Separating dispensing from medical practice in Taiwan
An innovation in recent years has been the programming
of a “leadership conference” during the congress week, for the presidents
or chairmen and chief executive officers of the associations in membership
of the International Pharmaceutical Federation.
The highlight was, without doubt the presentation
given by the Minister of Health for Taiwan, Dr Ming-Liang Lee, on the
experience in that country in separating dispensing from medical practice.
Taiwan’s population has grown from six million in
1941 to over 22 million and life expectancy is now over 78 years for women
and nearly 73 years for men.
There are nearly 19 physicians per 10,000 people,
with 9,402 clinics where Western medicine is practised, 2,461 for traditional
Chinese medicine and 5,500 dentistry clinics.
Health insurance scheme
A national health insurance (NHI) scheme was introduced
in 1995. The number of pharmacies in contract within the scheme grew from
about 800 at its inception to over 3,350 in 1998 but has now dropped to
just over 3,050, probably as a consequence of the way in which the change
from doctor dispensing has developed.
Before 1997, dispensing was traditionally part of
medical practice but most medicines were dispensed by non-professionals,
sometimes the wives of physicians. Patients were given no information
about the medicines supplied to them. In “retaliation” for doctor dispensing,
some pharmacists supplied prescription medicines without receiving a prescription.
The law for the separation policy — the Law of Pharmaceutical
Affairs — was amended and renamed in 1993. The strategy was to upgrade
the facilities in community pharmacies and the quality of the professional
services provided in them. The NHI scheme provided a map of the pharmacies
in contract and the intention was that they should begin to dispense the
commonly used medicines in 1995.
The problems encountered were as expected. People
complained of the inconvenience of not getting medicines when they went
to see their doctor, there was a decrease in the income of physicians,
they had little communication with pharmacists and there were insufficient
incentives for physicians to “release” prescriptions for dispensing in
pharmacies. In addition, people had little confidence in the quality of
service available from community pharmacists. The decision was then taken
to allow clinics to employ pharmacists and to implement the changes gradually
on a district by district basis.
On 1 March 1997, the two largest cities, Taipei
and Kaohsiung, started to implement the policy and by 1 May 2000 it had
been implemented everywhere in the country except one off-shore island.
So nowadays in clinics covering about 95 per cent of the total population,
over 80 per cent of prescriptions are dispensed by pharmacists as against
0.26 per cent previously. And a survey has shown that over 70% of the
population now like having their prescriptions dispensed by pharmacists.
On 3 November 2000, the Asian Wall Street Journal
said: “Taiwan has provided a textbook example of how to deprive doctors
of their dispensing privilege, without causing riots in the streets or
sick people clawing at closed emergency room doors.” And in July
2000, Scrip said: “Communication, education and gradual implementation
have played key roles in the relatively smooth separation of dispensing
from medical practice in Taiwan.”
This contrasts starkly with what happened in Korea
when the government pursued a similar policy. The physicians went on strike
and the president of the Korean Medical Association spent a short time
in prison for his role in the protest against the reforms.
The next phase in Taiwan will be designed to have
prescriptions for patients with chronic conditions released from the clinics
to be dispensed in community pharmacies. To achieve this there will be
strict regulations on the licensing of pharmacists to practise, with renewal
of a license at four yearly intervals being dependent on participation
in continuing education. Reasonable volumes will be set for dispensing
of prescriptions in medical centres, campaigns to make the public more
knowledgeable about medicines will be run and every effort will be made
to promote better communication between physicians, pharmacists and patients.
Patience and courage
When he was congratulated on his patience and courage,
Dr Lee said: “One cannot be too patient but one cannot be too courageous
either!” He emphasised that the key to progress in Taiwan had been gradualism
and the efforts made county by county to persuade the medical associations
to accept the change. The policy had been supported by two presidents
of Taiwan and three successive ministers of health, so persistence has,
without doubt, also been a very important factor. The overall goals of
the separation policy were safety, quality, professionalism for both physicians
and pharmacists, and public satisfaction. He added that the ball was now
very much in the court of the community pharmacists to improve the appearance
of their premises. The public would suspect that professional pharmacy
services were unlikely to be obtained “from premises that looked like
7 to 11 stores” — a perceptive and telling observation by the minister
who is, incidentally, a medical doctor.
—John Ferguson.
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