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International Journal of

Pharmacy Practice
International Journal of Pharmacy Practice 2015, , pp. 

Separation of prescribing and dispensing in Malaysia: the

history and challenges
John Jeh Lung Tionga, Chun Wai Maib, Pou Wee Ganb, James Johnsonc and Vivienne Sook Li Makd
a

School of Pharmacy, Taylors University, Subang Jaya, Selangor, Malaysia, bSchool of Pharmacy, International Medical University, Kuala Lumpur,

Malaysia, cStrathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK and dSchool of Pharmacy, Monash
University Malaysia, Bandar Sunway, Selangor, Malaysia

Keywords
dispensing separation; health care reform;
medicine; pharmacy
Correspondence
John Jeh Lung Tiong, School of Pharmacy,
Taylors University, No. 1, Jalan Taylors,
47500 Subang Jaya, Selangor, Malaysia.
E-mail: tjljohn@gmail.com
Received March 17, 2015
Accepted November 11, 2015
doi: 10.1111/ijpp.12244

Abstract
This article serves as an update to the work by Shafie et al. (2012) which previously reviewed the benefits of policies separating prescribing and dispensing in
various countries to advocate its implementation in Malaysia. This article seeks
to strengthen the argument by highlighting not only the weaknesses of the
Malaysian health care system from the historical, professional and economic
viewpoints but also the shortcomings of both medical and pharmacy professions in the absence of separation of dispensing. It also provides a detailed
insight into the ongoing initiatives taken to consolidate the role of pharmacists
in the health care system in the advent of separation of dispensing. Under the
two tier system in Malaysia at present, the separation of prescribing and dispensing is implemented only in government hospitals. The absence of this separation in the private practices has led to possible profit-oriented medical and
pharmacy practices which hinder safe and cost-effective delivery of health services. The call for separation of dispensing has gained traction over the years
despite various hurdles ranging from the formidable resistance from the medical fraternity to the publics scepticism towards the new policy. With historical
testament and present evidence pointing towards the merits of a system in
which doctors prescribe and pharmacists dispense, the implementation of this
health care model is justified.

The close relationship between pharmacy and medicine

has been in place since pre-historic times. In ancient
Egypt, pharmacy was a special branch of medicine which
caused significant ambiguity in the scope of practice.[1]
The earliest evidence of segregation of the two branches
of science can be traced back to the Hammurabis Code
of the Babylonian Empire which spelt out the separation
of disease diagnosis and treatment from medicine preparation.[1] The separation of medicine and pharmacy into
two independent scientific disciplines began in the 12th
century Arabia and the same concept was formalised in
Europe through the Edict of Salerno in 1231.[1] This legal
reform prevented exploitation of the sick by regulating
the practice of health care professionals. It fixed the prices
of medicines and went on to become the model for pharmacy regulatory practice in continental Europe.[1] The
benefits of this model as outlined by Shafie et al. has
prompted its implementation in the UK and USA in the
2016 The Authors. IJPP 2016 Royal Pharmaceutical Society

19th and 20th century, respectively, followed by numerous Asian countries such as Japan, Korea, Taiwan,
Indonesia, Philippines and India.[2]
Malaysia remains one of the few countries in the South
East Asia region without such a health policy owing to
the colonial era legislation, particularly the Poisons Act
1952 (and its subsequent amendment in 1989) which
granted the rights of dispensing to both doctors and
pharmacists. Despite having clearly demarcated prescribing and dispensing responsibilities for doctors and pharmacists in the home country, the British drafted the law
with the intention to address the low number of pharmacists during the pre-independence period. This served its
purpose in the early years after independence when pharmacy practice was still at its infancy. As the pharmacist
workforce grew steadily, the lobbying for separation of
prescribing and dispensing began.[2] The Malaysian Pharmaceutical Society (MPS) was formed in 1967 to unite
International Journal of Pharmacy Practice 2015, , pp.



pharmacists under one umbrella, and consolidate the

voice of the profession. A significant milestone was
achieved with the signing of a Memorandum of Understanding in 1986 between the Malaysian Medical Association and the MPS, which recognised the dispensing role
of pharmacists. Despite this, doctors in private practice
continue to dispense medications in the absence of legislation which prohibits them from doing so.
In common with global trends in pharmacy practice, in
the last decade, pharmacists in Malaysia now provide
extended health care roles, beyond the supply of medicine, either directly to the patient, or as policymakers. As
Malaysia is set to become an economically developed
nation in 2020, an exemplary health care system is
required to provide efficient and comprehensive health
services. In this changing context, and with evidence supporting the separation of prescribing and dispensing in
the interests of better patient care,, there is a renewed
incentive for the Malaysian government to introduce the
relevant legislation.
The authors agree with Shafie et al. that possessing
both prescribing and dispensing rights is widely perceived
as the root cause of over-prescribing which thereby provides lucrative profits for prescribers. This is corroborated
by the findings of WHO which revealed that dispensing
doctors are found to prescribe more medications and/or
costly medications than non-dispensing doctors.[3] Such
practice is evident in Malaysia where dispensing doctors
are found to dispense seven times more medicines compared to their non-dispensing counterparts albeit already
with significant price mark-up.[2] The inducements
offered by drug companies have also caused some prescribers to be in favour of branded products over effective
generic which goes against the concept of cost-effective
treatment.[2] Malaysian national health expenditure was
estimated at $13.6 billion (4.5% GDP) in 2012 and it has
been increasing since 1997.[4] Hence, WHO is of the
opinion that the health care system should be organised
in a way that prevents doctors from dispensing.[3] In fact,
diagnosis and dispensing are two complex roles which
should be undertaken by two separate health care professionals for an effective system of checks and balances.
This removes the preference of certain products or overprescribing in the presence of monetary enticement
thereby promoting rational drug use based on clinical
guidelines. This is shown by the reduction in unnecessary
drug use in Taiwan and Korea post-implementation of
dispensing separation.[2]
Annually, 7.1 million American patients are harmed by
medication errors and this correlates to 7000 preventable
deaths.[5] Most cases are attributed to prescribing errors
with 37% being cited as dosing misadventure.[5] The lapse
in the standard of care incurs additional costs on top of the
2016 The Authors. IJPP 2016 Royal Pharmaceutical Society

Separation of prescribing and dispensing in Malaysia

initial treatment given.[5] Unfortunately, the prevalence of

medication errors as a result of medical negligence often
goes under-reported in Malaysia. This is confirmed by a
recent study which identified a medication error rate of
41.1% in 12 primary care clinics; 48.5% of these errors were
wrong dosage or frequency prescribed, 47.2% due to inappropriate medication prescribed and 9.8% a drug interaction.[6] The routine screening of prescriptions by
pharmacists as happens in most other countries enables
them to identify and potentially rectify at least some of
these prescribing errors.[7] This is exemplified in a study
where American pharmacists intervened in 623 out of
33,011 new prescriptions to resolve prescribing-related
problems of which 28.3% were potentially harmful.[8] From
a health economics viewpoint, this directly resulted in cost
savings of $122.98 per problematic prescription.[9] Therefore, demarcation of professional boundaries could ensure
safer and more cost-effective delivery of health services.
Malaysia has a two tier health care system where the separation of prescribing and dispensing is implemented only in
government hospitals. For decades, doctors in private practice have possessed the legal right to prescribe and dispense,
rendering the dispensing role of community pharmacists
redundant. Ethical issues arise when some community pharmacists sell prescription-only-medication without valid prescriptions under the justification of the economic
subsistence of their pharmacy business.[10] Out of convenience and the interest of cost-savings, many patients
choose to purchase medications for their chronic conditions
(such as hypertension and dyslipidaemia) from the pharmacies without medical consultation and follow-ups with doctors. Such practice must cease since it is putting patients
health at risk while tarnishing the image of the entire pharmacy profession particularly in the eyes of doctors. In the
absence of faultless professional conduct, it is difficult to
expect doctors to put the rights of dispensing solely in the
hands of pharmacists.[10] The vision of pharmacists attaining the status of sole dispensers and/or supplementary prescribers may only be possible with strict professional selfregulation, law enforcement and adherence to guidelines in
close collaboration with physicians.
The advocacy of separation of dispensing has been
futile due to daunting resistance from the medical fraternity whose revenue depends significantly on the sales of
medications. Various reasons with vested interest were
cited for their objections. These include the shortage of
pharmacists, the heterogeneous distribution of pharmacies
(high density in urban area and few/non-existence in
rural localities) and the absence of 24-hour pharmacy services.[2,10] The issue of inconvenience should be of secondary concern since patients safety should never be
compromised. Nonetheless, heterogeneous distribution of
pharmacies may be addressed by the implementation of
International Journal of Pharmacy Practice 2015, , pp.



John Jeh Lung Tiong et al.

pharmacy zoning system. It is worth pointing out that

these are also some of the on-going issues in developed
countries like the United States where delineation of professional boundaries is already in place.[11] With a total of
11,400 registered pharmacists as of 2014 and approximately 1,000 pharmacy graduates joining the profession
annually, Malaysia is poised to meet the WHO recommended pharmacist-to-population ratio of 1:2,000 by
2016. Furthermore, with approximately 2600 community
pharmacies, the country has the prerequisites to embrace
this progressive health care system. Nevertheless, doctors
should be allowed to dispense in the absence of pharmacy
within the vicinity of the clinic under stipulated criteria
closely mimicking the United Kingdom National Health
Service (NHS) model applicable to rural areas.[12]
In the envisaged advent of dispensing separation, the
Malaysian Pharmacy Board has liberalised the pupillage
program (to be completed previously only in the government hospitals and agencies) allowing professional training
to be carried out in the private sector whilst shortening the
pharmacist mandatory public service from three years to
one. These initiatives are aimed at increasing the workforce
in the community setting in preparation for the health care
reform. Community Pharmacy Benchmarking Guideline
was also instituted in 2011 as a joint effort between the government and professional bodies for the quality assurance of
pharmacy services as well as regulating the conduct of community pharmacists. The pharmacy enforcement division in
the country has also strengthened its enforcement activities
to ensure practice compliance.[13] Within this context, the
display of practice standards and etiquette which projects a
professional image befitting of pharmacists is critical in pursuance of recognition of equal partnership between pharmacists and doctors. It is high time for pharmacy schools and
the professional bodies to reemphasise the code of ethics to
uphold the integrity of the profession rather than being fastidious with the symbolic customs of professionalism such
as the white coat and/or the dress code.
Perhaps the biggest stumbling block to the implementation of dispensing separation is the notion of an impending
rise in medical costs if the reform materialises. This is due to
the possible increase in the consultation fees charged by doctors to offset the loss of revenue from sales of medicines. A
well-thought-out national health insurance scheme should
be the way forward in expanding the access to affordable
health care to the entire population. Furthermore, the proposed legislative framework should be structured only after
comprehensive studies particularly by gauging the pros and
cons of the system in countries which have adopted it. We
call upon MPS and the government to organise a nationwide
campaign to enlighten the general public of the benefits of
dispensing separation in addition to emphasising the importance of the roles pharmacists in health care particularly in
International Journal of Pharmacy Practice 2015, , pp.



prescription checking and patient counselling. The public

should be encouraged to gauge the quality of the extra layer
of safety net provided by the role segregation policy in the
public hospitals to dispel misconception regarding this policy. It remains to be seen if the health care reform would be
tabled in the new Malaysia Pharmacy Bill in 2015. However,
it is the authors opinion that much remains to be done
before this reform will materialise.

Conclusion
Revisiting history has made us realise how far we have progressed in the art of healing. The common ancestry of medicine and pharmacy shown in history coupled with recent
evidence attest to the need of the two branches of science to
complement each other. A cordial inter-professional collaboration and understanding is crucial for the effective delivery of modern health services for patients benefit. The
authors concur with the view of Shafie et al. that dispensing
separation should be implemented in Malaysia, although
much remains to be done. Despite facing daunting challenges, pharmacists should remain steadfast in promulgating the importance of the profession in health care whilst
consolidating the need for dispensing separation. The ever
increasing expectation of the public towards the improving
quality of health care and the rise in the burden of chronic
diseases present imperatives for pharmacists to put their
expertise and education to good use.

Declarations
Conflict of interest
The authors declare that they have no conflicts of interest
to disclose.

Funding
This work received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.

Acknowledgements
The authors acknowledge Associate Professor Janie Sheridan
for her critical discussion on this article.

Author contributions
All authors contributed substantially to the development
and the completion of this manuscript. All authors have
read the final version of the manuscript and endorsed it
for submission.
2016 The Authors. IJPP 2016 Royal Pharmaceutical Society

Separation of prescribing and dispensing in Malaysia

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