improve dispensing practice signicantly in
Hanoi but only slightly in Bangkok.
The strength and level of evidence
The level of evidence demonstrated by the 21 studies
ranged from B to E (see Table 1). Three studies gener-
ated level B evidence, four with level C evidence, the
majority (11) produced level D evidence and three
generated level E evidence. The level B studies
involved RCTs evaluating the effectiveness of multi-
ple interventions to improve dispensing practice in
the management of diseases, and the role of pharma-
cists in weight management programmes. Level C
evidence focused on opportunistic screening and
early detection of chronic diseases in pharmacy. The
majority of studies producing level D evidence
employed simulated patient methodology to assess
the actual practice of pharmacy service provision,
while a minority used surveys. Studies with level E
evidence employed interviews as a means to explore
the knowledge and perception of pharmacists about
current services, in particular dispensing anti-TB
drugs, harm reduction services and generic substitu-
tion practice.
Across the range of research undertaken in the
region, the overarching limitation was a lack of broad
generalisability, as most studies were preliminary or
pilot studies employing small sample sizes, were con-
ducted in a narrow area of research and employed
non-random sampling techniques. In addition, only
two studies were carried out nationwide (Nimpi-
takpong et al. 2010, Chong et al. 2011). As a conse-
quence, it is not possible to extrapolate any of the
reported ndings to the wider community pharmacy
setting even within the same country. In addition,
most studies reported poor quality and low success
rates for public health services provided in pharmacy
which may indicate structural and systemic barriers
for provision of these services.
Given the variability in context within South-East
Asia, it is also not possible to extrapolate evidence
from one country to another. Despite nding that an
intervention is successful in one country, it may not
work in another. A good example is the study con-
ducted both in Thailand and Vietnam (Chalker et al.
2005). While there was strong improvement in prac-
tice in Hanoi, the same was not the case in Bangkok.
This suggests that while much can be learnt from
©2015 John Wiley & Sons Ltde18
A. Hermansyah et al.
other countries in designing pharmacy public health
interventions, they must be replicated and evaluated
in different settings in order to build and strengthen
the evidence base. This paper argues that cross-coun-
try learning is critical in implementing the best strate-
gies for improving pharmacy public health services in
developing countries.
Barriers to provision of services
A number of barriers that have hindered the provision
of public health services are highlighted in this review.
Lack of knowledge and skills has been reported as
contributing to inappropriate response in some chronic
diseases (Chuc et al. 2001, Thananithisak et al. 2008,
Saengcharoen & Lerkiatbundit 2010, 2013, Puspitasari
et al. 2011). Lack of condence (Chong et al. 2011) and
adequate training (Nimpitakpong et al. 2010) has been
documented as barriers in the case of generic substitu-
tion and smoking cessation services. External to the
pharmacy environment, barriers that have impeded
the uptake of pharmacy services and public health ini-
tiatives include lack of policies (Babar & Awaisu 2008,
Chong et al. 2011), low patient demand (Pong-
wecharak & Treeranurat 2011), poor recognition
within the healthcare system (Ping et al. 2008, Dhip-
payom et al. 2013) and patientsreluctance to use phar-
macy services (Sookaneknun et al. 2010).
Discussion
To the best of our knowledge, this is the rst system-
atic review of community pharmacy practice and
public health initiatives in developing South-East
Asian countries. This review is important because a
move into public health services is reective of the
expanding potential of community pharmacy as a
service provider. Identication and evaluation of cur-
rent pharmacy services in public health highlight
opportunities that exist at the present time, as well as
suggesting areas for future growth. The ndings have
also documented a range of barriers to implementa-
tion, and have outlined key reasons why they have
not been introduced more appropriately, adequately
and widely in the community.
The core nding of this study was that provision of
a range of pharmacy public health services has been
researched in the region, and these services can be clus-
tered into seven topics as presented in the results. On
the positive side, it is apparent that South-East Asian
pharmacy practice is moving in directions similar to
the international context and following the patterns of
developed countries (Anderson et al. 2004, Agomo
2012). However, the review has also revealed limited
evidence of the efcacy, effectiveness, generalisability
and sustainability of such services at the current time.
The majority of the reviewed studies were not
designed to produce a high level of evidence, thus sug-
gesting that the majority of the research was still proof
of concept rather than knowledge translation. Where
RCTs were undertaken, interventions to improve prac-
tice generally showed only limited success. The agenda
for public health practice in pharmacy has remained at
the level of vision rather than actively directed by
sound evidence-based health policy.
This review has furthered and strengthened the
ndings of previous reviews of pharmacy services in
developing countries by Smith (2009a,b), who
reported that private pharmacies in African, Central
and South American and Asian countries (including
Thailand, Vietnam and Indonesia) played an impor-
tant role in the supply of pharmaceuticals and had
the potential to contribute more to primary care and
public health. However, both reviews also high-
lighted that the quality of services in pharmacies was
far from acceptable.
Despite the differences between the geographical
scope and year of publication, common and consistent
themes are evident in this review and the two previ-
ous reviews that community pharmacy generally pro-
vided similar types of services. Despite the rapid
growth in the region, the evidence reveals that com-
munity pharmacy services in South-East Asia have not
changed signicantly in the last 5 years, suggesting
that barriers identied earlier continue to limit their
uptake in day-to-day community pharmacy practice.
Unlike the earlier reviews which focused only on
scope and quality of pharmacy services, in this
review we also explored the level of evidence for
pharmacy public health initiatives in the targeted
countries. The use of level of evidence allows a more
ne-grained analysis of the ndings and informs their
interpretation. Research with higher levels of evi-
dence is more likely to provide an explanation of
why the services were effective or ineffective (Rychet-
nik et al. 2002), and thus guide strategies for improve-
ment. Few of the reviewed studies employed RCTs,
thus highlighting the need for more robust research
to strengthen the evidence base. However, it should
also be recognised that public health interventions
are complex and context dependent and not always
amenable to RCTs. Observational (level D) or
qualitative studies (level E) may also provide impor-
tant and relevant information about the services. In
the search for effective pharmacy public health ser-
vices, stakeholders in the region must decide on an
acceptable level of evidence on which to base broad
implementation.
©2015 John Wiley & Sons Ltd e19
Community pharmacy and emerging public health initiatives
It is apparent that barriers associated with service
provision, many outside the pharmacists control,
have constrained successful introduction of high-qual-
ity programmes. If community pharmacists in these
countries aspire to expand their role and contribute
more effectively in the healthcare system, then resolv-
ing the barriers at all levels is critical. The approach
must be multi-faceted, and include both a willingness
on the part of pharmacists to become more involved,
as well as policies which recognise and utilise the
potential of community pharmacy to provide
expanded services. This review has identied the
need for fundamental structural and policy change to
encourage and facilitate delivery of high-quality ser-
vices by pharmacy. Furthermore, it has highlighted
fundamental anomalies within the health system:
demand for public health services is increasing but
there is limited capacity of the health system to meet
this demand; the number of pharmacies has increased
but they are underutilised. This is exacerbated by the
fact that community pharmacy in this region is effec-
tively independent of the mainstream healthcare sys-
tem and is not dened as a healthcare provider in
some jurisdictions. Signicant policy reform, founded
on a fundamental rethinking of the role and value of
community pharmacy, is needed.
Countries in the South-East Asian region might
reect on how developed countries have re-estab-
lished their roles in the public health system over
recent years. Regardless of the context, a common
thread through the experience of these countries is
the need to engage with the government in order to
be recognised as a legitimate public health provider
(Mossialos et al. 2013), and to be recognised by the
public as a useful and accessible source of public
health services. The process of achieving this is not
an easy task and requires sustained efforts over a
period of years.
Apart from policy change, attention must be direc-
ted to increasing public awareness of both service
provision and pharmacistsroles in public health.
Lessons from the UK and Australia show that public
understanding is critical to enhancing the uptake of
novel services. Although there is evidence of increas-
ing recognition of the expanded services among the
general public in both the UK (Taylor et al. 2012,
Saramunee et al. 2014) and Australia (White et al.
2012), it takes many years to change entrenched
community perceptions. Studies in both countries
illustrate that the key barriers to uptake have mostly
been related to lack of consumer awareness of the
services and of pharmacistsskills to deliver them.
Lack of demand and poor perceptions of pharmacists
have been consistently reported (Krska & Morecroft
2010, Eades et al. 2011). When consumers (and health-
care providers) are not aware of the breadth of the
pharmacists role and expertise in delivery of services
other than dispensing medications, they will not seek
those services in pharmacy and will remain unaware.
As a result, despite signicant uptake by pharmacists,
the services are still underutilised. Therefore, address-
ing these barriers is likely to increase utilisation of
the services.
The presence of these barriers is exacerbated by
the perception of pharmacy as a retail business. In
order for pharmacy to be regarded as a key player in
the provision of public health, patients must come to
view the pharmacist as someone who can assist them
to remain healthy, rather than purely as someone to
be consulted in the context of illness. Pharmacists
have a key role to play in promoting themselves and
their profession directly to the patients with whom
they come in contact, and this will in turn help to
promote credibility with governments which is neces-
sary to stimulate regulatory change.
There are some signs of progress, albeit relatively
small, in some South-East Asian countries. In Malaysia,
although pharmacies still lack support for a monopoly
over dispensing, the Community Pharmacy Bench-
marking Guideline has facilitated the initiation of
health promotion services in pharmacy, in particular
for smoking cessation and weight management (Min-
istry of Health Malaysia Pharmaceutical Services Divi-
sion 2011). In 2003, the Thai Pharmacy Council
introduced an accreditation programme for service
quality, and since 2005 has trained pharmacy to pro-
vide smoking cessation services in collaboration with
the Thai Pharmacy Network for Tobacco Control (Tha-
nanithisak et al. 2008, Nimpitakpong et al. 2010). Viet-
nam has implemented an accreditation system to
improve practice in pharmacy (Vu et al. 2012). Indone-
sia is moving forward to a policy of re-certication and
licensure that is aimed at improving pharmacistspres-
ence and capacity to work in pharmacy (Ikatan Apote-
ker Indonesia (Indonesian Pharmacist Association)
2014). These initiatives highlight the growing opportu-
nity for community pharmacy to play a more promi-
nent role in public health in the region.
Almost half of the studies reviewed in this paper
were published more than 5 years ago. Although
they do provide the framework for understanding
overarching public health practice, they also highlight
the dearth of research into current practice. As public
health achieves greater focus in pharmacy services,
research is increasingly critical as a vehicle for under-
standing the process of change. Studies in the deliv-
ery of pharmacy public health should continue to
investigate this process and its outcomes.
©2015 John Wiley & Sons Ltde20
A. Hermansyah et al.
This review thus has important implications for
future research and policy in community pharmacy
practice. To date, there is insufcient high-level evi-
dence to support a role for pharmacy in public health
practice in South-East Asia. Future research is needed
to improve the quality of evidence, which will in turn
provide a basis for rational health policy change to fos-
ter the signicant potential contributions of commu-
nity pharmacy to public health initiatives in the region.
Despite the signicant contribution of this review,
the decision to include only articles published in Eng-
lish may have limited the ndings as some poten-
tially relevant non-English language articles may not
have been identied. Furthermore, only original pub-
lished research articles were evaluated, and addi-
tional information available from the grey literature
may need to be considered in order to provide a
broader perspective.
Conclusion
Over the past 14 years, attempts have been made to
expand the scope of community pharmacy practice in
South-East Asia through piloting the introduction of
new services in both pharmacy and public health
practice. However, the pace of such expansion has
been relatively slow and is not supported by a strong
evidence base for pharmacist involvement in public
health. Several notable barriers internally and exter-
nally to the pharmacy environment such as lack of
knowledge, lack of condence, poor recognition from
the general public and lack of supportive policies
have constrained progress. There remains consider-
able scope for community pharmacy to extend their
practice into public healthcare initiatives, but this will
require clear and planned efforts to address the barri-
ers identied in this review. These efforts should
focus on a co-ordinated approach to change in both
public perceptions and the regulatory environment in
order to realise the signicant potential of community
pharmacy as a legitimate resource for the delivery of
public health services.
Acknowledgement
None declared.
Source of funding
The study was not funded.
Conflict of interest
There is no conict of interest.
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... Although medication dispensing and provision of limited medication advice currently remain the core role of community pharmacists across Asia, their role has been expanding to include additional healthcare services, such as the management of minor ailments, health screening, and health promotion advice [16,[21][22][23]. This reflects a move towards improving pharmacy practice standards internationally, in line with the Good Pharmacy Practice standards endorsed by the International Pharmaceutical Federation and the World Health Organization [24]. ...
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