In healthcare, it’s not just the diagnosing doctor or the caring nurse who are important; pharmacists dispensing medication also play a vital role.
To many, pharmacists are seen as individuals who merely dispense medicine behind a counter. While this perception isn’t entirely inaccurate, pharmacists are far more capable than commonly assumed, and this is not lost on the public. As Saw et al. (2015) stated, although many Malaysian healthcare consumers surveyed were unaware of the specific areas in which pharmacists are trained, they felt that pharmacists can play a greater role in our healthcare system.
A pharmacist’s role is not solely to dispense medicine. They offer advice on doctors’ prescriptions, administer vaccines, adjust medication dosages, treat minor ailments that do not require a doctor’s diagnosis, and provide information about supplements.
Most importantly, pharmacists serve as an essential information gateway for patients seeking to understand their medication.
Although people may not fully grasp the pharmacist’s role, they are generally supportive and believe in pharmacists’ greater potential, as summarised by Saw et al. (2015) and Ng et al. (2020). Notably, Loo et al. (2019) reported that 86.7% of Malaysians surveyed believe pharmacists have superior knowledge about medication compared to physicians.
Community pharmacists are integral healthcare providers within their communities. As Loh, Chua and Karuppannan (2021) highlighted, nearly all surveyed community pharmacists (99.5%) offer health screening and monitoring services. However, they encounter barriers in fully executing their duties, with the lack of dispensing separation identified as a primary obstacle (Selvaraj, Redzuan & Hatah, 2020; Loh et al., 2021).
Dispensing Separation
Dispensing separation divides the prescribing and dispensing process between doctors and pharmacists – doctors solely prescribe medication, while patients must go to a pharmacist to obtain their prescribed medication. This system functions as a check and balance, preventing doctors from overprescribing or unnecessarily prescribing medications, as pharmacists, being separate entities, oversee the dispensing process.
In Malaysia, doctors can both prescribe and dispense medication depending on their workplace. Currently, only public hospitals and health clinics are mandated to implement dispensing separation, while private institutions are exempt.
Doctors dispensing medication have led to serious issues. According to the report, pharmaceutical companies have paid billions of dollars to doctors for consulting, meals, and promotional talks, leading to higher volumes of drug prescriptions from these companies.
In the Malaysian context, a respondent in Saw et al.’s (2015) study mentioned that, based on their experience, consulted general practitioners (GPs) would occasionally prescribe unnecessary medication.
Another recent study in Malaysia by Kabir et al. (2021) revealed a significant positive relationship between sales promotions and the prescribing behaviour of Malaysian physicians. Those promotions even ranged from low-value gifts such as pens or mugs to high-value gifts like laptops or sponsorship to local and international conferences.
Dispensing separation is a crucial safeguard exactly against such scenarios, deterring unscrupulous doctors from overprescribing medication for financial gains.
The mandatory implementation of dispensing separation across Malaysia, would greatly empower community pharmacists, facilitating their enhanced contribution to community well-being.
Furthermore, pharmacists are not the sole proponents of the view that dispensing separation can improve our healthcare system; the Malaysian general public shares this sentiment. While Loo et al. (2019) reported that only 52.5% of respondents favoured the implementation of dispensing separation, a 2021 research by Ghani, Kamaruddin, and Mokhtar found that 66.5% of their respondents supported it, with 29.5% remaining neutral.
However, dispensing separation also raises its own concerns.
Challenges Ahead
Implementing dispensing separation would increase the viability of community pharmacies. A 2016 report highlighted that some pharmacists struggle financially, greatly relying on sales of non-medical items. Allowing them to dispense prescription-only controlled drugs would undoubtedly boost their income.
But the same argument applies to private GPs who own clinics. According to a 2014 report, since the Private Healthcare Facilities and Services Act 1998 (Act 586) has capped GP consultation fees at RM10 to RM35, medication sales serve as their primary source of revenue.
Mandating dispensing separation risks a widespread decline in private clinics, which would impact public health as patients flock to public hospitals and clinics.
Dispensing separation also raises concerns about the accessibility of community pharmacies in certain areas. Tew et al. (2021) noted that six districts lack a community pharmacy, two lack GP clinics, and eleven districts in East Malaysia lack access to both. Tew et al. (2021) also observed a significantly higher density of community pharmacies in urban areas compared to less populated ones, with Sabah facing a particularly concerning ratio of 1 pharmacy to 20,032 people.
Implementing dispensing separation without addressing this issue could have catastrophic consequences for people in areas with limited pharmacy access.
Navigating the Challenges
To prevent mandatory dispensing separation from crippling the private healthcare industry and leaving people in areas with limited pharmacy access without medication, we must address these two concerns before proceeding.
Fortunately, we are not starting from scratch in dealing with these problems.
To sustain private clinics post-dispensing separation, the government should consider reviewing the fees listed in Act 586.
In December 2019, the then government agreed to deregulate private GP consultation fees, but the change never materialised. In May 2023, the MADANI government once again proposed restructuring consultation fees after the parliament approved the Health White Paper (HWP).
However, upon closer examination of the HWP, there was no mention of restructuring private GP consultation fees.
Concerns exist regarding the deregulation of consultation fees, as there are fears that private GPs may overcharge for their services, making deregulation unsustainable for our healthcare system.
However, implementing periodic revisions of GP consultation fee regulation with establishing new price floors and ceilings according to the economic situation would allow doctors to adequately cover their expenses while preventing overcharging.
As for the lack of accessibility to pharmacies in certain areas, a zoning system for community pharmacies could be the solution we need. In 2012, the government already was exploring such a system to ensure a more even distribution of pharmacies between rural and urban areas. However, unfortunately, there has been no follow-up on this initiative since then.
The Malaysia Pharmacists Society mentioned past efforts in Johor, which saw limited success, likely due to insufficient public support at the time. However, the landscape has evolved significantly since then. A recent qualitative study shows that consumers are now cognizant of the uneven distribution of pharmacies between urban and rural areas, with some seeing zoning policy as a viable way to improve accessibility in rural areas (Leong et at., 2022).
Furthermore, Leong and Chong (2024) conducted a study from the perspective of community pharmacists, who also saw zoning policy as advantageous for improving the quality of healthcare services.
Coincidentally, both consumers and community pharmacists share concerns about the implementation of zoning policy, fearing the potential creation of monopolies in their areas. Both groups worry that once zoning occurs, the sole pharmacy in the area may increase prices or shorten operating hours due to limited competition.
Therefore, to address these concerns, community pharmacists propose zoning based on population size rather than area (Leong & Chong, 2024). The government regulation on operating hours coupled with price control can mitigate the adverse effects of potential monopolies.
It is worth noting that community pharmacists who participated in Leong and Chong’s research also emphasized the necessity of dispensing separation for zoning policy to be effective.
As mentioned before, without dispensing separation, community pharmacies can only sustain themselves by selling non-medical products.
However, the income gap between rural and urban areas remains wide, indicating much lower spending power in rural areas. Together with the rising cost of living, people are less likely to spend on products like health supplements, thereby reducing community pharmacy income.
Enforcing a zoning policy without dispensing separation would reduce the number of pharmacies in urban areas. However, due to the higher financial risk of operating in rural areas, few, if any, would establish businesses there.
If done right, dispensing separation has great potential to enhance the healthcare system and benefit a broader spectrum of people. However, addressing a few corresponding issues is crucial to prevent this well-intended policy from weakening our community healthcare system.
Chia Chu Hang is a Research Assistant at EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.
