Pharmacists in public health

S

Pharmacy and Public Health: Pathways for intersection, collaboration and

cooperation

Dr. Meghana V. Aruru, Ph.D., MBA, B.Pharm Associate Professor,

Indian Institute of Public Health – Public Health Foundation of India Adjunct Faculty, California Northstate University

U.S. FDA Consultant

Health

S  The World Health Organization defines Health (of an individual) as the state of complete physical mental and social well-being and not merely the absence of disease or infirmity.

Public Health

S  As defined in 1976 by a Milbank Memorial Fund Commission on Higher Education for Public Health, "Public Health is the effort organized by society

to protect, promote, and restore the people’s health. The programs, services,

and institutions involved emphasize the prevention of disease and the health

needs of the population as a whole." Higher Education for Public Health,

Milbank Memorial Fund, New York NY (1976)

S  “The science and the art of preventing disease, prolonging life and promoting

health and efficiency through organized community effort.” Winslow, C. The

untilled field of public health. Mod. Med. 1920; 2:183-191.

What public health is not!

S  Public health problems are not health problems considered as they occur in a series of individuals presenting themselves to a health-care provider, but are considered in the context of a community or a population as a whole.

S  The scope of public health is not infrequently misinterpreted as primarily medical care for the underserved.

Maeshiro, R. et al. Medical education for a healthier population: reflections on the Flexner Report from a Public Health perspective. Acad. Med. (85):2; 211-219. (2010)

Public Health functions

S  Micro level: S  Service is relatively direct as compared to the macro or planning level. S  For example, the director of a NCD clinic is functioning at the micro level, whereas

the individual who perceived the need in the population compared to other needs, determined that there should be such a clinic, and allocated resources for it, is functioning at the macro level.

S  Macro level: S  Formulation of health-care policy, health-care planning, and program

implementation, direction, and evaluation, especially at the national level. S  These foci affect the practice arrangements of other health professionals. This work

also leverages change in equity/disparity issues, quality of care, and access to health services by the population.

S  Pharmacy too often ignores the macro level of public health. As a consequence relatively few pharmacists are available as role models or decision leaders.

McKinlay’s Population based Intervention model

S  Downstream: Individual level interventions aimed at those with behavioral risk factors or suffering from risk-related diseases. Emphasis is on change, rather than prevention.

S  Midstream: Population level interventions that target defined populations in order to change and/or prevent behavioral risk factors.

S  Upstream: National and regional public policies or environmental interventions aimed at strengthening social norms and supports of healthy behaviors.

Historical Shifts

S  Dramatic reductions in mortality during the late 19th and early 20th Century

S  Clean water was responsible for nearly half of the total mortality reduction in major U.S. cities, three-quarters of the infant mortality reduction, and nearly two-thirds of the child mortality reduction.

Western world approach

S  The western approach of avoiding diseases, death and disability, traditionally focused on personal hygiene and public sanitation during the 19th Century.

S  This approach, combined with better food availability paid rich dividends in developed countries toward reducing morbidity and mortality.

Catalysts for change

S  Epidemiologic transition: S  Acute to Chronic diseases S  Improvements in Incidence/Prevalence of burden of Infectious diseases S  Dual burden of diseases – ID and malnutrition prevalent + Chronic disease

risk factors on the rise

S  Demographic transition: population increase, shift toward ageing population, life expectancy increase

S  Health care delivery and financing transition: S  Spiraling costs of health care S  Increase in private insurance spend S  Persistent health disparities

S  Migration and Displacement – e.g. recent Chennai floods

Average hospitalization costs

National Sample Survey Office (NSSO) 2014

Indian perspective on medicine

S  Enshrined in the concepts and principles of Ayurveda which means the ‘science of life’.

S  Ayurveda is one of the oldest systems of healthcare in the world.

S  Ayurveda deals with both preventive and curative aspects of health.

S  Health defined by WHO is very similar to concepts of Ayurveda.

India’s health sector

S  Responsibility of State, Local and Central Government

S  Service delivery established by states

S  Milestones: S  Primary health centers (PHCs): 1952 S  Family planning: 1952 S  Green Revolution: 1967-77 S  National health programs: 1957 onwards S  National Health Policy: 1982, 2002 S  National Rural Health Mission: 2005 S  Public Health Foundation of India: 2006

Public Health Foundation of India (PHFI)

S  Public-private partnership includes Indian and International academia, state and central governments, bilateral agencies, civil society groups

S  Response to redress institutional capacity in India for strengthening training, research and policy development in the area of public health

Vision Our vision is to strengthen India’s public health institutional and systems capability and provide knowledge to achieve better health outcomes for all. Mission •  Developing the public health workforce and setting standards. •  Advancing public health research and technology. •  Strengthening knowledge application and evidence-informed public health practice and

policy.

India’s health system

S  Total expenditure on health: 5.2% GDP

S  Public Health Investment: 0.9% GDP

S  Budget allocation for health: 1.3% of central budget S  Government expenditure: 25%

S  Out-of-pocket expenditure: 75%

How did we get here?

Public health before the colonial period

S  Little is known about public health activities before the colonial period.

S  Main stream system health care was Ayurveda.

S  Home-based care appeared to be predominant.

S  Few organised efforts or institutional care to treat diseases and prevent deaths.

Public health during colonial period

S  Evolution of public health system during the colonial period followed the same path as Great Britain.

S  Public health efforts were focused largely on protecting British civilians and army cantonments.

S  Sanitation was given top priority.

S  Focus was also on early detection and control of contagious diseases – cholera and plague.

PH during the colonial period

S  Training and Research Institutions in public health.

S  Public health legislation.

S  Sanitary departments S  Ascertaining local sanitary conditions. S  Vital registration. S  Monitoring disease trends. S  Vaccination programmes. S  Technical advice on control of epidemics.

PH during the colonial period

S  Restriction of public health efforts to British civilians and military.

S  Majority of Indian masses remained deprived of the dividends of these efforts.

S  At the time of Independence, only 3 per cent households in India had toilets.

S  Water, drainage and waste disposal services were utterly lacking.

PH during colonial period

S  Although, public health efforts were restricted to British civilian and military establishment, they had impact on Indian masses. S  Mortality spikes were sharply reduced.

S  Mortality from cholera and plague was sharply reduced.

S  Diseases like malaria and gastro-enteritis continued to take heavy toll.

Public health post colonial period

S  Evolution of public health care system in Independent India was shaped by two important factors:

S  The Report of First Health Survey and Development

Committee (Bhore Committee) constituted during the colonial rule.

S  Emergence of modern medical technology for the prevention and control of diseases, especially communicable diseases.

Bhore Committee

S  Appointed in 1943.

S  Recommended comprehensive remodeling of health services. S  Integration of preventive and curative health services at all levels. S  Hospital-based health care system. S  Development of primary health centres in two stages. S  Training in Preventive and Social Medicine.

S  The short-term plan S  A PHC for every 40,000 population. S  PHC to be manned by 2 doctors, 4 PHN, 4 Midwives, 4 trained dais, 2 Sanitary

inspectors, 2 health assistants, 1 Pharmacist and 15 class IV employees.

S  The long-term plan S  A primary health unit for every 10-20 thousand population with 75 beds. S  Secondary unit with 650 bed hospital. S  District unit with 2500 bed hospital.

PH in Independent India

S  The recommendations of Bhore Committee and the availability of preventive and curative medical technology resulted in the evolution of hospital-based public health system.

S  The public health arrangements created during the colonial period were replaced by hospitals and health centres.

S  Public health services were merged with medical services. In 1952, India was the first country to launch a national programme emphasizing family planning to stabilize the population at a level consistent with the requirement of the national economy.

S  Bhore Committee recommendations were accepted only partially: S  One primary health centre for every 30 thousand population. S  Only 6 beds in each primary health centre. S  Only one doctor. S  Truncated paramedical staff.

S  The situation has remained largely unchanged.

Public Health in Independent India

S  Since Bhore Committee, numerous committees were constituted to evolve the public health system.

S  Some of the recommendations of these committees were adopted; some were not by the government.

S  All committees retained the core of the model recommended by the Bhore Committee.

Public Health in India

S  Mudalliar Committee(1962) S  Strengthen PHCs before establishing new ones.

S  PHC should provide preventive, promotive and curative services.

S  Strengthen sub-divisional and district hospitals.

S  Creation of All India Health Services.

S  Chaddha Committee (1963) S  Malaria worker to function as multipurpose worker.


S  Mukherjee Committee (1965) S  Separate staff for family planning programme. S  Malaria activities to be de-linked from family planning

activities.

S  Jungalwala Committee (1967) S  A unified approach for all problems instead of a segmented

approach for different problems. S  Medical care and public health programmes to be put under

charge of a single administrator.


S  Kartar Singh Committee (1973) S  Concept of MPW(M) and MPW(F).

S  Shrivastav Committee (1975) S  Creation of bonds of paraprofessional and semiprofessional

health workers from within the community itself.

S  Development of a “Referral Services Complex.”

S  Establishment of Medical and Health Education Comission for planning and implementing reforms on the lines of UGC


S  Bajaj Committee (1986) S  Formulation of National Medical & Health Education Policy. S  Formulation of National Health Manpower Policy. S  Educational Commission for Health Sciences. S  Health Science Universities in various states. S  Health manpower cells. S  Vocationalisation of education at 10+2 levels as regards health

related fields. S  Realistic health manpower survey.

Public Health System in India

S  A population based normative approach is adopted for establishing hospitals and health centres S  SHC – One for every 5000 (3000 in hilly/tribal areas)

population.

S  PHC – One for every 30000 population (20000 in difficult areas) with 4-6 indoor/observation beds.

S  CHC – One for every 80-120 thousand population with 30 beds.


S  The norms are for government institutions and rural areas only.

S  For the urban areas, no norms have been defined.

S  Nearly all government civil and district hospitals and most of the CHCs are located in the urban areas.

S  Private health system? Opportunities for convergence?


Institution Number

SHC 145272 More than 6 SHC for each PHC, on average

PHC 22370 More than 5 PHC for every CHC, on average

CHC 4045

Rural hospitals 6298

Beds in rural hospitals 142396 About 23 beds per rural hospital

Urban hospitals 2774

Beds in urban hospitals 324206 About 117 beds per urban hospital


S  Focus on medical services.

S  Neglect of public health services.

S  No modern public health regulation.

S  Lack of systematic planning.

S  Poor sustainability of public health efforts.

S  Absence of epidemiological and statistical skills at district and below district level.

S  No micro-level planning, no public health action.

Achievements through the years

Epidemiological Shifts •  Malaria (cases in million) •  Leprosy (cases per 10,000) •  Small pox (No. of cases) •  Guineaworm (No. of cases) •  Polio

1951

75 38.1

>44,887

1981

2.7 57.3

Eradicated >39,792

29,709

2000

2.2 3.74

Eradicated

265

Infrastructure: •  SC/PHC/CHC •  Dispensaries & Hospitals •  Beds (Pvt. & Public) •  Doctors (Allopathy) •  Nursing Personnel

725 9209

117,198 61,800 18,054

57,363 23,255

569,495 2,68,700 1,43,887

1,63,181(99-RHS) 43,322

8,70,161 5,03,900 7,37,000

Source: National Health Policy, 2002

Source: Chronic diseases and Injuries in India, The Lancet, 2011

Current Scenario

S  Resurgence of communicable diseases S  Dengue, Chikungunya etc.

S  Declining public investments and expenditures in health and healthcare

S  Decline in access to basic health care services

S  Rising costs of healthcare and changed economics

S  Demand supply gaps (100 beds/100,000 – WHO norms: 300/100,000)

Continuing trends: Glass half empty or half full?

S  Value propositions: S  Stepping up of standards in medical care

S  Low cost but not necessarily poor quality

S  Diagnostics relatively inexpensive

S  Growing incomes and literacy

S  Health insurance

S  Healthcare BPO

S  Telemedicine: Rural population > 700 million

Continuing trends

Essential Public Health Functions

Pharmacy in Transition

S  Pharmaceutical Public Health: “The application of pharmaceutical knowledge, skills and resources to the science and art of preventing disease, prolonging life, promoting, protecting and improving health for all through the organised efforts of society” (Walker, R. 2000).

S  Pharmaceutical care is delivered at the individual patient level. “Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life.” (Hepler and Strand, 1990).

Ironic?

S  Of the four categories of health determinants at a population level, health care provision is the least important. Hereditary factors, environment, and lifestyle (behavior) are all considered more important.

Pharmacy Education & Public Health at Micro and Macro Levels

S  “Pharmacy education has failed to recognize the potential for pharmacists in public health …” Patricia J. Bush and Keith W. Johnson, Where Is the Public Health Pharmacist? Am. J. Pharm. Educ., 43,249-2S2( 1979)

Core elements of PH practice

Source: PharmacyHealthLink (PHLink), 2008-2009 ︎

1.  Surveillance and assessment of the population’s health and well being ︎

2.  Promoting and protecting the population’s health and well-being ︎

3.  Developing quality and risk management within evaluative frameworks (clinical effectiveness, quality assurance, risk management, identifying deficits of structure and process) ︎

4.  Collaboratively working for health, building alliances, partnerships︎

5.  Developing capacity to reduce health inequalities (design and delivery of services) ︎

︎

6.  Policy and strategy development and implementation, cyclical efforts to implement strategies and assess the impact of those policies on health improvement︎

7.  Advocating for the public and adapting services to better meet the needs of communities. ︎

8.  Strategic leadership –(reduction in inappropriate antibiotic use; mental health) ︎

9.  Research and development to improve health and well-being at a population level. ︎

10.  Commitment to life long learning to assure better models equitable use, distribution and access to resources. ︎

︎

Community Pharmacy and PH framework

Developing PH Pharmacy Policies

S  Assumptions: S  Social justice S  Improve safety and reduce financial burden of treatments

S  Policies to reduce costs: controlling profits, establishing profit limits, extending prescription providers, revising Rx classifications, emphasizing generics, establishing formularies

S  Public education: lifestyles, comorbidity (elderly population?)

S  PH perspective serves to maximize savings for all to increase access and improve population health – what about profit maximization?

Developing PH Pharmacy policies

S  Safety as a priority: S  Active regulatory role for government?

S  Litigation fears for focusing manufacturers attention on safety?

Important to align pharmacy policies with a PH perspective on safety and costs.

Opportunities

S  Cost-effective clinical roles for Pharmacists

S  Pharmacists represent the third largest healthcare professional group in the world. The majority of pharmacists practice in private retail pharmacies, few in public health facilities. There is very little published international data on the pharmacy workforce. However, in 2006 a survey by International Pharmaceutical Federation (FIP) revealed that the pharmacist to population ratios vary widely throughout the world from less than 5 to over 200 pharmacists per 100,000 population – Significant potential of pharmacy knowledge is untapped and wasted

Implications for education & training

S  Old paradigm: product focused

S  Reports, maps and tables on health providers focus exclusively on doctors and nurses. Pharmacists are hardly mentioned as health professionals. They tend to be listed “others, auxiliaries, support staff ” etc.

Interdisciplinary approaches for optimal PH outcomes

S  Quality control & improvement

S  Education & Outreach

S  Counseling

S  Behaviour change

S  Interdisciplinary collaboration

Think global…work local

Questions to think about

S  Are pharmacists well prepared to conduct activities within the public health arena? – Develop PH competence alongside clinical competence

S  What roles could pharmacists play in improving physical, financial, legislative barriers to access?

S  What are the future standards of pharmacy practice? How do we make PH pharmacy viable and sustainable? Business models for community pharmacy?

Thoughts to ponder…

S  In the west, PH and Pharmacy evolved independently

S  PH and Pharmacy are developing in India – opportunities for intersection and collaboration Identified target areas:

S  Pharmacoepidemiology, Pharmacovigilance S  Behavior change patterns

S  Counseling and education: Medications, Lifestyle S  Surveillance

S  Mapping policies for cost optimization

And last but not the least…

S  How will Pharmacists participate in the Public Health System to advance public health outcomes and what type of capacity building will be needed?

Health & Medicine

Pharmacists in public health