Mapping private pharmacies and their characteristics in Ujjain district, Central India

Private pharmacies in low and middle income countries are one of the first points of access for communities to healthcare advice and medication. Studies have reported that it is routine for people to seek the advice of pharmacists and medical shop attendants for common ailments [1, 2]. Numerous studies have established the important role of pharmacists in providing medications and advice for diarrhea [3], respiratory tract infections [4, 5], tuberculosis [6, 7], asthma [8], and sexually transmitted diseases [9, 10] in populations around the world. Such consultations are convenient and save time, money and the opportunity cost of waiting to see a physician [1, 2].

India has one of the most highly privatized health care systems in the world in terms of finance and delivery [11]. The private health sector in the country is complex; providers vary from being highly qualified specialists to unqualified persons, practicing different systems of medicine in diverse organizational setups. There has been no published estimate of pharmacies operating within the country's private sector. However it is reasonable to suggest that a large proportion of pharmacies are in the private sector, given that 72% of the country's health care expenditure is in the private sector [12]. Also a recent study of a province of central India indicated that three quarters of all qualified paramedical staff (including pharmacists) were in the private sector [13].

There have been a number of reports from India studying the dispensing patterns at pharmacies [14], antibiotic prescribing at these outlets [15] and treatment of different conditions by drug sellers [8, 16, 17]. There have been few studies that list, map and study the characteristics of private pharmacies reported in the literature. This study aims to survey all private pharmacies in one district of Central India, and map them on a geographical information system (GIS) to study their location including their rural-urban distribution, as well as their relationship to major roadways and the location of other healthcare providers. In addition, characteristics of these private pharmacies in terms of human resources, clients, availability of tracer drugs and infrastructure were studied.

A total of 475 private pharmacies were identified in the district, with more than three-quarter (77.7%) in urban areas. The overall density of pharmacies was 28 per 100,000 population (urban/rural distribution of 58.39 and 8.40 per 100 000 respectively). Most pharmacies (95%) were independent 'stand alone' units.

Distribution of pharmacies

The distribution of the pharmacies is as shown in table 1. The distribution of private pharmacies mirrors the distribution of qualified physicians in the district, 23% rural and 77% urban (unreported data from the same survey). The spatial location of pharmacies in Ujjain district is shown in Figure 2 which shows a concentration in the urban areas. In rural areas, pharmacies were located on main roads. Figure 3 shows the relationship between the location of healthcare providers and the location of private pharmacies in Ujjain city. Three quarters (78%) of all pharmacies were within 0-50 m radius from a health care provider (out patient clinic or hospital) while a further 17% were located between 51-100 m from a provider.

Location	Rural n (%)	Urban n (%)
Total private pharmacies	88 (22.3)	387* (77.7)
Stand alone pharmacies	82 (93.2)	370 (95.6)
Attached	6 (6.8)	17 (4.4)

*300 in Ujjain city

This is the first reported survey of characteristics and distribution of private pharmacies in an Indian district. The distribution of private pharmacies reflects the distribution pattern of private physicians and hospitals in Madhya Pradesh province [13]. This earlier study had reported ten times as many physicians and twenty times as many beds per unit population in urban than in rural areas. With pharmacies in Ujjain district, the urban rural distribution pattern was similar, with 75% of mapped pharmacies in urban areas. The availability per unit population was six times more in urban areas.

Figure 3 indicates the location of pharmacies in proximity to physician practices/hospitals in urban areas. Besides difficult access to these pharmacies for rural populations, there are other implications of such a skewed urban centric distribution [24]. Too many private pharmacies clustered around doctors' clinics/hospitals, implies fierce competition among them [2]. This could encourage potential malpractice (including pay backs to prescribers), compromises in human resources and in quality of medicines, particularly in a weakly regulated environment [24]. On the other hand, it could also imply convenient access to a wide range of medicines for urban clients (a third of the district) consulting at physician practices. Regulation of the minimal distance between pharmacies in some provinces has been attempted, but has not been successful [24].

The concentration of pharmacies around physician practices particularly in urban areas could also indicate that pharmacies in these areas are not points of first contact for patients, but rather that physicians are, and that pharmacies choose locations around these practices.

The GIS indicates the location of pharmacies on major roads that course through the district and the city. Concern has been raised about how this could affect the quality of medicines stored in pharmacies, as most do not have any air conditioning, and were open to the road throughout the working day, allowing heat, dust and dirt into the premises [24].

Urban and rural pharmacies in the district had a median number of 70 and 40 clients a day, respectively. There was no major difference in client numbers between 'stand alone' and 'attached' pharmacies in urban areas. In rural areas, attached pharmacies seemed to be better patronized than the stand alone pharmacies. In this study, nearly half of all clients purchased medicines without a prescription. A recent study from Tamil Nadu reported two thirds of clients purchased drugs from pharmacies without prescription in two study districts [14]. In attached pharmacies, where prescriptions from the parent institution were most likely to be received, the proportion of non- prescription clients was low both in rural and urban areas.

The availability of tracer medicines did not differ significantly between urban and rural pharmacies. The oral antibiotic combination amoxicillin + clavulanic acid which is used in special situations was available in 84.1% of all pharmacies in the district. Third generation injectable cephalosporin i.e. cefotaxime was also available similarly i.e 83.7%. Availability of injectable steroid dexamethasone was as high as 88.7% in the district. Though these are prescription drugs, their availability indicates that they could easily be dispensed over the counter. A recent report from south India indicates similar findings in pharmacies there. The study reports that 42% of antibiotics dispensed to clients were given based on the drug sellers recommendation, 37% were dispensed on client request while only 21% were dispensed in response to a prescription [14]. A much earlier study reported only 2.9% of antibiotics were given based on the pharmacists recommendation while 21% were client requested, [25] much lower figures than seen in the more recent study. There have been many such reports from other neighboring countries as well [26]. Another important observation in this study was that only 12% of staff in the pharmacies were trained pharmacists. This situation with regard to human resources was worse than reports from other parts of the country. In south India, 50% of pharmacies were reported to have trained pharmacists [27]. The regulations governing pharmacy practice in India state that, any prescribed drug should be supplied, only by or under the personal supervision of a registered pharmacist. The minimum qualification for registration as a pharmacist is a "Diploma in Pharmacy" (D.Pharm) or "Degree in Pharmacy" (B.Pharm) from an institution approved by the Pharmacy Council of India [20, 21]. While theoretically this means that every pharmacy must have a trained pharmacist (as a legal requirement), in practice few pharmacists were on location, and dispensing was often done by a supporting person who is less qualified [28]. Similar findings of inadequately qualified staff have been reported from other studies in India [2], as well as from other low income countries [29, 30]. In a study in New Delhi India poor education of the dispensing pharmacists was identified as an important contributor for irrational use of antibiotics [31]. Another study from Nepal also reported that the higher educated pharmacists had a more correct knowledge about contraceptive products [32]. Similar reports of poor practices by pharmacy staff have been documented in different studies from the country [6, 8, 14]. Having unqualified persons dispensing medications in pharmacies in settings where so much of treatment is client requested only furthers already high levels of irrational drug use. This issue thus requires attention particularly in the light of recent reports of high level resistance in India [33]. Apart from the regulations [20, 21] educational programmes for the qualified pharmacists have also been suggested by the other reports [31, 34]. There are other factors which influence pharmacy behavior including client expectation, economic incentives, local physician behavior and most importantly, the level of effective regulation [1].

Community pharmacy is still evolving in India, and the role of community pharmacists has not been defined beyond dispensing. Pharmacists have not been mentioned in the National Health Policy [35] or the National Pharmaceutical Policy [36], possibly because of a lack of clarity on their role beyond supply of pharmaceutical products [24]. The current regulatory framework does not recognize the need for clinical pharmacists at the national level [37]. Public awareness on the importance of a pharmacist is absent - they are viewed as traders and not as professionals [24, 38]. There has been some critique of pharmacy education in India as preparing pharmacists to take on roles in industry and not in community pharmacy [38, 39]. Trained pharmacists prefer the former as it is more remunerative, also community pharmacy is not yet considered a profession in its own right.

This study surveyed and mapped all private pharmacies in the central Indian district of Ujjain. It provides information on the location of private pharmacies, and evidence of close relationships between provider locations and pharmacy locations. The study reports of human resources and other characteristics were in line with other previously published literature and provide evidence for the need for the better implementation of regulation of pharmacies and the importance of supporting the evolution of regulated community pharmacy in the country.