The Role of the Pharmacist in Public Health

Policy Date: 11/8/2006

Policy Number: 200614
I. Statement of the Problem
The pharmacist's role is expanding beyond the traditional product-oriented funct
ions of dispensing and distributing medicines and health supplies. The pharmacis
t's services of today include more patient-oriented, administrative and public h
ealth functions. There are many functions of public health that can benefit from
pharmacists' unique expertise that may include pharmacotherapy, access to care,
and prevention services.1-5 Apart from dispensing medicine, pharmacists have pr
oven to be an accessible resource for health and medication information. The pha
rmacist's centralized placement in the community and clinical expertise are inva
luable. The reexamination and integration of public health practice into pharmac
ological training and pharmaceutical care is essential. The encouragement of cro
ss-training will also maximize resources and aid in addressing the work force ne
eds within the fields of pharmacy and public health.
II. Purpose
The American Public Health Association has historically supported the pharmacist
's role in public health.59 This policy aims to provide leadership and guidance
in identifying and promoting the pharmacist's current and future role in public
health and to describe the framework for maximizing this function. Through trans
disciplinary approaches, it is envisioned that the pharmacis's contribution to t
he public health work force, health education, disease prevention and health pro
motion, public health advocacy, and health quality will aid in achieving optimal
public health outcomes.
A. Role Recognition
Pharmacists are not formally classified as a profession within the public health
work force, unlike public health nutritionists, nurses and physicians. The publ
ic health role of the pharmacist is yet to be clearly defined, broadly recognize
d and sufficiently promoted by public health agencies, pharmacy educators or oth
er health care professionals.6 Pharmacists offer an accessibility that is rare a
mong health care professionals. The pharmacist has health knowledge on which to
build and is often uniquely sited in the community to provide public health serv
ices, in some cases 24 hours per day. No appointment is needed at most community
pharmacies. Pharmacists work in a variety of public settings, including hospita
ls, drug, grocery and retail stores, and nursing homes. This convenience creates
a large window of opportunity in which to provide public health services, there
fore filling a void related to access to care and prevention.
Further, pharmacists in the community are in an ideal position to act as informa
tion resources on lifestyle changes that can influence healthy outcomes.7,8 Phar
macists are involved in health screenings (e.g.,. diabetes, cholesterol, osteopo
rosis),9-11 immunizations,12 pain control,13 participatory and clinical research
, and counseling/ health education.14 They also provide information on self-mana
gement (e.g. hypertension, asthma, HIV), smoking cessation,15,16 alcohol, tobacc
o and other drug use prevention, family planning,17 medication indications and c
onditions (dyslipidemia).7,15
B. Public Health Education of Pharmacists
Due to the prominence of drugs in modern medicine, most health professionals are
trained to be familiar with pharmacological concepts. Public health nurses, phy
sicians, physician assistants, nurse practitioners, dentists, nutritionists and
other health workers need varying degrees of knowledge related to drug therapy.
Pharmacists of today are actively teaching physician assistants, nurses, and phy
sicians various techniques of prescribing medications and issues related to the
drug use process.14,18 Information about drugs is taught through mechanisms such
as in-service training, newsletters, seminars, courses in nursing and medical s
chools, and continuing education. These illustrate ways pharmacists can add to t
he refinement of knowledge within the public health system.19,20 Schools of publ
ic health have the opportunity to expose their students to the contribution phar
macists make to public health and the training of public health workers.
There is a growing need for dually trained professionals in pharmacy and public
health. A small number of colleges of pharmacy offer dual degree programs with P
harmD/MPH options,21,22 but overall, pharmacy students are only exposed to publi
c health concepts on a fleeting basis. Few courses are devoted solely to public
health in pharmacy, and virtually no textbooks exist to emphasize the role of ph
armacy in public health. Consequently, there exists a need for pharmacy schools
to incorporate public health and pharmacoepidemiology courses into their curricu
lum and train pharmacists as public health professionals.23,24 In 2004, the Amer
ican Association of Colleges of Pharmacy (AACP) recognized the important role ph
armacists can play in public health by including population-based care in its Ce
nter for Excellence in Pharmacy Education (CAPE) Educational Outcomes.25 The out
comes emphasized the pharmacist's role in "health improvement, wellness, and dis
ease prevention." It also highlighted the need for pharmacist involvement in ens
uring access to quality care and advancing public health policy.
C. Levels of Pharmacist Public Health Activity
Medicine continues to evolve from a disease-oriented practice to one that is mor
e patient-centered and focused on prevention. The profession of pharmacy has und
ergone a similar metamorphosis: from a concentration on medication dispensing to
a focus on safe and effective medication use to achieve optimal patient outcome
s. As patients move through the continuum of care, pharmacists have ample opport
unity to provide population-based care. In fact, studies have shown that pharmac
ists with more comprehensive responsibilities have lowered total costs and impro
ved quality of care outcomes achieved by health care systems, particularly relat
ed to chronic conditions.26-32
To fully utilize the pharmacist's expertise, these broad functions may be carrie
d out by individuals, systems, and facilities in diverse sectors, encompassing b
oth macro and micro level activities. At the micro level, public health activiti
es may be one of many tasks among a pharmacist's set of responsibilities. For ex
ample, a community pharmacist who speaks to community groups about drug abuse an
d provides hypertension screening in his or her pharmacy is providing public hea
lth services at the micro level, while a pharmacist who is the drug program admi
nistrator of a state Medicaid program is providing services at the macro level.
Performing public health activities on the micro level still preserves their ide
ntity as a pharmacist. Conversely, when a pharmacist works on the macro level in
the capacity of health planning, evaluation and administration, his/her identit
y as a pharmacist is oftentimes threatened. Many pharmacists have asserted thems
elves and established a pronounced functional capacity in public health. However
, overall, pharmacists are an underutilized source of factual and anecdotal heal
th data that could assist health planners as they seek to meet community needs.1
8 It is essential to transform the participation in public health activities as
more than additional tasks, but as a vehicle through which all activities are fi
ltered.
The ability to motivate public health action is particularly challenging within
the confines of the traditional fee-for-product system. In many instances, pharm
acists are not compensated for health promotion or disease prevention and manage
ment activities. Therefore, they are more inclined to curb these activities, and
maximize the duties of dispensing medications for which they can get paid. Phar
macists who perform duties on the micro level many times are not compensated for
this work, while financial incentives may exist for duties performed on the mac
ro level. For instance, the incorporation of preventive methods may have positiv
e fiscal implications on an institutional level. Consequently, the pharmacist in
senior management may strongly advocate and embrace public health strategies.
The macro level of public health has been frequently overlooked in the field of
pharmacy when exposing students and early professionals to public health. This i
s particularly due to the low proportion of pharmacists who hold such positions.
This dearth of pharmacists involved in public health activities on a macro leve
l also means there are relatively few pharmacists available to act as role model
s that make institutional changes.
Pharmacists that have specific health system management responsibilities oftenti
mes have core responsibilities that can be linked with public health efforts. Fo
r example, a pharmacist helping to design an institution's medication safety pro
cedures is supporting Healthy People 2010 by reducing the number of hospital adm
issions due to drug therapy management problems.33-35 Drug safety is extremely i
mportant in protecting lives and decreasing health care costs. Macro level pharm
acists with further training (to include health administration and health econom
ics) may be better prepared to address the public's needs and plan system-level
changes that provide incentives to pharmacists performing public health activiti
es.
D. Public Health and Pharmacists' Services
1. Essential Health Services and the Pharmacist's Role
Public health is "what we, as a society do collectively to assure the condition
for people to be healthy."36 Through the execution of essential health services,
public health has evolved through a variety of stages to arrive at sustaining c
ommunity health and quality of life. Through shared responsibility, the pharmaci
st is equipped to strengthen the existing public health system.
The pharmacist has many functions that align with those of the essential health
services that are critical to public health.60 Pharmacists are in a unique setti
ng central to the community that enables them to monitor health status, develop
and mobilize community partners and empower community members through education,
screening, and dissemination of information. The expertise of the pharmacist is
not isolated to the education of the immediate community, but can also be utili
zed to inform laws and regulations. As mentioned above, pharmacists are involved
in educating doctors, nurses and other health care professionals on various tec
hniques of prescribing medications and issues related to the drug use process,14
,18 thereby fulfilling the eighth essential health services function assuring a
competent public health and personal health care work force. Further, the ample
availability of pharmacists to the public can aid in meeting the health care nee
ds of the uninsured and underinsured while alleviating the burden of the existin
g public health work force.
2. Pharmacists and the Core Public Health Functions
The Institutes of Medicine (IOM) in the Future of Public Health in the 21st Cent
ury established three major functions of public health: 1) Assessment, 2) Policy
Development, and 3) Assurance.36 The topics of research, legislation/advocacy a
nd medical errors tie in nicely with the role of pharmacists in public health.
Assessment
A. The Pharmacist and Public Health Assessment through Research
The pharmacist can play a unique role in the evaluation process to assure that m
edications are effectively being utilized. It is envisioned that a population an
alysis of medications patterns can add to the body of public health knowledge ge
nerating better treatment regimens, identifying medication errors and adverse dr
ug events,37,38 and improving the quality of patient care.39 Research involving
pharmacists can create trend analyses and report longitudinal changes in pattern
s of medication use that may ordinarily be missed. Such findings will ultimately
benefit the community and population-at-large. This illustrates the need and op
portunity for public health and pharmacy professions to work in collaboration to
conduct valuable research.
Pharmacists have a role in developing "population-specific, evidence-based disea
se management programs and protocols based upon analysis of epidemiologic and ph
armaco-economic data, medication use criteria, medication use review and risk re
duction strategies as well.40 Pharmacists, health practitioners, public health ag
encies, and regulatory and other stakeholders should collaborate to generate ans
wers. Academia and health agencies can also initiate relationships with local ph
armacy organizations to provide epidemiological data on prescribing patterns, pa
tterns of illness, and various socioeconomic factors related to prevalent diseas
e states. A community pharmacist can be strategic in assisting health surveys, a
nd in advising people about and referring them to public health services.
B. The Pharmacist and Public Health Preparedness
A confluence of events has refocused attention on the role pharmacists can play
in public health planning and emergency preparedness. The importance of medicati
on distribution and patient care during disasters is vital.41 For example, many
local boards of health require that a pharmacist be a member of the group in res
ponse to potential public health dangers. Pharmacists often offer alternatives t
o care and solutions to staff shortages in emergencies.
Shortages are not limited to staff but also valuable resources. The emergence of
smallpox and influenza scares has called attention to the problem that dwindlin
g supply of critical medications pose.42 For instance, the development of a plan
for influenza vaccine redistribution is a potentially useful exercise that phar
macists hopefully will never need to execute but would be a very critical contri
butor. Plans such as these can be readily adapted to various natural disasters,
bioterrorism acts, or similar emergency situations.43,44 Pharmacists should be p
repared to quickly assess and respond to critical situations and have been a wel
comed addition to the collaborative emergency team. The critical role of the pha
rmacists to protect the nation from public health dangers is noted by one pharma
cist's leadership role as a part of the Commissioned Corps Readiness Force (CCRF
) team after Sept. 11 at Ground Zero to provide medical, mental and public healt
h services to responders.45 Additionally several pharmacists' service as members
of response teams at five anthrax events in the United States should also be no
ted. Pharmacists have become increasingly involved in emergency response, managi
ng the Strategic National Stockpile (SNS), responding to natural disasters,46,47
and working to rebuild health care infrastructure in Afghanistan and the drug r
egulatory system in Iraq.
Policy Development: The Pharmacist in Public Health Legislation, Regulation and
Advocacy
The promulgation of public health legislation and subsequent regulation is not a
field generally associated with the pharmacist's role. However, there are a myr
iad of public health concerns which legislators and regulatory agencies address
that relate to pharmacists and the products they dispense. Legislators and those
who develop and approve policy oftentimes need testimony, data and feedback on
pending and implemented laws and regulations. Pharmacists are in a prominent pos
ition to provide background data, legislative content and exposition to local, s
tate and federal governments. As medication-use experts and experienced health s
ystem administrators, pharmacists can and should contribute to public health leg
islation and regulation.
Many local, state and federal agencies have begun to recognize the need for phar
macists' input. At the federal level, pharmacists are employed in such entities
as the Agency for Healthcare Research and Quality (ARHQ), the Centers for Medica
re & Medicaid Services (CMS), the Food and Drug Administration (FDA), Department
of Veterans Affairs (VA), U.S. Public Health Service and the Bureau of Health P
rofessions of the Health Resources and Services Administration (HRSA). Although
they hold positions within these key agencies, there still exists a shortage of
pharmacists working within these areas. The need to increase pharmacists' involv
ement in regulatory agencies along with other public health stakeholders is esse
ntial. Pharmacists can take a more proactive role in impacting legislation and r
egulation through advocacy in state and local boards of health, their state boar
ds of pharmacy and national associations.
Pharmacists at the state and local levels administer the drug component of the M
edicaid and Medicare programs, as well as regulate the practice of pharmacy. Thi
s is particularly relevant in lieu of changes in the Medicare program to include
prescription drugs under Part D.48 Although pharmacists are generally recognize
d and compensated for dispensing medication under this plan, public health activ
ities and preventive services performed by pharmacists are not reimbursed. There
fore, recognition of pharmacists as Medicare providers is key. Pharmacists can p
lay a vital role in the success of Medicare Part D by decreasing health care cos
ts through appropriate medication use and prevention of medication errors.49 Lif
estyles changes are critical to evoke prevention. The pharmacist's role in promo
ting lifestyle changes is not recognized, and therefore coverage is lacking for
prevention activities, which poses an area of grave concern for pharmacy and pub
lic health professionals alike. It is important that local, state and federal ag
encies recognize the role of the pharmacist in contributing to the public's heal
th, and should identify mechanisms to include pharmacists' involvement.
Assurance: Improved Access to Quality Care, Prevention of Medical Errors and the
Pharmacist
Health care system managers, administrators, and evaluators are intimately invol
ved in assuring appropriate allocation of services to meet patient needs and dem
ands. Prominent considerations of the role of pharmacists in health care managem
ent include: the distribution of drugs and supplies, delivering drug related inf
ormation and consultation to meet needs of patients and health team members. Con
sequently, there should be more effort to fully utilize the wealth of drug knowl
edge the pharmacist brings. As aforementioned, the unique assets that pharmacist
s bring have already been recognized within many public health jurisdictions.
Pharmacists can prevent medical errors by both: 1) increasing patient health lit
eracy50,51 and 2) serving as a systematic check and balance.49,52,53The Institut
es of Medicine's book entitled "To Err is Human" reported "Because of the immens
e variety and complexity of medications now available, it is impossible for nurs
es or doctors to keep up with all of the information required for safe medicatio
n use. The pharmacist has become the essential resource& and thus access to his
or her expertise must be possible at all times.49 Inclusion of pharmacist service
s in the clinical services subsystem permits full interaction and use of his or
her expertise. In this manner, pharmacists may contribute to the system's manage
ment function by providing essential information (e.g., the number and cost of p
rescriptions dispensed), and meeting the needs of the system by providing health
care education and services. To aid in this expanded role, the pharmacist shoul
d be trained to contribute to a variety of public health services and functions,
particularly those involving abusable substances and medicines, and those requi
ring the cooperation of community pharmacists and public health workers.
Another key area of assurance is access to health services and resources. Pharma
ceuticals are among the most frequently used therapeutic modalities. There exist
s a need to provide counseling to patients to assist in increasing compliance wi
th therapeutic regimens based on empirical, up-to-date information to assure tha
t medicines are taken properly. In an era where chronic (i.e. hypertension and d
iabetes) and infectious diseases (HIV and tuberculosis)55 require lengthy medica
tion treatment regimens, pharmacists are vital. These needs, coupled with the ne
ed for primary care practitioners in underserved areas, point to the greater use
of the pharmacist.
A pharmacist currently contributes to patient care through hospitals, home care,
long-term care, community pharmacy or other components of organized health care
systems. Many inpatient and ambulatory care programs have added a clinical phar
macy segment to the traditional distribution function, and an increasing number
of pharmacy practitioners are engaged in clinical practice. Furthermore, much li
ke the role of the nurse practitioner and physician assistant, the role of the p
harmacist has expanded to allow for the provisional prescribing of medications i
n collaboration with a physician within some jurisdictions. This function would
be critical in areas where there may be a shortage of physicians or other qualif
ied health care professionals.
E. Pharmacists and Prevention
Through health screenings and health education, pharmacists play a key role in p
revention as well as access to care. In light of work force shortages among heal
th professionals, pharmacists may act as first responders, providing clinical ad
vice to include over-the-counter (OTC) relief that may aid in decreasing unneces
sary emergency room visits for common conditions. Protocols are often developed
and vetted by Pharmacy and Therapeutics (P&T) Advisory Committees. Pharmacists a
re often involved in the clinical management of chronic diseases, and minor dise
ase diagnosis and treatment. Further, pharmacists provide an excellent source of
human capital to the community by conducting primary prevention through health
education. Primary prevention is the essence of public health. Consequently, gre
ater emphasis regarding the role of pharmacists in the public health infrastruct
ure needs to be recognized.
Pharmacists also provide rehabilitation support to individuals and communities b
y giving advice on the use and selection of surgical appliances and equipment. T
he literature is abundant with examples of the pharmacist functioning in hyperte
nsive and colorectal screening, sexually transmitted disease control and contrac
eption programs, providing health education, and advising patients of OTC drug c
hoice and use. In rural areas, pharmacists have supported environmental programs
such as water pollution control, chemotherapeutic agents, sanitation, and waste
disposal.56
Pharmacists in rural areas are another key area of concern and fill a void in bo
th the pharmacy and public health arena. Given rural health often reflects an ar
ea of greater geographic need, the connection between rural and health dispariti
es cannot be ignored.57 In many rural areas that have fewer available resources,
the local pharmacist offers a much needed source of clinical expertise. This is
also true in impoverished urban areas. Pharmacists are particularly valuable as
sets in these disenfranchised sub-sectors of the community, because the pharmaci
st acts as an easily accessible resource for health information and screening. T
hrough consultation with local pharmacists, many community members may avoid cos
tly emergency room visits for those common acute ailments or conditions that tem
porary OTC drugs could provide relief, particularly among those lacking insuranc
e. Therefore, pharmacists can play a role in addressing and eliminating health d
isparities.35,58 Pharmacists, like all health providers, should be engaged in ac
tivities which may lead to eliminating health disparities, through cultural comp
etence training, collecting data on medication use in special populations and pr
omoting diversity in the work force.