This document outlines directives for hospital pharmacies in Nepal. It establishes a Drug and Therapeutics Committee (DTC) to manage pharmacy services and formularies. The DTC is responsible for approving medicine lists, manufacturers, distributors and treatment guidelines. It also inspects hospital pharmacies. Hospitals must have a pharmacy management committee and permanent pharmacists to implement the DTC's directives. Staffing requirements are based on hospital bed count. Basic pharmacy infrastructure like storage, counseling rooms and billing areas must be provided. Free medicines are obtained from government grants and private hospitals must provide free treatment and medicines to 10% of poor patients. Financial management, auditing and reporting procedures are also defined.

1. Hospital Pharmacy Directives
2072
Prepared by:
Rahi bikram Thapa
Sunsari Technical College
B.pharm 4th year

2. Preamble
Accessibility of medicine to all
population
Providing pharmacy service by use of
competent pharmacy manpower
 Providing Quality and cost effective
services to patient
 Well managed and effective services to
patient .

3. 1. Short title and Commencement
2. Definition
1. Ministry = Ministry of health and Population
2. Hospital = full or partial related or control by government
3. Pharmacy services
4. Committee = DTC
5. Hospital Formulary = book of medicine and devices
3. Hospital Pharmacy and DTC
Well managed and effective medicine and medicine related services
Composition
4.Functions, duties and
responsibilities of DTC1. Preparing list of medicines 2. Determine standard of medicine , manufactures as
well as distributors 3. Approval and rejection of based on quality and reliability
4.Approval and change of Formulary 5.ADR monitoring 6. Making standard
treatment guidelines 7.Design of prescription based on Formulary 8. Inspection of
hospital pharmacy time to time 9. Implementation of law

4. 5. Provision of DTC meeting
1 . At least 2 months
2. Agenda 48 hours before to all members by member secretraint
3. Presence of more than 50 % members
4. Higher vote wins , if equal vote by president
5, result approved by member secriant
6. Hospital Pharmacy Management
Comittee
Well manage operation of hospital pharmacy
Composition
Function , duties and responsibilities of hospital pharmacy head as approved by
DTC
7. Functions, duties and
Responsibilities of Pharmacy Head
1. Implementation of DTC agenda , preparing list of medicine , Clinical pharmacy
service ,Near expiry drug management , other works directed by DTC .

5. 8. Buying of medicine and allied
pharmaceuticals :
9. Selling price of medicine and allied
pharmaceuticals : <20% profit but NMT MRP
10.Manpower for Hospital Pharmacy
1. Permanent manpower , 2, Alternative manpower if not permanent
Required manpower (At least)
S.
N
Bed in
hospital
Clinical
pharmacist
Pharm
acist
Asst.
pharm
acist
Helper
1 100 up 1 3 6 2
2 51-100 1 2 4 2
3. 25-50 1 2 1
4. 15-25 2 1
Based on workload no may change

6. 12. Seed money
1. Enough space for dispensing and storage of medicines
2. Appropriate storage condition
3. Easily accessible location of pharmacy
4. Separate medicine counseling room
5. Separate storage place for drugs to be returned and expired drugs
6. Availability of billing dispensing site
7. Appropriate software for inventory control
8. Free available medicine list (seen by all people )
Provision of separate place for free and non free medicine
No commercial promotion of medicine (Except if based on scientific fact )
11. Basic infrastructure
Seed money by Government in from of grant

7. 13. Free medicines
1. Free medicine by Nepal government
2. Buying of free medicine free government grants
3. Not compulsion in case of out of stock ( state by pharmacist in prescription)
4. For very poor people , provision of free medicine. Detail of such peoples
publish monthly .
14. Free obtained medicine by
hospital
Free for free . Based on formulary drug only
15. Economic management
Separate fund , managerial head and hospital head ,
Fund consists
-government grants
-daily sales
-Public donations
10% to main hospital fund of sales

8. 16. Income and expenditure
 1 months after completion of year
 90% of profit on main hospital fund
 3 months after completion of year internal audit
 Preparation of Trial balance

9. 17. Not prescribing in Brand
18. Inspection , Evaluation and
sending report
Evaluation report s send to ministry at 4 month
19. Provision on hospital formulary
Disease pattern , minimum information , extra information , Price
comparison , focus on essential medicine
20. Provision on Private hospital
Government approved hospital will also provide pharmacy services
Free medicine and treatment to 10% of poor and helpless patients .

10. 21. Computer software in pharmacy
As directed by Ministry , uniformity maintain software , strict control on
narcotics and antimicrobials .
22.Right to give direction
23. Prevailing laws
Not mentioned.
24. Cancellation and saving
2070 cancelled . Activities performed by 2070 law will be considered be done by
New law .