Journal of Karnali Academy of Health Sciences

Review Article
Clinical Pharmacy Practice in Low and Middle-Income Countries;
Special Focus on Nepal
Sitaram Khadka1*, Mahesh Khatri1,2, Sabitri Lamichhane3, Sagar Dhakal4
1
Shree Birendra Hospital; Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
2
School of Science, Kathmandu University, Dhulikhel, Nepal
3
University of Toledo, Toledo, United States
4
Department of Drug Administration, Kathmandu, Nepal
*Corresponding Author: Sitaram Khadka; E-mail/Contact: [email protected] ,
[email protected]; +977-9851077589
ABSTRACT
The paradigm shift of pharmacy practice from the conventional compounding and dispensing role
towards more advanced patient-centered care has a positive impact on the health care system. Not only
has it rendered safe, appropriate, and cost-effective drug therapy, but it has also optimized the therapeutic
outcome. Though there is optimal growth of clinical pharmacy practice in the developed world,
incorporating these new models into action has become a challenge for low-and middle-income countries
(LMICs) like Nepal. Notably, the existing pharmacy curriculum is not updated to meet the current
healthcare needs. Currently, the job opportunities are limited to manufacturing roles in pharmaceutical
industries and as dispensers in the community and retail pharmacies. Pharmacists and pharmacy practice
have to evolve with the latest trends in demographics, epidemiology, societal factors, economy, and
technological advances. It is high time that the policy-making bodies prepare and implement guidelines
for strengthening clinical pharmacy practice in LMICs. The clinical pharmacy practice assures the
rationalization of therapeutic outcomes with proper protocols, effort from the pharmacists, sound
academic background and related training, and professional attitudes. This review sought to explore and
expand the role of clinical pharmacists in healthcare settings, particularly in LMICs like Nepal.
Keywords: Pharmacists, Developing Countries, Nepal, Professionalism, Patient-Centered Care

ARTICLE INFORMATION Source of Support: Self Conflict of Interest: None

Received: 13 January 2022 Accepted: 29 April 2022 Published Online: 30 April 2022
Copyright: © 2022 by the author(s) in which author(s) are the sole owners of the copyright of the content published.
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INTRODUCTION American College of Clinical Pharmacy (ACCP)

Pharmacy service is an indispensable part of a defines clinical pharmacy as a health science discipline
healthcare system. The pharmacists’ traditional role that constitutes the application by pharmacists of
has evolved from medication dispensing to the patient- scientific principles of pharmacology, toxicology,
oriented care. Besides maximizing therapeutic pharmacokinetics, and therapeutics to patient care. This
efficacy, this approach has also reduced medication concept is implemented in numerous developed
use-related problems.1 This is why we can say that the countries such as the United States, demonstrating the
pharmacists’ participation in inpatient care has paradigm shift of practice.2 Concerning this, the
contributed to the rational use of medicines. The clinical pharmacy is explained as promoting rational

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 Khadka et.al. Clinical Pharmacy Practice in Low and Middle-Income Countries ……………

drug therapy where the competent pharmacists ensure discrepancies between different health care
drug use and hence disease management according to settings.4 Clinical pharmacists can assess medication
patients’ social, psychological, and biological aspects adherence, efficacy, and safety of prescribed drugs,
for optimizing therapeutic outcomes. patient knowledge regarding medicines, adverse drug
Clinical pharmacy service has become reactions (ADRs), drug interactions (DIs), and
inevitable for a complete health care system. The potential drug misuse or abuse. With a sound
pharmaceutical care focused on the patients in a health theoretical and practical background, they can interact
care facility has gained momentum in today's world. with patients regarding current clinical conditions,
Clinical pharmacists gain expertise through specialized different pharmacologic and non-pharmacologic
education and training in the relevant field. A approaches to disease management, and the use of
multidisciplinary team comprising physicians, nurses, medical devices if necessary. This mutual interaction
other health care professionals, and clinical promotes patient adherence, which improves
pharmacists can ally optimizing therapy. therapeutic outcome and quality of life, and level of
Pharmaceutical service is a vital component of health patient satisfaction. This intervention also increases
care settings, ensuring the availability of the right patients’ understanding of medicine use and the
medicines to the right person at the right time.3 importance of lifestyle modification in chronic
In low-and middle-income countries (LMICs) like conditions.5 When clinical pharmacists take part in
Nepal, where a proper healthcare system is not fully ward rounds, it can facilitate individualized drug
established, clinical pharmacy is yet to be recognized therapy; understanding past medication history, current
and is in its infancy. Some government and private medical conditions, selection of appropriate treatments,
hospitals have hired pharmacists to work in clinical and discharge planning will improve the patient care
settings. The existing inadequacies in the pharmacy quality.6,7 Participation of pharmacists in therapeutic
curriculum have not been able to provide necessary drug monitoring (TDM) helps in pharmaceutical
clinical exposure to the students. The job openings are evaluation of drug use, improving the choice of drug
restricted to pharmaceutical industries where use and cost-effectiveness.8 TDM is the measurement
pharmacists perform manufacturing roles and in of specific drugs concentration in a patient's blood to
community and retail pharmacies where they play the ensure the safety and efficacy of that drug.9 To
role of dispensers. Whereas several previous studies optimize therapy, pharmacists apply pharmacokinetics
have discussed the clinical pharmacy practice in many and biopharmaceutics principles to interpret basic
other countries, in the current review, we will explore pharmacology into clinical pharmacology and
and expand the role of clinical pharmacists in pharmacotherapeutics.6,9 The selection of drug dosage
healthcare settings in LMICs, particularly in Nepal. regimens based on individualized drug therapy can
improve clinical outcomes. Graabaek T et al. reported
METHODOLOGY that clinical pharmacists’ medication reviews at
Google Scholar, PubMed, ScienceDirect, and current hospitals improve patient outcomes.10
affairs were electronically searched using specific Good knowledge of organic and inorganic
keywords like “Clinical Pharmacy” and “Clinical chemistry enables pharmacists to understand
Pharmacist” or “Pharmacy practice” and unexpected interactions between drug-drug and drug-
“Pharmaceutical Care” and “Nepal”. Related experts in food.6 They can be involved in drug interactions
the field were also consulted. Papers published in the surveillance programs to advise on interventions for
English language were included for the conduction of managing any adverse events that could affect drug
this narrative review. therapy. A significant number of morbidity and
PROFESSIONAL ACTIVITIES mortality occurs due to adverse events and ADRs
Knowing the patients' medication history is a related to drug use. Therefore, pharmacovigilance,
significant step in the medication reconciliation process which means studying the benefits and risks of drugs,
for a pharmacist. It helps protect the patients from can be another critical responsibility to be taken by
adverse drug events that might result from medication clinical pharmacists.11 Their involvement in detecting,
evaluating, monitoring, and minimizing ADRs

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 Khadka et.al. Clinical Pharmacy Practice in Low and Middle-Income Countries ……………

enhances patient compliance to medicine use. It, in “the responsible provision of drug therapy to achieve
turn, reduces hospitalization due to adverse events, definite outcomes that improve a patient’s quality of
harm to the patient, and ultimately the cost of therapy. life.”21 This model supported inter-professional
Pharmacovigilance programs address the problems of collaboration (IPC) and is widely adopted, enabling
underreporting and over-reporting of adverse events pharmacists to become an essential component of the
related to drug use. Such programs will help develop multidisciplinary health care team to deliver effective
interventions to prevent ADRs and adverse events and patient-centered care.22
management costs.12,13 The USA first embraced the clinical pharmacy
Clinical pharmacists support and participate in practice and has been gaining acceptance throughout
research activities to advance human health and health the world lately. American Association of Colleges of
care by developing research questions; conducting or Pharmacy (AACP) has approved Doctor of Pharmacy
participating in clinical, translational, and health (PharmD) as an entry-level pharmacy degree and the
services research; contributing to the evolving only professional degree in pharmacy.23 Lately,
literature in evidence-based pharmacotherapy; and/ or developing countries like Pakistan, India, Bangladesh,
disseminating and applying research findings that several countries in the Middle East, and Africa are
influence the quality of patient care.14,15 Their adopting this new curriculum in pharmacy education to
involvement in clinical trials and drug development create a better academic background for clinical
processes can also justify their roles in research and pharmacy practice.24
development.16 They can identify, resolve, and prevent Clinical pharmacists have a direct role in
medication-related problems. As a member of the inpatient care in the United States. This involves the
multidisciplinary healthcare team, clinical pharmacists selection, modification, and monitoring of patient-
can involve themselves in the prescription review, drug specific drug therapy. The IPC with other healthcare
use evaluation, investigational use of new drugs, etc. providers is vital. The provision of satellite pharmacies
Thus, conducting a well-designed drug utilization has decentralized pharmacy practice and brought
review (DUR) helps understand drug use problems and pharmacists and patients together; this partnership has
develop appropriate interventions.17 The formation of ensured the need for pharmacists in inpatient care.
different hospital committees that include clinical "Standards of practice for Clinical Pharmacists" was
pharmacists can contribute to developing plans and developed by ACCP and has highlighted the roles and
policies related to patient care.18 They can be involved responsibilities of clinical pharmacists for rational drug
in the formulary development process, drug therapy.15 Collaboration of clinical pharmacists with
management procedures, and Standard Treatment other members of the health care team in ward rounds
Guidelines (STGs) formulation. They can also be has resulted in a lower incidence of ADRs related to
involved in ambulatory care services. The extended prescribing. There was a reduction in medication errors
health service (EHS) practices, including tele- resulting from an inappropriate duration of use which
pharmacy health services, preventive health services, is common in the countries with high-income
disaster management programs, health service outreach economies and LMICs.14,25 Malaysian government has
programs (HSO), chronic disease management prepared and implemented guidelines focusing on ward
programs, etc., can further strengthen the clinical pharmacy, pharmacotherapy ward rounds, and clinical
pharmacy practice.1,16,19,20 pharmacokinetic services.26 In Kuwait, clinical
pharmacy is well perceived but has not been able to
HISTORICAL ASPECT: WHERE DO CLINICAL overcome the barriers; lack of firm policy, time
PHARMACISTS STAND? constraints, and poor clinical skills of pharmacists.27 A
The clinical pharmacy concept originated in the 1960s, study conducted in Vietnam after the commencement
which led to rapid evolution in pharmacists' role from of legal regulation of clinical pharmacy service found a
conventional duties to direct patient care. This gave a majority of the clinical pharmacy services non –
new perspective to patient-centered care and developed patient-specific in drug information, ADR counseling,
the concept of the pharmaceutical care model in 1990. reporting, etc.28 Pharmacists' professional identity,
The model emphasized the role of the pharmacists as work environment, and external barriers are also

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 Khadka et.al. Clinical Pharmacy Practice in Low and Middle-Income Countries ……………

hindrances to the delivery of clinical pharmacy government and other agencies would support and
services. Non-pharmacy healthcare professionals facilitate it.37 Distinct separation in dispensing roles is
consider pharmacists as an element of the supply chain. seldom seen as the pharmacists are not the sole
Common competencies like leadership, confidence are dispenser of medicine. There is a lack of separate
falling, which has been attributed to opposition from dispensing guidelines for pharmacists.36
other medical staff. Adequate numbers of pharmacists Clinical Pharmacy Status in Nepal
and pharmacy technicians with proper career plans a Pharmacists in Nepal are primarily employed in
firm policy are required.29 In countries like India and industries, government sectors, marketing, community,
Pakistan, significant numbers of pharmacy students and academic settings. The involvement of pharmacists
graduate each year. However, not much has been in a hospital setting is getting recognized lately for their
achieved in the clinical field as most of them are contribution to health care delivery. Though the
employed by pharmaceutical manufacturers.30 In pharmacists are involved in community-based
developed countries, pharmacists are given a pharmacy services, the function is limited to a mere
prescriptive authority in particular settings whereby shopkeeper without any guidelines and regulations.
they can contribute to the quality of drug therapy.31 In With limited rights and privileges, most pharmacists
the USA, the ambulatory care pharmacy residency working in hospital settings are reluctant to participate
program provides pharmacy residents with elaborative in clinical practice. Much needs to be done as they are
pharmacy practice training and experience in different included in drug procurement, storage, and inventory
settings. Clinical pharmacists monitor and supervise management functions. The appointment of
the anticoagulation services, which has led to pharmacists in clinical roles is still a farfetched dream
optimization of drug therapy with targeted in Nepal. In this regard, in the context of Nepal, clinical
International Normalized Ratio (INR).32 Clinical pharmacy is yet to get recognition and is in its early
pharmacy programs like pharmacists assisted stage of development. The job openings are limited to
antimicrobial treatment has led to optimized manufacturing roles in pharmaceutical industries and
antimicrobial treatment, which has led to a reduction in dispensers in the community and retail pharmacies. A
length of hospital stay, hospital mortality, and better handful of private hospital hires pharmacists to work in
pharmacoeconomic outcomes in many parts of the clinical settings.
globe.33 The existing inadequacies in the pharmacy
Clinical pharmacy practice, in particular, curriculum have not been able to provide necessary
clinical pharmacy services in LMICs, including South clinical exposure to the students. There is a need for
Asian countries, is lagging. The reason behind this is timely and evidence-based teaching-learning
inadequate faculty with expertise in a relevant field, techniques to produce efficient clinical pharmacists and
poor pharmacy practice setups, lack of awareness, lack recognition by policy-making bodies. The need for
of regulations from an authority, and diverse clinical pharmacy practice is crucial for pharmacists to
curriculums taught without appropriate scope and enroll and practice in clinical settings. Institute of
opportunities.34 A significant number of preceptors Medicine (IOM), Tribhuvan University (TU) was the
based in hospitals are lacking. Successful and effective first to start the proficiency certificate level (PCL)
preceptors require adequate training and preparation, pharmacy program in 1972. Kathmandu University
which again becomes a human resource issue. Hospital (KU) commenced the Bachelor of Pharmacy (BPharm)
pharmacists are often thought of as suitable program in 2000, which was a milestone for pharmacy
alternatives, but this also comes when the hospitals are education in Nepal. Subsequently, Master of Pharmacy
overwhelmed with patients.35 In Malaysia, doctors are (M.Pharm.) and Doctor of Philosophy (PhD) in
still involved in dispensing duties which are attributed pharmaceutical sciences began in KU in 2000 and
to a lack of pharmacists.36 EPS has been in practice in 2004, respectively. Pokhara University and Purbanchal
the developed part of the world. However, LMICs are University included B. Pharm and M. Pharm courses in
yet to implement policies to incorporate pharmacy their academics. KU also started a post-baccalaureate
services and build a positive attitude towards EPS
which could contribute to the quality of health if the

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 Khadka et.al. Clinical Pharmacy Practice in Low and Middle-Income Countries ……………

PharmD program in 2010 to produce graduate enhance the medication reconciliation process to tackle
pharmacists specialized in direct patient care.38 drug mis-adventuring.4
Experts have made efforts in relevant fields to Weaknesses
implement and strengthen clinical pharmacy practice. The pharmacy profession is in transition with
Formation of Drug and Therapeutics Committee uncertainty and ambiguity. Inadequate pharmacy
(DTC), hospital formulary committee, hospital personnel with limited medical logistics without
pharmaceuticals procurement and management sufficient training are common barriers to delivering
policies, pharmacovigilance, and drug information pharmacy care in LMICs.44 Pharmacists are constantly
services are positive steps. Though insignificant, under role stress. Pharmacists’ physical and mental
pharmacists in some government and private hospitals health has deteriorated due to changing roles and
such as Shree Birendra Hospital, Norvic Hospital, demands set forth. Unless respective regulators and
Mediciti Hospital, Bharatpur Hospital, and Patan policymakers address this, the future of the profession
Hospital have started patient-centered services like and the safety of the patient is at stake.45 The pharmacy
patient counseling, solo ward rounds, drug information workforce varies significantly amongst countries based
services, prescription writing consultations, and drug on population and economic indicators, so countries
therapy management services. with lower economic indicators will have lesser
In 2015, Hospital Pharmacy Service Guideline pharmacists, which will further cause disproportionate
was prepared and published by the Department of Drug access to medicines and medical expertise.46 Although
Administration (DDA), Ministry of Health and it is well-established fact that pharmacists' inclusion in
Population, Nepal, which states that every hospital the health care team has contributed to patient-centered
should have its pharmacy. It also recommends the care, the enthusiasm and effort to promote clinical
ADRs monitoring, hospital formulary development, pharmacy services is minimal.3 It is noteworthy that
and formation of DTC for better therapeutic outcomes. competent pharmacists are affluent, and their tendency
The guideline is the first kind to recommend the to work in urban areas causes shortages of qualified
presence of at least one clinical pharmacist for the pharmacists in rural areas where pharmacists could
hospital with a capacity of more than 50 beds.39,40 further strengthen the drug use process.36 Professional
Implementation of this guideline could provide a organizations, regulators, and concerned authorities
concrete platform for aspiring pharmacists pursuing should come forward and be vocal in including
their careers in clinical pharmacy. pharmacists in clinical practice to achieve definite
pharmaceutical outcomes for the patients.
SWOT ANALYSIS
Opportunities
Strengths
An effective team is paramount as there is an increase
Pharmacists in clinical settings are uniquely positioned
in co-morbidities requiring specialized patient care.
to provide complete drug therapy management services
Much-needed patient-centered care is the need of the
owing to their academic and professional expertise.
hour. This can be achieved by sharing the values and
When pharmacists work in association with the other
principles of each involved to form a cohesive team that
healthcare team, it will positively impact medication
delivers optimum care to the patient.22 Such a good
appropriateness, cost-effectiveness,
healthcare team requires the inter-and intra-
pharmacovigilance, adherence to drug therapy, and
professional collaboration of healthcare experts.
ultimately to health-related quality of life (HRQoL) of
Pharmacists’ roles can further be expanded to other
patients.41 Pharmacists are the first point of contact for
non-clinical yet significant ones to achieve desired
healthcare needs in a community where they see their
therapeutic success like patient advocacy. Clinical and
patients multiple times than physicians.42 Pharmacists
managerial roles are the two key positions that
in the community are the third largest healthcare
pharmacists can hold. Pharmacists with sound
professionals who can have a beneficial effect in
backgrounds in drug costing can be an asset for the
managing chronic illness at the community level.43
cost-effective management of therapy. This is of
Pharmacists working in clinical settings can further
particular importance in LMICs, where medical costs
are out of the pocket expenditure. Another chance for

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 Khadka et.al. Clinical Pharmacy Practice in Low and Middle-Income Countries ……………

pharmacists is to use their knowledge base and involve CONCLUSION

in different phases of clinical trials, including post- Much of the developed world has witnessed the optimal
marketing surveillance studies. A spontaneous growth of pharmacy practice towards patient-centered
reporting system widely used can be fortified by services and thereby promoting rational drug use. The
pharmacists. As a spontaneous reporting system, a LMICs are far from reaping the benefits of the expertise
pharmacovigilance system can be reinforced of pharmacists. As demographics, epidemiology,
conducting unhindered as under-reporting is a common societal factors, economy, and technological advances
problem. keep on changing, pharmacists and pharmacy practice
Threats have to evolve to suit themselves with the need. For
Pharmacists’ inclusion in the core healthcare teams is a proper implementation, continuation, and
big challenge, particularly in LMICs. Standardized strengthening of clinical pharmacy practice, the policy-
orientation and practice in clinical settings like making bodies, including leading pharmacy
residency programs are seldom conducted, further organizations and all concerned stakeholders, should
exposing the vulnerabilities of pharmacists. Possession step up their efforts in this part of the world. Thus,
of an adequate knowledge base in basic pharmacology clinical pharmacy practice is not an option but rather an
and therapeutics may be insufficient for optimal important obligation to be fulfilled to render safe,
delivery of pharmaceutical care in a patient-focused effective, and cost-effective drug therapy. Much-
approach. An inadequate workforce with minimal needed individualized pharmacy services can be
exposure in such work areas may increase the workload catered through clinical services given by pharmacists
on aspiring pharmacists and decrease their efficiency. at community, hospital, and other clinical settings.
Accepting the norms and values as clinical personnel is Clinical pharmacy services can fulfill the caring void
yet another challenge as they are often not considered that has been created due to inadequate inter-
healthcare specialists. professional collaboration. It can facilitate ethical
access to drug therapy at an affordable cost and
optimum quality.
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