The Pharmaceutical Journal
Vol 271 No 7280 p885-886
20/27 December 2003

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Challenges for pharmacists in India

Before returning to Cardiff University to complete her pharmacy degree, Nicola Husain spent three months working in a hospital pharmacy in India. In this article, she describes her experience

Holdsworth Memorial Hospital (HMH) was built in Mysore, India, nearly 100 years ago to provide accessible and affordable health care to some of the poorest women and children in the city. It was the first hospital to be built in Mysore and the founders chose a site in one of the most deprived areas of the city — a controversial decision because many believed it would attract the “wrong” class of people.

Now approaching its centenary, the hospital serves a large population of Hindus, Muslims and Christians from Mysore and the surrounding area. It has 320 beds and its wards include surgery, maternity and paediatrics. The hospital has radiology and pathology facilities, a blood bank and, of course, a pharmacy service.

Dispensing process

The two dispensaries are situated on the main site and at the children’s hospital, a short distance away, across a busy road. There are eight pharmacists who have studied for a minimum of two years, and the main pharmacy operates 24 hours a day. The pharmacists’ job primarily involves dispensing medicines and supplying surgical equipment for in- and outpatients. I was able to help with the dispensing workload, although locating drugs on the shelves was a near impossible task at the beginning — drugs were grouped by pharmacological action and many of the brands used were different from those in the United Kingdom.

The patient (or a relative) presents the prescription at the “billing window” and a pharmacist inputs the patient and drug details into a computer. This allows stock levels to be monitored — a critical process because storage space in the dispensary is limited. A bill is printed and a cashier takes the money for the medicine. The patient then presents his or her receipt at the dispensary window and a pharmacist collects the medicines or equipment. Tablets are packed in small paper bags and directions written using a notation, which indicates the number of tablets to be taken morning, noon and night. For example, “one in the morning and one in the evening” would be written “1 – 0 – 1”. This standard notation is necessary in India because of the many languages spoken.

Most inpatient prescriptions are only for a day’s supply. This ensures that medicines are not wasted but means that blister packs are frequently cut, and often dispensed with no identifying marks or information.

The dispensary is constantly busy and this, coupled with the lack of privacy, makes counselling difficult. Many languages are spoken in Mysore, including Kannada (the local language), Urdu, Hindi and English, and this can further complicate communication.

Pharmacy services

Before my arrival in Mysore in the summer, the hospital had begun to implement a medicines information service and an adverse drug reaction reporting system. Unfortunately, the chief pharmacist, who ran this service, died in a road accident two weeks into my work experience. I was asked to help continue part of this service by answering medicines-related questions from doctors. Most enquiries were concerned with side effects, interactions and the substitute to use when the drug required was not available.

Once qualified, most pharmacists in India receive little additional training and there is a shortage of up-to-date textbooks. I initiated weekly clinical training sessions for the pharmacists at HMH. The first session I ran was on the pathophysiology, diagnosis, treatment and counselling points of hypertension. The lecture took place in the dispensary and was interrupted every few minutes when a prescription arrived. At present, pharmacists work mainly in the dispensary but most hope that their clinical role will expand in the future.

Difficulties and challenges

HMH is affiliated to the Christian Church of South India and is known locally as the “mission hospital”. However, 97 per cent of the hospital’s income comes from patients’ fees so it cannot afford to offer free medical treatment to many patients. Exceptions include students, employees of the hospital and leprosy sufferers. In addition to consultation and overnight fees, patients are charged for medicines, intravenous fluids and all disposable equipment, such as needles, syringes, cannulas and catheters.

The hospital offers a 95 per cent refund on unused drugs (in unopened containers) and equipment. However, some patients still do not buy every item on their prescription and will often ask the pharmacist which is the most important medicine. Non-essential medicines are frequently rejected. Moreover, it is sometimes difficult to persuade patients to finish a course of antibiotics, when they feel better, because they know they can get a refund on any unused tablets.

Another difficulty pharmacists face is persuading patients to obtain the full quantity of medicine that has been prescribed. For example, one patient prescribed 30 cloxacillin (amoxicillin) tablets, two to be taken three times daily, requested just 10 tablets, even though this was only one and a half days’ supply.

Patients beliefs and expectations are also sometimes challenging. For example, there is a common belief in India that injections are more “powerful” than tablets or capsules, and patients at the hospital often insist on parenteral preparations, even when drug treatment is not indicated. Consequently, the pharmacy dispenses a large number of prescriptions for paracetamol and multivitamin injections or parenteral preparations, even though an oral preparation would have been sufficient.

Rural health care

In India, 80 per cent of doctors live in urban areas while 80 per cent of the population live in rural villages. This results in a huge imbalance between the health care available for people in cities and those in rural areas. Over half the patients attending HMH come from outside Mysore, some travelling up to 50km, and this, inevitably, delays diagnosis and treatment — patients who live in rural areas are commonly first seen in the later stages of an illness. Furthermore, most people living in the villages surrounding the Mysore area are farmers. This means that a poor crop or drought will affect their income and, therefore, their ability to pay for medical services.

HMH has a community health team of nurses who visit local villages to give immunisations and antenatal check-ups. The government provides DPT (diphtheria, pertussis, tetanus), polio, BCG and measles vaccines free of charge. In the villages covered by the hospital, immunisation rates are high. However, it has taken several years for the nurses to gain the trust of the people. For example, in the beginning, some believed that the injections would convert their babies to Christianity.

I accompanied the nurses on their visits and assisted by administering polio drops to babies and young children. After immunisations, mothers were given quarters of paracetamol tablets for their children, in case they developed fever.

Although mothers are encouraged to have their babies in hospital, the nurses have trained several women in each village in midwifery. These women are also responsible for encouraging mothers to attend their check-ups and immunisation clinics and promoting health and hygiene awareness. All new mothers receive baby soap and talcum powder and information cards, which are written in two languages (English and Kannada). Diagrams are also used for those who cannot read. The cards give advice on hygiene, sexual health and contraception, and dispel myths, such as that branding a newborn baby protects it from having seizures, or that manure placed on a child’s wound will promote healing.

Common conditions

The prevalence and treatment of many of the conditions seen at the hospital in Mysore (eg, hypertension, heart failure and diabetes) are similar to those seen in Britain. However, infectious diseases such as tuberculosis and malaria are particularly common and, generally, are harder to treat. Parasitic worm infestations are prevalent and are treated with mebendazole or albendazole.

While I was working at the hospital there was a local dengue fever outbreak, for which there is no cure, only symptomatic treatment. Many children and babies were admitted for gastroenteritis and fever. The risk of dehydration is severe because of the hot climate and IV fluids are administered to almost all patients suffering from these conditions.

A particularly interesting case was that of a breastfed baby who was admitted with seizures. He was found to be hypocalcaemic — a result of his mother’s vitamin D deficiency, caused from wearing a burka. The baby was treated immediately with calcium and the mother was treated for her vitamin D deficiency.

Reflections

India faces enormous challenges to provide adequate health care for its vast and growing population. However, at HMH much progress is being made to increase both health care awareness and accessibility.

My short time spent at HMH has given me an insight into the experiences and challenges faced by pharmacists in a developing country. I also saw diseases and treatments that I would not normally encounter in the UK. I would like to return to India to work again at HMH and would encourage other students and pharmacists looking for a challenging and rewarding experience to consider pharmacy work experience abroad.

HMH has now appointed a new chief pharmacist who hopes to expand the role of pharmacists in the hospital. In addition, clinical pharmacy qualifications are beginning to be introduced at several hospitals in India.