One of the main goals of a health system is to ensure that effective, safe and high quality medicines are affordable, accessible, and rationally used. Achieving this goal involves a range of determinants from policy making to health service providers. Community pharmacy is the latest ring of the medicine supply chain, and it is the last control station -sometimes with no return- of medication therapy management. It is an accessible health care facility with some specialized human resources to consider society health and to answer the patients' questions. Hence, community pharmacy is an undeniable determinant and plays a critical role in the affordability, accessibility and rational use of medicines. In many countries, most of the pharmacies are financed and managed privately. Although private community pharmacies are identified as health care facilities, they are highly affected by business management issues. Pharmacy is an example of private provision of public service (1). Private provision of public services is a popular kind of public-private partnership in the health sector as a solution for reducing governmental cost and improving health care efficacy. In private community pharmacy –as a public-private partnership model- there are two sides. One side is the health system as a public sector, while the other is a privately owned pharmacy. Consequently, they pursue two different types of goals. The health system maximizes social health outcomes, whereas the private provider maximizes its profit (2–4). This is obvious, as the private partner may not necessarily be satisfied by the public interest as a financial goal (5). Generally, public services are costly, but in private markets, a business enterprise has to be profitable to survive. Part of this conflict is due to the differences among the stakeholders and their particular attributes. Public-private partnerships involve various types of stakeholders that ignoring them could be accompanied by inefficiency in implementation health programs (5). Stakeholder analysis is an approach to understand the relevant actors in purpose to get a rich picture of their power, interests, relationships, and behavior. This information is vital to obtain a deep understanding of the context, evaluating activity environment, recognizing key-players, and then develop suitable strategies for managing these actors or mobilizing them to achieve organizational goals (6).
This study aims to identify private community pharmacy (PCP) stakeholders and analyze their saliency, situation, and their relationship with pharmacy. Pharmacy function varies from country to country in details due to variations in social factors or national policies. Hence, pharmacy relational dynamics could be different in different healthcare models or systems. Considering this point, the authors believe that the results of this study could be useful for policy makers as well as researchers.
Lessons from literature
Over the past two decades, researchers show further attention to the efficiency of the health care organizations and their management. Accordingly, several valuable multidisciplinary kinds of literature have been published and discussed the Health care managerial issues from the perspectives of the social sciences including economics, business, and operational research. McKenzie et al. have introduced stakeholder identification as the first step in the health planning process (7). The comprehensive identification might lead to initial commitment, vision development, role specifications, and next assuring access to the expected resources in an efficient way (7). Stakeholder analysis is an effective way to identify complex situations that involve many legal or natural persons (8). Hence, it has been seen as a valuable tool in health policy and management during the past decades (6, 9–12). There are several studies argue about pharmacy stakeholders in some specific programs. Vozikis et al. analyzed the policy environment of pharmacies and mapped the role of key stakeholders in pharmacy policymaking (13). The authors discussed the opportunities and obstacles of each group of stakeholders. Franco-Trigo et al. debated on the stakeholders of the cardiovascular prevention program in community pharmacies (11). They use a descriptive approach to identify three main groups of stakeholders across the cardiovascular prevention program in community pharmacies, including patients, related health professionals, and organizations associated with the program. Sabater-Hernández and colleagues used a stakeholder share vision to develop a community pharmacy service for patients with atrial fibrillation. Although the principal purpose of this study is not stakeholder identification, they defined the stakeholders as all those who are directly or indirectly influential on the service. As a result, potential service users, service providers, general practitioner, cardiologists, heart failure nurse practitioner, research nurse, and a representative from the local Stroke Foundation were considered (14). Hossain LN and colleagues focused on pharmacy services funded by the government. The main aim of the study was the identification of executive determinants for desired service without further emphasis on stakeholder analysis. Nevertheless, two groups of key-players were considered as project participants that have introduced in ground-level and primary health network. The ground level key-players incorporated service providers and recipients when primary health network key-players combined decision-makers associated with health system (15). The most recent study in this area analyzed stakeholders for developing a preventive community pharmacy service for cardiovascular diseases (16). The analysis was performed using the snowball methodology and the questionnaire tool. After categorization, they found several main groups of stakeholders including patients, health care professionals, regulatory bodies, scientific organizations, NGOs, government institutions, academic researchers, private health insurers, pharmaceuticals or medical devices suppliers, associated software providers, and media.
Notwithstanding having some rather novel lessons from previous literature, only a few studies have discussed the conflict of interests and power relations between stakeholders and their impacts on the efficiency of community pharmacies. Also, no study has concentrated on the private community pharmacies as an independent business enterprise. Business and financial issues could raise multiple conflictions with health objectives and lead to more complexity in the determination of real stakeholders and their behavior.
Theory of stakeholders
The predominant definition of stakeholder is attributed to W. Edward Freeman, who defined a stakeholder as “any group or individual who can affect or is affected by the achievement of the organization’s objectives” (17). Organization refers to an organized group of people with a particular purpose (18). In this case, we assume a private community pharmacy as an organization pursues two levels of purposes. 1- The economic purposes and profit maximization, and 2- the health care purposes that are induced and followed by the regulatory body. Freeman definition introduces a wide area of possible stakeholders. Mitchell and colleagues' (1997) suggested that managers might classify the characteristics of stakeholders (19). The theoretical concept of this study is based upon Mitchell and colleagues' hypothesis that stakeholder salience will be directly associated with the resultant accumulation of stakeholder attributes, including power, legitimacy, and urgency, recognized by managers (19). There is some evidence that attempts to clarify the issue that managers cannot take into consideration all the stakeholders' requests or demands and has to set out a series of priorities for managerial attention (20). Mitchell and colleagues’ definition of stakeholder salience has been accepted as the degree to which managers prioritize the consideration or even involvement of stakeholder in decision making. The main advantages of this model are in tree area: 1- policy-making, due to reflecting the organization as the result of conflicts of interests, 2- operationally practice, with specifying the stakeholders, and 3- dynamic environment, based on the possibility of changes in stakeholders’ attributes and their salience (21). These advantages make it possible to take benefit from this model to various fields of policy-making and macro management with the ability to re-evaluate the model and stakeholders positions over time.
In this method, the stakeholders are categorized according to either the possession or not of the attributes of power, legitimacy and urgency as illustrated in Fig. 1.
“Power” refers to the ability of stakeholders to exercise influence, which could be through using political, coercive, utilitarian, or normative means. “Legitimacy” pertains to a stakeholder whose actions are considered desirable and proper within the context of the social system. “Urgency” refers to the extent to which a stakeholder’s claims are considered critical or time sensitive and need attention.
The three-dimensional analytical matrix results from various combinations of these attributes. As per Fig. 1, there are eight zone based on the interactions over the three attribute that stakeholders could have between them. The next few paragraphs discuss the reasoning behind each class of stakeholder.
Definitive stakeholders have a direct relationship with the system. In this situation, managers or policy makers have a clear and immediate mandate to attend to and give priority to these stakeholders’ demands.
The relevant attribute of dormant stakeholders is power. Dormant stakeholders possess power to impose their request on the system, but due to lack of legitimacy or urgency, their power remains useless.
These stakeholders are both powerful and legitimate. So, their influence on the system is assured.
Although discretionary stakeholders possess the attribute of legitimacy, they have neither power nor urgency to influence the system. The strategic point regarding discretionary stakeholders is that, in the absence of power and urgency, there is absolutely no pressure on managers (or policy makers) to involve in an active relationship with such stakeholders, even though managers can choose to do so.
The stakeholders who lack power, but have urgent legitimate claims are categorized as “dependent,” because they depend on others (other stakeholders or the firm’s managers) for the necessary power to achieve their demands.
When the sole significant attribute of a stakeholder is urgency, the stakeholder is described as “demanding.” Demanding stakeholders are troublesome, but don’t necessarily need more than passing attention from the management.
When urgency and power characterize a stakeholder in the absence of legitimacy, that stakeholder will be compulsory and possibly violent, making the stakeholder “dangerous,” literally, to the system.