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HOSPITAL PHARMACY IN NEPAL

BACKGROUND
Nepal, a small country, lies in the central Himalayas, wedged between
India and China. The flat Terai plains in the south, the central hills and
the high Himalayas in the north define the countrys three geographical
areas. The history of medicine in Nepal may be considered to be fairly
long. From the Ramayana one learns that Hanuman was told to bring
the Sanjeebani from the mountains in the Himalayas. Without arguing
whether the actual mountain transported to Lanka was from India or
Nepal one can say that many herbal medicines were in use then in these
lands (1).
Lord Buddha (563-477 BC), who was born in Nepal, is said to have
attended regularly to all the sick disciples in his camps. His teachings
said to be born is to suffer, to die is to suffer, and to fall sick is to suffer
motivated his followers to look after the sick. Buddhist hospitals in Nepal
and India existed before the invasion of Alexander the Great in India. It
is to Gautam and his followers who emerged apparently the hospital
idea (2). It is the Ayurved or the science of life system of medicine that
is found in this part of the world. It has been recorded that Arogyashala
or ayurvedic hospital existed in Nepal during the reign of Amshu Verma
(605-620 AD) of the Lichchhavi period (3). These facilities were
extended in the reigns of subsequent rulers. Mention of these health
institutions is not found again till the time of Pratap Malla (1641-1674)
who established an ayurvedic dispensary in the Hanuman Dhoka
complex. This can be considered as the start of pharmacy service in
Nepal.
The first introduction of the modern medicine or allopathic system of
medicine in Nepal was done by the Christian Missionaries working in
Peking, China and Lhasa, Tibet. In those days one of the TransHimalayan trade route was via Kathmandu and the Christian
Missionaries have used the road and have felt health needs of the then
Nepal but the organized practice of modern medicine or in fact modern
pharmacy stated with the establishment of Prithivi Bir Hospital, the first
hospital of the country in Kathmandu in the year 1889 AD. In the same
year Cholera Hospital was established in Teku, Kathmandu near rope

way station. Additional Prithvi-Bir group of hospitals were established in


the same year in Birganj, Jaleshwar, Hanuman Nagar, Taulihawa and
Nepalganj. Leprosy Hospital was also established in Tripureshwor (4). To
make medicines more freely available, the Chandra Sale Dispensary
was set up at Bir Hospital in 1917. This is supposed to the beginning of
modern Hospital Pharmacy practice in Nepal. The specimens of
signatures of medical practitioners were registered and kept at the
Chandra Sale Dispensary so that there was no misuse of drugs. There
were said to be a total of eighteen hospitals and fourteen dispensaries in
various parts of the country by 1917 (2). Ramghat Dispensary at
Pashupati was inaugurated in 1929 AD and further dispensaries were
established in Sindhulimadi, Ramechhap, Okhaldhunga, and
Pashupatinagar (5) (6).
The profession of Pharmacy was introduced in Nepal by the British with
the Christian missionaries took the form of Shanta Bhawan Hospital in
1956 AD which was later converted to Patan Hospital by amalgamation
of Shanta Bhawan and Lalitpur district in 1982. Paul D. Spivey was
supposed to be the first hospital pharmacist in Nepal. Although a number
of hospitals were established in Nepal, the practice of professional
hospital pharmacy practice didnt occur due to the lack of pharmacists in
Nepal. Some hospitals started the hospital pharmacy services with the
training given to the other healthcare professionals. The pharmacy
profession was represented by a set of people known as compounders
whose status, functions and duties were ill-defined and improperly
understood. The practices of compounders are now as professionalists
which still continue. They have legal authority to sell and distribute
medicines (7) but the functions and duties they are doing are still illdefined and mostly unscientific in the present day context.
HOSPITAL PHARMACY AT PRESENT
Drug Act in Nepal came only in 1978 AD but the Drug Act and Nepal
Government are focusing on ensuring the integrity of medicine supply
without much improvement in the hospital pharmacy practice. There is
no hospital pharmacy, run and managed by the hospital under the
supervision of the Drug/Medicine Therapeutic committee (D/MTC) in any
national, regional, zonal and other government hospitals. Only some
non-government teaching hospitals have their own hospital pharmacy
(8). The poor hospital pharmacy practice is due to lack of policies

regarding the hospital pharmacy, lack of qualified manpower, lack of


standardized services and business motives of the hospital
management. Above all there are almost no legal provisions, standard of
practice and accreditation for hospital pharmacy practices in Nepal till
now. Government of Nepal published a guideline of private health
institutions in 2004. The guideline states that the pharmacy of private
hospitals with up to 25 beds should have at least one Assistant
Pharmacist on duty all day round, 25 to 100 bedded hospital should
have pharmacy supervised by a Pharmacist and hospitals with more
than 100 beds should have pharmacy whose service is provided by at
least one Pharmacist (9). However, the guideline has not been followed
due to the weak monitoring of the government and lack of inadequate
number of Pharmacists in the country. Most of the hospital pharmacies
are running as a retail counter. Hospitals rent the space to private
pharmacies. This provides them a fixed income and the hospital
management is free of managerial, regulatory and other worries.
However, in most cases, the private party running the pharmacy
recovers the high cost of investment through more drug sales and more
aggressivePROMOTION of the use of more expensive medicines (8) as
there are no accreditation system and no standard for practice.
FAILURE OF HOSPITAL PHARMACIES IN MANY OF THE
HOSPITALS IN NEPAL
After 1960s number of hospitals came into existence. The establishment
of first teaching hospital in Nepal was in 1978 AD. Along with the
government hospitals private hospitals as well as the hospitals owned by
NGOs and INGOs came into existence. As the number of hospitals
increased the requirement of pharmacists and the pharmacy technicians
also increased however the supply of pharmacy and pharmacy
technicians were scare due to the reason that there was no pharmacy
education in Nepal till 1994 and the graduates in pharmacy from India
and Bangladesh were more concentrated on industrial pharmacy rather
than the hospital pharmacy practice. While the Pharmacists and
pharmacy technicians who were trained in the existing hospitals started
to practice in the community since community pharmacy is more
lucrative than hospital pharmacy practice. Besides these, the migration
of the pharmacists and pharmacy technicians to the foreign countries is
too high. Due to this reason the diversification and upgradation of the

hospital pharmacy service is at stake and couldnt meet up with the


increasing need of the patients and hospital management. Due to the
influx of private hospitals the main motto of these hospitals is to earn the
money. This led to that fact that they saw hospital pharmacy as
moneyGENERATING department rather than focusing on the service to
the patients. Almost all of the government hospitals failed and the
hospital management rented the hospital pharmacy services to the
private firms and the private hospitals follow the same tends.
PROBLEMS IN THE PRESENT DAY HOSPITAL PHARMACY
PRACTICE IN NEPAL
The hospital pharmacy practice in Nepal is very primitive. Although there
are around 300 hospitals in Nepal the hospitals having their own
pharmacies are very less. Only 20 to 30 hospitals are running their own
hospital pharmacy services. The majority of the hospitals including the
government hospitals are renting their space for the private firms to run
the pharmacy. The rented pharmacies are used for the sale and
distribution of medicines with no any patient oriented services. The major
problems in hospital pharmacy practice in Nepal can be divided into
following categories:
1. Problems in the hospital pharmacy policy
Pharmacy practice is in fact come to legal framework very late. Drug Act
was established only in 1978 AD. But the drug act doesnt have any
specific policies for the hospital pharmacy practice. Due to the lack of
policies, rules and regulations, the hospital management has no any
standard criteria for the practice so the hospital pharmacy practice is the
least priority for the hospital management as there is no supervision and
monitoring of the practice by the authorities.
2. Lack of competent manpower
The lack of pharmacists in the hospital is the major problem in the
professional development of the hospital pharmacy practice in Nepal.
Graduate pharmacy education started in Nepal only in 1994 and till now
there are around 1000 graduates registered but the majority of the
graduates are working in the industries. This may be due to the fact that
the curriculum of the pharmacy graduates in India and Nepal from where
the pharma graduates are more oriented to the industrial practice than to
the hospital pharmacy practice. Besides, the pharma graduates are
moving aboard.

3. Lack of patient oriented practice in pharmacy


The practice of hospital pharmacy in Nepal is traditional so it focuses
more on the product that on the patients, and supply than on service.
The modern hospital pharmacy focuses on the patient care. But the
modernization of the hospital pharmacy service could not take place due
to the lack of manpower and lack of policy in the country.
4. Pharmaceutical care not considered the integral part in patient
care
The main drawback in the development of the professional hospital
pharmacy practice is that the pharmaceutical care is not considered the
integral part in patient care. Even the government hospitals focus the
patient care on the medical, surgical and nursing but the
mostIMPORTANT part the pharmaceutical care is left behind just as the
sale and distribution of the pharmaceutical products without any
professional pharmacy services.
STRATEGIC OPTIONS FOR THE FUTURE
The practice of hospital pharmacy practice is changing worldwide. The
traditional role of product oriented practice is shifting towards the patient
oriented practice. One or another day our practice has to be focused on
the patient care rather than on the product. The expectation of the
patients on pharmaceutical service is too high and healthcare providers
have to meet the patients expectations with the professional pharmacy
services. All the stakeholders, policy makers, academicians, practitioners
and students should team up for meeting the patients escalating
professional pharmacy practice. For the professional hospital pharmacy
practice in Nepal following things should be taken care of:
1. Policy reforms
The policy should be reformed. There should be long term vision for the
professional patient oriented practice. Appropriate rules and regulations
should be framed. Standard practice should be designed for hospital
pharmacy practice and accreditations for the hospital as well as the
hospital pharmacy practice should be designed. Effective monitoring of
the hospital pharmacist and hospital pharmacy should be carried out
routinely.
2. Inclusion of the clinical oriented curriculum in the pharmacy
schools
There is a discussion going on globally about the four year and six years

graduate education in pharmacy. Nowadays most Western countries and


even the Asian countries are changing their curriculum for six years.
There may be for and against this system based on Nepals low
economic status and ability to spend six years before graduation and job
after the graduation but any curriculum either six years or four years
should include the clinical orientation. The present day curriculum is
mainly focused on the industrial pharmacy and pharmaceutics which
lack the professional pharmacy practice. Most pharmacy schools are
running without the hospital of own and the intensive practice on the
hospital are almost negligible to the pharma graduates.
3. Continuing education for the pharmacy practitioners
The practice of pharmacy is changing continuously. Pharmacy
practitioners should be upgraded with the modern practice to meet the
needs of the patients. There should be facilitation from the government,
academics and hospitals for the professional upgradation. The
continuing education will help diversify the pharmaceutical services and
incorporate new services like Total Parenteral Nutrition services,
oncology services, Smoking cessation clinics, Diabetes care clinic etc. In
fact, there is a great scope in hospital pharmacy services. Pharmacists
haveIMPORTANT role in patient care. They could not only reduce the
medication cost of the patients but could also improve the patients
outcome with the professional hospital pharmacy practice. Nepal should
learn from the experiences of other developed countries and should
collaborate with them taking consideration of the local strength and
limitations. Nepal certainly will see the highest degree of professional
hospital pharmacy practice in the days to come.