Why Hospital Pharmacists Have Failed to Manage Antimalarial Drugs Stock-Outs in Pakistan? A Qualitative Insight

Purpose. This study aimed to explore the perceptions of hospital pharmacists towards drug management and reasons underlying stock-outs of antimalarial drugs in Pakistan. Methods. A qualitative study was designed to explore the perceptions of hospital pharmacists regarding drug management and irrational use of antimalarial drugs in two major cities of Pakistan, namely, Islamabad (national capital) and Rawalpindi (twin city). Semistructured interviews were conducted with 16 hospital pharmacists using indepth interview guides at a place and time convenient for the respondents. Interviews, which were audiotaped and transcribed verbatim, were evaluated by thematic content analysis and by other authors' analysis. Results. Most of the respondents were of the view that financial constraints, inappropriate drug management, and inadequate funding were the factors contributing toward the problem of antimalarial drug stock-outs in healthcare facilities of Pakistan. The pharmacists anticipated that prescribing by nonproprietary names, training of health professionals, accepted role of hospital pharmacist in drug management, implementation of essential drug list and standard treatment guidelines for malaria in the healthcare system can minimize the problem of drug stock outs in healthcare system of Pakistan. Conclusion. The current study showed that all the respondents in the two cities agreed that hospital pharmacist has failed to play an effective role in efficient management of anti-malarial drugs stock-outs.


Introduction
Efficient drug management is the key strategy in reducing costs of drugs and ensuring their availability in the healthcare facilities [1]. High incidence of drug stock outs is diverse and imitates perpetual problems including inadequate resources and weak healthcare systems to delineate procurement needs and manage stock flows [2]. The selection of most costeffective essential drugs to treat commonly encountered diseases, appropriate quantification, preselection of potential suppliers, procurement and monitoring of the performance of suppliers and the procurement system can be achieved by adopting efficient procedures. Failure in any of these areas leads to lack of access to appropriate drugs and waste of resources. Lack of properly trained staff in good procurement practices at key positions can also doom any procurement system to failure. Low incentives, inadequate posts, and lack of career development tend to confine potentials to attract and retain qualified staff in the healthcare facilities [3].
Medicines procurement is an effective way to supply right medicines at right price to the patients in the healthcare facilities. No public or private healthcare system in the world can afford to purchase all drugs circulating in the market within its given limited resources due to these choices that have to be made [4]. The concept of nationally developed formulary or selection based on the essential drugs has been introduced in both developed and developing countries' healthcare systems to concentrate resources on the most cost-effective and affordable drugs to treat prevailing health problems. A limited list of drugs for procurement, based on an essential drugs list or drug formulary, defines which drug will be regularly purchased and thus is one of the most effective ways to control drug expenditures in the healthcare facilities [5].
The availability of antimalarial drugs recommended in the national essential drug list can be a measure of assessing how well malaria control is being implemented in reality. Acute shortage of artemether/lumefantrine recommended in national essential drug list as well as in health policy in the healthcare facilities in Kenya was reported for several weeks [6]. Similar availability problems have been experienced in sub-Saharan Africa [7,8]. Prescribing inappropriate alternatives, due to shortage of recommended anti-malarial drugs, was seen as a common practice in the healthcare facilities in Uganda [9]. Delayed procurement process was held responsible for the shortage of anti-malarial drugs, and the need of addressing the current shortcomings facing antimalarial drug supply to the public sector by the national ministries of health and the international community was emphasized in Kenya [6].
Malaria continues to be a major public health problem in Pakistan. The total number of confirmed cases of malaria reported in 2011, in Pakistan (public sector), from all the districts was 319,592, out of which 205,879 (67%) cases were due to P. vivax infection, while 113,713 (33%) were due to P. falciparum infection. The actual malaria burden could be considered four to five times higher as nearly 70-80% of the population goes to private sector for treatment; and therefore, those malaria cases are not reported [10]. National treatment guidelines for malaria were designed and published in 2005 through collaborative efforts of directorate of malaria control, WHO, technical core group, and professionals from teaching institutions in Pakistan [11]. The guidelines have been formulated through an extensive deliberation and local research carried out by renowned professionals, malariologists, and clinicians. The policy of the National Malaria Control Program of Pakistan clearly indicates examining patients with fever microscopically or RDT kits especially children and patients with parasitemia should be treated. But due to lack of resources, technical experts, and surveillance system, microscopic diagnosis of parasitemia is usually not viable in the country. In this situation, utilization of a more specific clinical algorithm helps to diagnose accurately which assumes that when 90% of the treated patients do not have the disease and are better served by greater attention to alternative diagnosis and the prevention of overtreatment [10]. However, the positive predictive value of the algorithm remained quite low at 10% for an individual patient. Thus, even with an improved algorithm, healthcare workers should think about an alternative diagnosis, and policy makers should consider increasing the capacity for microscopic diagnosis [10].
Chloroquine is the first choice of drugs for empirical therapy in all cases of malaria when type is not confirmed through laboratory test. The treatment for malaria caused by Plasmodium vivax includes chloroquine plus primaquine, while artesunate plus sulphadoxine/pyrimethamine is recommended for the treatment of malaria caused by Plasmodium falciparum [12]. However, ACT (artemether + lumefantrine) should only be administered in confirmed cases of P. falciparum. Malaria Control Program is functional in the country but is confined to limited districts due to financial constraints and more focused at primary healthcare facilities. Diagnostic kits and medicines, for example, chloroquine-fansidar and artemisinin combination therapy ACT, are provided free of cost in the selected healthcare facilities in targeted districts. The national standard treatment guidelines are present but are rarely followed at healthcare facilities in Pakistan which reflects weak policy implementation by the Malaria Control Program. Malaria Control Program has planned proper coordination between the public and private sector in the next five years to improve coverage for better diagnosis and treatment practices for malaria at tertiary and secondary healthcare facilities in Pakistan [13].
Effective medicine can be practiced only where there is efficient drug management. The role of pharmacists in the procurement team is vital. They are qualified professionals who follow the principles of quality assurance [14]. They realize the particulars of the distribution chain and principles of efficient stock keeping and stock turnovers. They are familiar with the pricing configuration and technical information related to drug products available within the markets [15]. They act as an interface with clinical staff to ensure that all the medicines are available to the patients through the use of appropriate stock management systems and dispensing software [16,17]. On the other hand, hospital pharmacists have concerns about their present professional roles and face considerable barriers with regard to the provision of quality clinically focused pharmacy services in Pakistan [18]. They are more confined to traditional duties rather than patient-orientated pharmaceutical care. Their current role is more focused on pharmacy recordkeeping and is rarely involved in patient education pertaining to drugs. Although the pharmacist is part of the Drug and Therapeutic Committee, but is seldom involved in updating hospital's drug formulary [19]. Limited budget is allocated to healthcare especially for drug procurement in Pakistan like many other developing countries. Therefore, it is imperative to optimize expenditures for drug purchases through appropriate selection and procurement techniques ensuring the availability of key drugs from essential drug list for promoting the rational use of drugs. The responsibility of regulating drug prices lies with the Federal Ministry of Health. Open tender is placed through the Ministry of Health for procurement in the public sector while drugs are directly purchased from the vendors in the private sector. It is the responsibility of the Drug and Therapeutic Committee to ensure the availability of drugs in the healthcare facility in accordance with the standard treatment guidelines, but generally this is not taken into account. Therefore, the main objective of the present study was to investigate hospital pharmacists' perceptions towards factors underlying irrational treatment practices, ineffective drug management, and stock-outs of anti-malarial drugs in the two cities of Pakistan: Islamabad (national capital) and Rawalpindi (twin city).

Study Design.
A qualitative study was designed to explore the perceptions of hospital pharmacists regarding current treatment practices for malaria and responsible factors, role of healthcare system and Malaria Control Program, role of hospital pharmacist in effective drug management and influencing factors, current scenario and responsible factors of anti-malarial drugs stock-outs, and strategies to improve current practices and anti-malarial drugs stock-outs. The study protocol was approved by Malaria Control Program, Ministry of Health, Government of Pakistan. Semistructured interviews were conducted using in-depth interview guides to collect the data.

Participants.
The study participants were hospital pharmacists working in all the tertiary healthcare facilities. The sampling frame was comprised of professionally qualified pharmacists working in both public and private tertiary healthcare facilities in two cities of Pakistan: Islamabad (national capital) and Rawalpindi (twin city).

Sample Size and Sampling Technique.
Sixteen pharmacists took part in the study. Nonprobability sampling technique, that is, snowball sampling, was adopted. Snowball sampling is the best way to identify respondents with certain attributes or characteristics and is influential in population which is difficult to contact [20,21]. The researcher identifies the first respondent in snowball sampling, and then the respondent is asked to suggest more research participants.

Study Tool.
A semistructured interview guide was developed after extensive literature review and used as the study tool. A number of aspects to be addressed were already identified from the literature which ensured the inclusion of key issues regarding effective drug management and stockouts in treatment of malaria. While designing the questions, the focus was to keep them as open as possible to interviewees for maximum opportunity to express their views. The first draft of the interview guide was discussed among the authors and was modified after few rounds of discussion. The pretesting of the interview guide was carried out with eight hospital pharmacists to check whether particular questions were useful in the retrieval of information. Specific probes were identified during the pilot interviews, and the interview guide was subsequently modified. Semistructured one-toone interviews were conducted since it is the most practical and convenient way for busy professionals, and thematic saturation was considered to be a cut-off point to stop the sampling of subjects [22].

Procedure and Interview
Process. All the interviews were conducted from June to July 2011, at the offices of the respondents. Sixteen respondents via snowball sampling technique were recruited from tertiary healthcare facilities in Islamabad and Rawalpindi, Pakistan. Data collection was stopped at a point when no new themes emerged [22]. The identified participants were contacted in person or on phone to fix interview appointments. Written consent was obtained from each of the participants prior to the conduction of interview. Probing questions were used where necessary, and participants were given freedom to express their views at the end of the interview session. Each interview lasted approximately twenty to thirty minutes. All the interviews were conducted in the local language and at time convenient for the respondents. Permission for recording was obtained and all the interviews were recorded. Each interview was transcribed verbatim. Transcribed interviews were subjected to thematic content analysis, and the transcripts were analyzed for relevant content to identify the emerging categories [22].

Results
Most of the respondents were males and had B.Pharmacy qualification. Half of the respondents were working in public tertiary healthcare facilities while the other half were employed in private tertiary healthcare facilities as hospital pharmacists. Table 1 shows detail demographics of the respondents. All the respondents agreed that due to inappropriate diagnosis and undue recommendation of medicines on the basis of empirical therapy malaria is treated irrationally in both public and private healthcare facilities in Pakistan.
Basically malaria diagnosis is confused with typhoid which leads to irrational treatment practices by the prescribers. (Pharm. 13) I feel that the treatment offered for malaria is irrational which is mostly due to inappropriate diagnosis and undue recommendation of medicines on the basis of empirical therapy. (Pharm.10) Theme 3: Major Contributing Factors towards Irrational Treatment Practices for Malaria. In view of most of the pharmacist's inappropriate diagnosis, irrational prescribing practices, unavailability of drugs, and lack of awareness of prescribers regarding standard treatment guidelines and self-medication are the major factors promoting irrational treatment of malaria in Pakistan.   the public sector than in the private healthcare facilities. Drug stock-outs of chloroquine and sulfadoxine/pyrimethamine (fansidar) were more prevalent in both sectors. Financial constraints, inappropriate drug management, and inadequate funding were the reasons responsible for drug stock-outs by the respondents. Table 3 shows reasons for antimalarial drug stockouts.

Discussion
The healthcare system has failed to play a positive role in promoting rational treatment for malaria in Pakistan. The respondents agreed that inappropriate diagnosis and undue recommendation of medicines on the basis of empirical therapy are common trends in both public and private healthcare facilities, but still the public sector is comparatively more rational in their practices as compared to the private sector. The results of the present study are in line with the study conducted in Nigeria where the use of presumptive malaria diagnosis without laboratory support was a common diagnostic procedure for malaria and inclined to poor quality of malaria diagnosis and treatment [23]. In view of most of the pharmacists' inappropriate diagnoses, irrational prescribing practices, unavailability of drugs, and lack of awareness of prescribers regarding standard treatment guidelines and selfmedication are the major factors promoting irrational treatment for malaria in Pakistan. Similar patterns of irrational drug use in other countries have been reported [24,25].
All the respondents agreed that Malaria Control Program has not played its role effectively in promoting rational drug use and control of malaria in Pakistan. This might be due to the fact that Malaria Control Program has targeted mainly 19 districts in different provinces due to shortage of funds and has not been able to target tertiary and secondary healthcare facilities. However, the national malaria control programs were successful in reducing the number of malaria cases in Iran and Uganda [26].
The concept of essential drugs has been introduced in Pakistan to concentrate resources on the most cost-effective and affordable drugs to treat prevailing health problems. National Essential Drugs List of Pakistan was first prepared in 1994. The list was previously reviewed in 1995 and 2000 and has not been updated since 2007. The list contains 452 drugs of different pharmacological classes. Drug and Therapeutic Committee for procurement of drugs was placed in all the healthcare facilities. All the pharmacists working in public and private sector agreed that although the pharmacist is part of Drug and Therapeutic Committee in both public and private healthcare facilities in Pakistan, he/she has no significant role in drug selection and procurement. The clinical role of hospital pharmacists has not been accepted yet in Pakistan. Reluctance from physicians, unawareness of public regarding role of pharmacist, political reasons, and lower incentives were the factors responsible for inadequate role of pharmacist in effective drug management. This situation is quite similar in other developing countries [27]. Nearly all of the respondents were of the view that there is no collaborative working of physicians and pharmacists in Pakistan, but it can promote rational treatment of malaria. The results of the present study are in line with findings of another study which reported that interaction between the pharmacists and physicians is low in Pakistan and emphasized the need of collaboration of pharmacists with other healthcare professionals for achieving the goals of pharmaceutical care [19].
Drugs are selected on the basis of hospital formulary instead of Essential drug list and quantified on the basis of consumption data in both sectors. Drugs are procured annually through open tender system and distributed on the basis of First Expired, First Out (FEFO) in the hospitals and inventory and expiry of drugs are managed manually in the public healthcare facilities. On the other hand, drugs are procured quarterly through direct negotiation with the vendors and distributed on the basis of first expired first out (FEFO) in the hospitals. Expiry of drugs and inventory control is done through computerized system. The results of the present study are in line with another study which showed similar drug management system in different healthcare facilities in Nigeria [28].
Most of the respondents were of view that the problem of drug stock-outs is more frequent in the public sector than in the private healthcare facilities. Similar results of unavailability of key antimalarial drugs in healthcare facilities were reported by several studies. Drug stock-outs of chloroquine and sulphadoxine/pyrimethamine (fansidar) were more prevalent in both sectors in Pakistan. This might be due to unethical promotion of artemether/lumefantrine by the pharmaceutical industry. Financial constraints, inappropriate drug management, and inadequate funding were the reasons responsible for drug stock-outs by the respondents. Similar factors were responsible for the unavailability of key antimalarial drugs in healthcare facilities in Kenya [6].
Improved diagnostic and treatment facilities, prescribing by nonproprietary names, training of health professionals, accepted role of hospital pharmacist in drug management, and implementation of essential drug list and standard treatment guidelines for malaria in the healthcare system were stated as the most effective strategies by the respondents to promote rational drug use and control of malaria in Pakistan. Various intervention studies have reported significant impact on diagnostic and treatment practices [29,30].
Limitation of the Study. The study was conducted in the two cities of Pakistan. It is most likely that the health practitioners in other parts of the country would have similar perceptions regarding treatment practices carried for malaria, but the findings may not be generalizable to the other cities of the country.

Conclusion
Based on the results of this qualitative study, all the pharmacists agreed that irrational prescribing practices, ineffective drug management, lack of implementation of essential drug list, and problem of anti-malarial drugs stock-outs are the major factors contributing towards irrational treatment practices for malaria in both public and private sectors in Pakistan. Hospital pharmacists have failed to play an effective role in the efficient management of anti-malarial drugs stockouts. Reluctance from physicians, unawareness of public regarding role of pharmacist, political reasons, strong influence of pharmaceutical industry, and lower incentives are the factors responsible for this inadequate role of pharmacist. Innovative approaches are needed to allocate funds for the public sector through collaborative working with the private sector, implementation of national essential medicine list in all the healthcare facilities, and promotion of nonproprietary name prescribing to ensure the availability of drugs. For effective drug management and improved pharmaceutical care services, the role of the pharmacist as an integral member of healthcare team has to be accepted by the stakeholders, health professionals, and community in Pakistan.