Pakistan extends from the mountain valleys of the Himalayas to along the Arabian Sea bordering India, China, Afghanistan and Iran. It is strategically located along the ancient trade route between Asia and Europe[27
]. In 1947, Pakistan was created as British rule came to an end in India. In 1971, East Pakistan demanded independence, and after a bloody civil war it was transformed into what is now the country of Bangladesh. As one of the most populous countries in the world, Pakistan faces enormous economic and social crises. Fortunately, however, it possesses an abundance of natural resources that can help it overcome these challenges [28
With a population of approximately 160 million, Pakistan is the sixth most populous country in the world [29
]. The average growth rate in the economy over the past five years was 7%. Pakistan has enjoyed more than five years of sound economic growth and poverty reduction since 2002, yet in 2004/05, 24% – nearly 40 million – were still living below the national poverty line[30
]. In 2004/05, 52% of five to nine-year-olds went to school.
According to the adjusted gross domestic product (GDP), the per capita income comes to USD 812 in 2006 [32
]. Poverty rates, which had fallen substantially in the 1980s and early 1990s, started to rise again towards the end of the decade. More importantly, differences in income per capita across regions have persisted or increased. Poverty varies significantly between rural and urban areas and from province to province, from a low of 14% in urban Sindh Province to 41% in the rural North Western Frontier Province (NWFP) [33
]. Pakistan still faces formidable challenges (political, attitudinal and policy) to fully develop human capital, improve investment and increase productivity by bringing the economy to a rate achieved in earlier decades, i.e. an annual growth of 5% or more, to significantly reduce poverty [34
The health care system of Pakistan
National public health is a recent innovation in Pakistan. National health planning began with the Second Five-Year Plan (1960–1965) and continued through the Eighth Five-Year Plan (1993–1998). In addition to public- and private-sector biomedicine, there are indigenous forms of treatments. Some manufactured remedies are also available in certain pharmacies. Homeopathy is also taught and practiced in Pakistan. Prophetic healing is based largely on Islamic tradition pertaining to hygiene and moral and physical health; simple treatments are used, such as honey, a few herbs and prayer. Some religious conservatives argue that reliance on anything but prayer suggests lack of faith, while others point out that the Prophet Muhammad remarked that Allah has provided a cure for every disease other than death and old age [35
The Ministry of Health is responsible for all matters concerning national planning and coordination in the field of health. The Drugs Control Organization is a subsidiary of the Ministry of Health. It has been facilitating local pharmaceutical units and drug importers in registration and licensing and making their participation possible in various events organized worldwide [36
]. Under the Pakistani Constitution, the federal government is responsible for planning and formulating national health policies; provincial governments are responsible for implementation.
The private sector serves nearly 70% of the population, whereas the public sector comprises more than 10 000 health facilities, ranging from basic health units (BHUs) to tertiary referral centers. The BHU cover around 10 000 people, whereas the larger rural health centers (RHCs) cover around 30 000 to 450 000 people. In Pakistan, primary health centre (PHC) units comprise both BHUs and RHCs. The Tehsil Headquarters Hospital (THQ) covers the population at sub district level, whereas District Headquarters Hospital serves at district level as its name suggests [37
The health system of any country depends primarily on the human resources available. In the case of Pakistan, there is a lack of a clear, long-term vision for human resource development: the federal Ministry of Health and the provincial departments of health do not have units responsible for this important health system function. The health information system is fragmented. Each vertical programme has more or less its own information system and none covers the private health sector. There is no organized system of disease surveillance and there is limited capacity to use information for decisions. The overall capacity to undertake health policy and system research is deficient [38
As the population is growing and there are issues of poor housing, lack of exercise, pollution, improper diet and lack of health education, diseases are rampant. The health care system in Pakistan has been confronted with problems of inequity, scarcity of resources, inefficient and untrained human resources, gender insensitivity and structural mismanagement [39
]. Pakistan is facing a very precarious economic situation and there is a need of innovative health reform [40
Political instability has caused change in the government, thus resulting in changes in health policy. Till now, health policies have not been given enough time for proper implementation in the country [41
]. The low priority given to the health sector by the military regimes has resulted in a persistent contrast between reasonable economic growth and government expenditure on health[42
The pharmacy profession in PakistanAt the time of independence – 1947 – there was no institution offering pharmacy education in Pakistan. In 1948, the University of Punjab was the first institution to start a pharmacy department; in 1964 a Department of Pharmacy was established at the University of Karachi.
The pharmacy programme was initiated as a three-year baccalaureate programme, and then in 1978–1979, it was lengthened to a four-year programme. At that time, the pharmacy curriculum was directed mainly towards production of pharmaceuticals, which helped provide the pharmaceutical industry with well-qualified and skilled human resources, but there was no consideration of the public health role of the pharmacist [24
During recent years, in most of the public-sector hospitals, small numbers of pharmacists were appointed; their role was limited to drug delivery, procurement and inventory control. There was a lack of pharmacy services in the hospitals and community pharmacies because of the isolation and lack of recognition of pharmacists as health care professionals. The lack of trained personnel and the resulting lack of contact of pharmacists with the public are also among the main contributing factors towards the lack of recognition of the pharmacy profession.
In 2003, the Doctor of Pharmacy (Pharm.D) began to be offered as a five-year professional degree programme in Pakistan, focused mainly towards the clinical aspects of the pharmacy profession. Some 2587 pharmacists have graduated every year. With the current population, this number is not sufficient to provide optimal health care delivery [16
There are a total of 28 pharmacy institutions in the country [43
]. The Pharmacy Council of Pakistan was established under the provision of the Pharmacy Act of 1967. It regulates the practice and education of pharmacists in the country [44
]. It is also responsible for registration of pharmacy graduates and issuing the license permitting them to practice in the country. Registration activity is decentralized and the regional pharmacy councils (sub bodies) under the Pharmacy Council of Pakistan are responsible for controlling and registering pharmacists in their respective provinces.
It has been estimated that around 8102 pharmacists are present in Pakistan, of whom 2836 work in the public sector and 5023 in private settings, while 243 work in private, non-profit-making organizations [38
]. Among the total number of pharmacists in Pakistan, approximately 55% are engaged in the production of pharmaceuticals – 15% of them working at the federal and provincial drug control authority and hospital pharmacy level – with another 15% in sales and marketing of pharmaceuticals, 10% in community pharmacy, and the rest 5% in teaching and research [44
Although elsewhere in the world the role of pharmacists is recognized in community pharmacies, hospital and drug regulatory authorities, the health care system of Pakistan has yet to recognize this role [45
]. There are several reasons for the lack of recognition of the pharmacy profession in Pakistan, such as the lack of pharmacists in public health services and the lack of pharmacists in community pharmacies [46
], which leads to the lack of community-pharmacist interaction.
The lack of recognition by other health professionals of the pharmacist's role in the health care system is due to their lack of interaction with pharmacists, as most of the pharmacy institutions in Pakistan exist without an attached hospital where pharmacy students can acquire basic clinical knowledge. To overcome this problem, it has been suggested that existing pharmacy residency programmes or specialized internships in hospitals after completion of the five-year coursework should be extended from six months to one year [47
], and it should be made compulsory, with a stipend. Besides that final year, Pharm-D students must be involved in extensive clerkships in the hospitals to improve their skills as clinical pharmacists, as this will be important [48
]to meet the expectations and needs of the society.