Will dispensing separation finally become a reality?

This article first appeared in The Edge Malaysia Weekly, on January 28, 2019 - February 03, 2019.
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THE decades-old debate on dispensing separation (DS), or the separation of the professional responsibilities of doctors and pharmacists, has reignited in the pharmaceutical circle. But this time, the industry thinks DS is closer to becoming a reality.

According to Lim Jack Shen, the treasurer of the Malaysian Pharmaceutical Society (MPS), which represents pharmacists in the country, should DS be approved, it could commence as early as next year.

“However, its implementation may take time, depending on how it will be rolled out. A phased rollout by area or state, as it was done in Taiwan, may take four to five years,” he tells The Edge.

MPS’ optimism about the execution of DS follows the positive outcome of several meetings and dialogue sessions held between the society’s council, other stakeholders and Minister of Health Datuk Seri Dr Dzulkefly Ahmad. “We are optimistic because we believe that the minister genuinely wants to bring down the cost of medicines and create a better system for the rakyat,” Lim explains.

The minister also requested a roadmap to be prepared by the society with the integral intention of improving patient care and lowering the cost of medication.

Accordingly, MPS submitted a paper entitled “Roadmap to Dispensing Separation” to the minister in late December last year.

It is noteworthy that the minister was recently quoted as saying the doctors and pharmaceutical societies had converged with an understanding that it is patient care that they are fighting for. The minister also pointed out that doctors are trained to diagnose and to treat while pharmacists are the best trained to understand drugs at their most effective and their most toxic.

Today, there are 17,003 registered pharmacists in total with 14,172 holding an annual certificate. At the end of last year, there were over 2,300 community pharmacies, of which 1,625 were independent while 746 were chain outlets, such as Caring, Guardian, Watsons, Alpro, AEON Wellness, Health Lane, Multicare, My Pharmacy, Big Pharmacy, AA, Tigas and AM PM.

According to GlobalData, the Malaysian pharmaceutical market may be worth US$3.6 billion next year.

Dzulkefly recently also pointed out that because some locations have no pharmacies, it becomes the doctor’s responsibility to provide the necessary prescription. Thus, a law that inconveniences patients (because of DS) will not be created but the government “may look at a hybrid and flexible system”, he added. Incidentally, the minister is a pharmacologist by training and a former lecturer on the subject.

To a question on cost savings to patients should DS become law, Lim says comparisons between the prices of medication in community pharmacies and those of private hospitals show that the former are much cheaper.

“Market research by a community pharmacist member of MPS shows that medication prices at private hospitals are generally 10% to 30% higher,” Lim says, adding that it is hard to draw a comparison with prices at clinics because their bills are not itemised.

A study entitled “Affordability of essential medicine prices in Malaysia’s private health sector”, conducted from 2011 to 2015 and released in July last year, says “The lack of price control in Malaysia has resulted in high medicine prices, notably in the private sector. This largely affects patients’ out-of-pocket expenses in the private sector. Although generic medicines are preferred due to affordability, the prices are still notably high.”

The study was co-authored by Nur Sufiza Ahmad of the pharmaceutical services division of the Ministry of Health and Farida Islahudin of the Faculty of Pharmacy, Universiti Kebangsaan.

The five-year study reveals that the markup on generic medicine is between 31% and 402%, and between 24% and 86% on innovator medicine (patented drugs).

According to Lim of MPS, apart from cost savings, the advantage of DS is the optimisation of medication. He explains that sometimes patients go to different doctors and may take several drugs for the same condition or even drugs to treat the side-effects of other medication. But because pharmacists are experts in medicines, they can assist in reducing the number of medicines and the dosage, and even advise on non-medicinal therapies.

Lim adds that DS will also provide transparency when purchasing medication as the receipts will be itemised and the patients will know exactly what is charged for the various items. This differs from the practice at clinics where the medicines are often bundled and not itemised.

In some instances, the cost of medication can be brought down by substituting with generic medication that are bio-equivalent to the originator medicines and are much cheaper.

Lim stresses that DS could become a reality as it improves patient-centred care. “Both pharmacists and doctors have a role to play in ensuring that the patient gets the best treatment. A collaboration between doctors and pharmacists, and the implementation of DS will allow both professionals to focus on their expertise — doctors in prescribing and pharmacists in dispensing,” he says, adding that this will lead to an improvement in the outcome.

Lower cost means better control of it in healthcare. “This is already being done in public hospitals as pharmacists analyse the rational use of medication.”

Lim also points out the need for checks and balances, given the introduction of the B40 insurance scheme and Peduli Sihat, which will see the use of public funds and scrutiny of what is being prescribed by the doctor so that cost is kept low.

Dzulkefly is scheduled to meet the pharmaceutical industry players at a town hall forum in March. “The objective of the town hall is to be a platform for the health minister to relay the direction of the government with regard to the pharmaceutical industry and to be a place of dialogue and interaction and collaboration between the industry and the ministry,” Lim says.

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