[e-drug] Prescribing and dispensing in one hand? (8)

["Andy Gray" <Graya1@ukzn.ac.za>]

E-DRUG: Prescribing and dispensing in one hand? (8)
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Hi all,

Pascal Verhoeven has raised an interesting side issue to the larger question of the desirability of separating prescribing and dispensing.

There is some empiric evidence for the policy stance that favours separation - see, for example, the abstract below from Birna Traps's work in Zimbabwe. This stance is standard WHO fare, and was also promoted at the Second International Conference on Improving Use of Medicines (ICIUM 2004) - "Although challenging, policies to separate prescribing and dispensing are feasible to implement and can result in lower costs to consumers and programmes and improved use of medicines" - http://mednet3.who.int/icium/icium2004/Documents/ICIUM2004PolicyAndProgrammeRecommendations.doc. 

In South Africa, the 1996 National Drug Policy also included a clear policy statement: "Only practitioners who are registered with the relevant Council and premises that are registered and/or licensed in terms of the Medicines and Related Substances Control Act (No 101 of 1965) may be used for the manufacture, supply and dispensing of drugs. Medical practitioners and nurses will not be permitted to dispense drugs, except where separate pharmaceutical services are not available. In such instances/situations where dispensing by doctors and nurses has to take place, such persons will be in possession of a dispensing licence issued by the Medicine Control Council. Criteria for the granting of such licences will include inter alia, the application of geographical limits. Special concessions will be granted with regard to certain categories of providers such as occupational health services.. Proven competency of such persons to dispense drugs will be by virtue of the successful completion of a suitable training programme. All licences will be reviewed and renewed annually. These inspection functions will be delegated to the provinces."

This was codified in law, but immediately challenged by the medical profession. Finally, in 2005 the Constitutional Court struck down the "need" elements of the Regulations (in "The Affordable Medicines Trust v the Minister of Health and Others 2005 JOL 13932 (CC)"). As a result, medical practitioners and nurses have to complete a supplementary training course and apply for a dispensing licence, but all such applications are approved. There are currently about 8500 licensed dispensing practitioners (prescribers) in South Africa, and around 2400 community pharmacies in the private sector. In the public sector, almost all dispensing at clinics is done by nurses, in terms of a permit issued by a medical officer.

There is one more remnant of the policy in the Regulations governing the ownership of various types of pharmacies. Both community pharmacies and institutional (hospital) pharmacies in the private sector may not be owned by "an authorised prescriber". The legal construct runs along these lines: "Any person may .... own or have a beneficial interest in a community pharmacy in the Republic, on condition that such a person or in the case of a body corporate, the shareholder, director, trustee, beneficiary or member, as the case may be, of a body corporate .....is not an authorised prescriber".

However, where a single person holds both registrations - as a pharmacist and a medical practitioner (hence, prescriber) - then the regulatory authorities have allowed exceptions, provided that the person only practises one profession at any given time or place. A combined practice has not been allowed.

For details of SA law, visit the Medicines Control Council web site at http://www.mccza.com and the SA Pharmacy Council at http://www.pharmcouncil.co.za/ 

regards
Andy
~~~
Health Policy Plan. 2002 Sep;17(3):288-95.

Prescription habits of dispensing and non-dispensing doctors in Zimbabwe.

Trap B, Hansen EH, Hogerzeil HV.

Department of Social Pharmacy, Royal Danish School of Pharmacy, Copenhagen, Denmark. btrap@ehg.dk 

The number of dispensing doctors has increased in the last decade, but the implication of this trend on the quality of health care and drug use is unknown. We present a comparative drug utilization study of 29 dispensing doctors and 28 non-dispensing doctors in Zimbabwe based on standard indicators developed by the World Health Organization. Dispensing doctors prescribed significantly more drugs per patient than non-dispensing doctors (2.3 versus 1.7), injected more patients (28.4% versus 9.5%), and prescribed more antibiotics (0.72 versus 0.54) and mixtures (0.43 versus 0.25) per encounter. Dispensing doctors also spent significantly less time on each encounter (8.7 min versus 13.0 min) than their non-dispensing colleagues. The use of generic name, brand name and essential drugs did not differ significantly between the two groups of practitioners. Multivariate analyses controlling for gender, race, place of education, location of practice and patients seen per day showed that dispensing by doctors was associated with less clinically and economically appropriate prescribing. These findings suggest that the quality of health care--as related to drug use, patient safety and treatment cost--is lower with dispensing doctors than with non-dispensing doctors.

PMID: 12135995 


~~~~~~~~~~~~~~~~~~~
Andy Gray MSc(Pharm) FPS
* Senior Lecturer
Dept of Therapeutics and Medicines Management
* Consultant Pharmacist
Centre for the AIDS Programme of Research 
in South Africa (CAPRISA)
Nelson R Mandela School of Medicine
University of KwaZulu-Natal
PBag 7 Congella 4013
South Africa
Tel: +27-31-2604334/4298 Fax: +27-31-2604338
email: graya1@ukzn.ac.za or andy@gray.za.net