Ilvana Silva - univie.ac.at

Patient oriented health promotion

in Community Pharmacy in Portugal

Country Report

Ilvana Silva

Ordem dos Farmacêuticos

March 2001

Ordem dos Farmacèuticos Rua da Sociedade Farmacêutica, 18 PT-1150 Lisboa Phone:+ 351-1-3191370 Fax:+ 351-1-31913 99 Email:[email protected] http://www.ordemfarmaceuticos.pt

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Content

Project Data 3 Disease Management (Pharmacist Managed Programmes – Asthma, Diabetes and Hypertension) 3 Needle Exchange Programme 6 Methadone Substitution Programme 11 Management of a Nationwide Control Programme of Diabetes Mellitus 14 Nationwide Programme of Collection and Management of Medicine Package Waste and 18

out of date Medicines, after consumption - VALORMED

Health Care System 21

National Health Service 21

Community Pharmacy 22

Supporting & Hindering Factors 23

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Project Data

Disease Management (Pharmacist Managed Programmes – Asthma, Diabetes and Hypertension)

Contact Person

Suzete Costa

Associação Nacional das Farmácias

Rua Marechal Saldanha, 1

1200 Lisboa – Portugal

Tel.: + 351 21 3400600 Fax: + 351 21 3400759

Email: [email protected]

Commissioned by

National Association of Pharmacies (Associação Nacional das Farmácias)

Co-ordinated by

There is a head co-ordinator for all three programmes and a manager for each programme:

Suzete Costa – Head Co-ordinator and Hypertension Programme Manager

Anabela Madeira – Asthma Programme Manager

Rute Santos – Diabetes Programme Manager

Running time:

To start in October/November 2000 and after that it will be an ongoing process (aims to become an integral

part of everyday practice)

Current state:

For each Programme:

- Concept development phase is completed

- Programme guidelines are completed

- Implementation strategy is defined

- Current Phase (in May 2000): finishing instruments (for evaluation purposes)

- Next step: pre-test (June 2000)

- Pilot phase to begin in October 2000

Short description:

Problem description: Chronic disease patients bring along extra responsibilities for the community pharmacists,

but also opportunities for them to intervene as health care professionals, since these patients are regular

customers of a given pharmacy, acquiring (long term) medication prescribed by the physician.

Goals: The ultimate benefit of the patient and the whole health care system in general.

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Aims: To implement disease management programmes (currently: asthma, diabetes and hypertension) in

Portuguese pharmacies, by following a common strategy and methodological approach for all three

programmes.

To assess the impact of such programmes in target patients through data collection (structure, process and

outcome indicators) in participating pharmacies.

Targets: To have an increasing number of involved pharmacies and pharmacists in the programmes.

Strategy and Methods: The strategy has a common approach for all of the three programmes:

- Dynamic intervention strategy, targeted to chronic disease patients who are regular costumers of

Portuguese pharmacies (asthmatic, diabetic and hypertensive patients)

- Good possibilities for improved patient outcomes (clinical, economical, humanistic) through pharmacist

intervention

- Patient management by the pharmacist

- Co-operation with patient’s physician/prescribers

- Use of guidelines, forms and flowcharts to support the pharmacist’s intervention

- Programme evaluation

The implementation strategy of these programmes is based on sound epidemiological methodology, defining

the following:

1. Objectives

2. Intervention design

3. Participating pharmacies

4. Target Patients

5. Data to be collected (definition of indicators)

6. Instruments (forms and questionnaires)

7. Pre-test (to test the instruments)

8. Materials

9. Training of pharmacists

10. Pilot intervention

11. Programme evaluation

The current stage is between 6) and 7).

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Scope:

National – the overall goal is to involve all Portuguese pharmacies in these programmes

The pilot programme, however, will be conducted at a regional level.

Partners

Pharmaceutical Society (for validation purposes)

Medical Societies (disease specific)

Patients Organisations (disease specific)

Consulting Physicians

Community Pharmacists

Public Health experts

Pharmacoepidemiology experts

Health economic experts

Systematic project evaluation:

A systematic project evaluation has not yet been conducted. Baseline evaluation is planned before the pilot

intervention and subsequent evaluation will be made.

Available information:

Information is not yet available, as the pilot intervention has not yet started.

Factors supporting the development and implementation:

The most important factors supporting these programmes are the support by the professional organisations

and the training of pharmacists (both disease specific and concept relevant – political and professional

orientation).

Barriers to development and implementation:

We are not yet at that stage, however we assume the most important barrier will be that a systematic

documentation will be needed for evaluation purposes and pharmacists are not used to documenting their

activities, which will involve time and resource consumption. We expect the computer system to facilitate the

process.

Well-developed aspects:

Clear definition of implementation and evaluation strategies, so far.

Available publications:

Not available for public use.

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Needle Exchange Programme

Contact Person:

Alexandrina Teles




Tel.: + 351 21 3400600 Fax: + 351 21 3400749


Commissioned by

Ministry of Health, through the National Committee Against AIDS (Comissão Nacional de Luta Contra a SIDA)

Co-ordinated by


Alexandrina Teles – Head Co-ordinator

Running time:

The Programme has been running since October 1993

Current state:

Integral part of everyday practice

Short description:

Problem description: The community pharmacist has always had frequent contact with drug addicts, providing

them syringes.

As health professionals, pharmacists have a great responsibility to improve people’s knowledge and awareness,

with the aim of reducing behaviour involving risk in this field.

With the spread of new diseases such as AIDS and Hepatitis B among risk groups, mainly among people using

IV drugs, it was felt necessary to promote effective prevention of sexual and blood transmission of HIV in this

particular risk group, and in addition, to reduce the risk of needles causing accidental injury to the population in

general.

In response to this need, a needle exchange programme was developed entitled “Say NO! to a used needle”.

The behaviour patterns of IV drugs addicts determined the model and materials used in this programme, which

has been made available since October the 1st, 1993, through the 2,500 pharmacies throughout Portugal.

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In recent years, it has been found that the rate of HIV transmission among the various risk groups has tended to

become inverted. Formerly, homo- and bi-sexual groups occupied the leading position, followed by

heterosexual and drug addicts. It is now found that the latter groups are more susceptible to HIV transmission.

It is therefore considered that any measures planned with a view to altering this trend would be useful in terms

of public health.

In this particular case, both the government and non-governmental organisations linked to AIDS and to drug-

addiction, pharmacists, drug addicts and the population in general were unanimous in considering the

programme both positive and useful. Therefore, it is hoped that such a programme will continue to have an

important contribution to reduce the number of drug addicts infected with HIV.

Finally, it is important to mention that through this programme, the community pharmacist showed that with a

simple gesture of solidarity, he/she is in an excellent position to contribute to several health programmes and

reinforced his/her social role, as well as his/her public image.

Goals:

- To change behaviours and habits negative for public health, through awareness of the drug addict

population and motivation of health professionals

- To prevent sexual and blood transmission of HIV among IV drug addicts

Aims:

- To implement a syringe exchange network throughout the Portuguese pharmacies

- To assess the impact of the programme on target patients through data collection (structure, process and

outcome indicators) in participating pharmacies

Targets:

- Reduction of needle sharing and other injection paraphernalia

- Reduction of improper syringe disposal

- Promotion of condom use

- Promotion of changes in behaviour patterns

Strategy and Methods: In the early years, the programme consisted of exchanging a used syringe for a free kit

containing a sterile syringe, a condom, a small desinfective towel and a leaflet promoting behavioural change.

The analysis of the current behaviours of the IV drug addict population and the experience of almost 6 years in

exchanging syringes led to the necessity of reformulating the Kit contents, in order to adjust it to current

behaviours. Therefore, since August 1999, the new kit has contained two sterile syringes, two desinfective

towels, a condom, a filter, a little bottle with distilled water and an information leaflet.

The material available to the pharmacies includes descriptive literature on the programme procedures and

information about AIDS, such as how to deal with contaminated material, how to approach HIV-positive

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individuals, a professional leaflet, a poster to place in the pharmacy, various leaflets, containers for used syringes,

kits and a door sticker.

The poster, strategically placed in the pharmacy, invites drug addicts to come in and place their used syringe

and needle in a proper container, in exchange for a kit provided by the pharmacist, on the basis of a

“gentleman’s agreement”.

- two syringes = one Kit-

While exchanging syringes, the pharmacist has a chance to talk to IV drug addicts and to provide a warning of

the risks and consequences of such behaviour and can motivate the individual to take effective preventive

measures (improve self-care).

Since each pharmacy has a variable number of drug addicts, it is possible for the pharmacist to order the

necessary quantity of kits from the pharmaceutical distribution co-operative, as well as used-syringe containers,

the capacity of which varies between 160 to 700 syringes.

Seven co-operatives and two pharmaceutical wholesalers take part in the programme.

To help the pharmacist to handle the programme and to assist with any possible doubt or problem, a

telephone line was available free of charge during the first three months after implementation of the

programme in the pharmacy.

Every month the local authorities, or a private company hired for the purpose, collects the containers from the

pharmacies for disposal through incineration. In pharmacies that have a larger volume of used syringes, the

containers are collected every week or every fortnight.

While the programme was running, it was verified that in some urban areas a large number of drug addict were

exchanging syringes, making it necessary to provide mobile units to collect the syringes and deliver kits as a way

of supporting pharmacies located in those areas.

Also aiming at a higher suitability of the programme for certain groups of the target population, partnership

protocols were signed with several NGOs that develop activities of support towards drug addicts, as well as

AIDS prevention, which then started to exchange syringes and supply kits to the population with whom they

work.

Scope: National

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Partners: The programme was set up by the Health Ministry’s National Committee Against AIDS and the

National Association of Pharmacies, a non-governmental organisation which represents the majority of

Portuguese pharmacies, with the support of co-operatives, pharmaceutical wholesalers and local municipalities.


To assess the results of the campaign, it was necessary to determine the quantity of syringes held by each type

of container.

To administer and monitor the programme daily, specific software was developed to control stocks and to

record movements of kits and containers for each pharmacy.

Based on the total number of used syringes collected during the first three months of the campaign and on the

good acceptance of the programme by drug addicts, the entities involved decided to extend the programme

indefinitely.

A monthly report is made on the programme developments.


- The material available to the pharmacies includes descriptive literature on the programme procedures and

information about AIDS, such as like how to deal with contaminated material, how to approach HIV-

positive individuals, a professional leaflet, a poster to place in the pharmacy, various leaflets, containers for

used syringes, kits and a door sticker.

- Posters.

- Monthly report on the current state of the programme.


The main factors supporting the programme are the motivation of the pharmacists, the partnerships that have

been made and continue to grow with NGs and municipalities, and the improvement of drug addicts’ behaviour

towards society and vice-versa.

Furthermore, the results on the programme evaluation themselves express its success and support its

continuity. In fact, the results of the Campaign “Say NO! to a used needle” have largely exceeded all

expectations. After almost 7 years since the implementation of the programme (and which most certainly

represents the biggest action in terms of Public Health ever undertaken in Portugal), the over 18,739.041 used

syringes collected to 31 March 2000 support its success.

According to a study made in 1996 by the National Observatory in order to assess the programme users

needs, 86.6% of individuals said they had never shared a needle; 8.4% shared one sometimes; 0.3% share them

frequently; 27.7% shared the drug solution and 29.4% shared the filter. These results made apparent the

necessity to reformulate the kit in order to include some other materials apart from those already delivered to

adapt the kit to newly-identified risky behaviours.

The programme also made it possible to identify small groups within the drug addict population that were

particularly marginalized, lived in extreme conditions of poverty and isolation, and urged many NGOs to

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develop new protocols of collaboration with the programme coordinators in order to enable a larger coverage

of the programme and to enhance its adequacy to these particular groups.


In the beginning, and as with any programme involving drug addicts, the stigma associated to this group of the

population was one of the barriers to the implementation of such a programme. The initial lack of receptivity,

both from the general public and some health professionals was, however, overcome. The whole programme

and the huge awareness campaign that took place greatly contributed to this group being viewed differently,

thus reducing their lack of acceptance in society.

The drug addict himself is a difficult person to deal with and to get involved in ongoing projects that may

influence his/her health condition and inclusion in society.


The programme is well structured and is running smoothly.

The basis of the programme’s success is, undoubtedly, the intersectorial collaboration between the different

agents involved, who have ensured the preconditions needed for the execution of the programme’s goals.

The integration of pharmacies, as part of the health system resources, made a concerted and global action

possible, one hardly achievable by any other structure, due to its geographical situation and time availability.


2 Bulletins (nov. 97 e jul. 99) on the Programme developments and information (only in Portuguese):

- Bulletin 1 - "Diz não a uma seringa em segunda mão", November 1997, CNLCS & ANF

- Bulletin 2 - "Prevenção da infecção pelo VIH com populações utilizadoras de drogas por via endovenosa",

July 1999, CNLCS & ANF

The Drug Addict’s Manual to harm reduction (only in Portuguese, and adapted from the French version).

- Several articles published in professional newsletters and magazines.

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Methadone Substitution Programme

Contact Person:

Anabela Madeira




Tel.: + 351 21 3400600 Fax: + 351 21 3400759


Commissioned by

Minister of Health, through the Service for the Prevention and Treatment of Drug Addiction (SPTT)

Portuguese Pharmaceutical Society


Co-ordinated by


Anabela Madeira – Head Co-ordinator

Running time:

Started in June 1998

Current state:

A pilot phase has been completed and the programme has already been extended to some more districts.

Short description:

Problem description: The increasing number of individuals who take part in narcotic substitution programs

required the creation of a network in order to provide support to the Health Ministry’s Centres for Drug

Addiction (CAT).

Due to their technical and professional characteristics, and their equal distribution all over the country, the

pharmacies are an important interface in the network of support for the Centres for Drug Addiction (CAT).

The participation of pharmacists in this project is a vital contribution because it enables the patient to comply

with the treatment in his area of residence or professional activity, which means an important benefit in terms

of his private life and social integration.

During the first year, 65 pharmacies in six districts (Lisbon, Leiria, Santarém, Setúbal, Faro and Viana do Castelo)

developed this project.

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Goals:

- To involve pharmacists and pharmacies in the support network which provides Methadone Substitution

Programmes.

- To document, assess and report on the pharmacist’s intervention and the ultimate benefit to patients.

Aims:

- To improve the accessibility of the therapy, avoiding the need for patients to move outside their living or

working area to comply with the treatment.

- To develop new formulations of methadone hydrochloride.

Targets:

- To improve accessibility, enhance compliance and ensure the correct administration of methadone.

- To facilitate social, labour and reintegration into the family of the patients.

Strategy and Methods:

This program focuses exclusively on patients already integrated in substitution programs in CATs (Centres for

Drug Addiction).

The pharmacists give the patients a daily solution of methadone hydrochloride, in compliance with the

prescription. Thus, patients don’t have to move outside their living or working area to comply with the

treatment.

The maximum number of patients per pharmacy is 5 and the selection of patients is made by the team of the

respective CAT.

All pharmacists who want to take part in this project have to register for compulsory training courses that are

organised by the S.P.T.T. (Service for the Prevention and Treatment of Drug Addiction), the Pharmaceutical

Society and the National Association of Pharmacies (Associação Nacional das Farmácias).

Before initiating the programme, pharmacists undergo a training session of one day and a half with the CAT

team with whom they will work at a local level.

The development of this program is based on the co-operation between pharmacists and the therapeutic team

of the CAT: physicians, psychiatrist, nurses, therapists and social workers.

The pharmacists’ involvement in this project goes far beyond the administration of methadone. The pharmacists

are also responsible for the quality warranty of the raw materials and develop studies on the manufacturing of

new formulations of methadone hydrochloride. Therefore, pharmacists rely on the resources of ANF’s

Laboratório de Estudos Farmacêuticos (Laboratory of Pharmaceutical Studies) and Cetmed (Pharmaceutics’

Technological Centre).

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Scope:

National – the overall goal is to involve as many pharmacies as possible.

Partners:

- Consulting Physicians

- Community Pharmacists

- Psychiatrists

- Nurses

- Therapists

- Social workers


By April 2000, 88 pharmacies were participating in the project, providing therapy for 296 patients.

Available information

Agreement Protocol between the different partners.


Pharmacists already had experience dealing with the drug addict population through the needle exchange

programme and the addiction tracer medicines’ project.

The programme has evolved in a very positive way and according to the initial expectations. True team work

has been achieved and all the interested parties have established a cohesive partnership.

The evolution of the programme is continuing in a phased manner and according to the local CAT’s needs.

After a patient is selected to start the programme, he/she must sign a contract in which the duties of the health

providers as well as of the patient are stated and this contributes to implant a more responsible attitude in the

patients and to the accomplishment of the agreed goals.


The involvement of both private and public bodies made the structuring and consolidation of the whole

programme a slow process. However, the slow introduction of the programme has made it much more solid

and the objectives are being accomplished in a phased way.

The initial fear that the involvement of the pharmacies in the programme would lead to failure because the

patients would leave the CATs and would only use the pharmacies was overcome thanks to the strong

teamwork on which the partnership CATs/Pharmacies is based.


Every two months, a meeting is organised between the CAT team and the local pharmacists to evaluated the

current state of the programme in their working area and assess the patients’ progess.


Protocol

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Management of a Nationwide Control Programme of Diabetes Mellitus

Contact Person:

Ivana Silva

Ordem dos Farmacêuticos

R. Sociedade Farmacêutica, 18

1169-075 Lisboa – Portugal

Tel.: + 351 21 3191381 Fax: + 351 21 3191399


Commissioned by

Health Ministry

Co-ordinated by

The Advisory Committee to the Programme Management, composed by a member of each institution that has

subscribed the protocol and chaired by a representative of the Health Ministry.

Running time:

On 14 October 1998, a protocol of agreement towards the management of a nationwide control programme

of diabetes mellitus was signed by several health partners.

The subscribers reached an agreement following several months of negotiations, in which each of them has a

specific role in the management of a nationwide diabetes mellitus control programme.

The programme has been running since then in a phased manner. The first stage was to inform and train the

health professionals and make the products under protocol available in as many pharmacies as possible. This

has been achieved now and the next stage will be to expand the awareness of the general public of the

programme and to implement the systematic retinopathy diagnosis.

Current state:

Part of everyday practice.

Short description:

Problem description: Diabetes Mellitus is a serious problem of Public Health at an international level, not only

due to its increasing incidence, but also due to the enormous mobility and mortality associated to this particular

disease. It is estimated that in Portugal alone, there are between 300,000 and 500,000 diabetics, corresponding

to a prevalence of 3-5%, and of which 10-12% are insulin dependent.

The lack of information, education, early diagnosis and treatment accessibility are some of the factors that

urgently need to be overcome in order to reverse the increasing numbers.

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Goals: Conception of a nationwide control programme in which all health partners could be actively involved,

both from an economic and services provided perspective.

Aims: The Ministry of Health has defined guidelines, based on several reference documents including the St.

Vincent Declaration, towards the development of a diabetes mellitus control programme aiming at:

- The promotion of a growing share of responsibility taken by diabetic patients in what concerns their

treatment and disease management.

- The improvement of health care of diabetic patients.

Targets: The subscribed protocol foresees the following intervention areas:

price definition of strips for blood and urine glucose tests and urine ketones tests;

purchase, storage and dispensing of syringes, needles, strips and other material for blood and urine glucose tests

and urine ketones tests;

- use of the “Diabetic Patient Manual” by diabetic patients;

- use of the “Diabetes Binder” by health professionals;

- training of diabetic health care providers;

- patient teaching of self-surveillance and self-care of diabetes.

Strategy and Methods:

Each partner has certain obligations (both economic and service provided to fulfil, according to the protocol.

Thus, the Portuguese Pharmaceutical Society, for instance, has agreed to:

contribute to improve pharmacy practice in what concerns diabetic health education, healthy lifestyles for

diabetics and adequate diabetic patient counselling;

cooperate in specific training sessions aimed at pharmacists and/or other health professionals covering the

current control programme;

- keep the Ministry of Health informed of the participating pharmacies;

- certify pharmacists and pharmacies (following a training seminar and assessment) in order to enable them to

participate in the programme;

- keep diabetic patients informed of the services they are entitled to in a certified pharmacy;

- promote the proper use of the “Diabetic Patient Manual” and finally, to monitor an adequate dispensing of

the products to diabetic patients.

The National Association of Pharmacies, amongst other obligations, has agreed to dispense the products

(defined by the Ministry of Health) to diabetic patients without charging the profit margin due to the respective

pharmacies. This means that pharmacies have no profit in dispensing these products to diabetic patients,

provided they are holders of a prescription for this purpose only and the “Diabetic Patient Manual” which is the

I.D. card of diabetic patients (information filled by the doctor, the pharmacist and the patient).

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The wholesalers, amongst other obligations, have also agreed to distribute the products mentioned above to

the pharmacies, without charging their profit margin.

The Portuguese Association of Pharmaceutical Industry has also agreed to find companies willing to sell their

products at a lower cost – prices fixed by the Government.

The whole system is managed by the Ministry of Health.

Scope:

National

Partners:

- Ministry of Health;

- Portuguese Pharmaceutical Society;

- National Association of Pharmacies;

- Portuguese Association of Pharmaceutical Industry;

- Pharmaceutical wholesalers;

- Portuguese Society of Diabetology;

- Diabetic Patients’ Association.


In October, the programme will have been running for two years and so far, more than 90% of the total

number of pharmacies in Portugal have been certified by the Portuguese Pharmaceutical Society to participate.


Protocol


This historically unique protocol subscribed to by so many different health partners has made possible a

nationwide diabetes mellitus control programme which aims to provide health benefits for diabetic patients at a

lower cost, because the different partners involved have agreed to cut their margin of profit – the patient pays

only 25% of the purchase price of the products. The National Health Service co-pays 75% of the price fixed by

the Government for the Pharmaceutical Industry.

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The Diabetic Guide – a pocket guide where the patient has all the information he /she needs regarding the

objectives to be accomplished, according to his/her doctor, and presentation of which at the pharmacy is

mandatory in order to dispense the medicines and products under protocol.

The Diabetes’ Binder – a complete and comprehensive dossier with information to the professionals.

The Diabetes Mellitus Control Programme Guidelines - based on several reference documents, including the St.

Vincent Declaration.

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Nationwide Programme of Collection and Management of Medicine Package Waste and out of date

Medicines, after consumption - VALORMED

Contact Person:

Francisco Noronha

VALORMED

Av. Das Tulipas, Edifício Miraflores, n.º 6, 6º A

1495-161 Algés – Portugal

Tel.: + 351 21 4139650 Fax: + 351 21 4139659


Commissioned by

VALORMED – Sociedade Gestora de Resíduos de Embalagens e Medicamentos, Lda.

VALORMED is a non-profit society created under national legislation in order to respond to the waste

management legislation in force (resulting from the transposition of the EU Directive 94/62).

Co-ordinated by

Francisco Noronha – General Director of VALORMED

Running time:

The programme has been running since May 2000.

Current state:

Integral part of everyday practice.

Short description:

Problem description: To keep residual packages and out of date medicines at home increases the risk of using

medicines after its expiry date, incorrect self-medication, domestic accidents (especially with children), errors in

medication (especially with the elderly), etc.

It is also a public health and environmental issue as much of this waste is mixed in the urban garbage.

The available systems for waste collection with the objective of separation and recycling are not suitable, due to

health security reasons.

Goals: Implementation of an integrated system for collection and management of residual package waste and

out of date medicines still in the citizens’ possession.

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Aims:

- To involve pharmacists and pharmacies in the support network .

- To guarantee the elimination of the mentioned wastes in a safe manner.

Targets: To increase awareness of the population and share responsibilities in preserving public health and the

environment.

Strategy and Methods: The programme implementation was preceded by the distribution of informative

material and the VALORMED’s Manual, where the Standard Operational Procedures are included.

In addition, a major awareness campaign is being simultaneously conducted, including TV and the press. The

distribution of informative leaflets and public counselling is assured by the pharmacists at the pharmacies.

The collection of the residual packages and used medicines is made through containers placed in each

pharmacy which agreed to join the programme.

When the container is completely full, it is sealed and collected by the wholesaler who will be responsible for

its temporary warehousing.

The containers are then regularly transported from the wholesaler’s store to the incinerating station in order to

proceed with the elimination in strict compliance with environmental demands, apart from transforming the

waste into useful energy.

The whole process is documented in order to keep sound proof of the transportation process and to identify

possible non-conformities.

Scope:

National

Partners:

- VALORMED is a society whose members are the main organisations representing the pharmaceutical

sector:

- ANF, Associação Nacional das Farmácias - National Association of Pharmacies;

- APIFARMA, Associação Portuguesa da Indústria Farmacêutica - Portuguese Association of Pharmaceutical

Industry;

- FECOFAR, Federação das Cooperativas de Distribuição Farmacêutica – PharmaceuticalDistribution

Cooperatives’ Federation;

- GROQUIFAR, Associação de Grossistas de Produtos Químicos e Farmacêuticos – Chemical and

Pharmaceutical Products Wholesalers’ Association.

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There are other partners that have an advisory role:

- Portuguese Pharmaceutical Society;

- National Waste Institute;

- INFARMED (National Institute for Medicines and Pharmacy);

- Consumers Associations;

- Environmental Associations.


Every three months an evaluation report is prepared.


- Agreement Protocol between Pharmacies and VALORMED.

- Pharmacy and Wholesalers’ Standard Operational Procedures.


- More than simply a supportive factor, the legislation in force called for the creation of such an organization

and such a programme.

- The shared apprehension by the pharmacists, pharmaceutical industry, consumers and environmental

organizations for the improper treatment of pharmaceutical waste led to a rapid agreement and the

establishment of a solid partnership and collaboration in order to put forward an integrated system.

- The integrated system is financed by the pharmaceutical industry.

- There are health professionals involved from the collection till the elimination.

- The high receptiveness of pharmacists to implement the programme in the pharmacies.


Institutional VALORMED brochures (only in Portuguese).

Public information leaflet (only in Portuguese).

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Health Care System

According to UN data, Portugal occupies an intermediate position in terms of the provision of health care

services, though in the main urban centres the panorama is similar to the average situation in Europe.

Portugal has 30,431 doctors and 33,454 nurses, an average of 3.0 doctors and 3.3 nurses per 1,000 inhabitants.

Portuguese health infrastructure includes 221 hospital establishments (of which 129 are public and 92 are

private) with a total of 37,442 beds and a further 2,279 primary health care centres. (Data of 1997)

The population is tending to age due to a sharp improvement in life expectancy – now standing at 71.4 years

for men and at 78.7 for women – and to a negative birth rate. (Data of 1997)

Portugal has seen an increase in its expenditure on health in general, and on medicines in particular. These costs

now account for 8.2 % of the Gross Domestic Product, of which 2.1% refer to medicines (some 300 billion

escudos being spent annually on medication). (Data of 1999)

National Health Service

Portugal has had a national health service (Serviço Nacional de Saúde – SNS) since 1979, funding for which

comes from compulsory social insurance contributions, paid partly by employees, but mainly by their employers.

The constitution was amended in 1989 to the effect that the SNS would not be totally free at the point of use,

but would continue to follow a free “tendency” according to the economic status of an individual. A more

radical health law was adopted in 1990 advocating the principles of deregulation, competition between the

public and private sectors, and freedom of choice for the consumer. As a result, many activities (e.g. laboratory

services, diagnostic services, medical rehabilitation) are subsidised through the SNS via conventions.

For administrative purposes, the country is divided into 22 districts – 18 on the mainland, three in the Azores

and one on Madeira. The Azores and Madeira are autonomous regions with their own health services which

are managed by their respective regional governments. On the mainland, at the regional level, the five health

authorities (ARS) – based on Porto, Coimbra, Lisboa, Évora and Faro – have the responsibility for the

integration of services between the public and private sectors, and for the location and administration of health

centres. Integration of primary and secondary care since 1994 has come under these health units.

With the aim of rationalising costs, the Ministry for Health is preparing to introduce profound alterations to the

health care system, particularly with regard to the privatisation of the management of several public services.

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Community Pharmacy

There are 2,549 pharmacies in Portugal, a coverage ratio of 4,692 inhabitants per pharmacy.

There are pharmacies in every municipal district of Portugal permanently available to the public. They are

essential links in the health care system and are the links of the chain closest to the public which they serve.

Pharmacy ownership in Portugal is restricted to pharmacists, who are obliged to undertake the technical

management of the pharmacy, permanently and effectively. Furthermore, to ensure a service capable of

meeting the needs of the community, setting up pharmacies is subject to demographic and geographic criteria

and also to public tender. Moreover, the Portuguese legislation requires that the pharmacy has at least an area

to serve the public, a laboratory and its annexe, lavatories and proper lighting and ventilation.

Pharmacy opening hours are set in keeping with citizen’s requirements and emergency services are provided to

ensure that a medicine can be obtained at any time of the day or night.

Of the 7,825 Portuguese pharmacists, 4,075 are community pharmacists. There are 6,313 technical workers,

split between Technical Assistants and Trainees. On average, each pharmacy employs 4.69 workers, of whom

1.40 are pharmacists and 3.29 technicians. (Data of 1999)

The community pharmacist in Portugal makes an active contribution to the adoption of healthy habits and the

prevention of illness, making the pharmacy a place of health care that plays an increasingly active role in the

rational use of medicines and in promoting the well-being of the population. Indeed, the pharmacist plays a

most active role in promoting the rational use of medicines, in pharmaco-surveillance, in health education, in

detecting certain disease, in fight against AIDS, and in providing information both to doctors and to patients.

Given the degree of confidence and credibility which the pharmacists inspires among the population, and the

ease of dialogue between pharmacist and patient, several education campaigns have been successfully

promoted, aimed at health care and at the prevention and detection of disease.

In addition to the Pharmaceutical Society, which represents all pharmacists in general, Portuguese community

pharmacists, in particular, are represented by the National Association of Pharmacies (ANF), which has been

committed to the support of its members’ interest for the last 25 years, particularly with regard to professional,

economic and legal aspects. As an associative structure, the ANF, over the last two decades, has created an

ample network of services, centralising the collection of reimbursements on medicines from the state and from

health care sub-systems, as well as economic and financial consultancy, information technology support and

professional training, in an endeavour to meet all requirements of its members.

One of the ANF’s chief concerns is the professional aspect. On-going training programmes for pharmacists have

therefore been in place for the past 16 years, held jointly with the Lisbon, Oporto and Coimbra Faculties of

Pharmacy, with the Pharmaceutical Society and the ANF. Organised in different areas, the continuing education

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system has been undergoing a consolidation process in the last few years, with 57% of the Portuguese

community pharmacies having already received training curricula. Courses are multi-disciplinary and cover the

various areas of the pharmacist’s activity, from clinical pharmacy to pharmacotherapy, including medicines for

veterinary use, nutrition, dietetics, dermopharmacy and naturally, health education. Co-ordinated by the ANF’s

Training and Professional Relations Department, these permanent updating courses are not aimed just at

pharmacists. Training courses are also given for pharmacy technicians, particularly aimed at improving the quality

of the service provided to the public. Underlying both types of courses is a constant concern to maintain the

high level of competence of pharmacy workers, ensuring the excellence of the service that pharmacists provide.

Supporting & Hindering Factors

It is important to emphasize that all the programmes described in the first part of this report have been an

initiative of the pharmacists, through their professional organisations (Pharmaceutical Society and National

Association of Pharmacies) which, however, have found solid ground afterwards within the Ministry for Health

with whom they have been established protocols of collaboration (including financial support).

Pharmacists have always tried to promote partnerships with other health professionals, although the link with

the Public Health Department in the development of these programmes has been rather poor or non-existent.

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Ilvana Silva - univie.ac.at