Can Pharmacies Improve Global Health Delivery By Taking Tests Closer to People?

Discussion
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1

Please see my Forbes post on the role of pharmacies in addressing the diagnostic gap in global health delivery:

I would like your thoughts on whether this feasible and examples of pharmacies conducting tests.

Thanks
Madhu

2

Thanks for a great post, Madhu. You’ve hit on exactly what we’re doing in Ghana at Redbird (www.redbirdht.com). In short, Redbird supplies pharmacies with everything they need to provide rapid diagnostic services in 9 different areas, including Hb/Hematocrit, Lipid Panel, and Blood Sugar, all using POCTs. In addition, pharmacies also have access to Redbird’s health records software, which means that the patient can go to any Redbird partner pharmacy and their health record follows them. This can save patients hours of time waiting at a tertiary facility. We’ve seen rapid uptake and growth and have grown to over 60 pharmacies since August. As you say in the article, it’s not simple (we include training and marketing support as part of our service to the pharmacies), but seeing the uptake in Ghana, there’s no doubt in my mind that decentralized testing in trusted facilities is the future, especially for managing chronic disease. Keep an eye on Ghana if you’re interested in this space!

Patrick

3

I see the same situation here in the Philippines where there are more pharmacies around localities providing easy access to patients than health facilities (clinics, hospitals) do. I appreciate the value of not missing this opportunity for reaching closer to patients.

As mentioned by Patrick, we can only maximize the use of POCTs in these pharmacies. Waived tests can be performed by laymen and can provide valuable information even prior to the disease course (screening). A good example would be the Xpert MTB/Rif where one-module can be used in bedside or outside the usual laboratory facility (as promoted by Cepheid). But in the Philippines setting, 4-module GeneXperts are more available at the health centers and hospitals with accompanying public health/clinical labs.

At present, commercial pharmacies are providing free services including medical and dental consultation (on schedule), glucose testing (CBG) and blood pressure monitoring. These are usually availed by the clients especially those who are financially constraint. Moreover, as the complexity of tests increases, the more that it should be referred to laboratories where trained laboratory staff could perform the job. We can have pharmacists trained so they can perform rapid diagnostic tests (RDTs) that will not require complex skills and higher qualifications. This, in my opinion, will not become a threat to the laboratory profession. In fact, this happens in the country where Xpert MTB/Rif testing does not require a medical technologist but generally any 4-year course with basic computer literacy.

While our attention is focused on solving the “underutilization” of pharmacists in the healthcare system, and considering that pharmacies are a source of first contact care, there are some comments that need to be addressed:

  1. If pharmacists will be allowed to “identify” disease using POCTs or RDTs, are they allowed to dispense appropriate medicines to patients right away? When you use “identify” in the statement, “Simple respiratory rate counters and pulse oximeters might allow pharmacies to identify severe pneumonia,” do you mean the same as “diagnose”? If that is the case, will the medical community allow pharmacists to “diagnose” and “treat” the disease? Pharmacists as de facto health providers should be guided properly.

  2. In response to the previous statement, I would see it better if there will be referral systems in place for those who tend to have positive results. Referral from a pharmacy to a health facility or directly to a provider (physician) can be instituted so that proper history, physical examination, and a confirmed diagnosis can be made (unless the test at the pharmacy is perfect). If this happens, bringing patients to a health facility/provider will still consume time and incur additional costs. But, in the long run, this can prevent misdiagnosis and waste of resources (giving medicines to a person without the disease).

  3. Instead of focusing on the pharmacies and giving them new roles in the testing process, why not focus our attention on improving laboratory networks, like what you stated in the paper. There has been a shortage of staff in the laboratory workforce globally and locally, especially in LMICs. This can not be addressed instantly. But on the other hand, if we concentrate on the current workforce that we have – improving their work motivation, maintaining professional development and allowing them to think possible solutions that will bring them closer to the patients.

  4. Since “testing” pharmacies seem to create more issues, why not concentrate on establishing also the link between pharmacies and lab facilities so that testing can still be done at an earlier time.

Though I myself is part of the laboratory profession, I understand the value of task shifting from one profession to another because of the demands and current limitations in the healthcare system context. Hopefully, we can find solutions as we do and share more studies and best practices that we can benchmark on or use as a basis for developing new ideas.

Thanks
Coach

4

Patrick and Coach, good comments.
Madhu, great article as usual.

The article could, in fact, go further in describing the testing happening in US, (some) Canadian, and UK pharmacies. Not only are there HIV, glucose, cholesterol tests, there are a variety of drug screening, allergy screening, genetic mapping, and others. Additionally, the CVS Minute Clinic and in-pharmacy clinics at Walmart, Walgreens, and RITE-AID demonstrate this is going well beyond self-testing. To me, they demonstrate the validity of your proposal –

  1. There is a profitable business case to be made for pharmacies moving into this space
  2. Partial rebuttal to your comments Coach, doing testing in pharmacies doesn’t necessarily mean that pharmacists are doing a doctor’s job; simply positioning a community doctor at the pharmacy addresses the patient experience problem and capitalizes on rapid results. Trained nurses or doctors are working at the Minute Clinics, so it’s not a case where we have to trade off quality or safety to get these results.
  3. The rapid uptake of these services adds validity to Madhu’s assertion that patients want more convenient options and are willing to pay for them.

Excellent article.