Jumpstarting Good Pharmacy Practices in Viet Nam

Here in the US, in ever-changing signs of the time, local independent pharmacies are finding it hard to compete with the Walgreens and CVS’s that mark most corners, just as mom-and-pop stores are being stamped out by Wal-Mart superstores. The fact is that big chain drug stores are standardized, have more resources, and can operate more efficiently. Pharmacies, as professionally-operated chain stores, are fairly common in developed countries but this “new” concept may be part of Viet Nam’s future.

In late 2007, as one of the targets for Viet Nam Drug Retail System by 2010, the Ministry of Health (MOH) set out a policy to encourage pharmaceutical companies to set up drugstore chains adopting Good Pharmacy Practice (GPP). The GPP-standardized pharmacy system is patterned after the pharmaceutical retail model of developed countries like the US. The aim is to bring practical benefits to patients as consumers, ensuring the drugs supplied 1) are clear origin; 2) are stored under proper conditions; 3) are dispensed only with a prescription; 4) are reasonably priced and 5) dispensed by a certified pharmacist present to offer advice for effective and safe use. The stipulation was that non-GPP pharmacies – those that did not meet sales and consulting standards – would be forced to close.

The reality is that many pharmacies in Viet Nam are having difficulty meeting the new government regulations. Obstacles still exists – particularly for rural areas limited in resources and health care workforce capacities – as pharmacies race to register their facilities under GPP standards.

In order to appreciate the implication of these changes, one must first understand how the current health system and existing pharmacy practice came about.

Public Health 101

The current health system in Viet Nam is a mixed public-private provider. The system is hierarchically structured and bureaucratically organized. Little can be done at the lowest level unless there is consent from higher levels in the health-care system.

Prior to the implementation of a free market policy reform “Doi Moi” in 1989, Viet Nam had a centrally planned economy and health-care system. Health care personnel were hit hard economically during the 1980s. Private practice was banned, and because salaries were quite low, many turned to employment outside of the health care system for additional income.
After the radical change of Doi Moi, along with economic reform, the free-market policy made private practice for pharmacists and doctors possible and importation of medicines easier. Currently, any physician or pharmacist with more than 5 years of service with the government can apply for and receive more-or-less automatic approval to set up an “after hours” private clinic or private pharmacy. macy. It created a society of practitioners with dual and sometimes competing personal interests and public obligations.

Who are the licensed drug sellers?

According to international standards set by World Health Organization (WHO), the pharmacist is expected to be a communicator, a quality drug supplier, a trainer and supervisor, a collaborator, and a health promoter – all in one person. Pharmacists are members of a health care team and their primary role are as legal custodians of medicines and consumer health educators.

Unfortunately, the role of the pharmacist in Viet Nam is not well-defined and responsibilities unclear. There are no demands from the central level or expectations from the consumers for pharmacies to provide quality drugs and pharmacists as drug experts. The population (in general) and the medical doctors (in particular) do not seem to be fully aware of the pharmacists’ capabilities as health educators.

Then again, in order to live up to those expectations and to fulfill their roles as part of the health care team, pharmacy personnel need access to updated information. The long economic and political isolation had its effects on medical training and knowledge about medicines. There is a gap between Viet Nam’s increasing demand for qualified pharmacists and its limited capacity and infrastructure to train and prepare sufficient numbers to meet the need. Currently, there are seven pharmacy schools in Viet Nam which offer a 5-year Bachelor in Pharmacy program. In contrast to the Doctorate of Pharmacy programs in the United States, the scope of the pharmacy training in Viet Nam is comparatively limited. The focus of the current curriculum emphasizes heavily on drug development rather than clinical pharmacy training pharmacists to work in pharmaceutical industries – either as supervisors in drug development or as field representatives. More notably, in the hospital and community level, the main responsibility of the pharmacist is still on distribution and dispensing of medications.

In the US, pharmacy leaders advocate a system that provides for checks and balances, whereby clinical pharmacists are part of the health care team in order to ensure high quality of care. “Clinical pharmacy” is still a new concept in Viet Nam. It was only added to the pharmacy curriculum two years ago and is now a sub-department of the Department of Pharmacology & Clinical Pharmacy.

At the community pharmacy level, there are other problems to contend with – dispensing physicians and pharmacists who are often viewed and see themselves as business people rather than health experts. Despite the apparent conflict of interest, physicians often dispense medications at their private clinics. Likewise, while state regulations require pharmacies to have a “qualified pharmacist” in order to be granted a license, businessmen bypass this requirement by paying for the services of a qualified pharmacist on a part-time basis. Private pharmacies are largely staffed with minimally trained or untrained persons while pharmacists are officially employed but are physically absent. Most of these “signature pharmacists” have full-time jobs in a chemical factory, pharmaceutical company, or even public service positions. A few are retired pharmacists from a public hospital or a municipal clinic. They are hired to sign the bills for scheduled medicines made out to customers by shop attendants. This job takes a signature pharmacist less than an hour every few days, providing a monthly income in addition to his/her other paid employment.

What is the quality of the pharmacies?

Viet Nam is at an early stage of the development of national standards for good pharmacy practice (GPP) with continual efforts made to establish a basis for national pharmacy quality standards. However, there is a marked difference between the law and quality of pharmacy services in real world situations.

As a general rule, pharmacies are located in or close to the market places and vary considerable differences between the districts in terms of socio-economic structure and access to pharmacy services. Patients in Viet Nam commonly present directly to the hospital’s outpatient pharmacy or private pharmacies located nearby. In a hospital setting, prescription practices depend upon the internal organization and management of hospitals. On the other hand, there are few regulations when it comes to privately owned pharmacies. Competition among private pharmacies is intense, especially in areas where shops are clustered together near large public and private hospitals. For example, there can be six different competitors within a small radius, not to mention those operated from private residences.

What is the quality of the dispensing?

Viewed strictly as a business, a pharmacy may not need a pharmacist but from a public health perspective, there are several inherent dangers in having untrained personnel behind the pharmacy counters. In most cases, customers rarely interact with a qualified pharmacist, as he/she is either absent or busy managing the cash-counter. Sadly, on the rare occasions where a qualified pharmacist is present, they seldom advised customers about side-effects, contraindications, dosages and when medicines should or should not be taken.   Customers usually deal with auxiliary pharmacists with either one or three years of pharmacy training.  While some have years of experience, others are simply untrained shop attendants.  They (more often than not) are unable to recognize inappropriate combinations of medicines and unable to advise customers about how medicines should be taken, what their side effects are, and when they are contraindicated.

How has the regulatory system been applied?

Customers in Viet Nam, like those in many developing countries, prefer to buy their drugs directly from the local pharmacies.  Self-medication has become the norm because drugs are more readily available than in the public sector.  Private pharmacies can get drugs from many different sources including the state, private donations and companies.  Some of the essential medicines are locally produced and traditional medicine is widely used. While illegal imports of pharmaceuticals are not that uncommon in Viet Nam most medications come legally from other Asian countries.  In particular, Thailand, China, Singapore and Hong Kong are important sources.  Among the numerous problems with drug supply system in Viet Nam is its weakness in drug regulations and inspections.  It is expanding almost without control.  There are few to non-existent prescription regulations and pricing policies of the pharmaceutical market.  Price to consumers are decided by owners of private pharmacies rather than regulated by laws.

Based on the current state of affairs, Viet Nam still face many obstacles in moving towards a good pharmacy practice system. Ultimately, in order to ensure good health and improve the quality of pharmaceutical services, Viet Nam needs to realize the urgency of enforcing the GPP pharmacy model.   At this time, the number of GPP pharmacies in the country is still very small.  According to Vietnews, since it began offering GPP certification in 2008, Ho Chi Minh City has granted them to about 1500 pharmacies, 41% of the total.  All 94 hospital pharmacies, and the remainder comprised of private pharmacies and GPP-standard chains run by pharmaceutical firms, including My Chau, V-Phano, Saphaco, and Eco (pharmaceutical companies based in Ha Noi, HCM City, Can Tho, and Da Nang).

Given the existing barriers to improving pharmaceutical care in Viet Nam, please share your thoughts and/or recommendations on how to GPP can best be implemented.

1) What does all this mean to the average Vietnamese patient/consumer?

2)  How do you think the Vietnamese consumers will react to strict regulations applied by GPP pharmacies (i.e. requiring prescriptions)?

3) How do you think GPP regulations will impact pharmacy practice in the countryside (i.e. qualified pharmacists, documentation, etc.)?

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References:

1. World Health Organization (WHO) (1994) The role of the pharmacist in self-care and self-medication. Essential drugs and medicines (EDM). Policy document Ref. no. 94.569. Available online at http://www.who.int/medicines.

2. Chuc NT, Tomson G.  “Doi moi” and private pharmacies: a case study on dispensing and financial issues in Hanoi, Vietnam. Eur J Clin Pharmacol. 1999 Jun; 55 (4): 325-32.

3. Kasturi Sen, Meri Koivusalo.  Health care reforms and developing countries – a critical overview. The International Journal of Health Planning and Management. Volume 13, Issue 3, 1998. Pages 199-215.

4. Kitti Pitaknetinan, Viroj Tangcharoensathien, Anuwat Supachutikul, Sara Bennett and Anne Mills, Profit, payment and pharmaceutical practices: perspectives from hospitals in Bangkok, Health Policy, Volume 46, Issue 3, , March 1999, Pages 179-194.

5. Olsson E, Tuyet LT, Nguyen HA, Stalsby Lundborg C.  Health professionals’ and consumers’ views on the role of the pharmacy personnel and the pharmacy service in Hanoi, Vietnam–a qualitative study. J Clin Pharm Ther. 2002 Aug;27(4):273-80.

6. Wolffers, Ivan.  The role of pharmaceuticals in the privatization process in Vietnam’s health-care system. Soc Sci Med. 1995 Nov; 41(9):1325-32.

7. Vietnam Financial Review:  http://www.vfr.vn/index.php?option=com_content&task=view&id=1126&Itemid=21

8. Vietnam Business News: http://vietnambusiness.asia/building-gpp-pharmacies-obstacles-still-exist/