Challenges in Implementing Pharmaceutical Care in

Private Hospitals in Davao City

Jezeel Larnelle A. Ballenas, Wimmylaine Franz C. Galias, Jessame C. Molina,

Charmaine D. Piamonte, Veronica Ruth S. Santos

University of Immaculate Conception Fr. Selga Street, Davao City, Philippines

jessamem@gmail.com
________________________________________________________________________

Abstract
This study determined the private hospital pharmacists‟ challenges to
implementation of the pharmaceutical care practice in Davao City. It employed a
descriptive research design using the self-administered survey as data collection
method. The weighted mean scores from the results of the Likert scale were used
to determine the challenges to the implementation of pharmaceutical care. A
total of 36 pharmacists from the private hospitals in Davao City participated in
the study. The identified challenges to the implementation of pharmaceutical
care among hospital pharmacists were the patient‟s lack of fund, low literacy
level of the patient, lack of the documentation skills, hospitals are under staff,
and there are not enough drug information given. The result of the study shows
that the steps need to improve in their pharmaceutical care are determining the
presence of medication- therapy problems, initiating the pharmaceutical
regimen, and collecting and organizing pertinent patient-specific information.

Keywords: Challenges, Implementation, Pharmaceutical Care, Pharmacist,

Hospital

Introduction
Pharmaceutical care is a necessary element of healthcare; it is delivered at the
individual patient level. This concept was first defined as: “The care that a given
patient requires and receives which assures safe and rational drug usage.” Since
1975 there have been many changes to this definition, but the one that lays a
foundation for this is that attributed to Hepler and Strand (1990).
“Pharmaceutical care is the responsible provision of drug therapy for the
purpose of achieving definite outcomes that improve a patient‟s quality of life”.
The outcomes are clinical, humanistic, and economic. To achieve this end,

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pharmacist needs to cooperate with patients and with other health care
professionals in designing, implementing, and monitoring a care plan aimed at
preventing and resolving drug related problems. This in turn involves three
major functions namely: identifying potential and actual drug related problems;
resolving actual drug related problems; and preventing potential drug related
problems.
The practice of pharmaceutical care is new, in contrast to what pharmacists
have been doing for years. The key words are “responsible provision” and
“definite outcomes”. Whether pharmacists are reviewing a prescription or a
patient medication record, talking to a patient or responding to symptoms, they
are automatically assessing needs, prioritizing and creating a plan to meet those
needs. What they often fail to do is to accept responsibility for this care.
Consequently, they may not adequately document, monitor and review the care
given. Accepting such responsibility is essential to the practice of pharmaceutical
care. The responsibilities associated with drug therapy have become so
numerous and complex that the need for a practitioner with this focus has
become urgent. The need for this practitioner results from the following reasons:
multiple practitioners writing prescriptions for a single patient, often without co-
ordination and communication; a large number of medications and an
overwhelming amount of drug information presently available to patients.
patients playing a more active role in the selection and use of medications; an
increase in the complexity of drug therapy; an increase in self-care through
alternative and complementary medicine; a high level of drug-related morbidity
and mortality which results in significant human and financial costs.
In the recent decade, the pharmacy practice has moved from product
orientation to a patient focus. Hepler and Strand stated that it is not enough to
dispense the correct drug or to provide knowledgeable pharmaceutical services,
or will it be sufficient to plan new technical functions. Instead, a pharmacist must
stop looking inward and start redirecting their energies to the greater social good
by reducing drug-related morbidity and mortality. Van Mil, Schulz, and Tromp
reviewed the European developments in concepts, implementation, teaching,
and research related to pharmaceutical care, which led to the following
proposition: “Pharmacists should move from behind the counter and start
serving the public by providing care instead of pills only.
Delivery of pharmaceutical care has been accepted worldwide as the
primary mission of pharmacists. Pharmaceutical care is quite clear about its
responsibilities to patients and its orientation toward outcomes but the
implementation of this practice is difficult especially for a developing nation.
Pharmacists need to find out what are their difficulties and prioritize the
problems that need to be solved first. A local study was conducted and its
objective is to determine the current practices of hospital pharmacists in Metro
Manila and their perceived levels of understanding, competence, importance and

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practicability of the pharmaceutical care practice in the Philippines. A total of 197
pharmacists from 17 hospitals in Metro Manila participated in the study. Lack of
support by physicians and other health professionals and lack of information
technology support for data collection and documentation were identified as the
perceived major barriers to the implementation of pharmaceutical care. The
results could implicate that the slow progress of pharmaceutical care in the
Philippines may be attributed to the low understanding and perceived barrier
identified. (Agacenta, CC.et al,.2013).
The objective of the study was therefore to identify the present
knowledge, challenges in implementing and steps of implementing
pharmaceutical care in private hospitals in Davao City.

Materials and Methods

The study areas were level III and Level IV hospitals in Davao City. The
Pharmacists population comprised of Staff Pharmacist, Senior Pharmacist, Chief
Pharmacist, and Clinical Pharmacist who were given the study questionnaire as
they were seen.
Instrument for data collection The survey instrument, a self-administered
questionnaire, was constructed and validated, consisting of three sections:
demographic information section such as age of respondent, gender, marital
status, current qualification, practice area and years of experience; pharmacist‟s
knowledge of pharmaceutical care practice section; pharmacist‟s activities they
undertake; knowledge of militating factors against their practice of
pharmaceutical care section that was classified into patient factors, pharmacist
factors, and environmental factors; and implementing methods of
pharmaceutical care.
A total of forty questionnaires were distributed but only thirty-six were
answered. Some were delivered to Pharmacists in their practice premises or to
the Attendants when the Pharmacist-in-Charge was not available. The
participants were educated on the reasons for and content of the questionnaire as
their consents was obtained and the questionnaire distributed.
The retrieved questionnaires were sorted and entered into IBM SPSS Statistics 21
for analysis. Descriptive statistics was used and the 5-point Likert scale section of
the questionnaire was analyzed using mean and standard error of the mean.

Results and Discussion

Out of the 10 hospitals requested to participate, only 7 hospitals confirmed
to participate in the study. All of the 7 hospitals were privately owned. A total of
40 questionnaires were distributed to the different hospitals, 36 were returned

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giving a response rate of 90%. The final sample size consisted of 36 pharmacists.
There were 25 (69.4%) female and 11 (30.6%) male respondents. The majority of
the respondents were within the age range of 21-29 years (77.8%). This is
particularly important because they are the determinants of the labor force to
take charge of pharmaceutical care implementation. The older age group, 30–39
years old and 40-49 years old with a percentage range of 8.3% and 13.9%, are
usually predominantly for managerial responsibilities. Sixty-nine percent were
Pharmacist, 8.3% were Senior Pharmacist, 5.6% were Chief Pharmacist and 16.7%
were Clinical Pharmacist. Most of the respondents in all the areas of practice are
well experienced having been in practice for more than 5 years (Table 1).

Table 1: Demographic Profile of Respondents (n=36)

Variables No. of respondents % Percentage
Gender :
Male 11 30.6
Female 25 69.4
Age:
<30 years old 28 77.8
30- 39 years old 3 8.3
40- 49 years old 5 13.9
50- 59 years old 0 0
60 years old and above 0 0
Marital Status:
Single 35 97.2
Married 1 2.8
Position:
Pharmacist 25 69.4
Senior pharmacist 3 8.3
Chief Pharmacist 2 5.6
Clinical Pharmacist 6 16.7
Years of experience:
1-10 years 31 86.1
11- 20 years 3 8.3
21- 30 years 2 5.6
More than 30 years 0 0
Out of 40 questionnaires administered, 36 were completed and returned
giving a response rate of 90%. 25 (69.4%) of the respondents were female and
11(30.6%) were males. Most of the respondents were below 30 years old with a
percentage of 77.8%. 69.4% were Pharmacist, 8.3% were Senior Pharmacist, 5.6%
were Chief Pharmacist and 16.7% were Clinical Pharmacist. The majority of the
respondents had less than 11 years working experience (Table 1).

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Table 2: Knowledge of Pharmaceutical Care
Variable No. (N=36) % Percentage
Awareness about PC?
Yes 35 97.2
No response 1 2.8
Where did respondent learn about
PC?
Journal 1 2.8
School 35 97.2
Internet - -
Others - -
Which is the focus of PC?
Rx or OTC request 2 5
Physician or Health professional 3 8
Patients 32 88
Other - -
Which is/are the objective of PC?
Prevent medication errors 8 22.2
Improve patient outcomes/ lifestyle 22 61.2
Perform a care plan/ schedule of 6 16.6
medication
Others - -
Would PC improve adherence and
compliance of DT?
Yes 36 100
No - -
Are healthcare professionals
supportive of PC?
Yes 27 75
No 9 25
Awareness of PC among Pharmacist?
Yes 17 47.3
No 19 52.7
Is PC practice in the hospital?
Yes 26 72.3
No 10 27.7
The pharmacist‟s knowledge of pharmaceutical care practice is shown in
Table 2. This data also consist of information regarding the practice of
pharmaceutical care in private hospitals in Davao City.
From the table 2, all the respondents had heard about pharmaceutical
care, the majority (97.2%) of the respondents agreed that there is enough
awareness of pharmaceutical care among Pharmacists. 88% of the respondents
agreed that patient are the focus of Pharmaceutical Care and 61.2% agreed that

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Pharmaceutical Care can improve the patient's outcome or lifestyle. All of them
agreed the Pharmaceutical Care improve the adherence and compliance of drug
therapy. The majority (75%) of the respondents said that other healthcare
professional are supportive of Pharmaceutical Care. The majority (52.7%) of the
respondents answered that there is no awareness of Pharmaceutical Care among
pharmacist. The majority (72.3%) of the respondents said that Pharmaceutical
Care is practice in the hospital.

Table 3: Activities You Undertake

Variable No. (N= 36) % Percentage
Evaluate prescription before dispensing 33 91.6
Conduct patient interview 32 88.8
Counseling patients 27 75.0
Monitor patient drug therapy 12 33.3
Medication review with health providers and 11 30.5
patients consent
Monitoring patient compliance 10 27.7
From the table 3, 91.6% of the respondent said that they evaluate
prescription before dispensing, 88.8% conduct patient interview, and 75% in
counseling the patients. The least activities they do are monitor patient
compliance, medication review with health care providers and monitoring
patient compliance with a percentage of 33.3%, 30.5%, and 27.7% respectively.

Table 4: Challenges in Implementing Pharmaceutical Care

Variable Mean ± SD
PATIENT’S FACTORS
Patient‟s lack of fund 3.7780 ± 1.01723
Low literacy level of the patient 3.5000 ± 0.81064
Non- adherence to drug therapy 3.4444 ± 0.87650
Patient past medical experience (drug allergy) 3.0833 ± 1.02470
Patient does not want to be interviewed 3.0278 ± 0.94070
Patient does not want their prescription evaluated 2.5833 ± 0.90633

PHARMACIST FACTOR
Lack of documentation skills 3.1111 ± 1.08963
It is easier to focus on treating the disease symptoms 3.0556 ± 0.92410
Lack of communication skills 3.0556 ± 1.06756
Monitor patient improvement is the role of the physician 2.9444 ± 0.89265
Pharmacist‟s current knowledge of therapeutics may not be 2.8890 ± 0.82038
adequate in counseling patient

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Pharmaceutical care requires too much effort 2.8600 ± 1.22222
Unconcern attitude of the pharmacist 2.8056 ± 1.28329
Conducting patient interview is the role of physician 2.7500 ± 1.07902
Pharmaceutical care is time-consuming 2.6111 ± 1.12828
I am not sure what to look out for in drug related problems 2.5556 ± 0.77254

ENVIRONMENTAL FACTORS
There are not enough pharmacist personnel 3.7778 ± 1.33333
Non-availability of drug information center 3.6389 ± 0.83333
Non-availability of affordable drugs 3.3333 ± 1.09545
No adequate awareness of pharmaceutical care 3.2778 ± 0.94449
Nonavailability of patient current laboratory findings 3.2500 ± 1.07902
Health care professionals are not cooperative 3.2222 ± 1.14919
Hospital management does not fully accept the concept of 3.0556 ± 1.19390
pharmaceutical care
Scale: 1= stongly disagree, 2= disagree, 3= moderately agree, 4= agree, 5- strongly agree
The challenges in implementing pharmaceutical care is shown in table 4
with their respective mean ± sd. The descriptive statistics of the respondents‟
opinions have been grouped into three factors namely: patient, pharmacist/
respondents, and environmental factor.
On patient factors, the respondents disagreed with the opinion that the
patients are opposed to either the patients don‟t want their prescription being
evaluated or not being interviewed. The respondents agreed that the highest
patients‟ factor is that patient‟s lack of fund. On Pharmacist factors, the
respondents agreed that there is a lack of documentation skills among the
pharmacist and disagreed that they are not sure of what to look out for in drug-
related problems.
On environmental factor, most respondents agreed that more personnel
are needed to effectively practice Pharmaceutical care and most of the
respondent disagree that the hospital does not accept the concept of
Pharmaceutical care.
As espoused by Strand in 1998 that Pharmaceutical care is a practitioner
driven service, this portrays that pharmacist‟s encountered challenges are very
important in the implementation of the service. According to the responses of
the pharmacists in patient factors segment, the pharmacists seem not to perceive
any challenges to the implementation of their service as the patients‟
prescriptions are readily evaluated (M= 2.58) and patients grant them interview
without objection (M= 3). This could be due to patient satisfaction with the
practitioners‟ services especially as it is a process that calls for pharmacist-patient

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co-operation, in part. One of the major challenges when it comes to patient factor
in implementing pharmaceutical care is that patient‟s lack fund or money.
From the Pharmacist factors segment of this study, the respondents were
majorly of the opinion that pharmaceutical care services require documentation
(M= 3.11) and communication skills (M= 3.06). They disagreed with the opinion
that „the pharmacist is not sure what to look out for in drug-related problems‟
and that „pharmaceutical care is time consuming‟. Documentation is an
important element of pharmaceutical care which is needed for continuity of care,
research, re-imbursement, evidence of action taken among others (Erah, PO. et
al., 2005). In this study, most of the respondents reported to have identified drug
related problems but neither the errors nor their interventions were documented.
Efforts made by pharmacists to improve the care given through appropriate
documentation could be of national importance in policy on cost effective PC as
the available market for drug therapy is enormous and worth investing more
time (Oparah, CA. et al.,2005).
On the environmental factors such as lack of pharmacist personnel and
non-availability of drug information center, the pharmacists agreed to their
inadequacies. Lack of enabling environment, knowledge deficit, inadequate
pharmacy personnel, and excess work load among others could be responsible
and need to urgently be addressed (Suleiman, I. et al., 2011). Most of the
respondent disagree that the hospital does not accept the concept of
Pharmaceutical care.

Table 5: Steps that Contribute Pharmaceutical Care

Mean ± SD
Determining the Presence of Medication- Therapy 2.9444 ± 1.32976
Problems
Initiating the Pharmacotherapeutic Regimen. 2.6944 ± 1.36945
Collecting and Organizing Pertinent Patient- Specific 2.6667 ± 1.28730
Information
Designing a Pharmacotherapeutic Regimen 2.5833 ± 1.33898
Summarizing Patient‟s Health Care Needs 2.5556 ± 1.20581
Specifying Pharmacotherapeutic Goals 2.5556 ± 1.46277
Developing a Pharmacotherapeutic Regimen and 2.5556 ± 1.31897
Corresponding Monitoring Plan
Designing a Monitoring Plan for the Pharmacotherapeutic 2.4722 ± 1.36248
Regimen
Monitoring the Effects of the Pharmacotherapeutic 2.4444 ± 1.42316
Regimen
Redesigning the Pharmacotherapeutic Regimen and 2.3889 ± 1.53582
Monitoring Plan
The respondents of this study implement pharmaceutical care by
redesigning the pharmacotherapeutic regimen and monitoring of the plan. Most

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of the respondents never or seldom initiate in coming up with a
pharmacotherapeutic regimen and determining the presence of medication-
therapy problems.

According to ASHP Guidelines the steps that the pharmacist should do to

implement pharmaceutical care are collecting and organizing pertinent patient-
specific information, determining the presence of medication-therapy problems,
summarizing patients‟ health care needs, specifying pharmacotherapeutic goals,
designing a pharmacotherapeutic regimen, designing a monitoring plan for the
pharmacotherapeutic regimen, developing a pharmaceotherapeutic regimen and
corresponding monitoring plan, initiating the pharmacotherapeutic regimen,
monitoring the effects of the pharmacotherapeutic regimen, and redesigning the
pharmacotherapeutic regimen and monitoring plan.

An essential element of pharmaceutical care is that the pharmacist accepts

responsibility for the patient‟s pharmacotherapeutic outcomes. The same
commitment that is applied to designing the pharmacotherapeutic regimen and
monitoring plan for the patient should be applied to its implementation.

Conclusion
The study concluded that pharmacist in the studied hospital has good
knowledge of the pharmaceutical care. The challenges in implementing the
pharmaceutical care are the patient‟s lack of fund, don‟t want their precriptions
being evaluated or not being interviewed, pharmacist‟s lack of documentation
skills and don‟t know what to look out for in drug-ralated problems.
Environmental factor, most respondents agreed that more personnel are needed
to effectively practice Pharmaceutical care and most of the respondent disagree
that the hospital does not accept the concept of Pharmaceutical care. Determining
the presence of medication- therapy problems, initiating the pharmaceutical
regimen, and collecting and organizing pertinent patient-specific information are
the steps that needs to improve in their pharmaceutical are practice. Knowledge
without the corresponding action is limiting. Let these actions drive the full
implementation of pharmaceutical care in the hospitals.

Recommendations
The researchers recommend that the private hospitals in Davao City should
match their Pharmaceutical Care knowledge with actions in their various
hospital practices through seminars, conference, continuing professional
education and trainings. Other health care professionals should be oriented on
the importance of pharmaceutical care and the institution should employ more
pharmacists to enhance staff strength.

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 Acknowledgements
We wish to express our profound gratitude to the participants, and the
management of the participating hospitals for their immense support during
the data collection processes. We would like to thank our panelists Ms.
Maureen Canda, Ms. Anna Lou Grace Manluyang, Ms. Ferlien Brieta, and our
adviser Mr. Ferdinand Ribo for their technical and moral support in the course
of this work.

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