PharmD Education in Nepal: the challenges ahead.

To the Editor. Nepal is a Himalayan country located between India and China. With a population of 25 million (90% live in rural areas), Nepal ranks as one of the poorest countries in the world.1 Health care in Nepal is delivered through zonal hospitals and district hospitals in urban areas and through health posts and health centers in rural areas. The primary problem that Nepalese health care is facing is a lack of health care providers at peripheral health care facilities and the need for safe, effective, and rational use of medicines. One strategy to tackle these problems is to develop a quality pharmacy education program and produce enough pharmacists for the country. Pharmacy education in Nepal is a recent phenomenon. It started with the commencement of the Intermediate in Pharmacy (similar to a diploma) program at the Institute of Medicine in 1972, and subsequently the establishment of the bachelor of pharmacy (BPharm) program in Kathmandu University in 1994; BPharm programs later were started at Tribhuvan University, Pokhara University and Purbanchal University. The neighboring county, India, started the 6-year doctor of pharmacy (PharmD) program and 3-year post-baccalaureate PharmD in 2008, which were focused mainly on the clinical and community aspects of the profession and mandatory practical training at practice sites.2 Basak and colleagues have argued that introduction of the PharmD program may not help clinical pharmacy education and practice in India. Jamshed and colleagues further stated that the initiation of the 6-year and 3-year PharmD program in developing countries may be due to an upsurge in clinical pharmacy rather than a general interest in a practice-based model of pharmacy.3 Hence, there are differing viewpoints about the PharmD program in developing countries, especially in south Asia and it is too early for pharmacy educators and policymakers to reach any conclusions about the success and impact of the program on the healthcare sector in general and pharmacy practice in particular. Over the years, pharmacy practice has moved away from its original focus on medicine supply, ie, distributive function, towards a more inclusive focus on patient care. Increasingly, the pharmacists' task is to ensure that a patient's drug therapy is appropriately indicated, effective, safe, and convenient for the patient. The PharmD program in the United States is the epitome of the practice-based model as it evolved from industrial and compounding pharmacy to a more patient-focused program.2 Following this global trend in pharmacy education, Kathmandu University started a post-baccalaureate PharmD program in Nepal in the year 2010. The objective of the program is to train the graduate pharmacist in the area of patient care and to orient them with the clinical pharmacist thought process. The PharmD program covers 2 years of basic modules on pharmacotherapeutics of various systems, clinical pharmacy practice, critical literature evaluation and research methodology, clinical pharmacokinetics, and clinical rotation in different hospital departments, followed by a specialization internship in the final 6 months. The concept of the PharmD is quite new to Nepal, where pharmacists are still struggling to get into the patient care areas. Bhandari and colleagues has stated that ward rounds with clinicians, providing drug information, and research and publication can be some of the activities for pharmacist in Nepalese hospitals, besides their regular responsibilities of dispensing and counseling.4 Because it is a patient care approach, where pharmacists perform the role of pharmaceutical care provider, there are numerous challenges for the PharmD program ahead. When it comes to the aspect of pharmacy education, curriculum content, manpower, and infrastructure are crucial issues. Pharmacy colleges are rushing for changes and glamor, without seriously thinking about the quality of graduates that will be distributed in the healthcare market and negatively impacting the healthcare system as well as the image of the pharmacy profession. Getting a well-trained faculty member with clinical pharmacy exposure is very difficult in a country like Nepal. In addition, creating a well-structured curriculum emphasizing the clinical and patient care approach and getting proper facilities for student to train in this area is a big challenge. For a country like Nepal with limited resources, getting a super-specialty hospital with ward-based pharmaceutical care provision, well-structured curriculum, an evidence-based critical literature database, and conducting clinical research projects is a daunting task. Sustainability of the PharmD program depends mostly on the performance of its graduate as well as the performance of the pharmacy colleges. Jamshed and colleagues remind us that the PharmD program should not be used as a tool for the pharmacist to be employed internationally or as a sole instrument of professional power and status.3 The PharmD program must be structured such that the graduate can work in their local settings and provide pharmaceutical care in their own health care structure. The medical college and tertiary health care institution in Nepal offers an ideal practice setting for the PharmD graduate. In Nepalese hospitals, there is adequate patient flow, a variety of patient cases, and the patient are willing to participate in pharmacy care. Therfore, Nepal can provide a great setting for the PharmD student to be trained in patient care. If the PharmD program can create the necessary pharmacy practice structure in hospitals and develop a practice-based academic unit bridging the pharmacy practice with academia, there is great hope for the PharmD program in Nepal. KC Bhuvan,1 Subish P,1 Mohamed Izham MI2 1College of Medical Science Teaching Hospital, Chitwan, Nepal2Qassim University College of Pharmacy, Al Qassim, Saudi Arabia.