Atif and Malik Journal of Pharmaceutical Policy and Practice (2020) 13:33

https://doi.org/10.1186/s40545-020-00240-4

COMMENTARY Open Access

COVID-19 and community pharmacy

services in Pakistan: challenges, barriers
and solution for progress
Muhammad Atif* and Iram Malik

Abstract
In the wake of atrocious rise in COVID-19 cases, developed countries are leveraging a range of community
pharmacy services with the goal of improving access to essential medication and healthcare services. While in the
developing nations, including Pakistan, pharmacists are unable to perform COVID-19 containment roles in
community, since presence of pharmacists at community pharmacy settings and delivery of pharmacy services have
historically been plagued by shortcomings at various levels. In this document, we identified these shortcomings
which need to be resolved on many fronts. Broadly, a number of intertwined government related, public related,
academic curricula and pharmacist related, and drug retailers’ related factors refrain community pharmacists from
performing and facilitating Pakistan’s fragile public and healthcare system in the midst of COVID-19 pandemic.
Government led multifaceted approaches are urgently needed to strengthen this unrecognized domain and
thereby effectively combat COVID-19 by utilizing community pharmacy services, as evidenced in the developed
world. [Note: Part of this article is published in Pakistan Observer Newspaper; dated 17 May 2020).
Keywords: Drug Regulatory Authority of Pakistan, DRAP, Pharm-D, Punjab Drug Rules 2007, Drugs Act 1976,
Pharmacy proprietors, Pharmacist

Main text pharmacists in developed nations, such as China, Australia,

COVID-19 has put unprecedented pressure on healthcare Canada, the United States (US) and the United Kingdom
systems of every nation [1]. Specifically, owing to a number (UK) have acted swiftly and are offering a broad range of the
of voids in their healthcare system, the developing nations quality pharmaceutical service [3–7]. These include, drug re-
are unable to meet the healthcare needs of the population view and monitoring, clinical consultation and treatment,
and adopt the recommended COVID-19 response strategies medication therapy management, pertinent drug informa-
to flatten the contagion curve. To this end, there is emerging tion, assessment of patients and their treatment outcomes,
recognition across the globe that community pharmacists are and mitigation of drug shortages through various strategies
in a unique position to provide medicines, therapeutics, vac- etc. These evidences from developed countries provides
cines and essential healthcare services in the wake of atro- insight to the resource-deprived nations – with fragmented
cious rise in COVID-19 cases [2]. Many countries across the health care systems – for planning and operating pharmacy
globe are leveraging a range of community pharmacy ser- services to combat current and future epidemics.
vices with the goal of improving access to essential medica- In Pakistan, community pharmacy services are highly
tion and healthcare services. As a result, community warranted as the devastating COVID-19 pandemic is
swiftly spreading and the country does not have the cap-
* Correspondence: pharmacist_atif@yahoo.com; muhammad.atif@iub.edu.pk acity to meet the international standards of care due to a
Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, number of public health and healthcare system related
Punjab, Pakistan

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Atif and Malik Journal of Pharmaceutical Policy and Practice (2020) 13:33 Page 2 of 4

vulnerabilities. Despite being described under the Drug do not mandate availability of pharmacist at their prem-
Regulatory Authority of Pakistan (DRAP) Act 2012, a ma- ises, and pharmacists rent out their pharmacy license in
jority of pharmacy services don’t exist in the country and lieu of small sum of money and this is even without as-
only a few core services [8], such as dispensing, storage, dis- suring their presence on the premises [8]. Besides regu-
tribution and management of therapeutic goods are avail- latory loopholes, the government resists underwriting
able at drug retail outlets. However, there is a mounting list facilities for community pharmacy proprietors, such as
of previously known threats to the optimal use of medicines fair profit margins (difference between retail and trade
(e.g., adverse drug reactions, medication errors, misuse of price), low cost electricity and non-profit loans. Analo-
controlled substances and excessive) [9] and medicine- gous to previous patterns, Pakistani healthcare regulators
related practices (e.g., inappropriate use of medicines, espe- have not yet announced any sort of support to this sec-
cially antibiotics, formulation issues, over-the-counter tor despite the COVID-19 triggered a high need for
(OTC) availability of prescription medicines, unsafe storage community pharmacy services.
and disposal of medicines, and poor availability of medi-
cines) that demand advanced community pharmacy ser- Public or patient related factors
vices in the patient’s welfare [10–15]. Whilst, in the current The other factors that place the establishment of com-
situation, when healthcare system is buckled under the bur- munity pharmacy services at stake are relevant to the
den of public health crisis and the country is attempting to general public or patients. The majority of the Pakistani
adhere to the recommended preventive measures against population has low rates of health literacy [19]. As a re-
COVID-19, full-blown community pharmacy services are sult, pharmacy customers rarely seek and acknowledge
urgently needed. The importance of community pharmacy pharmacy services. Moreover, massive proportions of
services during COVID-19 havoc could be gauged by the people in Pakistan only recognize physicians as qualified
fact that many developed nations have amended pharma- and capable healthcare practitioners [20], while regard
ceutical policies, introduced reimbursement schemes and pharmacists as purveyor of medicines. This in effect re-
released new instructions for community pharmacies to ex- duces the demand of pharmacists at these settings. In
pand pharmacy services [3–7]. For Pakistan, however, this brief, pharmacist’s identity in community pharmacy is
may not be easy, since both the presence of pharmacist and questioned. Their abilities are marked unreliable, and
provision of patient centered pharmacy services at commu- are regarded as pre-packaged drug dispensers. However,
nity settings have historically been plagued by shortcomings as a result of reduced public enthusiasm for visiting hos-
at various levels. Therefore, pharmacists are currently not pitals due to fear of catching COVID-19, community
able to perform COVID-19 control roles in public. This pharmacists around the globe have a great opportunity
commentary highlights a set of factors that refrain commu- to gain recognition as competent healthcare practi-
nity pharmacists from performing and facilitating Pakistan’s tioners. The demand of telepharmacy and home delivery
fragile public health and healthcare system in the midst of of medication and services has grown globally along with
COVID-19. other key services. The patients in need of these services
are interacting and acknowledging the full potential of
Government related factors community pharmacists. The same could happen in
In response to ongoing public health crisis, regulatory Pakistan if government supports pharmacists and phar-
authorities throughout the world have been found to macy proprietor in offering a set of advanced pharmacy
play a key role in ensuring the delivery of essential pa- services.
tient care services through utilization of community
pharmacy services [3–7]. However, the community phar- Academic curriculum and pharmacist related factors
macy services are inadequately provided in Pakistan Considering the rapid spread of COVID-19 and the lim-
mainly due to lack of attention at government level [8]. ited frontline healthcare personnel and diagnostic facil-
Healthcare regulators in Pakistan regulate community ities, healthcare regulators are looking for strategies to
pharmacies as ordinary commercial entities rather than meet the healthcare needs of massive population. There
considering these as healthcare settings and pharmacists are growing discussions about engagement of commu-
as promising healthcare professionals. Though, rules and nity pharmacists in different patient-centered activities.
regulations in the form of Drugs Act, 1976, Pharmacy Aside from previously recognized advanced patient care
Act, 1967 and Punjab Drug Rules 2007 are in place, but services, community pharmacists are anticipated to be
partially implemented specifically in terms of assurance tasked with testing, treatment and immunization of
of qualified persons’ presence at the community phar- communities. However, aspect that may negatively af-
macy settings [16–18]. Recently, Atif and colleagues re- fects the adoption of these much needed envisaged com-
vealed that there is an excessive breach of existing rules munity pharmacy services in Pakistan is the lack of
in the country; such as the owners of drug retail outlets expertise of pharmacists resulting from deficits in
Atif and Malik Journal of Pharmaceutical Policy and Practice (2020) 13:33 Page 3 of 4

academic curricula and other pharmacist related factors patients. On the other hand, pharmacists have low de-
[19, 21]. Although, a transition from the four-years B. mand from the pharmacy customers. Pharmacists on the
Pharm program to the five-year Pharm-D program has other hand find it humiliating to work as a sale staff (i.e.,
been observed in Pakistan [22], the content of pharmacy prescription filling without patient counseling) after
curriculum does not comply with the needs of advanced studying a nerve racking five-year professional course.
pharmacy services [8]. Moreover, clinical sessions and Given the foregoing reasons, it is very difficult not only
clinical research at under-graduate stage are introduced for community pharmacists to integrate themselves in
only as a formality. Pharmacy students, therefore, lack the community pharmacy settings during COVID-19,
the necessary knowledge and competence regarding ad- but also for pharmacy owners to satisfy the expectations
vanced pharmacy services [23]. This in turn impacts of pharmacists.
self-confidence of pharmacists and ultimately the stand-
ard of even core pharmacy services, including patient Concluding remarks
counseling skills [19]. Fresh graduates are also reluctant There are a number of intertwined government, public,
to acquire professional skills at community pharmacies academia, curriculum, pharmacist and drug retailers re-
owing to lack of recognition and low remuneration. In lated factors in Pakistan which are hindering the estab-
this episode of COVID-19, this attitude of Pakistani lishment of community pharmacy services regardless of
pharmacists refrains them from possible interaction with COVID-19 driven high demand for such services. Gov-
the public and patients. ernment led multifaceted approaches are urgently
Furthermore, a large number of pharmacy graduates needed to strengthen this unrecognized domain. The ex-
in Pakistan are female, however, due to socio cultural istence of a multi-stakeholder committee led by pharma-
barriers and traditional orthodox society their presence ceutical regulators and foreign experts appears to be
at the community pharmacies is sparse [24]. Therefore, essential in tackling these challenges. The government
the low uptake of community pharmacy services in the level initiatives are urgently required to attract and en-
country during COVID-19 is highly related to this gen- courage pharmacists to perform their role in community
der imbalance driven low availability of experienced pharmacies during ongoing pandemic.
community pharmacists. The government should consider the provision of suf-
ficient interest free loans to the pharmacy graduates
Drug store proprietor related factors which will enable them to open their own pharmacies.
In the wake of COVID-19, nations are facing a huge On the other hand, the government should urgently
challenge associated with access to essential medicines. consider increasing profit margins for the proprietors
In order to mitigate medication disruption, community (i.e., increase in the difference between trade and sale
pharmacies in the presence of pharmacists have been price) and later emphasizing them to ensure the pres-
temporarily authorized to offer additional services, such ence of pharmacists at their setting. The Pharmacy
as medicines compounding, re-packaging of non- Council of Pakistan has a crucial obligation to act pro-
prescription medicines, digital image prescriptions and gressively to overhaul and synchronize pharmacy educa-
continued dispensing of essential prescription only tion and practices. Not only do pharmacists need to
medicine without a prescription. Nevertheless, authori- work closely to deal with the continuing challenge of
zations for these services in Pakistan will be curtailed COVID-19, they do need to understand that their
due to unavailability of pharmacists at community set- strength lies in the acquisition of identification rather
tings, which is fuelled by a range of aspects at pharmacy than authority.
proprietor level. First, fully compliant drug store propri-
Acknowledgements
etors are earning less owing to low profit margin in None.
medicines and related products. As a result, they cannot
fulfill even reasonable salary demands of pharmacists, Authors’ contributions
which is one of the key factors why pharmacists in Both authors made equal contributions in writing this commentary.

Pakistan are unwilling to opt this profession as a full- Funding

time job. Second, the proprietors tend to sale “prescrip- No funding sources.
tion only” and “controlled drugs” easily in the absence of
Availability of data and materials
a qualified pharmacist. Therefore, most of pharmacy Not applicable.
owners infringe the regulation and avoid recruiting phar-
macists at their premises. Third, proprietors do not want Ethics approval and consent to participate
Not applicable.
to pay fresh pharmacists merely because of their qualifi-
cation. This is because fresh pharmacists have minimal Consent for publication
competency to fill the prescriptions and counsel Not applicable.
Atif and Malik Journal of Pharmaceutical Policy and Practice (2020) 13:33 Page 4 of 4

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