Background: Pharmacy developed as a profession over several decades with the advent of apothecaries and was formalized as a profession and regulated in India beginning 1948 with the Pharmacy Act. Public health, existent for centuries was only formalized in India in 1987 through the Model Public Health act. Clinical pharmacy through structured and formalized PharmD education is fairly new to 21st century India. Clinical pharmacists play a very important role in promoting public health through various initiatives – health education, health communication, medication review, medication adherence to name a few. There is however, little recognition for clinical pharmacists as public health professionals even in developed countries where public health and pharmacy systems have co-existed for decades. In India, as both fields emerge, it is important to find synergies and open up pathways for collaboration and cooperation to ensure a stronger pool of public health field clinicians, researchers and professionals. This session will focus on identifying the roles of public health pharmacists with focus on areas of convergence and models for collaboration and cooperation between public health and pharmacy professionals. Session aim: Discuss strategies to enhance capacity of pharmacists to advance public health outcomes. Session objectives: At the end of this session, participants will be able to: • Explain how pharmacists can play pivotal roles in disease prevention and health promotion • Identify key interdisciplinary approaches where pharmacists can help achieve optimal public health outcomes • Discuss strategies to integrate public health practice into pharmacological training and pharmaceutical care. Content: Throughout the world, pharmacy as a profession is evolving. In recent years, several entities involved in pharmacy education have identified public health as a major area for improvement and expansion within the core pharmacy education. Pharmacists have been identified as key healthcare professionals in achieving health goals as mentioned in Healthy People 2020. In order to successfully integrate pharmacists as public health professionals, there is a need to introduce the principles and concepts of public health early on in pharmacy education. It is equally important to create and develop opportunities for practicing pharmacists and demonstrate the impact of pharmacists toward improving the population’s health. In this session, targeted interventions to outcomes assessment, differences and similarities will be discussed with implications for effectively advancing the capacity of pharmacists to achieve public health outcomes. References 1. Policy Statement: The Role of the Pharmacist in Public Health. Policy Number 200614. American Public Health Association. November 8, 2006. 2. Capper, SA, Sands, CD. The Vital Relationship Between Public Health and Pharmacy. The International Journal of Pharmacy Education. Fall 2006, Issue 2.

1. S
Pharmacy and Public Health: Pathways
for intersection, collaboration and
cooperation
Dr. Meghana V. Aruru, Ph.D., MBA, B.Pharm
Associate Professor,
Indian Institute of Public Health – Public Health Foundation of India
Adjunct Faculty, California Northstate University
U.S. FDA Consultant

2. Health
S The World Health Organization defines Health (of an individual)
as the state of complete physical mental and social well-being and not
merely the absence of disease or infirmity.

3. Public Health
S As defined in 1976 by a Milbank Memorial Fund Commission on Higher
Education for Public Health, "Public Health is the effort organized by society
to protect, promote, and restore the people’s health. The programs, services,
and institutions involved emphasize the prevention of disease and the health
needs of the population as a whole." Higher Education for Public Health,
Milbank Memorial Fund, New York NY (1976)
S “The science and the art of preventing disease, prolonging life and promoting
health and efficiency through organized community effort.” Winslow, C. The
untilled field of public health. Mod. Med. 1920; 2:183-191.

4. What public health is not!
S Public health problems are not health problems considered
as they occur in a series of individuals presenting themselves
to a health-care provider, but are considered in the context
of a community or a population as a whole.
S The scope of public health is not infrequently misinterpreted
as primarily medical care for the underserved.
Maeshiro, R. et al. Medical education for a healthier population: reflections on
the Flexner Report from a Public Health perspective. Acad. Med. (85):2; 211-219.
(2010)

5. Public Health functions
S Micro level:
S Service is relatively direct as compared to the macro or planning level.
S For example, the director of a NCD clinic is functioning at the micro level, whereas
the individual who perceived the need in the population compared to other needs,
determined that there should be such a clinic, and allocated resources for it, is
functioning at the macro level.
S Macro level:
S Formulation of health-care policy, health-care planning, and program
implementation, direction, and evaluation, especially at the national level.
S These foci affect the practice arrangements of other health professionals. This work
also leverages change in equity/disparity issues, quality of care, and access to health
services by the population.
S Pharmacy too often ignores the macro level of public health. As a consequence
relatively few pharmacists are available as role models or decision leaders.

6. McKinlay’s Population based
Intervention model
S Downstream: Individual level interventions aimed at those with
behavioral risk factors or suffering from risk-related diseases.
Emphasis is on change, rather than prevention.
S Midstream: Population level interventions that target defined
populations in order to change and/or prevent behavioral risk
factors.
S Upstream: National and regional public policies or environmental
interventions aimed at strengthening social norms and supports of
healthy behaviors.

7. Historical Shifts
S Dramatic reductions in
mortality during the late
19th and early 20th
Century
S Clean water was
responsible for nearly
half of the total
mortality reduction in
major U.S. cities, three-
quarters of the infant
mortality reduction, and
nearly two-thirds of the
child mortality
reduction.

8. Western world approach
S The western approach of avoiding diseases, death and
disability, traditionally focused on personal hygiene and
public sanitation during the 19th Century.
S This approach, combined with better food availability paid
rich dividends in developed countries toward reducing
morbidity and mortality.

9. Catalysts for change
S Epidemiologic transition:
S Acute to Chronic diseases
S Improvements in Incidence/Prevalence of burden of Infectious diseases
S Dual burden of diseases – ID and malnutrition prevalent + Chronic disease
risk factors on the rise
S Demographic transition: population increase, shift toward ageing
population, life expectancy increase
S Health care delivery and financing transition:
S Spiraling costs of health care
S Increase in private insurance spend
S Persistent health disparities
S Migration and Displacement – e.g. recent Chennai floods

10. Average hospitalization costs
National Sample Survey Office (NSSO) 2014

12. Indian perspective on medicine
S Enshrined in the concepts and principles of Ayurveda which means
the ‘science of life’.
S Ayurveda is one of the oldest systems of healthcare in the world.
S Ayurveda deals with both preventive and curative aspects of health.
S Health defined by WHO is very similar to concepts of Ayurveda.

13. India’s health sector
S Responsibility of State, Local and Central Government
S Service delivery established by states
S Milestones:
S Primary health centers (PHCs): 1952
S Family planning: 1952
S Green Revolution: 1967-77
S National health programs: 1957 onwards
S National Health Policy: 1982, 2002
S National Rural Health Mission: 2005
S Public Health Foundation of India: 2006

14. Public Health Foundation of
India (PHFI)
S Public-private partnership includes Indian and International
academia, state and central governments, bilateral agencies, civil
society groups
S Response to redress institutional capacity in India for strengthening
training, research and policy development in the area of public
health

15. Vision
Our vision is to strengthen India’s public health institutional and systems capability and
provide knowledge to achieve better health outcomes for all.
Mission
• Developing the public health workforce and setting standards.
• Advancing public health research and technology.
• Strengthening knowledge application and evidence-informed public health practice and
policy.

16. India’s health system
S Total expenditure on health: 5.2% GDP
S Public Health Investment: 0.9% GDP
S Budget allocation for health: 1.3% of central budget
S Government expenditure: 25%
S Out-of-pocket expenditure: 75%
How did we get here?

17. Public health before the colonial
period
S Little is known about public health activities before the
colonial period.
S Main stream system health care was Ayurveda.
S Home-based care appeared to be predominant.
S Few organised efforts or institutional care to treat diseases
and prevent deaths.

18. Public health during colonial
period
S Evolution of public health system during the colonial period
followed the same path as Great Britain.
S Public health efforts were focused largely on protecting British
civilians and army cantonments.
S Sanitation was given top priority.
S Focus was also on early detection and control of contagious
diseases – cholera and plague.

19. PH during the colonial period
S Training and Research Institutions in public health.
S Public health legislation.
S Sanitary departments
S Ascertaining local sanitary conditions.
S Vital registration.
S Monitoring disease trends.
S Vaccination programmes.
S Technical advice on control of epidemics.

20. PH during the colonial period
S Restriction of public health efforts to British civilians and
military.
S Majority of Indian masses remained deprived of the dividends of
these efforts.
S At the time of Independence, only 3 per cent households in
India had toilets.
S Water, drainage and waste disposal services were utterly lacking.

21. PH during colonial period
S Although, public health efforts were restricted to British
civilian and military establishment, they had impact on
Indian masses.
S Mortality spikes were sharply reduced.
S Mortality from cholera and plague was sharply reduced.
S Diseases like malaria and gastro-enteritis continued to take
heavy toll.

22. Public health post colonial
period
S Evolution of public health care system in Independent India
was shaped by two important factors:
S The Report of First Health Survey and Development
Committee (Bhore Committee) constituted during the colonial
rule.
S Emergence of modern medical technology for the prevention
and control of diseases, especially communicable diseases.

23. Bhore Committee
S Appointed in 1943.
S Recommended comprehensive remodeling of health services.
S Integration of preventive and curative health services at all levels.
S Hospital-based health care system.
S Development of primary health centres in two stages.
S Training in Preventive and Social Medicine.
S The short-term plan
S A PHC for every 40,000 population.
S PHC to be manned by 2 doctors, 4 PHN, 4 Midwives, 4 trained dais, 2 Sanitary
inspectors, 2 health assistants, 1 Pharmacist and 15 class IV employees.
S The long-term plan
S A primary health unit for every 10-20 thousand population with 75 beds.
S Secondary unit with 650 bed hospital.
S District unit with 2500 bed hospital.

24. PH in Independent India
S The recommendations of Bhore Committee and the availability of preventive and curative
medical technology resulted in the evolution of hospital-based public health system.
S The public health arrangements created during the colonial period were replaced by hospitals
and health centres.
S Public health services were merged with medical services. In 1952, India was the first country
to launch a national programme emphasizing family planning to stabilize the population at a
level consistent with the requirement of the national economy.
S Bhore Committee recommendations were accepted only partially:
S One primary health centre for every 30 thousand population.
S Only 6 beds in each primary health centre.
S Only one doctor.
S Truncated paramedical staff.
S The situation has remained largely unchanged.

25. Public Health in Independent India
S Since Bhore Committee, numerous committees were
constituted to evolve the public health system.
S Some of the recommendations of these committees were
adopted; some were not by the government.
S All committees retained the core of the model
recommended by the Bhore Committee.

26. Public Health in India
S Mudalliar Committee(1962)
S Strengthen PHCs before establishing new ones.
S PHC should provide preventive, promotive and curative services.
S Strengthen sub-divisional and district hospitals.
S Creation of All India Health Services.
S Chaddha Committee (1963)
S Malaria worker to function as multipurpose worker.

27. Public Health in India
S Mukherjee Committee (1965)
S Separate staff for family planning programme.
S Malaria activities to be de-linked from family planning
activities.
S Jungalwala Committee (1967)
S A unified approach for all problems instead of a segmented
approach for different problems.
S Medical care and public health programmes to be put under
charge of a single administrator.

28. Public Health in India
S Kartar Singh Committee (1973)
S Concept of MPW(M) and MPW(F).
S Shrivastav Committee (1975)
S Creation of bonds of paraprofessional and semiprofessional
health workers from within the community itself.
S Development of a “Referral Services Complex.”
S Establishment of Medical and Health Education Comission for
planning and implementing reforms on the lines of UGC

29. Public Health in India
S Bajaj Committee (1986)
S Formulation of National Medical & Health Education Policy.
S Formulation of National Health Manpower Policy.
S Educational Commission for Health Sciences.
S Health Science Universities in various states.
S Health manpower cells.
S Vocationalisation of education at 10+2 levels as regards health
related fields.
S Realistic health manpower survey.

30. Public Health System in India
S A population based normative approach is adopted for
establishing hospitals and health centres
S SHC – One for every 5000 (3000 in hilly/tribal areas)
population.
S PHC – One for every 30000 population (20000 in difficult
areas) with 4-6 indoor/observation beds.
S CHC – One for every 80-120 thousand population with 30
beds.

31. Public Health System in India
S The norms are for government institutions and rural areas
only.
S For the urban areas, no norms have been defined.
S Nearly all government civil and district hospitals and most of
the CHCs are located in the urban areas.
S Private health system? Opportunities for convergence?

32. Public Health System in India
Institution Number
SHC 145272 More than 6 SHC for each PHC, on
average
PHC 22370 More than 5 PHC for every CHC, on
average
CHC 4045
Rural hospitals 6298
Beds in rural hospitals 142396 About 23 beds per rural hospital
Urban hospitals 2774
Beds in urban hospitals 324206 About 117 beds per urban hospital

33. Public Health in India
S Focus on medical services.
S Neglect of public health services.
S No modern public health regulation.
S Lack of systematic planning.
S Poor sustainability of public health efforts.
S Absence of epidemiological and statistical skills at district and
below district level.
S No micro-level planning, no public health action.

34. Achievements through the years
Epidemiological Shifts
• Malaria (cases in million)
• Leprosy (cases per 10,000)
• Small pox (No. of cases)
• Guineaworm (No. of cases)
• Polio
1951
75
38.1
>44,887
1981
2.7
57.3
Eradicated
>39,792
29,709
2000
2.2
3.74
Eradicated
265
Infrastructure:
• SC/PHC/CHC
• Dispensaries & Hospitals
• Beds (Pvt. & Public)
• Doctors (Allopathy)
• Nursing Personnel
725
9209
117,198
61,800
18,054
57,363
23,255
569,495
2,68,700
1,43,887
1,63,181(99-RHS)
43,322
8,70,161
5,03,900
7,37,000
Source: National Health Policy, 2002

35. Source: Chronic diseases and Injuries in India, The Lancet, 2011

36. Current Scenario
S Resurgence of communicable diseases
S Dengue, Chikungunya etc.
S Declining public investments and expenditures in health and
healthcare
S Decline in access to basic health care services
S Rising costs of healthcare and changed economics
S Demand supply gaps (100 beds/100,000 – WHO norms:
300/100,000)

37. Continuing trends: Glass half
empty or half full?
S Value propositions:
S Stepping up of standards in medical care
S Low cost but not necessarily poor quality
S Diagnostics relatively inexpensive
S Growing incomes and literacy
S Health insurance
S Healthcare BPO
S Telemedicine: Rural population > 700 million

38. Continuing trends

39. Essential Public Health Functions

40. Pharmacy in Transition
S Pharmaceutical Public Health: “The application of
pharmaceutical knowledge, skills and resources to the science and
art of preventing disease, prolonging life, promoting, protecting
and improving health for all through the organised efforts of
society” (Walker, R. 2000).
S Pharmaceutical care is delivered at the individual patient level.
“Pharmaceutical care is the responsible provision of drug therapy
for the purpose of achieving definite outcomes that improve a
patient’s quality of life.” (Hepler and Strand, 1990).

41. Ironic?
S Of the four categories of health determinants at a
population level, health care provision is the least important.
Hereditary factors, environment, and lifestyle (behavior) are
all considered more important.

42. Pharmacy Education & Public
Health at Micro and Macro Levels
S “Pharmacy education has failed to recognize the potential for
pharmacists in public health …” Patricia J. Bush and Keith W.
Johnson, Where Is the Public Health Pharmacist? Am. J. Pharm.
Educ., 43,249-2S2( 1979)

43. Core elements of PH practice
Source: PharmacyHealthLink (PHLink), 2008-2009︎
1. Surveillance and assessment of the population’s
health and well being︎
2. Promoting and protecting the population’s
health and well-being︎
3. Developing quality and risk management within
evaluative frameworks (clinical effectiveness,
quality assurance, risk management, identifying
deficits of structure and process)︎
4. Collaboratively working for health, building
alliances, partnerships︎
5. Developing capacity to reduce health inequalities
(design and delivery of services)︎
︎
6. Policy and strategy development and
implementation, cyclical efforts to implement
strategies and assess the impact of those
policies on health improvement︎
7. Advocating for the public and adapting services
to better meet the needs of communities.︎
8. Strategic leadership –(reduction in inappropriate
antibiotic use; mental health)︎
9. Research and development to improve health
and well-being at a population level.︎
10. Commitment to life long learning to assure
better models equitable use, distribution and
access to resources.︎
︎

44. Community Pharmacy and PH
framework

45. Developing PH Pharmacy
Policies
S Assumptions:
S Social justice
S Improve safety and reduce financial burden of treatments
S Policies to reduce costs: controlling profits, establishing profit limits,
extending prescription providers, revising Rx classifications,
emphasizing generics, establishing formularies
S Public education: lifestyles, comorbidity (elderly population?)
S PH perspective serves to maximize savings for all to increase access
and improve population health – what about profit maximization?

46. Developing PH Pharmacy
policies
S Safety as a priority:
S Active regulatory role for government?
S Litigation fears for focusing manufacturers attention on safety?
Important to align pharmacy policies with a PH perspective on
safety and costs.

47. Opportunities
S Cost-effective clinical roles for Pharmacists
S Pharmacists represent the third largest healthcare professional
group in the world. The majority of pharmacists practice in private
retail pharmacies, few in public health facilities. There is very little
published international data on the pharmacy workforce. However,
in 2006 a survey by International Pharmaceutical Federation (FIP)
revealed that the pharmacist to population ratios vary widely
throughout the world from less than 5 to over 200 pharmacists per
100,000 population – Significant potential of pharmacy knowledge
is untapped and wasted

48. Implications for education &
training
S Old paradigm: product focused
S Reports, maps and tables on health providers focus
exclusively on doctors and nurses. Pharmacists are hardly
mentioned as health professionals. They tend to be listed
“others, auxiliaries, support staff” etc.

49. Interdisciplinary approaches for
optimal PH outcomes
S Quality control & improvement
S Education & Outreach
S Counseling
S Behaviour change
S Interdisciplinary collaboration
Think global…work local

50. Questions to think about
S Are pharmacists well prepared to conduct activities within
the public health arena? – Develop PH competence
alongside clinical competence
S What roles could pharmacists play in improving physical,
financial, legislative barriers to access?
S What are the future standards of pharmacy practice? How
do we make PH pharmacy viable and sustainable? Business
models for community pharmacy?

51. Thoughts to ponder…
S In the west, PH and Pharmacy evolved independently
S PH and Pharmacy are developing in India – opportunities for
intersection and collaboration
Identified target areas:
S Pharmacoepidemiology, Pharmacovigilance
S Behavior change patterns
S Counseling and education: Medications, Lifestyle
S Surveillance
S Mapping policies for cost optimization

52. And last but not the least…
S How will Pharmacists participate in the Public Health
System to advance public health outcomes and what type of
capacity building will be needed?