Is Malaysia ready for separation of dispensing?

It’s nearing the end of 2014 and come 2015 there are rumblings again of the issue of separation of dispensing in Malaysia, a scenario where doctors only prescribe and pharmacists dispense.
Are we ready for this?
In a previous post on Separation of dispensing, I made the point that separation of dispensing (hereby abbreviated to SOD) should not precede a National Healthcare Financing System (NHFS). If there is no NHFS, basically it will be taking the away the right of the consumer on choosing where to get medication from.

As Dr. Steven Chow commented on the article, Call for watchdog on drug dispensing

The choice of where to obtain his/her medications, whether from a pharmacy or from a clinic must be the RIGHT of the patient. To enact a law/regulation to restrict this choice will take away this RIGHT. If the clinic is over charging, the patient has every right to refuse medications from there. The fact of the matter is that most clinics are able to package consultation fees and treatment at an affordable cost to the patients. This issue of separate prescription and dispensing is being raised because BIG BOYS have now gone into the business of dispensing in Malaysia. This is in preparation for commercial opportunities of impending 1-Care. At the end of the day, cost goes up, quality and continuity of care goes down and the patient ends up paying more and have to undergo more inconvenience. Imagine a mother with two sick children in tow trying to cross a busy KL street on a hot and humid day just to get medications from a pharmacy located miles from the clinic…might even have to end up waiting again as the dispensing pharmacist might be out for lunch break….. There is lots of merit for the 1-stop medical care delivery system that we have today in Malaysia. Improve it by all means but don’t dismantle what works….Even patients from the UK, USA and other countries appreciate and commend highly on this patient-friendly one-stop system. I say we should go for a properly conducted nation-wide public referendum on this issue.

What are the repercussions of imposing SOD on the rakyat?
Recount this scenario: Doctors Prescribe, Pharmacists Dispense, Patients Suffer

Madam Ong is a 52-year-old lady with a twelve-year-history of hypertension and diabetes. She complained of generalised lethargy, lower limb weakness, swelling and pain. She brought along her cocktail of medications for my scrutiny. Her regular medications included the oral antidiabetics metformin and glicazide and the antihypertensives amlodipine and irbesatan. Madam Ong also had a few episodes of joint pains three months ago for which she had seen two other different doctors. The first doctor suspected rheumatoid arthritis and started her on a short course of the potent steroid prednisolone. Thereafter, she developed increasing lower limb swelling for which a third doctor prescribed the powerful diuretic frusemide.

Madam Ong was not on regular follow-up for hypertension and diabetes. Additionally, she has been re-filling her supply of steroids and diuretics at a pharmacy nearby with the purpose of saving up on the consultation charges.

I took a more complete medical history and performed a thorough physical examination. I concluded that this lady’s health was in a complete mess.

She was under sound management by the family physician until the day she defaulted follow up and was started on prednisolone by a doctor who was unaware she was diabetic. The steroid probably helped in relieving her arthritic pains though the suspicion of rheumatoid arthritis was never proven serologically.
However, it also worsened her sugar and blood pressure control and weakened her immune system.

Her legs swelled up because of the fluid retentive properties of the steroids. In addition, early signs of cellulitis were showing up around her legs due to a weakened immune function. The diuretic prescribed by the third doctor helped a little with the swollen limbs but she became weak from the side effects of diuretics.

Madam Ong’s problems escalated when she decided to forgo her doctors’ opinion altogether and decided to self-medicate simply by collecting all her medications from the pharmacist who supplied them indiscriminately. Unknowingly, the pharmacist had added to the lady’s problems in spite of the wealth of knowledge the pharmacist must have possessed.

The above scenario is a fairly common scene in the Malaysian healthcare. We see here an anthology of errors initiated by doctors, propagated by the patient’s health seeking behavior and perpetuated by a pharmacist.

Such a scenario is commonplace and will probably get worse with SOD, and we’ll likely see more self-medicating poorly controlled patients with chronic illnesses and many more pharmacists playing doctor. We have an ongoing thread in Doctors forum Dobbs called, Separation of Dispensing is coming Soon where by there are tales of pharmacists happily dispensing drugs like Hydroxyurea and Methotrexate without prescriptions and even pharmacists making their “diagnoses” like BPH (I presume pharmacists in Malaysia don’t do rectal examinations though one confused ex-Malaysian pharmacist down under thought he had the right to perform intimate examination and was arrested for digital rape) and dispensing drugs like this without the patient having seen a doctor or have a prescription


SOD to be imposed on the rakyat? Are we ready? Big business is licking their chops but I say no to SOD as things stand.

Some articles for your reading pleasure:

Taking your medicine
Should doctors stop dispensing medicine? Not so soon, say GPs

Forum links:

Discussion on Separation of Dispensing in the DOBBS Doctors forum
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Malaysian physician, haematologist, blogger, web and tech enthusiast