A Formule, a manufacturing pharmacy in Salvador |
Salvador is situated on the north east coast of Brazil and is the capital
of the state of Bahia. It is home to approximately two and a half million
people, 85 per cent of whom are of African origin. Their facial features,
often a mixture of African, European and Amerind, are among the most interesting
I have seen. Salvador is a culturally rich city. It is a stronghold of
Afro-Brazilian customs and its spicy cuis-ine relies mainly on West African
ingredients and cooking methods.
Although Brazil’s gross domestic product outweighs that of other
Latin American countries, poverty and illiteracy (literacy level is about
80 per cent) are still major barriers to development. The average monthly
income in Salvador is about £300 and pharmacists earn around £500
per month. Salvador has two schools of pharmacy, which between them have
100 graduates a year. “Too many,” I was told by my guide. The
numbers of pharmacists who are trained are not controlled in Salvador,
unlike the numbers of doctors, nurses and teachers. A pharmacist’s
education and training takes five years: four years at university and one
year’s practical training in a pharmacy.
Much of Salvador is shanty town with sanitation a problem in the poor neighbourhoods.
Life expectancy has risen considerably during recent decades from an average
of 59 years in 1970 to 71 years in 2004. This is due mainly to reduced
infant and child mortality, which has been achieved, in part, by a government-funded
immunisation programme: more than 99 per cent of one-year-old children
are now immunised against tuberculosis, diphtheria, tetanus, whooping cough,
polio and measles.
Pop into your pharmacy … for a coffee
The first pharmacy I visited was part of a group of 12 pharmacies named
A Formule, and unexpectedly modern. Smart and bright, with a retail
area similar in size to a small pharmacy in Britain, it also had a
small coffee shop for customers and a counselling room. This pharmacy
employs three pharmacists along with 60 other employees, including
technicians, assistants and cleaners. I wondered why the staff was
so large until I was taken behind the pharmacy counter to be shown
the first of what turned out to be a range of small manufacturing units.
About 60 prescriptions a day (10 per cent of the total) are prepared
extemporaneously. This is unusual — in Brazil, as in many other
countries, most dispensed items are ready prepared medicines. On the
ground floor there was a preparation room for external preparations and
a consulting room for a chiropodist. Upstairs, powders, capsules and
liquids were made. Powders were prepared and weighed in one room, capsules
were filled in a second, and medicines packed into bottles in a third.
Protocols hung on the walls in each area and work flow seemed highly
efficient.
If a doctor prescribes a branded medicine, this is what must be dispensed,
but if a generic medicine is prescribed, this can be made extemporaneously.
So, a prescription for omeprazole 20mg, for example, can be dispensed
extemporaneously. Strengths can also be manipulated. My guide explained
that payment to the pharmacy for each extemporaneously dispensed item
is about £1.
One of the three pharmacists also practised acupuncture and Shiatsu in
a clinic, which was part of the pharmacy. Again, this is not typical
of a Brazilian pharmacy, though the Federal Council of Pharmacists in
Brazil has recently established regulations for the practice of pharmacists
in homoeopathy and phytotherapy, as well as acupuncture, and requires
that pharmacists who wish to practise these complementary therapies are
trained appropriately.
The second pharmacy I went to, Estrela Galdino, was situated in a large
shopping
centre. It was one of a chain of 35 pharmacies and a complete contrast
to A Formule. The pharmacy was like a small supermarket,
selling everything from food and cosmetics to domestic cleaning products
and toiletries. The pharmacy area was tiny compared with the sales area
and there was one pharmacist on duty, with another available to cover
the long opening hours (8am to 10pm).
The dispensary was like a galley kitchen, making excellent use of a tight
space. Almost all the dispensing in this pharmacy was from original packs.
Controlled Drugs in Brazil (which include benzodiazepines and anticonvulsants
as well as opioid analgesics) must be kept in a locked cupboard and records
are kept in a large A4-sized black book. Other medicines were visible
to the public and items, such as beta-blockers and non-steroidal anti-inflammatory
drugs, which are prescription-only medicines, are sometimes sold over
the counter. The prices that patients are charged for medicines can vary
greatly. In addition to branded and generic medicines, “similares” were
also evident. These are medicines that claim to be similar to, or identical
to, their brand name counterparts. They are available in many countries
in Latin America, where they are considered as legal and inexpensive
alternatives to patented drugs. Essential drugs are often unavailable
in Brazil and counterfeit medicines are also common. Pharmaceutical care
Community pharmacists in Brazil operate mainly as commercial establishments
although there are a few exceptions, like the first pharmacy I visited,
which also offered a nurse-led immunisation service. However, the
Federal Council of Pharmacists has developed a new model of community
pharmacy
in which pharmacies are to be encouraged to become health care centres
and will carry out health education campaigns, immunisation and so
on. Similar to the UK, the intention is that pharmacists will practise
pharmaceutical care with programmes for the control of diabetes,
hypertension and other diseases and, as a result, new training programmes
for pharmacists
at both undergraduate and postgraduate levels are being devised.
In March this year, the minister of health in Brazil included pharmacy
services for the first time in a new primary health care bill and allocated
funds for pharmaceutical care. This is expected to result in more rational
use of medicines (the unnecessary use of drugs is high in Brazil) and
improve patient care through concordance and safer use of
medicines.
Pharmacists in Brazil face enormous challenges. In every country there
will be beacons of good practice that will help to effect change and
drive pharmaceutical care, and I am mindful that the two pharmacies
I visited are good examples. I have no doubt that pharmacies in the
old
city are rather different to the pharmacies that I was taken to see. |
The
Pharmaceutical Journal