In the present study, 8 main categories and 26 sub-categories were identified by guided content analysis to determine the challenges of drug supply.
Table 2
Challenges of drug supply at the pharmacy level
Principle | Category | Sub-category |
Autonomy | Patient independence | Participating patient in decision-making process Giving required information to patient |
Patient privacy | Respecting patient’s privacy, confidentiality, preserving information privacy, same-sex care delivery |
Communication principles | Pharmacist-patient relationship, physician-patient relationship |
Non-maleficence | Patient harm avoidance | Educational system in teaching pharmacological ethics Pharmacists’ awareness of own professional commitment Not letting pharmacy license Lack of ignorance and not rushing to deliver drug to patient |
Supervision | Pharmacist’s monitoring of drug storage condition in the pharmacy Import of foreign medications Advertising of drugs based on effectiveness, and not based on their brand Disposal of pharmacological waste |
Beneficence | Patient-centered services | Considering patient’s interests Increasing patient’s awareness Sense of responsibility in pharmacological system Acceptable quality of medications |
Optimization of drug use | Standardizing pharmacy in terms of space, temperature, humidity, shelving Criterial for entry/exit of drug from drug list Culturizing prescription and rational drug use Drug hoarding by distribution companies |
Justice | Distributive, procedural and interactive justice | Equitable distribution of drug Justice in provision and distribution of drug Equitable distribution of responsibilities and interpersonal interests Justice in law enforcement Justice in protecting people’s rights |
Principle 1: Autonomy
Human dignity should be respected in any circumstances, but a patient or a healthy person who has a health need deserves special attention and respect. Based on the findings, three main categories related to autotomy were identified in this study.
Category 1: Patient Independence
The ability to make informed or rational decisions and to act upon them is only made in caring situations. Patient independence is influenced by following factors and categories:
Participating patient in decision-making was one of the codes of patient independence category. One participant in this regard stated:
"…Lack of patient participations in decision-making on treatment is a moral challenge, and based on the principles of evidence-based medicine, the patient must be given the right to choose and it is wrong to use clinical power when prescribing a treatment…" (Pharmacist 5).
"…Lack of ethical decision-making models in pharmacies has caused them to not adhere to ethical principles and give, for example, calculus syrup to patient instead of prescribed calculus tablet regardless of patient's preferences..." (Insurance inspector 1)
Giving patient the required information for decision-making was one of the codes of patient independence category. The participants in this regard stated:
"…Presence of pharmacist in the pharmacy gives patient the right to receive information about drug treatment. Also, all information on how to use drugs in treatment process or other information should be given to patients according to their level of knowledge, literacy and health status, so that it would be understandable for them and their next of keens..." (Pharmacist 2)
"…If the pharmacist does not give information to patient on how to use the drug and its side effects, the patient cannot get a favorable outcome from the treatment, so it is useless and dangerous to administer drug without providing information about its use. This is why the pharmacist should be obliged to provide pharmaceutical information as the last treatment loop... "(Food and drug administration inspector 4)
Category 2: Patient Privacy
Preserving patient physical privacy was one of the codes found in this student. In this regard, some participants stated:
"…Physical privacy is a place that surrounds a person's body and is actually a protective area for the person. The pharmacy’s space should be such as to create an opportunity for respecting people’s privacy…" (Patient 4)
"…A pharmacy is an environment where patients have fewer facilities and more often their privacy is not respected and this is a moral challenge which inflicts harm…" (Pharmacist 2)
"…Patients’ privacy is not respected in pharmacy due to the lack of space physical which means that, there must be some private space between them and other clients when buying. One of our challenges is the crowded pharmacies and physical contact between ladies and gentlemen…"(Pharmacist 2)
Privacy and confidentiality was another code which was found in this study. Participants in this regard stated:
"…This issue is not specific to Iran, and countries such as the United States, Britain and Scotland also insist that pharmacists and pharmaceutical technicians should strive to respect the patient and protect their right to confidentiality..." (Pharmacist 1)
"…Patients want their pharmaceutical information to be kept confidential by pharmacist. The concern of some when visiting a pharmacy is that their colleagues, friends and neighbors will see or hear their pharmaceutical information..." (Patient 4)
"…This is one of the most important ethical issues in the pharmacy environment and the need for serious and practical commitment of pharmacy’s staff is evident. They are also obliged to adhere to this right by Sharia and law. But a problem that I have always seen in Kerman province is that patient’s privacy and confidentiality is not important to pharmacist and pharmacy staff... "(Patient 1)
Gender proportion or same-sex care delivery: The vast majority of participants believed that:
"…People tend to get their medication and ask their questions from their same-sex peers, and adhering to the principles of same-sex care in the health sector will increase the morale of patients and reduce their stress when receiving a service..." (Pharmacist 7)
Category 3: Communication Principles
Proper communication is a win-win process for the pharmacist, the patient, the physician, and the healthcare system in general. This communication should be a two-way communication and have its own rules. This category had two subcategories as follow:
Pharmacist-patient relationship/communication: The majority of participants believed that:
"…The treatment environment should be such that the patient realizes staff are here because are valuable to them. Also, appropriate relationship and preserving patient dignity regardless of race, skin color, nationality and income are fundamental to an effective communication in clinical environment and its absence is a moral challenge... "
"…Sometimes pharmacists are faced with unethical and unprofessional request For example; people want cosmetic drugs instead of prescription drugs, or want illegal document for insurance without a prescription. Such issues are due to the patient's unethical relationship with the pharmacist...” (Pharmacist 4)
"…The relationship between pharmacist and patient is a relationship of two people that should be based on respect and trust, but unfortunately for a number of reasons, including self-interest good communication principles are not respected…" (Pharmacist 5)
Physician-pharmacy relationship/communication: Treatment process causes physician to have a close relationship with pharmacist, but sometimes the physician-pharmacy relationship presents an ethical challenge. Participants in this regard stated that:
"…The physician's family relationship with the pharmacist is one of the ethical challenges in this field, and the physician should prescribe medication based on patient's needs, but sometimes it is based on financial interest and other motivations. For instance: the daughter of a pharmacy owner is dermatology specialist who send her clients to her father’s pharmacy, justifying it by saying that, this pharmacy reads the prescription better, is more skillful in making mixed medicines, and has a complete list of drugs without a deficit. "(Insurance Inspector 2)
"…Occasionally, there is contract between physician and pharmacist in the way that, the pharmacist gives the list of its near-term medications and the physician prescripts these unrelated drugs to patients….” (Patient 5)
Principle 2: Non-maleficent
Category 1: Patient harm avoidance
The pharmacy is permitted to take actions that their interests are greater than their risks. In relation to this ethical principle, two main categories were extracted from the interviews, including patient harm avoidance and supervision.
Educational system in teaching the principles of pharmaceutical ethics: according to the participants' perspectives:
"…There is no any related module/course for pharmacy students. After graduating, pharmacists are unaware of the principles of ethics in pharmacy and the rules that apply to their pharmaceutical activities. They think that pharmacy like the local supermarket is a place for selling drugs. This issue can cause irreparable damage to the country's health care system..”.
Pharmacists' awareness of own professional commitment was one of the codes of this category. One participant in this regard stated that:
"…The pharmacist must be aware of the requirements and principles within the pharmacy system and prevent any harm to patient and the pharmacy. Professional tasks should be done by the pharmacist and the pharmaceutical technicians should not be allowed to arbitrarily and unknowingly prescribe medication and by doing so affect the health system..." (Inspectorate of food and drug administration 1)
Not letting pharmacy license: Participants believed that:
"…Letting the pharmacy degree is one of the ethical challenges in the pharmacy system in our country. Pharmacy graduates in the country lend their in pharmacy license to investors at exorbitant prices. A pharmacist, who does not have a billion Tooman to buy a property and medicines to open a pharmacy, lends his license to an investor. Is it a pharmacy or a supermarket? The main issue is avoiding harm to patient..”.
Lack of negligence and not rushing the deliver drug to patient are effective measures to prevent harm to patients. One participant in this regard stated that:
"…The pharmacists should manage their pharmacy with the view of giving priority to patient and avoiding patient harm..." (Pharmaceutical Technician 3)
"…I saw a pharmacy where, the manager rated technicians based on the number of prescriptions they prepared, and this had increased carelessness and negligence. Patients’ life depends on medication and negligence puts patient’s life in danger, which its moral responsibility is on the pharmaceutical technicians..." (Deputy Inspector 1)
Category 2: Supervision
Pharmacist’s monitoring of drug storage in the pharmacy: Participants in this regard stated:
"…Due to the reactive and supplementary substances in medicines, heat, cold, humidity, and light affect the nature of drugs...” (Pharmacist 1)
"…In the pharmacy evaluation guideline, which is issued every 3 months, the storage condition has for 50 points out of 1000 evaluation points. Although this indicator is very important and affects the quality of drugs, it pint is much less than other indicators…” (Food and drug administration’s inspectorate 1)
Import of foreign drugs: although the participants believed that:
"…Large number of drugs is currently imported and some of these drugs have national samples. Pharmaceutical import restrictions have created many challenges in the pharmaceutical field that need supervision…" (Pharmacist 2)
"…Drugs sanction has led to a large volume of drugs being trafficked in the country, and supervision is one of the reasons for this problem...” (Patient 4)
"…Inadequate supervision over the entry of foreign drug may cause irreparable harm to patient. Another participant in this regard stated: The entry of foreign complementary drugs into the country have increased, and when the country is faced with a shortage of resources to meet its pharmaceutical needs, the cost-effective studies should be carried out on complementary drugs..." (Pharmacist 6)
Advertising drugs based on their effectiveness and not just paying attention to their brand: According to the participants' statements, one of the current challenges in pharmacies is supplying drug based on their brand and not their effectiveness. In this regard a participant said:
"…Many physicians, including dermatologists prescribe branded drugs advertized by the drug salesmen without knowing their safety and effects on health...” (Insurance inspector 2)
"…Prescribing an effective drug ensures positive treatment outcome and now prescribing foreign drugs are being prohibited by internal physicians under Sect. 6 Sixth of the Developmental Law. This is while the quality of national drugs is not the same as foreign ones and this paves the way for drug trafficking… " (Pharmacist 3)
Disposal of pharmaceutical waste: Based on the findings of this study, all participants believed that:
"…Disposal of pharmaceutical waste is not done properly, and abandoning drugs in nature or household waste can cause many problems, including microbial resistance…"
Principle 3: Beneficent
The health system strives to maximize beneficence for individuals in line with its health goals. Beneficence means taking activities that benefit patients. Patient-centered services and drug use optimization were the two main categories identified in relation to beneficence.
Category 1: Patient-centered Services
Providing patient-centered service is influenced by the following known factors:
Considering the patient’s interest was one of the factors highlighted in this study. The participants believed that services provided to patient should be such that, the patient's benefit overrides the financial and economic benefit of the pharmacy.
"…When drug supply in the pharmacy is seen as a business, the patient's interest goes away and the profits from the sale take priority" (Pharmacist 4). Another interviewee stated that: "In pharmacy, financial gain is more important than serving patient, and when the basis is just money, patient will not be in priority. In such situation, the public view pharmacists as thieves..." (Food and drug administration inspector 2)
Increasing patient awareness: This prepares people mentally and emotionally in facing disease-induced anxiety. Below are the interviewees' statements about patient awareness:
"…The patient has the right to know how to take the medication. Not giving information or giving wrong information to patients breaks the treatment cycle. In such situation, the patient will not be treated and the treatment will not be effective. However, despite the importance of increasing patient awareness both legally and morally, this is not implemented for the sake of pharmacist benefit..." (Pharmacist 7)
"…Putting similar drugs than those written in prescription without informing physician and patient is a moral challenge. The pharmacy has the right to consult, but has no right to change the prescription..." (Insurance inspector 1)
"…We should inform patient about the near-expire drugs on the prescription. The patient could be an illiterate old man or woman who keeps the medication for few months without knowing that they will be expired soon..." (Pharmaceutical Technician 4)
Another interviewee in this regard stated: "Patient should be aware of any mistake in insurance deductions created by physician that could cause him/her to pay full charge for the drugs." (Patient 3)
"…According to the participants' comments, information on the technical fees, drug interactions, medication costs, adverse effects of the drug, and how to use the drug are among the issues that the patient should be aware of..."
Sense of responsibility in pharmaceutical system: Another issue that emerged in relation to patient-centered services was taking responsibility in the cycle of pharmaceutical system. In this regard, the participants stated that:
"…Morality means a sense of responsibility and should be not only in the pharmacist but also in the pharmacy technician. The technician should check the validity of prescription so that the pharmacy will not be fined..." (Pharmacist 6)
"The pharmacist must give clear and legible information to patient and this responsibility cannot be delegated to technicians as this is the last thing that patients do before leaving the pharmacy.” (Insurance inspector 2)
"…Our challenge is the targeted sources of information, such as visitors of pharmaceutical companies, specially the cosmetic companies that promote expensive and in some cases less-effective drugs for more profit. In such situations, nothing but a sense of responsibility and conscience of technical officer can prevent this problem..." (Insurance inspector 3)
Acceptable quality of medication was another code related to patient-centered services. In this regard, the participants believed that:
"…The production of low quality drugs is a waste of resources and sometimes a risk to people's health. The production of poor quality drugs is a problem..." (Pharmacist 5)
"…The herbal medicines that are being distributed and the ointments and creams that are manufactured manually in the pharmacy may not have the required quality. For instance, the Zarband herbal company changes the expiry dates of its products and sends them to pharmacies to be sold to patients. Ointments and creams are also occasionally seen to be made by non-pharmacists...” (Pharmacist 8)
Category 2: Drug Supplier
The optimization of drug use is influenced by following factors:
Standardization of the pharmacy in terms of space, temperature, humidity and shelving: According to most participants, this is important as it affects people's health, but it is less important in the pharmacy environment. Below are some of the participants' statements in this regard:
"…At the pharmacy, the condition of drug storage, cleanliness of the pharmacy environment and the instructions of drug storage in order to achieve optimal conditions should be monitored and supervised..." (Insurance inspector 1)
"…The physical standards of pharmaceutical care have been developed by the Food and Drug Administration in 8 articles and have been issued to pharmacies and drug stores. This regulation requires pharmacies to comply with standards regarding temperature, humidity, light and shelving, but it is not respected and considered important for many reasons..." (Food and drug administration inspector 4)
"…Sometimes pharmacies use lasers and lighting effects to make cosmetics products more luminous and noticeable, which can affect the chemical formulation of the products and medications and make them ineffective..." (Pharmaceutical Technician 5)
"…One ethical challenge that seems to be regular for pharmacy technicians is the use of cooler or heater for air conditioning. At one of my pharmacy inspections, I saw a KPTVA spray that was placed next to the heater with very high temperature and no one was concerned that the heat could decrease its effectiveness. Not controlling the temperature and humidity of pharmacy may cause financial loss and personal injury...” (Food and drug administration inspector 4)
The criteria for entry or exit of drug to drug list was another code related to optimization of drug use. In this regard, the participants stated that:
"…There are currently many drugs on the nation's drug list that cannot be prescribed at all. When the selection of drugs on the list is based on proper and evidence-based criteria, the health indicators would improve too..." (Pharmacist 4)
"…Adding or removing drugs from the drug list and updating the drug list is in line with the Sixth Developmental Plan, but because the workgroup is novice the criteria for drug entry into the drug list are causing discontent and challenges in the public and pharmacies…" (Pharmacist 5)
Culturizing prescription and rational drug use: Proper prescription and rational use of medication is currently one of the most important factors in health care. We are seriously wasting resources in the field of medication. All participants, while emphasizing on the culturizing prescription and rational drug use, believed that:
"…Culturizing is a very important factor in prescribing and taking medication. If the pharmacy send patient home with a large bag of drugs, the patient thinks that the physician is good and this is one of the causes of irrational prescription..." (Patient 3)
"…Physician knows that if he writes a simple prescription for patient, he will not get a good response from the patient and sometimes, patient will not follow-up his treatment. It can also be a bad advertising for the physician. We have a cultural problem and the prescription and rational drug use is a problem in Iran..." (Pharmacist 6)
"…One factor that causes irrational drug use is a faulty system of drug prescription and distribution which is caused by false propaganda and claims of some pharmaceutical companies and visitors that reward physicians and pharmacists to use their products..." (Insurance inspector 2)
Drug hoarding by distribution companies: Drug hoarding or stoking and refusal to supply drug was another code related to optimization of drug use from the participants' point of view. For example, participants stated that:
"…The country has been sanctioned by some countries because of political issues. As a result, raw materials and technology are difficult to be imported into the country and this creates a suitable situation for drug trafficking and increasing price. Government must set policies to prevent hoarding… "(Insurance inspector 2)
"…Hoarding medicines that are directly linked to health and well-being may endanger the lives of thousands of innocent people, and the primary mission of pharmacists is to benefit society..." (Patient 5)
"…One of the factors that disrupt the optimum drug cycle is that, pharmacists and distribution companies stoke drugs in stores other than their pharmacies due to the shortage of medicines and become drug hoarders..." (Pharmacist 1)
Principle 4: Justice
The complexity of justice in medical ethics and health system suggests that achieving it is difficult because of different philosophy and evaluation of ethics. Justice, which means equity in allocation of scarce health care resource and deciding who receives what treatment, was emphasized in three categories.
Category 1: Equitable Distribution
Equitable distribution of drugs: was one of the codes highlighted in the present study. The participants believed that:
"…The transfer of pharmacy capital is not fair and the pharmacy capital is determined by the brokers according to the insurance-related license and the amount of pharmacy sales, which is licensed by the food and drug administration..." (Food and drug administration inspector 3)
Justice in the supply and distribution of medicines: in this regard, the participants stated that:
"…There is no justice in the allocation of medicines. Currently in the province, we do not have certain medications and in the distribution of medicines large cities are always prioritized...” (Patient 4)
"…Quota medicines are not distributed fairly, and we cannot track how many quota medications have been given to each pharmacy. Because people at the top of the Food and Drug Administration have their own pharmacy, so it is in the best interest of distribution companies to make these powerful people happy…." (Pharmacist 3)
Equitable distribution of responsibilities and interpersonal interests was one of the subcategories of equitable distribution that was highlighted in the present study. In this regard, the participants stated that:
"…The distribution of responsibilities and interests in the pharmacy must be based on fairness and benefit of the patient. Effective communication should also be established between individuals and this will happen when the allocation of tasks is done correctly….”
Category 2: Procedural Justice
Procedural justice is the extent to which the rules and procedures specified by the policies are followed uniformly in all cases. One of the codes extracted from the interviews was justice in law enforcement.
Justice in law enforcement: Seeing individuals equal in law enforcement can provide a good basis for achieving justice in the community. It also increases patients' trust in the drug system. According to the interviewees:
"…People want the law to be implemented equally for everyone. If there is no justice in law enforcement, mistrust is created. Mistrust is the most serious problem in our health system, and if mistrust is the result of injustice in law enforcement, it cannot be corrected by guidelines and regulations”.
Category 3: Interactive Justice
Interactive justice is one of the main categories of justice. People are sensitive to the quality of their interpersonal interactions and tend to have relationships based on politeness, honesty, and respect especially between patient and healthcare provider. Interactive justice is about the ways by which customers who received a faulty service are treated.
Justice in protecting people’s rights was one of the subcategories of interactive justice, which was highlighted in the present study. In this regard, the participants stated that:
"… Interactive justice is felt when people's rights are being respected and unsatisfied customer is treated honestly, compassionately and politely. Pharmacies should treat patients as they would like to be treated by other pharmacies. …"