Introduction
In the midst of the COVID-19 pandemic, there are increasing calls for pharmacists to play a more active role in the public health response, beyond dispensing of medicines and other supplies. In particular, it has been suggested that in the context of pandemics, pharmacists could be involved in outbreak surveillance,
1
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vaccine delivery,
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testing,
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and programs to support patient medication adherence.
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These roles become critical when clinical services are heavily committed, especially in countries where health systems are under-resourced.
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On the frontline against COVID-19: community pharmacists’ contribution during a public health crisis.
However, the operation of pharmacies and drug stores during COVID-19 poses significant challenges. A small but growing number of studies have pointed to major gaps in measures to control disease transmission inside pharmacies
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Community pharmacy services and preparedness during COVID-19 outbreak in Madinah, Saudi Arabia.
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Readiness of community pharmacists to play a supportive and advocacy role in the fight against corona virus disease.
as well as inappropriate behaviour by clients that can undermine staff safety.
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Personal protective practices and pharmacy services delivery by community pharmacists during COVID-19 pandemic: results from a national survey.
Studies have also raised concerns about the lack of appropriate training in pandemic preparedness available to pharmacy staff.
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Pharmacy Emergency Preparedness and Response (PEPR): a proposed framework for expanding pharmacy professionals’ roles and contributions to emergency preparedness and response during the COVID-19 pandemic and beyond.
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In Indonesia, community pharmacies and drug stores often serve as the first point of contact with the health system for many patients. Community pharmacies must always be attended by a qualified pharmacist and drug stores by a pharmacy technician, who oversee the dispensing of medicines. Only community pharmacies can sell prescribed medicines including antibiotics. Hereon we refer to them both as ‘drug retail outlets’. According to official data from the Indonesian Ministry of Health (MOH), the country’s population of around 270 million is served by approximately 135,000 licensed drug retail outlets.
, Around 10% of these outlets serve the provider network for Indonesia’s national health insurance scheme, the Jaminan Kesehatan Nasional or simply the ‘JKN’, which is designed to make health services accessible to all citizens by the end of 2024.
19
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Meilianti S. Primary health care policy and vision for community pharmacy and pharmacists in Indonesia.
There have been increasing calls for greater involvement of pharmacists and pharmacy technicians (who typically work under the supervision of pharmacists) in the response to COVID-19,
8
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- Kristina S.A.
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Community pharmacists roles during the COVID-19 pandemic.
which is taking a huge toll on the population and health system of Indonesia. As of early February 2022, more than 4·3 million cases and 144,000 deaths were reported in the country, including thousands of frontline health workers.,
In this paper, we report findings from a survey of the attitudes, self-reported knowledge and practice of pharmacists and pharmacy technicians in Indonesia during the COVID-19 pandemic. After presenting the findings, we discuss recommendations to strengthen their contribution to future response activities in Indonesia and other Low- and Middle-Income Countries (LMIC). To our knowledge, this is the largest empirical study of health professionals working in drug retail outlets during the COVID-19 pandemic in Indonesia.
Discussion
Many studies have explored the actions and experiences of public sector health workers during the COVID-19 crisis but far fewer have focussed on pharmacists and pharmacy technicians working in private drug retail outlets. Our study highlights the important roles these providers perform during the current pandemic in Indonesia as well as the challenges they face. It was revealed that reliable information including guidelines for those working in drug retail outlets has not been readily available. While stadard operating procedures were issued by key professional organisations including the IAI and the FIP in early March 2020,
,
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Indonesian Pharmacist Association. Standard operational procedures on provision of services to clients during COVID-19 pandemic [Standar Prosedur Operasi Pelayanan Pelanggan Selama Masa KLB COVID-19]. 2020.
these had not reached all providers by the time of the survey. Easy access to accurate and timely information is crucial, especially given the proliferation of “infodemic” around COVID-19, much of which is driven by social media.
35
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- Tagwireyi D.
Risks to the community pharmacists and pharmacy personnel during COVID-19 pandemic: perspectives from a low-income country.
Compared to pharmacists, fewer pharmacy technicians reported having received information about COVID-19. Increased steps should be taken to ensure guidelines and training are available to all pharmacists and pharmacy technicians.
Actions to protect staff and clients from COVID-19 including the wearing of face masks, instructing clients to wear a face mask, and providing hand sanitiser to clients were commonly practised. Most respondents also provided COVID-19 related information to clients including advice on wearing a face mask and washing their hands properly. While these safety measures have been widely implemented by staff working in community pharmacies in many countries,
13
- Itani R.
- Karout S.
- Khojah H.M.J.
- et al.
Community pharmacists’ preparedness and responses to COVID-19 pandemic: a multinational study.
,
14
Readiness of community pharmacists to play a supportive and advocacy role in the fight against corona virus disease.
,
16
- Hoti K.
- Jakupi A.
- Hetemi D.
- Raka D.
- Hughes J.
- Desselle S.
Provision of community pharmacy services during COVID-19 pandemic: a cross sectional study of community pharmacists’ experiences with preventative measures and sources of information.
there have been reports that they have sparked patient anxiety and even aggression,
5
The challenges of COVID-19 for community pharmacists and opportunities for the future.
fuelled by longer waiting times
5
The challenges of COVID-19 for community pharmacists and opportunities for the future.
and increased out-of-pocket costs.
16
- Hoti K.
- Jakupi A.
- Hetemi D.
- Raka D.
- Hughes J.
- Desselle S.
Provision of community pharmacy services during COVID-19 pandemic: a cross sectional study of community pharmacists’ experiences with preventative measures and sources of information.
Similarly, our study showed that some respondents were worried about frightening clients by using PPE, particularly face shields. They also reported barriers to accessing PPE and infection control products such as hand sanitiser, a challenge experienced in many other LMIC.
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This highlights the need for further strategies to assist pharmacists and pharmacy technicians in implementing safety and security measures during pandemics.
Around a third of respondents mentioned that they had provided antibiotics to clients suspected of having COVID-19. Over-the-counter dispensing of antibiotics without prescription is common in Indonesia, driving another impending pandemic, antimicrobial resistance.
42
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Prior to the COVID-19 pandemic in Indonesia, we documented the frequent dispensing of Fradiomycin/Gramicidin lozenges by staff at community pharmacies and drug stores.
27
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- Khan M.
- Liverani M.
- et al.
Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study.
In this current study, we confirmed reports of the increase in demand for the antibiotic Azithromycin. This is likely because it is specifically mentioned in guidelines for management of patients with COVID-19.
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Burhan E, Susanto AD, Nasution SA, et al. Protokol Tatalaksana Pasien Terkonfirmasi Covid-19. 2020;4.
Although most patients with COVID-19 do not also have a bacterial infection and therefore do not require any antibiotics, in the face of the pandemic, avoiding the use of antibiotics has been challenging. Other studies have also reported increased use of antibiotics in the community in both LMICs
43
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and high income countries.
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Pharmacy technicians were more likely than pharmacists, to report selling antibiotics and other prescription-only medicines. This finding is consistent with a study (pre-COVID19) from Abu Dhabi showing that pharmacy technicians are more likely to sell antibiotics to their clients compared to pharmacists.
39
- Dameh M.
- Green J.
- Norris P.
Over-the-counter sales of antibiotics from community pharmacies in Abu Dhabi.
Countries should be closely tracking the use of antibiotics amid the COVID-19 pandemic and training health workers on antimicrobial stewardship.
40
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The use of antibiotics in COVID-19 management: a rapid review of national treatment guidelines in 10 African countries.
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Inappropriate antibiotic use in Zimbabwe in the COVID-19 Era: a perfect recipe for antimicrobial resistance.
Most respondents in this study were willing to support COVID-19 response efforts by providing verbal advice to clients, distributing information leaflets, and/or participating in early warning systems in the event of a disease outbreak. Given that pharmacists and pharmacy technicians are often the only point of contact with the health system for rural and/or remote communities, there is potential to expand their role as sources of reliable information both for COVID-19 and future pandemics. Smaller outlets were more willing to engage in outbreak surveillance activities. This might have been due to the less complex administrative issues that the smaller outlets would have needed to complete compared to the larger outlets, particularly those working in chain pharmacies.
At the time of the survey, drug retail outlets were not authorised to sell COVID-19 rapid antibody test kits or any type of test kits for COVID-19, yet it had been reported that some were selling these test kits at highly variable prices.
46
PatKlin PDS. Revisi Panduan Tatalaksana Pemeriksaan Rapid Test Antibody SARS-CoV-2 Metode Imunokromatografi. 2020 p. 1–15.
In our study we asked participants about whether they suspected test kits were being sold despite the prohibition, and whether they felt retail drug outlets had a future role to play in their distribution. Around half of the respondents in our study believed these tests (sourced from online sellers or wholesale sellers) were being sold and conducted at drug retail outlets and a quarter were in support of this.
A recent qualitative study from Jordan suggested a high level of willingness among community pharmacies to be involved in testing but expressed concerns about their lack of preparedness and training.
10
- Mukattash T.L.
- Jarab A.S.
- Abu-Farha R.K.
- et al.
Willingness and readiness to test for COVID-19; a qualitative exploration of community pharmacists.
In order to explore the possibility of extending the role of pharmacists or pharmacy technicians in providing COVID-19 testing in Indonesia, it will be important for the government to engage with drug retail outlets proactively.
47
- Hendarwan H.
- Syachroni S.
- Aryastami N.K.
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Assessing the COVID-19 diagnostic laboratory capacity in Indonesia in the early phase of the pandemic.
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48
- Djalante R.
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One of the main limitations of this online survey is that it is difficult to ascertain the non-response rate and whether there were systematic differences between those who chose to participate compared to those who did not, which might have in turn influenced our findings.
49
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For example, the under-representation of staff above 50 years of age, which may have been due to higher levels of internet illiteracy among older age groups, could have biased our results. We also could not determine if a respondent completed the survey more than once. It is also important to note that this study was conducted in the initial months of the COVID-19 pandemic. Given how quickly the pandemic is evolving in Indonesia, it could be that some of the issues identified have changed or been addressed. Caution should also be taken when interpreting the result on number of clients visiting the outlets, as this was based on estimates provided by drug outlett staff.
Our research has identified several key lessons for future response efforts. First, it has exposed the fragility of medical supply chains for infection control products including PPE and the need to strengthen local sourcing and production to help prevent the risk of stock-outs during any future health crises. Second, our results point to frequent antibiotic use among COVID-19 patients attending drug retail outlets in Indonesia. The potential knock-on effects this can have on the containment of antimicrobial resistance are significant.
50
- Lucien M.A.B.
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- Kilgore P.E.
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Antibiotics and antimicrobial resistance in the COVID-19 era: perspective from resource-limited settings.
Third, it is likely that COVID-19 rapid antibody test kits were available among drug retail outlets (especially via online pharmacies) despite not being approved for purchase. Future response efforts must involve the early monitoring and regulation of these tests to ensure their safe use in the community. Fourth, provided they have access to accurate guidance and information, many pharmacies are willing to actively participate in response efforts including through surveillance and communication. Thus, our study supports recent calls for expanding the role of private drug outlets during future outbreaks.
6
- Aruru M.
- Truong H.A.
- Clark S.
Pharmacy Emergency Preparedness and Response (PEPR): a proposed framework for expanding pharmacy professionals’ roles and contributions to emergency preparedness and response during the COVID-19 pandemic and beyond.
Finally, what COVID-19 has shown globally is that effective whole-of-health system responses are needed to effectively deal with major public health threats. In countries like Indonesia where there is a dominant private sector, the ability to rapidly mobilise these actors is critical. What we have observed in this study is that while pharmacists have taken on many different roles to protect the community and their staff during the COVID-19 pandemic, these actions on the most part have been ad hoc and not well-integrated into national pandemic management. This is an ideal time for countries such as Indonesia to begin strengthening and updating existing regulatory and community health frameworks to accommodate the changing roles of drug retail outlets during public health crises.
Contributors
Conceptualisation: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Mishal Khan, Astri Ferdiana, Ari Probandari, Tri Wibawa, Neha Batura, Marco Liverani, Richard Day, Stephen Jan, Gill Schierhout, Shunmay Yeung, Virginia Wiseman
Data curation: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Astri Ferdiana, Ari Probandari, Tri Wibawa, Marco Liverani, Matthew Law, Shunmay Yeung, Virginia Wiseman
Formal analysis: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Shunmay Yeung, Virginia Wiseman
Funding acquisition: Ari Probandari, Tri Wibawa, Marco Liverani, Shunmay Yeung, Virginia Wiseman
Investigation: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Mishal Khan, Astri Ferdiana, Ari Probandari, Tri Wibawa, Neha Batura, Marco Liverani, Richard Day, Stephen Jan, Shunmay Yeung, Virginia Wiseman
Methodology: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Mishal Khan, Astri Ferdiana, Ari Probandari, Tri Wibawa, Neha Batura, Marco Liverani, Richard Day, Stephen Jan, Shunmay Yeung, Virginia Wiseman
Project administration: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Shunmay Yeung, Virginia Wiseman
Resources: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Shunmay Yeung, Virginia Wiseman
Supervision: Ari Probandari, Tri Wibawa, Marco Liverani, Shunmay Yeung, Virginia Wiseman
Validation: Ari Probandari, Tri Wibawa, Marco Liverani, Shunmay Yeung, Virginia Wiseman
Visualisation: Yusuf Ari Mashuri, Luh Putu Lila Wulandari
Writing – original draft: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Shunmay Yeung, Virginia Wiseman
Writing – review & editing: Yusuf Ari Mashuri, Luh Putu Lila Wulandari, Mishal Khan, Astri Ferdiana, Ari Probandari, Tri Wibawa, Neha Batura, Marco Liverani, Richard Day, Stephen Jan, Gill Schierhout,
Djoko Wahyono, Yulianto, John Kaldor, Rebecca Guy, Matthew Law, Shunmay Yeung, Virginia Wiseman.
Data sharing statement
The data that underpin these findings may be released following a written request to the last author.
