Does deregulation in community pharmacy impact accessibility of medicines, quality of pharmacy services and costs? Evidence from nine European countries

Community pharmacy services in the late COVID-19 period: What has driven change?

BACKGROUND

Community pharmacy appears to have undergone considerable change over the years.

OBJECTIVES

The objective of this research is to study the range of community pharmacy services provided in late stages of the COVID-19 pandemic and during the last decades and to identify potential drivers for change.

METHODS

Four European countries (Austria, England, Estonia, and Portugal), which represent a balance in terms of income, organization of the health system and pharmacy services, were selected as case studies. For each country, a factsheet on pharmacy services provided in 2023 and recent developments was populated based on a literature review and validated by country experts in community pharmacies. A semi-structured interview was conducted with a community pharmacist in all study countries to gather additional information, in particular on potential drivers for change.

RESULTS

In all case study countries, community pharmacies offer a range of medicines-related and non-medicines-related services, ranging from core activities such as dispensing and counselling to information on general health topics, point-of-care testing, disposal of returned medicines and needle-exchange programs. Certain services are only permitted in some countries (e.g., vaccinations, generic substitution). Developments (e.g., additional tasks) were observed in the last decades, but some changes were only introduced recently in response to the pandemic (e.g., testing for COVID-19, COVID-19 vaccinations). Several, mostly facilitating, factors, such as high accessibility and acceptance of community pharmacies, the growing relevance of the primary health care concept and an appetite of community pharmacists to take over additional tasks, have contributed to changes in the range of services in community pharmacy in recent years and over the decades.

CONCLUSIONS

The study confirms changes in community pharmacy, with overall extension of the services offered. The COVID-19 pandemic was reported to have played an important role but was not considered the sole driver for change.

How does OTC drugs consumption relate to prescribed drugs and health care consultations in Europe?

Self-medication is prevalent in European countries, where health systems are committed to providing universal and equitable access to medicines and health services. This study aims to explore the relationship between the use of over-the-counter (OTC) and prescribed drugs, as well as between OTC drug use and healthcare service utilization. Data from the European Health Interview Survey, wave 2019, were analyzed using logistic regressions on a sample of employed individuals from 26 countries. The main findings point to complementary and triangular relationships between the consumption of over-the-counter and prescribed drugs, and the use of health care consultations. Additionally, it was confirmed that the consumption of over-the-counter drugs is more likely when people are absent from work for health reasons. Finally, the study recommends fostering collaboration between pharmacists and healthcare providers to create comprehensive medication profiles for patients.

Over-the-counter drug consumption and related factors, evidence from the European Health Interview Survey

Background

The aim of this work is to find the factors related to over-the-counter drug (OTC) consumption in Europe considering the differences in OTC market regulation.

Methods

A sample obtained from the European Health Interview Survey (EHIS) of 2019 is used to estimate a logistic regression. This sample includes 286,413 people from 26 countries. The outcome variable is derived from the question about the use of non-prescribed drugs. The independent variables include a set of predisposing, enabling, and need factors. Finally, countries with similar OTC retail market regulations are considered to control for heterogeneity in this regard.

Results

The main findings show that OTC market deregulation is not strictly related to the share of OTC consumption. Despite some heterogeneity based on the type of OTC retail market regulation, there is a set of common drivers for its use by people across countries, such as age, gender, education, suffering from chronic disease or pain and being on a waiting list for medical treatment. When considering individual country and cluster of countries controls, there are some relevant results such as the role played by accessibility to pharmacies and OTC retailers; the positive correlation between OTC drugs and prescribed drug consumption, and the positive correlation between unmet health care needs due to financial household constraints and OTC drugs use.

Conclusions

There is no clear relationship between OTC drug use and OTC retail market regulation. There are several predisposing, enabling, and need factors that promote the use of OTC drugs. The relevant policies relate to the inequal access to OTC drugs across countries that may result from different market regulations and different consumption drivers.

The juggling act of pharmacists in Sweden: a qualitative study on balancing healthcare professionalism and retail employment

BACKGROUND

Community pharmacies in Sweden merge a state-funded professional community service with a retail business. While previous research has recognized its challenges, less attention has been paid to the potential conflict of interest it could result in regarding the work of pharmacists. This study aims to increase understanding of how pharmacists in Sweden combine their healthcare ambitions and obligations with those concerning being employees in a retail business.

METHODS

Semi-structured interviews were conducted with 28 pharmacists employed by pharmacy chains in Sweden. The data were thematically analysed.

RESULTS

In the analysis, three themes were formulated: Different interests, The conflict between professional work & business work, and Strategies to manage the conflicts. The analysis of the data reveals that pharmacists in Sweden experience a conflict of interest. They grapple with balancing being healthcare professionals with a focus on patient care and being valued retail employees that also focus on financial results. This conflict manifests in various situations, such as time management, communication focus, preferred behaviours, and different tasks. The different strategies applied by individual pharmacists to manage the work are results of job crafting. Pharmacists employ strategies such as compromise, mandate stretching, avoidance, and acceptance to manage the conflict. However, these strategies lead to compromises in their work.

CONCLUSION

This study aimed to understand how pharmacists combine their healthcare ambitions and obligations with those of being employees in a retail business. The study demonstrated that Swedish community pharmacists need to perform a juggling act to be both professional healthcare workers and viewed as valuable retail employees. In situations when the conflict of interest occurs, the pharmacists use different strategies when determining how to prioritize between the professional work and the business work. The conflict of interest in the pharmacists' work need to be taken into consideration when discussing pharmacists practices, the profession, or role it's in the healthcare system.

"Opportunities and responsibilities": how do pharmacists assess their professionalism?

INTRODUCTION

Professionalism is fundamental to the existence of professions. In pharmacy, interest in this theme improved with events that examined the resocialization of pharmacists in care. With this, evaluating professionalism can help the operationalization of the theme and, consequently, the development of strategies for pharmacy consolidation before its challenges. Therefore, this study aimed to evaluate the professionalism of Brazilian pharmacists.

METHODS

To meet the objective, a cross-sectional study was conducted between March 2022 and August 2023. Data were collected using the Brazilian version of the "Modification of Hall's Professionalism Scale for Use with Pharmacists". The scale has 39 items grouped into the domains: autonomy, vocation, professional council, self-regulation, continuing education, and altruism. Data were analyzed using descriptive statistics and an ANOVA analysis of variance with post-hoc Hochberg or Games-Howell tests with Bootstrapping was conducted to verify differences between groups.

RESULTS

600 pharmacists participated in this study. The majority (69%) was female and carried out their professional activities in community pharmacies (50%). Professionalism scores ranged between 14 and 29 points, with an average of 22.8 points. Pharmacists working in outpatient clinics had higher scores in most factors, namely, altruism, continuing education, professional council, vocation, and autonomy. This indicates that the inclination of pharmacists to occupy areas focused on care can be significant to assess professionalism.

CONCLUSIONS

The data obtained indicate that pharmacists working in outpatient clinics had higher professionalism scores compared to others. This corroborates the worldwide trend experienced by pharmacy in recent decades, which is the execution of increasingly patient-centered practice models.

Medicines prices in International (Geary-Khamis) Dollar. The comparison between regulated and deregulated markets

BACKGROUND

Affordability of medicines is key for effective healthcare. Thus, we compared medicine prices using International Dollar (I$), which allows confronting the values of different currencies. Besides, we intended to verify if pharmaceutical market deregulation leads to lower medicines prices.

MATERIALS AND METHODS

We conducted the study between December 2019 and September 2022 collecting data from 21 countries. From the preliminary sampling of 30 medicines, we selected 10 brand names (5 Rx and 5 OTC brands) for the analysis. In each country, we collected price information from 3 pharmacies and then converted them to the I$ using the rates published by the International Monetary Fund.

RESULTS

There were differences between regulated and deregulated markets in prices presented in I$. For instance, Aspirin C® (10 soluble pills) was on average I$ 5.41 in Finland (regulated market) and I$ 13.25 in Brazil. The most expensive Xarelto® 20 x 28 pills (I$ 538.40) was in Romania, which in the case of other medicines, was in the group of cheaper countries. There was no statistical significance in price comparison between regulated and deregulated markets. In some cases, however, regulated markets offered lower prices of the same medicine than deregulated markets.

CONCLUSION

The analysis revealed differences in I$ prices between countries. Pharmaceutical market regulation does not mean higher prices of medicines. There is a need for affordable medicines. Hence, decision-makers should work on the medicines prices and adjust them to the local economies. I$ could be important in creating pharmaceuticals prices, and the conducted study should encourage other researchers to present their results using this currency.

From symbiosis to independence: Investigating changes in the relationship between general practitioners' presence and pharmacies' market size in Slovakia

Using the Slovak pharmacy retail market case, this study examines the evolving interdependency between general practitioners (GPs) and pharmacies. Traditionally, they have operated symbiotically, with pharmacy revenues heavily reliant on prescriptions. However, the development of the market structures of these providers after the liberalization of the pharmacy retail market in 2005 raises a question about the stability of this relationship. By analyzing entry thresholds as a measure of the market size required for pharmacies to cover their entry costs, the study reveals that the dependency of pharmacies on the presence of GPs has diminished over time. In the initial year following the liberalization, the presence of a GP decreased the market size sufficient to cover entry costs for the first pharmacy by about 83% compared to a market without a GP. However, in 2019, this effect decreased to approximately 65%. This could imply worsened coverage of pharmaceutical services in small and rural areas with GPs as the entry decision of pharmacies is less elastic towards their presence.

Competition Among Pharmacies as a Determinant of Drug Expenditures

This study explored and compared the associations between pharmacy competition and drug expenditures by individuals with influenza. This study used a dataset consisting of 6 694 534 individuals who purchased drugs for influenza at pharmacies from 2015 to 2019 in China. Patients' annual average influenza-specific drug expenditures per visit at pharmacies was the outcome variable of interest. Pharmacy competition was measured using the Herfindahl-Hirschman index. A 3-way fixed-effects model combined with a lagged identification strategy was constructed to estimate the association between pharmacy competition and drug expenditures. When the radius of the market was set to 1, 5, and 10 km, for each 10% increase in the degree of total competition in the market, an individual's annual average influenza-specific drug expenditures per visit fell by 0.65%, 2.21%, and 5.20%, respectively. With a more detailed understanding of the underlying mechanism through which pharmacy competition affects the behaviors of health care providers, competition can be considered as a potential tool to assist decision makers in the design of policies to curtail the growth in drug expenditures.

A quantitative classification of OTC medicines regulations in 30 European countries: dispensing restrictions, distribution, pharmacy ownership, and pricing systems

BACKGROUND

This paper reviews the regulations of over-the-counter (OTC) medicines in 30 European countries with the goal of identifying the regulatory trends and clusters as of May 2022.

METHODS

To that end, we reviewed the regulation that directly or indirectly might have an impact on OTC medicines. The data were gathered from the national legislation, reports from international organizations, and the existent literature. The 12 regulatory items obtained were classified into four categories: price, pharmacy ownership, distribution modes, and dispensing restrictions. In addition, these items were also employed in the cluster analysis.

RESULTS

Pharmacy ownership is mainly private, and in the majority of countries, OTC medicines are not subject to any pricing system. Almost every country studied allows online selling of OTC medicines, and 16 countries allow non-pharmacy retail to sell OTC medicines as well. The dispensing restrictions applicable in pharmacy retail are similar in the countries studied: they rely on the staff, OTC medicines are placed behind the counter and the doses dispensed tend to be restricted. Concerning non-pharmacy retail, additional dispensing restrictions might be imposed, such as the establishment of buyers' minimum age, the requirement of a pharmacist to supervise the operations, a regulation on the location in the store, and further restrictions on the package sizes, strength, or pharmaceutical form. The cluster analysis resulted in an initial division between countries that widely allow the sale of OTC medicines in non-pharmacy retail and countries, where pharmacy retail has an OTC monopoly. Based on the regulations, 7 subsequent groups were identified evidencing wide regulatory heterogeneity within the countries studied.

CONCLUSIONS

Our findings point out that OTC medicines are in general not subject to pricing systems, selling is allowed online, and ownership of pharmacies is mostly private. However, regarding dispensing restrictions, pharmacy chains, and establishment restrictions of pharmacies, we found heterogeneity that is also visible in our cluster analysis, since we identified 7 clusters.

Power dynamics and interprofessional collaboration: How do community pharmacists position general practitioners, and how do general practitioners position themselves?

Power differentials and medical dominance can negatively affect collaboration between physicians and pharmacists. Norway is recognized as having a relatively egalitarian work sector, which could affect power differentials. In this qualitative study, we used positioning theory as a framework to explore the aspect of power dynamics between Norwegian general practitioners (GPs) and community pharmacists. We used the concepts of reflexive and interactive positioning to identify how GPs positioned themselves and how they were positioned by pharmacists in six focus groups. Data were analyzed using systematic text condensation. We found positioning theory to be a useful lens through which to study power dynamics in relation to collaboration between community pharmacists and GPs. Our findings imply that the presence of medical dominance poses challenges even in an egalitarian Norwegian setting. However, although both GPs and pharmacists draw on a 'medical dominance' storyline, we have also identified how both pharmacists and GPs draw on alternative and promising storylines of collaboration between the two professions.

Community Pharmacists' Beliefs about Suboptimal Practice during the Times of COVID-19

Introduction: Community pharmacies are high-performance workplaces; if the environment is not conducive to safe practice, mistakes can occur. There has been increasing demand for pharmacists during the COVID-19 pandemic as they have become integral to the response. Suboptimal practices in the work environment and with pharmacists and their teams can impact the safe delivery of services. New Zealand pharmacists' perceptions of the current work environment and beliefs around whether suboptimal practice have increased within the last five years and the effect of the COVID-19 pandemic on their practices are unknown. Aim/Objectives: To assess what New Zealand pharmacists associate with suboptimal practice in their workplace and investigate the effect of the COVID-19 pandemic on pharmacists and their workplaces. Methods: We employed an anonymous online questionnaire derived from a human factors framework utilised in the aviation industry to explore the potential environment, team and organisational factors as the determinants of suboptimal work practices. The software, hardware, environment and liveware (S.H.E.L.L) model was adapted to create questions classifying the risk factors to potentially identify aspects of work systems that are vulnerable and may provide risks to optimal practice. Additional perceptions around the effect of COVID-19 on their workplace and roles as pharmacists were explored. Participants were community pharmacists working in New Zealand contacted via a mailing list of the responsible authority for the profession. Findings: We received responses from 260 participants. Most participants indicated that suboptimal practice had increased in the last 5 years (79.8%). The majority of participants indicated that COVID-19 had impacted their workplaces (96%) and their roles as pharmacists (92.1%). Participants perceived that suboptimal practice was associated with a lack of leadership and appropriate management; poor access to resourcing, such as adequate staff and narrow time constraints for work tasks; a lack of procedures; competition; and stress. A lack of experience, professionalism and poor communication between staff, patients and external agencies were also issues. COVID-19 has affected pharmacists personally and their work environments. Further study in this area is required. Conclusions: We have identified that pharmacists across all sectors of New Zealand agreed that suboptimal practices had increased in the last 5 years. A human factors S.H.E.L.L framework can be used to classify themes to understand the increases in suboptimal practice and the role of COVID-19 on pharmacist practice. Many of these themes build on the growing body of the international literature around the effect of the pandemic on pharmacist practice. Areas for which there are less historical data to compare longitudinally include pharmacist wellbeing and the impact of COVID-19.

Application and utility of geographic information systems in pharmacy specific health research: A scoping review

BACKGROUND

Geographic Information Systems (GIS) are considered essential tools to analyze spatially referenced health data.

OBJECTIVES

The purpose of this scoping review is to describe how GIS is used in pharmacy specific health research.

METHODS

During July 2020, the following databases were searched: EMBASE, MEDLINE (PubMed), Web of Science and Scopus. The search strategy included terms relating to spatial analysis and pharmacy. Studies were considered eligible if they involved the use of GIS and focused on pharmacies. A narrative and tabular synthesis of the results was carried out, structured around the spatial analysis methods utilized across studies, as well as the characteristics of pharmacies evaluated in studies.

RESULTS

After a review of 6967 sources, 48 studies were included in this review. Twenty-nine studies were conducted in the United States (60.4%) and thirty-six focused on accessibility (75.0%; n = 36). Twenty-two studies investigated the relationship between sociodemographic aspects of the population and the accessibility and availability of pharmacies (45.8%). Twelve studies (25.0%) performed distance analysis and six studies (12.5%) performed geostatistical analysis. Community pharmacies were the setting evaluated most frequently, with over-the-counter selling products being the most evaluated pharmacy variable (13.3%; n = 6). Population density (58.3%; n = 28), income indicators (43.8%; n = 21) and minority community composition rates (41.7%; n = 20) were the most used population variables.

CONCLUSIONS

GIS have been increasingly used in pharmacy specific health research. Generally, research has sought to identify potential barriers to access and their effects on the population. Future research may benefit by utilizing robust spatial methods and applications across countries outside of the United States. Doing so could help to confirm the impact of sociodemographic characteristics on the availability and/or accessibility of pharmacies globally.

Access to Medicines via Non-Pharmacy Outlets in European Countries-A Review of Regulations and the Influence on the Self-Medication Phenomenon

Non-pharmacy trade concerns the sale of medicinal products outside of pharmacies, such as limited-service pharmacies, supermarkets, petrol stations, shops open to the public, and kiosks. Access to medicinal products via non-pharmacy outlets varies across the European countries, with a general deregulation of this market area observable. Increasing the availability of medicines by allowing patients to obtain them outside of pharmacies contributes to the spread of self-medication. The aim of this article was to review the legal regulations enabling the non-pharmacy trade in OTC (over the counter) medicinal products in European countries, with particular emphasis on the analysis of active substances contained in medicines available in the non-pharmacy trade. This analysis has made it possible to distinguish three categories of countries: (1) where there is a non-pharmacy trade in OTC medicinal products, (2) where there is a limited non-pharmacy trade in OTC medicines, (3) where there is only a pharmacy trade in OTC medicinal products. In the context of these considerations, we highlight the impact of patient access to medicinal products via non-pharmacy sources on raising the prevalence of self-medication. This article identifies the advantages and risks of self-medication, emphasising the role of the pharmacist as an advisor to patients within the scope of the therapies used.

To evaluate the impact of opening up ownership of pharmacies in South Africa

Background

Following the democratic elections in 1994 the South African private pharmaceutical services were mostly in metropolitan centred with a scattering of pharmacies in less densely populated areas. The Government introduced regulations relating to the ownership and licensing of pharmacies on the 25th of April 2003 to improve access to pharmaceutical services by removing ownership restriction to only pharmacists.

Objective

To assess the outcomes of the policy implementation in improving access to pharmacies.

Method

The register of pharmacies at the South African Pharmacy Council was analysed from 1994 to 2014. Each registration was assigned GPS coordinates using Q-GIS(V3.6) and mapped per province at a district level, following clean-up and verification of the register. New registrations were also categorised as either corporate or independent pharmacy. Population census was obtained from Statistics South Africa and used to determine the number of pharmacies per 100,000 population.

Main outcome measure(s)

Number of active pharmacies; Number of independent pharmacies; number of pharmacies in each district.

Results

The number of active pharmacies increased from 1624 at the end of 2003 to 3021 by 2014. The closure rate decreased from 137 to 86 pharmacies per year post regulations, a 37.23% reduction with a net gain of approximately 127 pharmacies per year. About 38.30% of all pre-2003 pharmacies (622 of 1624) closed by 2014. The population increase in the study period was approximately 20.66% but the overall growth of pharmacies was only 1.88 pharmacies per 100,000 population (3.55 to 5.43). Following the regulations in 2004, 23.9% of pharmacies active within the system closed between 2004 and 2014, of which, 91.7% of them were independent pharmacies.

Conclusion

Opening up of pharmacy ownership in South Africa increased the number of pharmacies in the country but did not result in increased access in previously less populated areas. There was still clustering of pharmacies in a well resourced areas, with a steady growth in corporate pharmacy (35%) ownership.

Rationales and arguments behind the adoption of self-selection of nonprescription medicines in Denmark

Background

Pharmacies in Europe have undergone considerable changes in their regulation over the last decades, also regarding nonprescription medicines (NPMs). In 2001, selected NPMs were released for sale outside pharmacies in Denmark. To ensure consumer safety, it was decided that NPMs must be stored behind the counter. In 2018, an amending act came into force, which allowed self-selection of NPMs. The purpose of this study was to examine the rationales and related arguments, including their validity and relevance, behind the policy on self-selection of NPMs in Denmark.

Methods

A qualitative study design, combining document analysis and individual interviews with key stakeholders, was used. Legislative documents were retrieved from the Parliaments’ homepage. Interviewees were recruited through purposeful sampling. Interviews were analyzed using directed content analysis. Rationales and supporting arguments were identified, thematized and analyzed as to their validity and relevance.

Results

In total, 24 stakeholders (including political parties) were represented in the documents, whereof 7 were interviewed. Ten supported the new policy and 13 were against; 1 was on both sides. Six rationales and 9 supportive arguments were found. The advocates’ main rationale was increased accessibility and arguments related to freedom of choice and discretion. The opponents’ main rationale for not adopting the policy was consumer safety and arguments related to perception of NPMs and counseling. The validity and relevance were questionable in both advocates’ and opponents’ arguments, yet slightly better in the case of the opponents’. Although not mentioned in the documents, economic interests were probably behind some stakeholders’ position.

Conclusion

The formal rationale behind the adoption of self-selection of NPMs was increased accessibility. However, bearing in mind the rationales and their supporting arguments, economic interests and previous changes within the sector, it could be argued that an underlying rationale behind adopting the policy was to liberalize the Danish pharmacy sector even further.

Community Pharmacies in Poland-The Journey from a Deregulated to a Strictly Regulated Market

Community pharmacies are the primary entities providing drugs to individual patients in Poland. The pharmacy market has been changing for many years due to significant changes in market regulations. These changes significantly affect the profitability of pharmacies, which may impact the quality of pharmacotherapy. The small number of pharmacies, which resulted from changes in the law in 2017, can influence the level of patient care. The article presents the community pharmacies market in Poland. Particular attention is paid to the legal regulations affecting community pharmacies and the impact of these regulations on the overall shape of the market. The Polish system's specificity, including the pharmacy market indicators, has been compared with data from other European Union countries.

The 2017 deregulation of pharmacies in Italy: Introducing non-pharmacist ownership

Italy is the last European country to adopt policies on the liberalization of pharmacy ownership. In August 2017, the Italian government approved the law n. 124 (annual market and competition law), despite the opposition of some stakeholders. This law extended the ownership of pharmacies to non-pharmacist business partners. Law n. 124 is an important turning point for pharmacists in Italy and could lead to a general reorganization of the Italian pharmaceutical system. As has already happened in several European countries, the removal of barriers to pharmacy ownership incentivizes finance companies and pharmaceutical wholesalers to make significant investments in this sector, leading to the emergence of commercial pharmacy chains. The future of community pharmacies is uncertain and is closely linked to the fate of the current government. However, progressive polarization between independent pharmacies and pharmacies that are part of chains can already be observed.

Cross-sectional Study on the Impact of Discount Pricing and Price Competition on Community Pharmacy Practice

Background

Without stipulated legislation, a free pricing policy can lead to a disparity in prices among private healthcare setups. Competition is especially rampant among community pharmacies, especially in the Sabah state of Malaysia, where the recent years have witnessed the steady growth of pharmacy players from Peninsular Malaysia. Thus, this study aimed to examine the impact of price competition and discount pricing on the practice of community pharmacy in Sabah, Malaysia.

Methods

This was a cross-sectional study using an online questionnaire. Survey participants included community pharmacists practicing in Sabah. The validated and pilot-tested questionnaire consisted of three parts: background information of the pharmacy, attitudes and perception toward medicine prices, and practice of discount pricing. All required data were collected from community pharmacists practicing only in Sabah. Data were then analyzed by using descriptive, Chi-Square, and Kendall's tau-b tests.

Results

Of the 150 community pharmacists contacted, only 70 responded, providing a response rate of 47%. In terms of pharmacy type, 71% of the respondents were pharmacist-owned independent pharmacies, while 19% were pharmacy chains owned by community pharmacists. The remaining were pharmacies owned by non-pharmacists (10%). Sixty percent of the community pharmacies had been in existence for more than 10 years, with 12% in existence for less than two years, and 28% in existence for three to 10 years. More than 80% of the respondents stated that the business aspect of community pharmacy had overwhelmed the professional practice aspects and that community pharmacists have become providers of products instead of providers of care. In terms of professionalism, 87% also noted that they are being perceived as profiteering in the medicine business at the expense of patients.

Conclusions

The free market situation in Malaysia for medicine pricing has brought a detrimental consequence for community pharmacists with each one trying to undercut prices. Differing pricing mechanisms of medicines based on the quantity ordered contribute to the problem of discount pricing and price competition. Most community pharmacists, as indicated by this study, want the problem to be addressed.

Entry and price competition in the over-the-counter drug market after deregulation: Evidence from Portugal

In the last two decades, many European countries allowed the sale of over-the-counter (OTC) drugs outside pharmacies. This was expected to lower retail prices through increased competition. Evidence of such price reductions is scarce. We assess the impact of supermarket and outlet entry in the OTC drug market on OTC prices charged by incumbent pharmacies using a difference-in-differences strategy. We use price data on five popular OTC drugs for all retailers located in Lisbon for three distinct points in time (2006, 2010, and 2015). Our results suggest that competitive pressure in the market is mainly exerted by supermarkets, which charge, on average, 20% lower prices than pharmacies. The entry of a supermarket among the main competitors of an incumbent pharmacy is associated with an average 4% to 6% decrease in prices relative to the control group. These price reductions are long-lasting but fairly localized. We find no evidence of price reductions following OTC outlet entry. Additional results from a reduced-form entry model and a propensity score matching difference-in-differences approach support the view that these effects are causal.

Factors associated with health service orientation and active product marketing orientation in Finnish community pharmacies: a nationwide study among private pharmacy owners

BACKGROUND

Little is known about pharmacy owners' commitment to public health and health policy goals in the strategic planning of their business. The aim of this study was to explore factors associated with health service orientation and active product marketing orientation of Finnish community pharmacy owners.

METHODS

A national cross-sectional e-mail survey was sent to private community pharmacy owners in Finland (n = 581) in 2013. Based on the structured, Likert-type survey instrument, two sum scales measuring strategic orientation towards health service provision (13 items, score range 0-26) and active product marketing (8 items, score range 0-16) were developed (Cronbach's Alpha 0.836 and 0.699, respectively). Characteristics of the pharmacy owners and their pharmacy business as well as actual service provision were used as background variables.

RESULTS

Concerning health service orientation, 50% of the respondents received at least 20 points out of the maximum 26 points (score range: 0-26). For active product marketing orientation, 75% of the pharmacy owners had at least 14 points and 44% received full 16 points (score range: 0-16). The score distribution was skewed towards strong health service orientation, but the actual service score was heavily skewed towards few services or no services. Two-thirds of the pharmacy owners reported having available 2 or less services. The health service orientation was not influenced by any of the background variables used, but three of them influenced active product marketing orientation, namely business location, annual prescription volume and belonging to a marketing chain of individual community pharmacies.

CONCLUSION

Large pharmacies located close to rivals and belonging to marketing chains of individual community pharmacies differentiated as those having a high product marketing orientation. The health service orientation was not influenced by any of the explanatory variables used in this study. The discrepancy between high health service orientation scores and low actual service provision scores needs further investigation. The contradiction that exists between pharmaceutical policy goals and the generation of income of pharmacies should also be examined as a contributing factor in this respect.

How does the general public balance convenience and cognitive pharmaceutical services in community pharmacy practice

BACKGROUND

Community pharmacy is shifting its focus from traditional, product-focused roles to the provision of cognitive pharmaceutical services (CPS). Previous research has indicated that community pharmacists predominantly want to devote their capacity to CPS. Ideally, services provided also address users' needs. The general public's preferences regarding the services provided by community pharmacists are currently less understood.

AIM

This study investigates the general public's preferences and perceived importance of CPS versus convenience in community pharmacy practice.

METHOD

An online survey of 1.500 members of the Dutch Health Care Consumer Panel containing questions regarding preferences for CPS and convenience was distributed. Descriptive statistics and linear regression analysis were performed to investigate the relationship between preferences and participant characteristics.

RESULTS

516 panel members completed all questions regarding preferences and importance of the availability of services. The majority preferred convenience (68.2%) and a smaller proportion preferred CPS (27.7%). However, participants considered it important from a societal viewpoint that CPS is provided (45.0%). Participants who preferred CPS over convenience were generally older (p < 0.001) and used more medicines (p < 0.001).

CONCLUSION

Convenience of community pharmacy services is most preferred by the general public. However, CPS is perceived as important, especially for elderly who use more medicines. Elderly patients who use more medicines more often rate CPS as more important than convenience. These findings suggest that community pharmacists should ensure that pharmacy logistics are organized efficiently before focusing on the provision of CPS.

Pharmacies for the Pharmacists—Ukrainian Fears and Polish Experiences

In 2017, a regulation referred to as “pharmacies for the pharmacists” was implemented in Poland, and Ukraine is going to implement a similar act of law. The study was to collect Ukrainian pharmacists’ opinions about the upcoming market regulation and to compare their views with opinions obtained from Polish pharmacists collected two years following the amendment of this legislation. The study was conducted in Poland and Ukraine using a self-designed questionnaire. Of 2162 questionnaires received, 2043 were included in the study (1623 from Ukraine and 420 from Poland). Ukrainian pharmacists (76.8%) feared that medicine prices would increase. Moreover, they presented concerns related to poorer access to pharmaceuticals and reduced turnovers of pharmacies. Two years after the market regulation, 55.23% of Polish pharmacists pointed out that none of the fears reported in Ukraine were observed in Poland. However, 33.10% revealed that market regulation led to “a reduction in the number of pharmacies”. Ukrainian pharmacists are afraid of community pharmacies’ regulation. Polish pharmacists, however, have not observed such problems during the two years following the market regulation. The only noticeable market change in Poland was the reduced number of pharmacies.

A spatial analysis to evaluate the impact of deregulation policies in the pharmacy sector: Evidence from the case of Navarre

Community pharmacies represent unusual enterprises as their main function is intrinsically related to the provision of healthcare services. Hence, market competition in this sector needs to be regulated, in order to ensure equitable accessibility, efficiency and quality of services. However, recently a general deregulation trend may be observed in Europe. In this paper, we focus on location restrictions, i.e. on demographic and geographic constraints to open new pharmacies, and we evaluate the impact of their relaxation. In particular, we analyze the case of the city of Pamplona (ES), where a striking increase in the number of pharmacies occurred, after the introduction of a new regulatory system in 2000. We evaluate, thanks to an in-depth spatial analysis, the evolution of the system to date and the effects produced on the consumers, in terms of accessibility, and on the competitors, in terms of market shares distribution. By comparing the obtained results with the ones related to the case of a second Spanish city, characterized by more strict restrictions, it emerges that the deregulation risks to produce a limited improvement in terms of accessibility and to exacerbate differences among consumers. Moreover, an increasing number of competitors does not necessarily imply a more equitable distribution of market shares, thus putting at risk the desired effects in terms of cost reduction and service quality improvement.

Methodological considerations in clinical outcomes assessment of pharmacy-based minor ailments management: A systematic review

Background

The accessibility of services within community pharmacies provides an ideal opportunity to manage minor ailments, yet over £1.1 billion is spent by the National Health Service (NHS) in the United Kingdom (UK) in managing minor ailments in high cost settings. There is a need to review the evidence base around clinical effectiveness of pharmacy-based management of minor ailments since the absence of such may lead to under-utilisation of pharmacy services and non-implementation of available pharmacy service models. This study aimed to systematically review the methodological approaches used to assess clinical outcomes of pharmacy-based management of minor ailments in the research literature.

Methods

A systematic review was conducted to identify relevant literature using the following databases: Medline, EMBASE, CINAHL, IPA, CRD, CDSR, and Google Scholar from publication year 2000 onwards. Studies were included if they evaluated clinical outcomes of pharmacy-based management of any minor ailments, with or without a comparator setting such as Emergency Departments (EDs) or general practices. Screening and selection of titles, abstracts and full texts followed by data extraction and quality assessment (QA) was conducted. Paired researchers, from the team, reviewed papers using a protocol based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). QA was undertaken using the Critical Appraisal Skills Programme (CASP). Reporting was conducted in accordance with PRISMA checklist and statements.

Results

A total of 19 studies were included. The majority of studies were observational, conducted in community pharmacies, and did not use a comparator participant group nor a comparator setting. Interventions included counselling, medicines supply and provision of advice on the management of minor ailments. One study used the randomised controlled trial (RCT) design with majority of the study utilising observational design. A range of clinical outcomes including symptom severity, pattern, resolution, and quality of life were reported. Methods used for the assessment of clinical outcomes were, overall, poorly reported. This included a lack of information on the development and validation of the data collection tools and the timing of baseline and follow-up data collection. Adverse clinical outcomes data were collected by only seven studies.

Conclusions

Currently, there are methodological limitations in the studies that have sought to assess clinical outcomes of pharmacy-based management of minor ailments. Such lack of high quality evidence may contribute to failings to shift care from high cost settings, such as EDs and general practices. Generation of high quality evidence is likely to influence public choices when seeking care for minor ailments. There is scope for development of a core outcomes set specific to minor ailments management and development of a validated methodology for measuring such outcomes in a research study.

Geographical accessibility to community pharmacies by the elderly in metropolitan Lisbon

BACKGROUND

In ageing societies, community pharmacies play an important role in delivering medicines, responsible advising, and other targeted services. Elderly people are among their main consumers, as they use more prescription drugs, need more specific health care, and experience more mobility issues than other age groups. This makes geographical accessibility a relevant concern for them.

OBJECTIVES

To measure geographical pedestrian accessibility to community pharmacies by elderly people in the Lisbon Metropolitan Area (LMA).

METHODS

The number of elderly people living within a 10- and 15-min walk was estimated based on the exploitation of population census data, the address-based location of 801 community pharmacies, and a Google Maps Application Programming Interface (API) method for calculating distances between pharmacies and the centroids of census statistical subsections. Results were compared to figures attained via traditional methods.

RESULTS

In the LMA, 61.2% of the elderly live less than a 10 min walk from the nearest pharmacy and 76.9% live less than 15 min away. This opposes the common view that pharmacies are highly accessible in urban areas. In addition, results show a high spatial variability of proximity to pharmacies.

CONCLUSIONS

Despite the illusion of good coverage suggested at the metropolitan scale, accessibility measures demonstrate the existence of pharmaceutical deprivation areas for the elderly. The findings indicate the need for more accuracy in both access measurements and redistribution policies. Measurement methods and population targets should be reconsidered.

Challenges in the management of community pharmacies in Malaysia

BACKGROUND

The provision of professional pharmacy services by community pharmacists continues to be limited, particularly in low and middle income countries. It was postulated that multiple management challenges faced by community pharmacists contribute to this situation.

OBJECTIVE

The primary aim of the research was to determine the challenges faced in the management of community pharmacies in Sarawak (the largest state in Malaysia), and practical strategies to cope and overcome the challenges.

METHODS

Semi-structured interviews were carried out with community pharmacists practising in Sarawak. Purposive and snowball sampling were employed to ensure a diverse group of informants. The interviews were audio-recorded and transcribed verbatim, with the resultant data analysed using thematic analysis. Data collection, coding, interpretation were carried out iteratively until theoretical saturation.

RESULTS

Twenty respondents from different demographic characteristics were recruited. Six major themes were identified. Management challenges faced by community pharmacists traverse five major domains: market competition, legislative issues, customers' knowledge and expectations, macroeconomic impacts and operational challenges. Most of these challenges require government intervention to be resolved. In the meantime, improving customer service and expanding the range of professional services were seen as the most viable strategies to cope with existing challenges. The main concern is that current legislative and economic landscape may hinder these strategies. Enactment of dispensing separation and more protective measures against market competition were suggested to alleviate the challenges faced.

CONCLUSION

Numerous management challenges faced by community pharmacists that distract them from delivering professional pharmacy services have been highlighted. Urgent affirmative actions by the government are warranted in supporting community pharmacists to realise and maximise their potentials.

Perceptions and attitudes of community pharmacists toward professional ethics and ethical dilemmas in the workplace

BACKGROUND

Formal training in pharmacy ethics is relatively new in Croatia, and the professional code of ethics is more than 20 years old. Very little is known about how practicing pharmacists implement ethical considerations and relevant professional guidelines in their work.

OBJECTIVES

This study aimed to provide the first description of the perceptions and attitudes of Croatian community pharmacists toward ethics in pharmacy practice, how often they face certain ethical dilemmas and how they resolve them.

METHODS

A cross-sectional survey of 252 community pharmacists, including community pharmacists and pre-licensing trainees, was conducted in Zagreb, Croatia. This group accounts for 18% of licensed pharmacists in Croatia. The survey questions included four sections: general sociodemographic information, multiple-choice questions, pre-defined ethical scenarios, and ethical scenarios filled in by respondents.

RESULTS

More than half of pharmacists (62.7%) face ethical dilemmas in everyday work. Nearly all (94.4%) are familiar with the current professional code of ethics in Croatia, but only 47.6% think that the code reflects the changes that the pharmacy profession faces today. Most pharmacists (83.3%) solve ethical dilemmas on their own, while nearly the same proportion (75.4%) think that they are not adequately trained to deal with ethical dilemmas. The pre-defined ethical scenarios experienced by the largest proportion of pharmacists are being asked to dispense a drug to someone other than the patient (93.3%), an unnecessary over-the-counter medicine (84.3%), a generic medicine clinically equivalent to the prescribed one (79.4%), or hormonal contraception over the counter (70.4%).

CONCLUSIONS

The results demonstrate a need to improve formal pharmacy ethics education and training in how to assess ethical issues and make appropriate decisions, which implies the need for stronger collaboration between pharmacists and their professional association. Our results also highlight an urgent need to revise and update the Croatian code of ethics for pharmacists.

Legal and organisational innovation in the Italian pharmacy system: commercial vs public interest

Pharmacy services are undoubtedly an important part of primary care. Pharmacists are entrepreneurs and simultaneously they are entrusted with a public mission in the health care sector. Pharmacies then reflect a contrast between a commercial/economic objective and public interest, which is to be identified with citizens' universal right to health care services. This is the reason why in Italy, as in many other EU countries, pharmacies supply their services according to a prior authorisation granted by public authorities. In common with many EU countries, this authorisation is secured according to a demographic criterion. It is only by means of these licensed pharmacies that citizens can buy drugs under medical prescription. Accordingly, the health system is to be driven by public interest, which has yet to prove how competing interests may be regulated in serving health needs. In the light of EU law, the article advocates for an innovative legal and organisational tool whereby to organise the Italian pharmacy system in order to combine economic consideration and public benefit.

Stakeholders' expectations and perceived effects of the pharmacy ownership liberalization reform in Sweden: a qualitative interview study

BACKGROUND

Reforms in the health-care sector, including the pharmacy sector, can have different rationales. The Swedish pharmacies were prior to 2009 organized in a state-owned monopoly. In 2009, a liberalization of the ownership took place, in which a majority of the pharmacies were sold to private owners. The rationales for this liberalization changed profoundly during the preparatory work, making it probable that other rationales than the ones first expressed existed. The aim of this study was to explore the underlying rationales (not stated in official documents) for the liberalization in the Swedish pharmacy sector, and also to compare the expectations with the perceived outcomes.

METHODS

Semi-structured interviews were conducted with representatives from key stakeholder organizations; i.e., political, patient, and professional organizations. The analysis was performed in steps, and themes were developed in an inductive manner.

RESULTS

One expectation among the political organization participants was that the ownership liberalization would create opportunities for ideas. The competition introduced in the market was supposed to lead to a more diversified pharmacy sector. After the liberalization, the participants in favor of the liberalization were surprised that the pharmacies were so similar. Among the professional organization participants, one important rationale for the liberalization was to get better use of the pharmacists' knowledge. However, all the professional, and some of the patient organization participants, thought that the counseling in the pharmacies had deteriorated after the liberalization. As expected in the interviews, the post-liberalization pharmacy sector consists of more pharmacies. However, an unexpected perceived effect of the liberalization was, among participants from all the stakeholder groups, less access to prescription medicines in the pharmacies.

CONCLUSIONS

This study showed that the political organization participants had an ideological basis for their opinion. The political stakeholders did not have a clear view about what the liberalization should lead to, apart from abolishing the monopoly. The perceived effects are quite similar in the different stakeholder groups, and not as positive as were expected.

Consumer preferences for over-the-counter drug retailers in the reregulated Swedish pharmacy market

Following a large regulatory reform in 2009, which ended the state's pharmacy monopoly, non-pharmacy retailers in Sweden today sell certain over-the-counter (OTC) drugs. The aim of this study was to investigate consumer preferences regarding OTC drug retailers and the reasons for choosing a pharmacy versus non-pharmacy retailer. We conducted a web survey aimed at Swedish adults. Out of a stratified sample of 4058 persons, 2594 agreed to take part (48% women; mean age: 50.3 years). Questions related to OTC drug use, retailer choice and factors affecting the participants' preferences for OTC drug retailers. Logistic regression was conducted to analyse OTC drug use and reasons for retailer choice in relation to sex, age and education. Nine in ten participants reported OTC drug use in the 6 months prior to the study. For their last OTC purchase, 76% had gone to a pharmacy, 20% to a grocery shop and 4% to a convenience store, gas station or online. Geographic proximity, opening hours and product range were reported as the most important factors in retailer choice. Counselling by trained staff was important to 57% of participants. The end of the state's pharmacy monopoly and the increase in number of pharmacies seem to have impacted more on Swedish consumers' purchase behaviours compared with the deregulation of OTC drug sales.

The Raison D'être for the Community Pharmacy and the Community Pharmacist in Sweden: A Qualitative Interview Study

Community pharmacies are balancing between business (selling medicines and other products) and healthcare (using the pharmacists' knowledge in order to improve drug utilization). This balance could be affected by regulations decided upon by politicians, but also influenced by others. The aim of this study was to explore important stakeholders' views on community pharmacy and community pharmacists in Sweden. The method used was that of semi-structured qualitative interviews. Political, professional, and patient organization representatives were interviewed. The results show that informants who are pharmacists or representatives of a professional pharmacist organization generally have a healthcare-centered view on community pharmacy/pharmacists. However, different views on how this orientation should be performed were revealed, ranging from being specialists to dealing with uncomplicated tasks. Political organization representatives generally had a more business-oriented view, where competition in the market was believed to be the main driving force for development. A third dimension in which competition was not stressed also emerged; that community pharmacies should primarily distribute medicines. This dimension was most prevalent among the political and patient organization representatives. One conclusion to be drawn is that no stakeholder seemed to have a clear vision or was willing to take the lead for the development of the community pharmacy sector.

Inequalities in medicine use in Central Eastern Europe: an empirical investigation of socioeconomic determinants in eight countries

BACKGROUND

Equitable access to essential medicines is a major challenge for policy-makers world-wide, including Central and Eastern European countries. Member States of the European Union situated in Central and Eastern Europe have publicly funded pharmaceutical reimbursement systems that should promote accessibility and affordability of, at least essential medicines. However, there is no knowledge whether socioeconomic inequalities exist in these countries. Against this backdrop, this study analyses whether socioeconomic determinants influence the use of prescribed and non-prescribed medicines in eight Central and Eastern European countries (Bulgaria, Czech Republic, Hungary, Latvia, Poland, Romania, Slovenia, Slovakia). Further, the study discusses observed (in)equalities in medicine use in the context of the pharmaceutical policy framework and the implementation in these countries.

METHODS

The study is based on cross-sectional data from the first wave of the European Health Interview Survey (2007-2009). Multivariate logistic regression analyses were carried out to determine the association between socioeconomic status (measured by employment status, education, income; controlled for age, gender, health status) and medicine use (prescribed and non-prescribed medicines). This was supplemented by a pharmaceutical policy analysis based on indicators in four policy dimensions (sustainable funding, affordability, availability and accessibility, and rational selection and use of medicines).

RESULTS

Overall, the analysis showed a gradient favouring individuals from higher socioeconomic groups in the consumption of non-prescribed medicines in the eight surveyed countries, and for prescribed medicines in three countries (Latvia, Poland, Romania). The pharmaceutical systems in the eight countries were, to varying degrees, characterized by a lack of (public) funding, thus resulting in high and growing shares of private financing (including co-payments for prescribed medicines), inefficiencies in the selection of medicines into reimbursement and limitations in medicines availability.

CONCLUSION

Pharmaceutical policies aiming at reducing inequalities in medicine use require not only a consideration of the role of co-payments and other private expenditure but also adequate investment in medicines and transparent and clear processes regarding the inclusion of medicines into reimbursement.

Widening the Access to HIV Testing: The Contribution of Three In-Pharmacy Testing Programmes in Spain

BACKGROUND AND OBJECTIVE

Spain has implemented several in-pharmacy HIV testing programmes performed by pharmacists as part of their everyday routine. We aim to assess the feasibility and the main outcomes of three programmes implemented in three Spanish regions with different sociological profiles and also different epidemiology for HIV.

METHODS

The characteristics of the 24151 people tested between 2009 and 2013 at 74 urban pharmacies are studied. We compare the main outcomes of the programmes with those of each Regional HIV Surveillance System (RHSS) assessing the contribution to the total new diagnosis in each region and if priority groups are being reached.

RESULTS

45.7% were heterosexual men (MSW), 14.4% men who have sex with men (MSM), and 27% women. The 35% were younger than 30 and 9.6% foreigners. The 52% were previously untested, and women were the most likely to be untested. The three programmes altogether diagnosed 226 people, resulting in a global prevalence of 0.9% (95%CI: 0.8-1.1); 3.4% in MSM (95%CI: 2.8-4.0). The prevalence among Spaniards was 0.8% (0.7-1.0) vs. 2.2 (1.6-2.9) among foreigners. The percentages of MSM diagnosed by all three programmes were higher than the one reported by their respective RHSS. Thirty four percent of the reactive MSM and the 71.4% of the reactive MSW did not have a previous HIV test although big testing history differences were observed across the programmes. Altogether, these services contributed with the 10.6% of all HIV diagnoses in these regions.

CONCLUSIONS

In-pharmacy HIV testing programmes are a valuable testing option, having been able to uncover 1 out of 10 the new diagnoses reported in each region. They showed a good capacity of reaching and diagnosing previously untested populations, not only a priority population such as MSM but also heterosexual population who are more affected by delayed diagnosis. They seem to be particularly suitable for regions without large cities and specific HIV diagnostic services.

Competition among pharmacies and the typology of services delivered: The Portuguese case

OBJECTIVE

To analyze the impact of individual and market characteristics (such as competition) on the typology of services delivered by a community pharmacy after a recent Portuguese pro-competitive regulatory change.

METHODS

In this paper, market concentration indices are used to identify market competition groups in the sample. These competition groups are then described with regard to the typology of services on offer by pharmacies within the group. Finally, a system of structural equations is estimated to verify if the decision of a pharmacy to offer or not to offer each of the studied pharmaceutical services is affected by local market regulated competition.

RESULTS

In some cases, pharmacies belonging to different competition groups do not present significant differences in terms of the typology of services on offer, but according to our regressions, it seems that vaccines and medicines administration services, pharmaceutical care programmes and medicines management programmes are more likely to be offered in pharmacies located in higher competitive markets. These are also urban areas, in which there is already easy access to products sold in pharmacies, and to health services in general.

CONCLUSIONS

Access to additional pharmacy services may in some cases increase as market competition increases. Thus, pro-competitive regulatory measures may have led to an asymmetric distribution of pharmacy services across the country, favouring more competitive urban marketplaces. If policy-makers are interested in a more symmetrical distribution of pharmacies services all over the country, they are recommended to take action to ensure equitable access to these services.