The Malaysian Pharmaceutical Society have been pushing hard for the dispensing of medications to be handled solely by the pharmacists with the tacit approval of the authorities. Things have come to the fore lately over likelihood of Pharmacy Bill which being tabled in the Parliament in April 2015; however this was recently denied by the MOH and MMC.

Dispensing Separation (DS) has been hotly debated by both divides of the healthcare profession, ie. the doctors versus the pharmacists. More than 95% of the pharmacist support it; while most of the doctors are against.

This article is about doctors’ point of view:

Does DS save cost of total national healthcare?

It is true, by means of bulk purchase and sales especially by the few giant pharmacy chains that dominate the market that drugs costs and sales prices would drop at the retail outlets.

However, this leads to rebound effects. The total cost of health cares (costs of consultation, dispensing, transportation and ancillary services) has been shown in studies in countries such as UK, Taiwan, South Korea and Hong Kong to be either the same, or increased.

The government in Korea attempted to force the comprehensive DS system down onto the people without prior informing and preparing the public for the change, as well as imposing low consultation fees on the doctors.

The result was a national strike by doctors which led to government realizing its mistake and hence provided for an increased consultation fees.

It is the same for Hong Kong; the people did not realise that the inevitable increase in consultation and other fees would either make cost not only either unchanged or even increased.

The Taiwan government was more proactive in increasing the fees before imposing DS. A few years ago, the government of Taiwan had to create another supplementary taxation in the form of national fund as the existing fund was found inadequate; this suggests that the costs have not been properly contained.

So, DS indeed has been shown to be unable to contain the overall costs of national healthcare.


What are the other controversies around DS system?

There are 5 major areas that we all, as health stakeholders should be concerned about in a new untested DS system.

We need to know that not all DS systems are the same. The advanced countries have overall well developed conditions which enable DS to be highly efficient and regulated.

There are 8 systems as far as the writer know; basically it is divided into first world country system and the third world system.

Before we can think of implementing DS in our country, we need to know, ultimately, are the benefits more than the risks of having the system.

Here are the 5 areas of concerned:

1) Safety: Is pharmacy dispensing necessarily safer?

Ideally, it is; however in practice on the ground especially in Malaysia, it is not so straightforward.

Dispensing by pharmacists must be subject to tight regulation and laws, as well as tight online monitoring, features which are extensively available in the advanced countries.

We are not having this system in place. This safety advantage of pharmacists’ dispensing is probably the sole advantage of DS, which Doctors’ Dispensing can overcome with better enhancements.

Healthcare is not just about medication. It is a holistic care where doctors know everything relevant about the patient, his family and community; he also know about the laws governing cares. Dispensing is not just about giving medication according to a specific diagnosis or about giving the cheapest brand. But more importantly, about how the medication can adjust to the whole person of the patient.

This is simply not available to the pharmacists. Doctors can prescribe and dispense better by being more accurate in giving the right brand and dosages in line with the total person of the patient and his conditions.

We have to realise that according to outcome studies done on the USA; errors by pharmacists in dispensing even in the in-house institutions have fairly high rates.

On the other hand, doctors normally have a niche patient pool with whom he has become very familiar with; over time the prescription and dispensing for a limited number of patient types become highly accurate with minimal side effects. The pharmacists have probably exaggerated the risks of doctors’ dispensing by giving anecdotal cases as highlights.

Doctors have repeatedly over time been presented with cases which have suffered either side effects of the medications, commonly of which are the highly potent steroids, or deterioration of health conditions due delayed presentation to the doctors after being treated by Pharmacists over long periods of time.

2) Holistic health care: Is pharmacists’ dispensing more holistic?

Pharmacists have been providing care services to the public in general. However, this would not be applicable in cases of patients cares. Malaysia has a unique endemic problem in that many, though not all, pharmacist hold stethoscopes, examine patients and attempt to diagnose the diseases without competence; some even skip these steps to prescribe.

Needless to say, this is not only illegal, it is also unethical. This has caused severely damages to the holistic healthcares by doctors.

Pharmacists’ dispensing is also not as holistic as the doctors’ primary – secondary cares clinics, because the latter is located practically anywhere in the country, many with 24 hour services.

DS emphasizes separation of cares where the pharmacist gain excessive amount of independence in managing patients; this is also not holistic.

In our country it is not uncommon for pharmacists to dispense based on various factors, which include availability, costs, substitutes, and personal preferences independent of the doctors’ prescriptions or even consultations.

Pharmacists know more about drugs and drug to drug interactions. This does not mean doctors cannot and would not know as much about drugs. Better and longer courses on Pharmacology in the medical schools would enhance the skills on drugs prescriptions and dispensing; employing a diploma level pharmacist would put doctors on par with store pharmacists. Use of dispensing aid using technology and software would enhance the dispensing standard.

Doctors’ dispensing is also more holistic because it reduce the practical burdens of the sickly patients of having to travel to another area for medications. It is more than just being inconvenient; for a sickly person, comfort, and one stop centre become a necessity. Even in the internet, we see many public forums on DS both in the developed and developing countries where grouses were heard about how troublesome it was to go to two places for treatments.

3) Suitability: Is Malaysia suitable for DS?

There are numerous reasons why DS is not ideal for Malaysia.

The mains one are:

Firstly, the unique care culture whereby pharmacist manage patients all by himself will make DS highly risky to the health of patients. There appear to be widespread anecdotes of practices of Pharmacists throughout the country performing substandard and dangerous clinical workouts, such as taking Blood Pressure, performing blood tests, etc. Some retail outlets share a few pharmacists so that at times sales and cares were provided by lay counter persons.

Our public culture of implicitly trusting the pharmacists as diagnostician and primary care providers whether in the less developed states or more developed areas allow this kind of practice flourish and does not provide enough checking on the validity of pharmacists' services.

On the other hand the enforcement of laws against this anomalous situation is at best lax and inefficient, despite these laws are in place. There is simply no system of checking on the works of pharmacists, especially an online or actual stringent check by the MOH, as such are potential high health risks to the public.

This is unlike the cases in the developed countries where the people are highly knowledgeable about their conditions and necessary treatments, and the laws are far more tightly enforced on errant Pharmacists. So, can we say our health system is ready for DS?

There is also general reluctance by the pharmacists to make referrals to doctors for such primary duties by the pharmacists in the communities.

Other local scenarios which make DS inappropriate:

The consequence of DS here would be that the law of the jungle would prevail among the pharmacists with the giants competing against the smaller retailers, as well as the domineering manipulation by the pharmacist over the doctors. DS before establishment of an airtight and efficient national health scheme would lead to this scenario: Widespread practice of having one Pharmacist running several outlets across districts or even states.

4) Commercialisation of Healthcares: Does DS lead to an unhealthy business monopoly?

We need to see the total picture of the implications of DS.

Control of dispensing immediately leads to giant pharmacy chains monopolising the while market at the expense of the smaller retail pharmacists and doctors.

This changes the nature of healthcare system of the country, when the holistic medical cares become beholden to the business giants whose commercial interests override the public interest.

Already there are now ePharmacy in the market doing commercial promotions to sell directly to consumers and probably patients bypassing doctor’s clinical cares.

There are also link ups with laboratory diagnostic centres which give the public a false perceptions that anyone can seek dispensing just by laboratory values without knowing that full clinical assessment and management cares by doctors are still and always will be the cornerstone of sound and safe medical cares.

Political favouritism is often linked to corporate advantages. It is not too unrealistic to see that laws of the jungle in terms of price wars and market shares may prevail in our national healthcare.

The authorities in national health care would possibly relinquish the healthcare standard to the vicious forces of market, unless it sets up an overarching control system to strictly prevent this from happening.

However, it does not seem that the authorities would be able to do so, as it had happened to TPA/MCO having total control over the doctors fees with the authorities having virtually no power to rectify the anomalies.

DS would result in chaos in the private healthcare system in the country because 1) it causes the demise of many GPs immediately upon implementation, 2) it causes doctors to fight each other according to law of jungle because the authorities concerned refuse to promise a reasonable pricing control for the doctors and let the public know it is not concerned. Even if 1care versions come in later, no authorities would promise anything in concrete terms. In fact at worst it may suppress and total regulate our remunerations.

5) Readiness: Is Malaysia ready for DS?

Have the stakeholder of public consumers been thoroughly consulted on DS? This is the most critical point of note. Why is this so? Because these are the people, the patients, who are going to ultimately face the whole risks and benefits of a changed dispensing system.

Difficulties arise in the implementations occur in Korea and Japan because of lack of fair and widespread consultations with the public.

In Malaysia, this had never been done in a large enough scale.

The online public survey by the pharmacy community was not earnestly done to call on the attentions of the general public but is apparently just a show of fulfilling a requirement. Hence, to determine the acceptance of DS among all patients throughout Malaysia, there is now with an ongoing nationwide unbiased survey by a neutral company appointed by the GP Community. The result will be available soonest possible.

Our Pharmacist Bill was conceived in secrecy despite these affects every major stakeholders of healthcare i.e. the people and the doctors. Any open discussions are limited and not comprehensively conducted.

The Bill blueprints had been forbidden from viewing by the public, doctors, and politicians except perhaps the Malaysian Pharmaceutical Society. In fact with the backdrop of secrecy we see a massive flourishing of Pharmacy chains all over the country over a short span of time suggesting their utter confidence of coming of DS.

We need to learn the hard lessons from South Korea which face doctors’ national strike during its comprehensive implementation of DS.

There was lack in strategic plan for implementation. The government of Korea also fail to appreciate that the policy making paradigm of the authoritarian mean no long works. There was also lack of supporting policy infrastructure for pharmaceuticals.

Furthermore there was failure to convince consumers of the benefits of the reform. Korea needs societal institutions of consensus-building on major health policy issues, which are founded on fair and transparent rules that every participant should follow.

Malaysia has been practicing such secret style of governance and therefore is in danger of moving along the same ways as the Koreans.

Therefore, we are simply not ready for DS.

Who are against DS:

1. Malaysian Consumer Association
2. Muslim Consumer Association
3. Malaysia Consumer Movement
4. General Practitioners Groups
5. PERDIM (Datuk Dr. Ahmad Shukri Bin Ismail)
6. MCPAM (Dr Jim Loi)


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**Written by Dr Low Boon Teck, Dr Mohd Hanifah Hamidon, Dr Raj Kumar Maharaja, Dr Mior Yusof, Dr Aman Shah, Dr Raja Kohlia, Dr Thirunavukarasu Rajoo
**The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the position of Astro AWANI