Pharmacy the Taiwan way

By Sultan (SID) Dajani

The pharmacists’ associations of Kaohsiung, Taipei County, Taichung City, Hsinchu, Tainan and Taipei City along with the Pharmacist Associations of ROC, the Department if Health, GlaxoSmithKline and the School of Pharmacy at the National Taiwan University organised and sponsored a one day international conference on community pharmacy services on the 20 September 2009. The aim was to learn about, and learn how to participate in, patient-centred pharmaceutical care and to learn about public health initiatives. Speakers from America, the UK, Japan, New Zealand and Australia spoke about pharmacies in their countries.

Taiwan was in the world news recently when typhoon Morakot hit the southern part of the island in August 2009. Two metres of rain fell in one weekend causing the worst flooding in 50 years. Roads, bridges and buildings were washed away while a massive landslide killed over 800 people.

The images shocked the world. The Taiwan people rallied together knowing they did not have time to mourn as the recovery process had to be swift to avoid disease. There were many complications, not least because food and medicines were in urgent need as the water damaged all local sources and demand was high. Pharmacists played a key role and were among the first to be mobilised to the stricken areas.

Pharmacists like Ling-Chun Chou and her husband Chin-Tsai Lin, who own Chou Pharmacy at Tainan were quick to organise support. They sourced medicines from all over Taiwan, transported them, co-ordinated their supply and distribution, aided search and rescue operations, carried out first aid and delivered care wherever possible. In addition stands were erected, manned by volunteers offering health support and assistance to those well enough to travel. Pharmacies throughout Taiwan became donation centres while those on site also helped to clear the debris.

Understandably, the human losses were severe but without the population coming together and without the expertise of pharmacists, those losses would have been far worse.

Remuneration hinders modernisation

Unfortunately, while Taiwan pharmacists are proudly keen to translate Taiwan’s miraculous manufacturing and technological record into health, their remuneration is sorely lacking; it is hard to think of any other country where money in pharmacy is so low.

Contrary to practice around the world, Taiwan community pharmacists only get one fee (about US $2) regardless of the number of items on a prescription form and those pharmacists who have to re-dispense an item due to a GP’s error, do not get paid another fee.

Taiwan has 4,300 pharmacies, which are classed as clinical pharmacies (GP located pharmacies) or community pharmacies. Only licensed pharmacies can dispense national insurance prescriptions. There are about 23,500 pharmacists in Taiwan; 18 per cent of these work in community pharmacy however only 1 per cent of all prescriptions are dispensed in community pharmacies —  the rest are dispensed at clinics and hospitals.

To make matters worse, the medical profession is extremely self-protecting and powerful and this is a major source of frustration. Hence any initiatives like issuing medication books or auditing prescribing errors, as in the Tainan region, have to be entirely self-funding. This inevitably leads to a perverse incentive where good professionals get poorer and those who do not champion patient care, invest less and get richer.

Training pharmacists

Taiwan's orthodox education system is six years at primary school, three years at junior high, then three years at senior high followed by four years at university. So university freshmen are 18 years-of-age or older.

Six out of seven pharmacy schools offer four-year courses, and one offers a five-year course. The School of Pharmacy at the National Taiwan University also offers a six-year program for a small proportion of students.

The Chinese for pharmacist translates into English as “happy herb teacher” and provides a testament to its foundation in Chinese medicines. Some pharmacies still practise the ancient art of extemporaneously dispensing age-old secret Chinese medicines formulations alongside conventional medicines. To the outside world this may be seen as a contradiction, but in the pharmacists’ eyes they are meeting the needs of two medical philosophies. Others believe the adage whereby Chinese medicines keep you well, conventional medicines make you well.

Research in pharmacy in Taiwan is in its infancy but is gradually becoming more requisite. Tony, Yen-Heui Tarn, director at the division of health technology assessment, Centre for Drug Evaluation, says: “In Taiwan, people can access medical services freely and the services are covered by the health insurance programme. The downside of this is the waste of the medical resources utilisation. The Bureau of National Health Insurance (BNHI) tried to restrain the outpatient clinic visit on the high frequency user (>100 visits/year) but in vain in the recent three years. Now, they have asked for a proposal from the National Union Pharmacist Association (NUPA) to try to resolve the problem.”

NUPA proposed a pharmacist home care programme in which the BNHI would provide lists of frequent users so that pharmacists could arrange home visits. Pharmacists providing this service would need to be trained and certified as long-term care pharmacists to provide the home care service. Each patient would be followed once a month for 12 months with the aim of achieving the following goals:

• To decrease the number of visits so that yearly medical care expenditure falls by 10 per cent
• To cut annual drug expenditure by 10 per cent
• To reduce problems arising from drug treatment
• To achieve appropriate drug therapy goals

The BNHI agreed to the proposal and offered US$300,000 for a pilot. Details such as the certification processes, service process, reimbursement process, fees and data management are under negotiation. This is the first time the BNHI has been willing to pay for pharmaceutical care and is the beginning of more professional care mechanisms if more items of service can be shown to be valuable and cost effective.

Pharmaceutical public health is in early development

Public health strategies through community pharmacies are still very much in the development stage. For example, nicotine replacement therapy can be bought, but free smoking cessation schemes are only GP-led, so few people buy NRT.

The Department of Health along with representatives of the Bureau of Health support the progressing role of pharmacists but do not know where to begin or how.

Susan Hu, chief of the Public Health Bureau in Tainan City, says that pharmacists are an important resource. Her role is to meet 84 annual health, environmental and Social targets and pharmacists are being used wherever possible. Many pharmacists feel however that their skills remain unrealised and that more could be attained and delivered if they had better support in terms of appropriate funding and professional aspirations.

The island’s 24 local pharmacists’ associations, along with the Pharmaceutical Society of Taiwan and the Pharmacist Associations of ROC represent pharmacists and aim to attain their professional vision. Many of the regional associations, which can have as many as 3,000 pharmacists from across all sectors including hospital, academia and industry, are proactive and aware of health needs. These organisations also have a role in PR and actively lobbying politicians.

The Pharmaceutical Society of Taiwan was founded in 1942 and is a member of the International Pharmaceutical Federation and the Federation of Asian Pharmaceutical Associations). It publishes The Chinese Pharmaceutical Journal. Its mission is to unite academics and practitioners of the pharmacy societies who are interested to promote pharmacy research, education, and services.

Pharmacy has local political support

Taipei is located in the Northern part of Taiwan. Taipei County Pharmacists Association was originally part of the Taipei City Pharmacists Association but as the numbers of Practicing pharmacists grew within the County it separated and is now under the jurisdiction of the Taipei County government. Next year Taipei County will become a municipality and be renamed Taipei City. Pharmacists hope this will open up new opportunities, while the mayor of Tainan City, who is looking for an unprecedented third-term election victory, is keen to highlight the role of pharmacists in public health and to champion patients rights.

With this in mind, the pharmacists’ associations of Kaohsiung, Taipei County, Taichung City, Hsinchu, Tainan and Taipei City along with the Pharmacist Associations of ROC, the Department if Health, GlaxoSmithKline and the School of Pharmacy at the National Taiwan University decided to organise and sponsor a one day international conference on community pharmacy services on the 20 September 2009. The aim was to be learn about, and learn how to participate in, patient-centred pharmaceutical care and to learn about public health initiatives. Speakers from America, the UK, Japan and Australia spoke about pharmacies in their countries.

Marialice Bennett, president-elect of the American Pharmacists’ Association and professor of clinical pharmacy at Ohio State University, outlined how medication therapy management (MTM) is conducted through US community pharmacies.

She explained that such reviews could be conducted with patients in any private setting. The reviews could be comprehensive, targeted or general and can include preferred outcomes. The future of MTM would be to demonstrate value, and thus seek reimbursement, and change the way students are trained.

John Bell, FIP vice-president and past-president of the Pharmaceutical Society of Australia, gave an overview of public health, its definition, determinants, links to pharmacy and examples in practice.

Governments world-wide are recognising pharmacy's potential

Mr Bell told participants that governments are now recognising the wider role of pharmacists in public health and that pharmacists are one of the most trusted professions, surpassing doctors and the armed forces. Public health issues he outlined included resistance to antibiotics, counterfeit medicines, harm minimisation, immunisation, health promotion (including smoking cessation and weight management) and pharmacovigilance. Mr Bell concluded his presentation by identifying some of the ways pharmacists can be involved in public health strategies especially in the areas of cardio-vascular disease, diabetes, weight management and smoking cessation.

UK pharmacist Sid Dajani spoke about the role of pharmaceutical care and clinical services in the UK. He provided a breakdown of pharmacy and explained the role of the Royal Pharmaceutical Society and its national boards. He also explained how the profession had become more clinical and pharmaceutical care orientated in the past ten years. This had implications for workloads, clinical governance, CPD and revalidation.

“We had to build new partnerships and look at providing packages of care, not just packages of medicines,” he said.

It also meant winning over the hearts and minds of the public, as well as other healthcare professionals and ensuring pharmacists were confident enough to perform the extended roles.

“The strengths of pharmacy are that we are at the frontline of healthcare, experts in self-care and because we are firmly placed in the community we are best positioned to provide preventative care and support public health,” he said. “Our education means we can also support other healthcare professionals to provide the right medicinal care, reduce errors and reduce adverse reactions, side effects, etc.”

Proof of worth was valuable in persuading those in government to invest in pharmacy. He went on. Barriers should not be seen as insurmountable obstacles but as challenges and, above all, pharmacists had to recognise that people who hide from risk also hide from its reward. Pharmaceutical care is the future, ignore it at your peril, he advised.

Nobumasa Imura, director general at the Japan Pharmacists Education Centre spoke about the education system and how the four- to six-year pharmacy training programme affected the profession. He also explained about postgraduate certification and the regulation of pharmacies.

Long-term care insurance is being considered

Ching-Yu Chen, Department of Family Medicine, National Taiwan University, said that the rapidly increasing older population in Taiwan meant that long-term care insurance was being proposed by the government. Polypharmacy would be more commonplace and he felt pharmacists had to join the community medical group or organise a community public health group to reduce (ADRs) through counselling, education and reviews. Beyond medicines, pharmacists could also engage in public health, community rehabilitation and chronic care. He said community pharmacy had exciting times ahead.

Ming-Neng, director general at the Taipei County Public Health Bureau, spoke about a community pharmaceutical care centre project established in 2005. So far, this programme hade reviewed the medicines of 8,337 patients and significant compliance issues had been discovered. In 2008, a home care pharmaceutical care services initiative had discovered 27 medication-related issues in 110 consultations. These projects highlighted the need for improving self health care management and potential roles for community pharmacists, he said.

Chen-Shen Li, director executive, Pharmacist Associations of ROC, called for the separation of dispensing and prescribing in clinical pharmacies so that pharmacists could demonstrate their professionalism and their roles in public health. This would improve healthcare services and quality outcomes.

The status and the challenges of community pharmacy in Taiwan and Asia will be further discussed at the Federation of Asian Pharmaceutical Associations’ congress in November 2010. This is organised every two years and Taiwan will host the 2010 congress. Symposium topics will include Taiwan community pharmacy and society, drug and patient safety, and health technology assessments

Taiwan and mainland China have a long history of interaction but Taiwan has its own distinct culture and traditions and much more besides. Taiwan is remarkable for many reasons — its preservation of Confucianism, its elegant Chinese architecture, the astounding variety of traditional Chinese arts, the large number of Japanese buildings and houses, and dining which includes the cuisines of Taiwan, mainland China and Japan enhanced with local modifications.

Healthcare through pharmacies, however, has yet to flourish. Its time has not yet arrived, but clearly if an opportunity is presented, the enthusiasm, dedication, aspirations and professionalism of the pharmacists will prove they can be the Taiwan miracle for healthcare.

Statue commemorating the surrender of the Dutch in the 1600s About Taiwan Taiwan is a small island, only about 400km long and 150km wide and, at only 15 million years of age, is geologically quite young. However its size or age is inversely proportional to its fascinating history. Studies show human habitation from as long as 37,000 years ago, but the first Western contact was only in 1500, when the Portuguese dubbed it the Ilha Formosa or Beautiful Island. Further visits by Westerners continued including failed colonisation attempts by the Dutch and Spanish during the 17th century. Later that century, migrants from mainland China began flooding across the straits to establish settlements. Following the end of the Sino-Japanese war in the 19th century Taiwan was ceded to the Japanese and for nearly 60 years, since 1949, political and social developments resulted in an end to most exchanges between Taiwan and mainland China. Taiwan now is a vibrant and happening place. It has made great strides in improving its economy and its productivity. It is home to two of the largest manufacturers of bicycles in the world and hosts the largest bicycle exhibition in Asia as well as the second largest computer show in the World, CeBIT. Taiwan’s meteoric rise as one of the world’s largest producers of computer products in the 1990s is just one example of what is known as the Taiwan miracle.