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Pdf (Accessed 15 Sep 2014) Puspitasari HP, Aslani P, Krass I. Challenges in the management of chronic noncommunicable diseases by Indonesian community pharmacists. Pharmacy Practice 2015 Jul-Sep;13(3):578. doi: 10.18549/PharmPract.2015.03.578 Original Research Challenges in the management of chronic noncommunicable diseases by Indonesian community pharmacists Hanni P. PUSPITASARI, Parisa ASLANI, Ines KRASS. Received (first version): 24-Feb-2015 Accepted: 27-Jun-2015 * ABSTRACT INTRODUCTION Objectives: We explored factors influencing Indonesian primary care pharmacists’ practice in chronic Updated projections of global mortality from 2015 to noncommunicable disease management and proposed a 2030 rank ischaemic heart disease and stroke as model illustrating relationships among factors. the top two causes, with similar trends predicted to Methods: We conducted in-depth, semistructured occur in both high-income countries (HICs) and low- interviews with pharmacists working in community health and middle-income countries (LMICs) in the centers (Puskesmas, n=5) and community pharmacies European Region, Eastern Mediterranean Region, (apotek, n=15) in East Java Province. We interviewed and South-East Asia Region.1 In Indonesia, participating pharmacists using Bahasa Indonesia to explore facilitators and barriers to their practice in chronic although the burden of communicable diseases disease management. We audiorecorded all interviews, remains high, cardiovascular diseases (CVDs) have 2 transcribed ad verbatim, translated into English and been reported as the leading causes of death. In analyzed the data using an approach informed by common with other LMICs, Indonesia is facing a “grounded-theory”. double burden of disease from both communicable Results: We extracted five emergent themes/factors: and noncommunicable chronic diseases.3 pharmacists’ attitudes, Puskesmas/apotek environment, pharmacy education, pharmacy professional associations, The fundamental management of chronic diseases and the government. Respondents believed that primary differs from acute care because it crucially depends care pharmacists have limited roles in chronic disease on long-term follow up with regular monitoring.4 It management. An unfavourable working environment and has been suggested that primary health care is the perceptions of pharmacists’ inadequate knowledge and most appropriate setting for chronic care because of skills were reported by many as barriers to pharmacy practice. Limited professional standards, guidelines, its relative proximity to the patients’ home enabling leadership and government regulations coupled with low providers to easily deliver follow-up, resulting in 4,5 expectations of pharmacists among patients and doctors more effective continuity of care. Based on the also contributed to their lack of involvement in chronic Chronic Care Model5, interactions between patients disease management. We present the interplay of these and health care providers will occur in health factors in our model. systems that have well-developed organizational Conclusion: Pharmacists’ attitudes, knowledge, skills and health care supported by adequate resources and their working environment appeared to influence policies. This suggests that governments around the pharmacists’ contribution in chronic disease management. To develop pharmacists’ involvement in chronic disease world need to have well-established primary care management, support from pharmacy educators, teams to address challenges of chronicity. pharmacy owners, professional associations, the government and other stakeholders is required. Our In LMICs in Asia and Africa, the primary health care development strategy has been implemented by findings highlight a need for systematic coordination 6 between pharmacists and stakeholders to improve primary establishing community health centers (CHCs). In care pharmacists’ practice in Indonesia to achieve Indonesia, a CHC is a public health care facility, continuity of care. which is supported and supervised by the District Health Office (DKK).7 In addition to CHCs, there are Keywords: Community Pharmacy Services; Professional other forms of primary health care facilities, as Practice; Attitude of Health Personnel; Qualitative described in Table 1. To enable these facilities to Research; Indonesia provide comprehensive health services, support services from clinical laboratory and pharmacy (apotek) units are required. These support facilities can be either incorporated within the primary health 8 care facilities or available independently. * Hanni Prihhastuti PUSPITASARI. BSc(Pharm), MPhil. Because pharmacy assistants have been able to Lecturer at Universitas Airlangga, Fakultas Farmasi in fulfil the distributive function in medicine supply Surabaya, East Java Province (Indonesia). within Puskesmas, it has not been considered 9 [email protected] necessary to employ qualified pharmacists. Parisa ASLANI. BPharm(Hons), MSc, PhD, Following the issuance of the Government Grad.Cert.Ed.Stud. (Higher Ed.), is an Associate Regulation 51/2009 regarding pharmacists’ Professor. Faculty of Pharmacy, University of Sydney. responsibility for pharmaceutical work in health care Sydney, NSW (Australia). [email protected] facilities10, the DKK in Surabaya (the capital city of Ines KRASS. BPharm, Dip.Hosp.Pharm., East Java Province) has taken advantage of its Grad.Dip.Educ.Studies (Health Ed.), PhD. Professor. additional authority under the 2001 Indonesia’s Faculty of Pharmacy, University of Sydney. Sydney, NSW 11 (Australia). [email protected] decentralized health system to initiate the www.pharmacypractice.org (ISSN: 1886-3655) 1 Puspitasari HP, Aslani P, Krass I. Challenges in the management of chronic noncommunicable diseases by Indonesian community pharmacists. Pharmacy Practice 2015 Jul-Sep;13(3):578. doi: 10.18549/PharmPract.2015.03.578 Table 1. Primary health care facilities in Indonesia Facility Sector Location Community health centers Sub-districts, at least 1 CHC per sub- Public (CHCs) district* Privte, run by physicians who may also Not specified, but within the relevant Physician practices work in public sector district Privte, run by dentists who may also Not specified, but within the relevant Dentist practices work in public sector district Not specified, but within the relevant Primary clinics Public/private district Primary hospital type D Public/private Remote areas * A sub-district is the division of administrative region under a district/city, and includes health-related facilities. placement of pharmacists in almost all Puskesmas prevention and management, we found that the in Surabaya on a local government contract.9 majority of pharmacy preceptors from both apotek and Puskesmas in East Java Province only Despite efforts to improve public health service 11 provided the most basic practice exclusively delivery through decentralization , the quality of focusing on dispensing and medicine counseling, public health facilities remains poor resulting in a whereas the provision of comprehensive high demand for private sector health care services, pharmaceutical care was uncommon (the results even in preference to highly subsidised public 12 have been reported at the Australasian services. Chee, Borowit, and Barraclough also Pharmaceutical Science Association (APSA) reported that approximately half of Indonesians self- Conference 2013 and the International Social treated their illness and sought health care from 12 Pharmacy Workshop (ISPW) 2013). In this article, private apotek. However, the quality of private we present research findings on factors influencing pharmacy services in Indonesia, similar to other 13 their practice as well as a model illustrating LMICs , has been reported as suboptimal, mainly relationships among factors. due to poor professional standards and lack of pharmacists’ attendance so that activities including advising clients have usually been delegated to METHODS nonpharmacist staff.14,15 Research design Since the introduction of the Pharmaceutical Care concept by Hepler and Strand16, there has been a We conducted an exploratory qualitative study using global paradigm shift in professional pharmacy in-depth, semistructured, face-to-face interviews using an approach informed by “grounded- practice, from a purely supply focus to a patient- 26,27 centered approach. In delivering pharmaceutical theory”. We received ethical clearance from the care, “a pharmacist cooperates with a patient and University’s Research Ethics Committee in other professionals in designing, implementing, and Surabaya prior to the commencement of the study monitoring a therapeutic plan that will produce between June and August 2013. We interviewed specific therapeutic outcomes for the patient”.16 To pharmacy preceptors who worked at apotek in East help Indonesian pharmacists implement the Java Province and at Puskesmas in Surabaya who pharmaceutical care model and improve the quality were in partnership with the Faculty of Pharmacy at of pharmacy services, the Department of Health the University. (DOH) issued pharmaceutical services guidelines in We applied a maximum variation sampling 17,18 Puskesmas and standards in apotek , which approach27 to enable sampling a wide variety of have just been revoked and replaced with the apotek pharmacists, with respect to gender, position 19,20 recent Minister of Health Regulations. In respect in apotek, and years of practice experience. We to CVD, the DOH has also endorsed also sought representation of pharmacists
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