Reintroduction of Post-Baccalaureate Doctor of Pharmacy (PharmD, Post-Bac) Program in Nepal: Exploration of the Obstacles and Solutions to Move Forward

Introduction

Globally, the pharmacy profession is one of the most well-known and recognized professions. Over recent decades, the pharmacy profession has begun to undertake significant changes in practice. However, in Nepal, pharmacy practice is still in its infancy. There has been a considerable increase in pharmacy colleges and pharmacy graduates; however, a clear career path for pharmacists still lacks.^1,2 With the continuity of this situation, the brain drain will be challenging to avoid. Clinical pharmacy is well developed and accepted in western society, but the situation is still woeful in Nepal.^1,3,4

Dramatic changes in the health care system are creating many new and exciting roles for pharmacists. Pharmacists are now responsible for the safe and effective distribution of prescription and non-prescription medications. However, they also assume the role of pharmaceutical therapy advisor and manager in providing patient-care services.

Most pharmacists enter either into the pharmaceutical industries or academia in Nepal and rarely in the community-level health care or hospitals. After being a part of health care for such an extended period since Kathmandu University (KU) first launched the Bachelor of Pharmacy (BPharm) program in 1994 it is high time that pharmacists gain and implement the global experiences in hospital, clinical and community pharmacies. Later, postgraduate programs in pharmacy such as MPharm in Pharmaceutical Care, MPharm in Industrial Pharmacy were launched by KU, MPharm Clinical Pharmacy by Pokhara University (PU), and Purbanchal University. The Medical Education Commission (MEC), the only government body for regulating health science programs of all universities and affiliated colleges in Nepal, has recently permitted KU to launch two new specializations of MPharm, namely in Pharmaceutical Analysis, and Pharmacognosy and Phytochemistry. In addition, MEC has also consented to the relaunch of the postponed PharmD (Post-Bac) program. From 2022 KU would be running two clinical-oriented courses, MPharm in Pharmaceutical Care and PharmD (Post-Bac) in parallel unlike the previous year.

Unlike the developed countries where pharmacy education and curriculum change because of the changing practice, in developing countries, the demand is to change the curriculum with a hope of changing practice - a change model that is quite feasible. According to the International Pharmacy Federation (FIP) framework, the development of initiatives in education, practice or regulation can prompt or serve as drivers of change in others.⁵

PharmD Program Initiation in Nepal

To meet the demand for change in practice and realize the need to make the pharmacists eligible to provide clinical pharmacy services, PharmD, the post-baccalaureate course, was introduced in the Department of Pharmacy, School of Science, KU, in 2010 for the first time in Nepal.⁶ The PharmD (Post-Bac) curriculum was so designed that a pharmacist will advise, consult, and help doctors select and dispense medicines to patients and play a significant role in medication therapy management (MTM). The three-year PharmD program received equivalency of Master’s degree in pharmacy from Tribhuvan University (TU), Nepal (the only authority in Nepal to provide equivalency and approve the programs). Other modalities of PharmD programs such as six-year PharmD and five-year PharmD from India and Pakistan, respectively, after the intermediate level, were recognized as the Bachelor’s degree by TU.

The three-year PharmD, Post Bac. program, introduced by KU, was divided into two phases: Phase I – consisting of the first and second academic year with two semesters in each and Phase II – consisting of internship or residency training in the speciality units of hospitals during the third year. PharmD, Post-Bac students, were trained in different dimensions of pharmacy practice during the internship, such as pharmacotherapy of various body systems (eg, cardiovascular, nervous, respiratory, gastrointestinal, and others) and clinical pharmacy practice. In addition, students were deputed in different departments of hospitals (eg, medicine, surgery, anesthesiology, cardiology, dermatology, paediatrics, pharmacy, pharmacovigilance, and medicine information centre, gynaecology-obstetrics, neurology, dentistry and others). In addition to this, students were provided weekly three-day exposure to clinical ward rotations at the Dhulikhel Hospital for the first one and half years. Project work of one semester was included at the end of the second year, where the students developed and presented the report of their clinical research output akin to a thesis. Altogether, KU trained 29 PharmD, Post-Bac graduates, all of whom are contributing well to the health care arena in Nepal and abroad in clinical pharmacy setup at tertiary care and medical college hospitals, academia at universities and affiliated colleges, central and provincial government regulatory authority, pharmaceutical products development and marketing, community pharmacies and clinics, Research, training, and publication. The country demands significant input from clinical pharmacists in all these areas, including other unexplored ones such as clinical trials, consultant pharmacists, and others. More quality human resources are required. As there is already a pre-established set-up and faculty availability for the PharmD (Post-Bac) program at the department, KU can reintroduce the postponed program with the new vision. KU has developed the mechanism of providing more bed-side evidence-based clinical rounds and practice opportunities to the future PharmD aspirants under the guidance of a dedicated in-house clinical preceptor, following the pathway of the PharmD program elsewhere.⁷ The MEC has recently mandated KU to relaunch the PharmD program with ten enrollment in a batch, as of the previous format.⁸ As KU is the pioneer in introducing undergraduate and postgraduate programs in pharmacy in Nepal, the introduction or postponement of any of its programs carries national attention. The ad-hoc postponement of the only PharmD (Post-Bac) program was not free of its national-level impact in clinical pharmacy and the whole pharmacy profession in the country. The Department of Pharmacy (KU) initiated the Pharm D (Post-Bac) program to produce specialized, trained human resources to cater for the needs of individualized patient care and support the paradigm shift towards patient-oriented practice. Despite realizing the untapped potential of clinical pharmacists, the university was bound to keep the PharmD program on hold. Amidst the multiple arrays of challenges faced, the most significant setback was the frail job market for the clinical pharmacists and the relatively low pay scale offered by the working institutions. Considering the risk of unemployment along with challenges mentioned above, an unpleasant decision for holding the program was taken. However, a silver lining was seen when the Ministry of Health and Population (MOHP), Nepal, developed the Hospital Pharmacy Directive 2072 in 2015, stating the recruitment of a clinical pharmacist in every hospital with 51–100 beds.⁹ This was thought to amplify the importance and platforms of clinical pharmacists seemingly. However, as of 2021, the implementation is hardly visible in practice, irrespective of positive changes. Despite reflecting on the many challenges that still can stand as an impediment to the program, KU spearheaded a second bold attempt to change the status quo for clinical pharmacists and an effort to consolidate a more patient-oriented approach in health care.

Potential Areas for PharmD Graduates in Hospitals of Nepal

With the increase in various general and specialty hospitals in Nepal, there is an emerging scope for PharmD graduates in Nepal. After PharmD graduation, clinical pharmacists can play an essential role in identifying, preventing, and mitigating drug therapy-related problems and stand as pharmaceutical care providers. A few of the potential clinical pharmacy areas that PharmD graduates can focus on and are doing well in the capacity of clinical pharmacists are listed in Table 1.

Table 1 Potential Areas for PharmD Graduates

PharmD graduates have other potential roles as well besides those mentioned in Table 1, such as academics, clinical research, marketing, and regulatory affairs.³⁸

Challenges and Potential Solutions to the PharmD Program

Comparison of PharmD Program with MPharm Pharmaceutical Care and MPharm Clinical Pharmacy Programs

Although two-year courses MPharm in Pharmaceutical Care (being run by KU), and MPharm Clinical Pharmacy (being run by PU and Purbanchal University) may appear to be potential alternatives to the PharmD program, these programs are devoid of dedicated annual internship in their core curricula. The PharmD graduates undergo an intensive internship of one year to empower them with the knowledge and skills required to provide individualized patient care, medication review, therapeutic drug monitoring (TDM), clinical ward round participation, etc.

Owing to the one-year short duration, these two programs have condensed internship exposures to only six weeks in hospitals and have aligned more of their focus to academia and research practice. Hence, PharmD program can surpass all theoretical, practical, and clinical practice requirements of these programs and can successfully cater to many service-based requirements in the hospital and community pharmacies, academia, research, and regulatory affairs. Also, PharmD can better be viewed as a practice-based course that prepares the graduates exclusively for direct patient care services with the needful knowledge, exposure, and competency. Besides, PharmD is the only program globally compatible for further specialty certification courses like Board-Certified courses in the USA.

The dominant driving force behind pioneering the PharmD program in Nepal was meeting national need for skilled human resources with clinical competency to practice in a team of health-care professionals involved in direct patient care. Though small, PharmD graduates of this university have made their decent presence in various clinical settings, government regulatory settings, pharmaceutical products development and marketing, research areas with multiple publications in renowned journals, and academia, which clearly reflects success of the program.

There are several possible challenges, such as recognising the role of clinical pharmacists, implications of higher course fees and return of investment, and availability of trained clinical preceptors (Table 2). However, despite the possible hurdles, their national need for skilled human resources with clinical competency to practice in a team of health-care professionals involved in direct patient care was the dominant driving force behind pioneering the PharmD program in Nepal.

Table 2 Challenges and Solutions of PharmD Program

This achievement was due to the headstrong impulse the graduates moved ahead to establish their identity amidst the challenges. The graduates from the previous batches are firmly in favour of reviving the PharmD program, which according to them, is one of the avenues to revamp the shadowed and unexplored profession of clinical pharmacy. However, they believe that the past three years’ experience of running the PharmD must be brought to the best of its use to bring it up as a sustainable program in the future. The department has greatly valued their feedback and has developed a modality to gradually address these in the reintroduction phase of the program to make the program viable and sustainable and make the impact of the program a milestone in the clinical pharmacy practice in the country.

Higher Cost

Those with PharmD qualifications might have a higher expectation for salary firstly due to the relatively higher cost of the program and the challenging nature of clinical practice jobs. There exists a difference in the tuition fees of MPham in Pharmaceutical Care and PharmD, Post Baccalaureate programs. Secondly, a PharmD graduate spends one extra year to achieve the degree in contrast to the two-year postgraduate programs in Pharmaceutical Care and Clinical Pharmacy. A higher expected salary for those with PharmD qualifications might be a barrier to entering the market later. However, this is a subjective perception that may vary among individuals.

The challenges and solutions to the PharmD program are shown in Table 2.

Conclusion

This commentary targets reflection on the challenges faced in the past and internalizing the possible remedies to the PharmD program’s reintroduction and making it sustainable. There is a realization that we need to be more patient-oriented health professionals and be a part of the health-care team. When considering education as a practice change driver, it is essential to consider various elements like infrastructure, availability of hospital-based pharmacy practice environment and exposures, employment opportunities, etc., to ensure the program sustainability. The initiation of the PharmD course by KU Department of Pharmacy had provided a roadmap for the upliftment of clinical pharmacy practice in Nepal. However, the sudden postponement of the program has created an irreparable vacuum to the same, which is, fortunately, being fulfilled by the MEC’s new decision of authorizing the university to reintroduce the program from 2022 intake. Reintroducing the program with the new vision of evidence-based clinical ward rounds in speciality units of the hospital in the guidance of a dedicated in-house clinical preceptor would help the program be sustainable in the days to come.