1. Introduction

In the face of rising demands and skyrocketing costs, all the occupations and institutions in the field of health care are being challenged to develop more effective and economical interventions for the delivery of their services. Improvement in medicine use is very much dependent on the health systems within which care is delivered ^[1]. Planning is taking place for integrated health care systems in which responsibilities are reallocated among the health professions and their associated health professions. Besides the role of physicians, nurses and midwives, it is widely recognized that pharmacist is the most accessible or sole provider of healthcare advice and services in most instances. Any attempts to improve health systems and access to and appropriate use of medicines cannot be addressed without taking their role into consideration ^[2]. Globally pharmacists are the third largest health care professional groups and are well acknowledged as pharmacy workforce for public health roles. They have been well utilized in terms of their clinical and administrative skills and have stopped performing the counting, pouring, packaging and labeling routines and these functions have been delegated to appropriately trained and qualified technicians ^[3].

The contributions of pharmacy practice has helped many countries in achieving better health outcomes, reducing the costs of treatment, building the patient trust on healthcare system, reduced side effects and risk of treatments, decreased morbidity and mortality, improved access to safe and timely treatments and improved quality of life resulting in achievements of millennium development goals ^[4]. However pharmacy profession has a long way to go in order to contribute significantly in health care systems of low and middle income countries. There is acute shortage of pharmacists in these countries and their role is merely as a store keeper. The profession needs timely recognition at all levels ^[5]. There have been different dialogues around the potential for improvement in pharmacy practice although it is not possible to apply a single change model to pharmacy service provision worldwide. In this context it is very important to develop a long-term collaborative initiative for managing the changes required in pharmacy practice to meet the health care needs ^{[6, 7]}.

2. Pharmacy Practice in Pakistan

In the last one decade pharmacy profession has seen vibrant changes in policy and education in Pakistan. Introduction of Pharm.D program and now recognition of pharmacy practice as fifth pillar in pharmacy education and practice has increased the acceptability of pharmacy graduates in Pakistan and abroad ^[8]. There is a need of collaborative model of pharmacy practice in Pakistan which is evidence based and has a local context in its conceptualization and implementation. The area being new to Pakistan, needs more deliberation to set future direction most suited to local conditions and environment. The Action Plan for Pharmacy Practice is a long-term collaborative initiative for managing the changes required in pharmacy practice to meet the health care needs of Pakistani population.

In an effort to address this issue, all Pharmacy stakeholders need to work together to achieve a common vision and implement a coordinated plan of action. Higher education institutions have to invest in research capacity building initiatives to support successful implementation of effective pharmacy practice models in Pakistan. Hamdard Institute of Pharmaceutical Sciences, Hamdard University took a new initiative for collaborative concept mapping that embodies effective capacity building processes by enabling exploration, articulation and negotiation of shared motives and opportunities to formulate strategy and action plan for effective pharmacy practice in Pakistan. The authors commenced this journey by first conceptualizing different pharmacy practice models as a working paper in developed and developing world as it appears in the literature and then moved to capacity building process as there is chronic shortage of pharmacy practice experts in Pakistan [8-20]^[8]. There are few professionals holding PhD in pharmacy practice in Pakistan till date. Hamdard Institute of Pharmaceutical Sciences is fortunate to have two of them as faculty members. Hamdard Institute of Pharmaceutical Sciences has this privilege to be the pioneer in commencement of Masters Program in Pharmacy Practice in Pakistan to develop a task force of Pharmacy Practice in Pakistan. A focus group discussion was held on the theme “Need for Action Plan for Pharmacy Practice in Pakistan” as the first step towards translating this action plan into practice. Approximately fifteen stakeholders all pharmacists from Drug Regulatory Authority, Academia, Hospitals and Community pharmacies participated in the discussion.

The Focus group discussion was planned in two rounds. The authors acted as moderators for the discussion. The discussion started with the introduction of all the participants. After the introduction, the moderators formally started the discussion by sharing the main themes of their working paper conceptualizing different pharmacy practice models as reference for initiation of action plan for Pharmacy Practice in Pakistan. They highlighted, structure and requisite engagement at community level as critical areas for promoting healthcare delivery services rather just merely quantifying health GDP ratio. In other words access to health is through access to pharmacy. Three very important things were emphasized to be taken into account to persuade policy makers for any kind of reforms i.e. timing, relevance and cost benefit analysis. Another challenge to be addressed is building professional competence through continuous education to advance pharmacy practices in Pakistan. Government and policy makers must realize that role of pharmacist is critical in enhancing healthcare services delivery in Pakistan and minimizing economic burden on the patient. Unfortunately, pharmacists are not in the main stream of policy making. This valuable component is vital to participate in the main stream of policy development. The participants from Drug Regulatory Authority and academia emphasized that there is need to strengthen the current curriculum and promote research to meet the challenges of changing realties in health care services particularly in pharmacy. Pharmacoeconomic and research experts need to be involved in policy development. Accelerative legislative and regulatory changes are required to expand scope of pharmacy practice in Pakistan.

Participants from development sector enlightened that as a result of devolution of 18^th amendment the role of provincial government is more important whereas the role of the federation is to facilitate provinces. It is important that this kind of focal group discussions should also be conducted at provincial levels and representatives of provincial level participating in these discussions should act as advocate to further advance this idea at the grass root level. On the other hand hospital pharmacists signified the role of pharmacist in improving health related quality of life in chronic disease management. They accentuated on building strong relationships with patients and caregivers which can enhance overall quality of life. They highlighted the need of e-prescribing and drug information systems, enhanced experiential education in hospitals and primary care and promotion of collaborative working of pharmacists & other healthcare professionals. Beside this, community pharmacists highlighted on the need of a national public relations campaign for awareness regarding pharmacy practice. They also emphasized on tracking and forecasting pharmacy human resources requirements, integration of regulated pharmacy technicians and designing & implementing Pharmacy Services business models.

In the second round of discussion, the moderators concluded the discussion after taking into consideration the themes from the working paper and comments from all the participants. They cogently articulated the outline of the action plan need to be considered for incorporation to reinforce the current healthcare system which is currently quite disjointed. For this the changing role of pharmacist in this paradigm shift by embracing six key areas was underscored: (i) changing scope of practice of pharmacist through effective legislation and regulation; (ii) addressing shortage of human resources; (iii) capacity building of health professionals through requisite education and training; (iv) delivering good value of money through effective pharmacoeconomics (v) adopting information and communication technology (vi) redefining framework of patient care services. Finally after the mutual consensus of all the participants, patient centric model which aptly defined the aims and means of the action plan for successful implementation of pharmacy practice was proposed to be implemented in Pakistan.

3. Conclusion

This report gives an account of academia attempt to use focus group discussion as a tool to conceptualize and make explicit the “how” of developing effective pharmacy practice model in Pakistan. The findings of this focus group discussion indicated that effective capacity building processes and patient centric model by involving all stakeholders is the ultimate action plan for implementation of effective pharmacy practice model in Pakistan. The focus group discussion enabled shared exploration, articulation, and negotiation of intentions and opportunities through collaborative working and research, produced a collective concept map that conceptualized and documented an action plan. The proposed plan highlighted a clear motive and purpose by all stakeholders to understand their role and commit to shared goals, such as inclusion of status of pharmacist as provider care, implementation of integrated hospital and community practice models, capacity building, training and research.

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