Current situation of Pharmaceutical Care teaching in Latin America

A work group from the Pan American Health Organization recommended in 1998 a Basic Plan for Pharmaceutical Education, which incorporated⁴⁹:

Subjects on Community Pharmacy, Hospital Pharmacy, Pharmaceutical Industry, teaching and research, as areas for common pharmaceutical practice.

Use of a teaching methodology where the student is the central axis of the teaching-learning process; as well as the incorporation of activities to develop critical thinking, encourage solving problems, team work, communication and leadership skills, integration of knowledge, and the use of information and communication technologies.

Permanent training for teachers.

Even though not strictly for PhC, there are developments in Hospital Pharmacy associated to resident programs in Argentina, Brazil and Peru. However, only in Brazil and Argentina there was a noticeable trajectory in formal education for this specialty²⁶.

On the other hand, the School of Pharmacy of the Universidad de Chile has made changes since 1998 to their Clinical Pharmacy courses, directing them towards the PhC philosophy; this has been one of the first signs of the Chilean approach for PhC teaching²⁶.

In Cuba, the process for PhC implementation developed from a research intended to address the need to strengthen Pharmacist training for working within the healthcare team³⁵. Even though it was recorded that the plans of study for pharmacy in Cuban universities include new knowledge and skills required for PhC, this information was not available on-line.

In Costa Rica, PhC is the transversal axis for the plan of study at the School of pharmacy of the Universidad de Costa Rica; besides, patient is the center, and all knowledge, attitudes, skills and abilities that are intended to be generated in students will converge towards the patient. These changes in study plans are intended to train better Pharmacists, adequate to the needs of our current situation³¹.

In Mexico, changes were detected in the areas of professional practice by the Pharmacist, primarily Community and Hospital Pharmacy, as well as the inclusion of the PhC concept⁴³. Since then, schools of pharmacy have tried to amend their study plans, including a more practical teaching methodology, and directing learning towards solving problems and developing skills for communication, leadership and responsibility in making decisions on therapy and patient care⁴³.

In Peru, different barriers have been identified for the implementation of PhC in pharmaceutical centers. Basically, limitations are reported in: 1) research designed to determine the educational gaps between universities; 2) number of courses focused on PhC activities; 3) proportion of practical activities with patients; 4) specific training to offer PhC in the graduate and postgraduate settings; and 5) in the record of evidences for patient benefit⁴⁷.

In Uruguay, the optional subject of PhC was incorporated since 2000 in the Universidad de la República in the study plan for the Pharmaceutical Chemistry program. Besides, an active method of teaching was adopted for teaching PhC, which has allowed the development of practical skills in students.

In Colombia, there was a change in the study plan for the Pharmaceutical Chemistry program of the Universidad de Antioquia in 1987, where PhC was incorporated as a new subject, and Clinical Pharmacy as compulsory⁵⁰. Subsequently, between 1998 and 2000, the PhC Specialty was created; and since the year 2000, the Group for Pharmaceutical Research, Promotion and Prevention has generated evidence for PhC strengthening and development in the country⁵⁰. On the other hand, the Labor Observatory for the Pharmaceutical profession reported in 2015 that the Pharmacy programs in the country had conducted amendments in their study plans, including an increase of subjects within the patient care area, and PhC, clinical pharmacy and dispensing concepts, among others²⁹.

Plans of study or curricula

Information was collected from the study plans of 146 universities offering pharmacy programs in 18 Latin American countries; 55 (37.7%) of these programs are accredited, and the degrees granted are: Pharmacist, Pharmaceutical Chemist, Bachelor in Pharmacy, Bachelor in Pharmaceutical Chemistry, Biologist Pharmaceutical Chemist, Biochemist, Pharmacobiological Chemist, Biotechnological Pharmaceutical Chemist, Industrial Pharmaceutical Chemist, Biochemist and Pharmacist. Figure 2 shows the number of Pharmacy programs per country, with access to their websites and their on-line plans of study.

Figure 2.  Pharmacy programs in Latin American countries with access to their websites. 

In Brazil, there was access to 44 plans of study from the same number of universities. Overall, the creation of the Single Health System (SUS) stood out in 1988; this generated, since 2002, the need to reorganize the study plan for the Pharmacy degree, oriented towards training a Pharmacy professional with the ability to offer PhC services in the health system⁵¹. Accordingly, 100% of universities include PhC teaching; 75.0% include Clinical Pharmacy and 88.7% include Hospital Pharmacy. On the other hand, accreditation for Pharmacy programs was observed in 29.5% of the universities in this country.

In Argentina, according to the information available for the study plans from 16 universities, 37.5% of these included PhC teaching, and 81.3% included clinical pharmacy. However, the micro-curriculum for some of the clinical pharmacy subjects includes topics such as Pharmacy and Therapeutics, Patient Follow-up, and Pharmacovigilance, which are associated with Pharmaceutical Care. Accreditation was only referenced in 31.2% of Pharmacy programs.

In Mexico, no evidence of PhC teaching at graduate level was found in 15 universities; however, five (33.3%) study plans included teaching Hospital Pharmacy. Besides, three universities offered post-graduate degrees, such as a specialization in Pharmaceutical Medicine at the Instituto Politécnico Nacional; a master in Pharmaceutical Sciences, with line on Pharmaceutical Care and Services, at the Universidad Autónoma Metropolitana of Xochimilco, and another one on Clinical Pharmacy at the Universidad Veracruzana. The accreditation of pharmacy programs was identified in 78.6% of these.

In Chile, according to the plans of study from 10 universities, 60% included PhC as a subject; 80% included Community Pharmacy, and 100% Pharmaceutical Care and Clinical Pharmacy. Besides, 90% of them have accredited pharmacy programs.

In Colombia, only one program (11.1%) of the nine universities that offer the pharmacy program included a specific PhC subject. However, PhC teaching forms part of the contents of subjects such as Clinical Pharmacy and Hospital Pharmacy. In this sense, 55% included Pharmaceutical Care and 45% included Clinical Pharmacy. Moreover, the program by the Universidad de Antioquia includes early academic practices in the community (level 3 - second year), academic practices in Pharmacy services and centers (level 5 - third year), academic practices in the productive sector (level 6 - third year), practices in Clinical Pharmacy (level 9 - fifth year) and final academic practice (level 10 - fifth year, either in the industrial or healthcare sector). In Colombia, 66.7% of universities had accreditation for the program.

In Costa Rica, 75% of the four programs reviewed included in their plan of studies the subjects: Community Pharmacy, Pharmaceutical Care, and Clinical Pharmacy; but PhC teaching was only specified in one of them. Three out of these four programs have high-quality accreditation.

In Paraguay, two (40%) of the five pharmacy programs found included PhC as a subject, and two had accreditation.

In Cuba, no plans of study were available in their university websites. However, Alina Martínez states that all Pharmacy programs are accredited by the Cuban Council for Higher Education Accreditation (CCAES), the organization responsible for developing and evaluating education standards³⁷.

On the other hand, no on-line evidence was found for the countries below regarding accreditation for pharmacy programs:

Nicaragua, with seven plans of study, which have subjects such as Hospital Pharmacy but not PhC, and Community Pharmacy in only 71.5%.

Panama, with four universities offering the pharmacy program: 75% included PhC and 100% Hospital Pharmacy.

Dominican Republic, with four plans of study for pharmacy, but only 25% include the PhC subject; however, all four include Pharmaceutical Care, Clinical Pharmacy and Community Pharmacy.

Methodologies for teaching Pharmaceutical Care

Evidence of the use of active teaching-learning methods were identified in universities from Brazil^17,20-22,25, Costa Rica³² and Mexico⁴³. Active methodologies encourage critical-reflexive processes, with involvement and commitment by students towards learning. In the specific case of Mexico, the use of a model based on transformation objects or modular teaching was identified in the Universidad Autónoma Metropolitana-Xochimilco⁴³. In Brazil, the Centro Universitario Franciscano reported using the study of cases with health issues, pharmacotherapy and drug-related problems. In this sense, it was worth highlighting the training of students able to intervene and build their own future with responsibility and commitment with a humanistic and general training²⁰. Additionally, a doctoral thesis on the use of active methodologies for PhC training demonstrated a significant improvement in student performance, in terms of the perception of their skills for PhC practice, associated with satisfaction with the discipline²².

Brazil was the Latin American country with the highest evidence of use of the simulation strategy for PhC teaching. Since 2002, the methodology of structured objective clinical examination was implemented in this country, targeted to evaluate the clinical abilities of students. This strategy consists of three stages: a) preparation of the place and the cases, b) simulation, and c) evaluation. This teaching system allows students to improve their skills and attitudes for providing PhC¹⁹. Additionally, the use of the Pharma VP system has been implemented; this is a tool that allows to simulate clinical cases and patient visits remotely. The authors considered that the Virtual Patient tool contributed to the development of the skills required for PhC practice, but that it should be used as a complementary technique²³. In other Latin American countries, no publications were found regarding the use of simulation as a strategy for teaching PhC. On the other hand, the use of blended training, with positive results in PhC teaching, was another outstanding finding in Brazil. For example, the Pharmacy program at the Universidad Federal de Paraná showed the effect of this type of teaching on the generation among students of a sense of responsibility, self-evaluation, motivation, time management, and skills for accessing information²¹.

Continuous education in Pharmaceutical Care

The review showed the need for continuous education in PhC, including permanent training and postgraduate courses for Pharmacists. In this context, the conclusion from a study conducted in the Universidad de Costa Rica was that it is necessary to generate training options for tutors, in charge of PhC teaching³³. Additionally, some countries are implementing this type of educational programs for outpatient Pharmacists, such as compulsory and permanent learning programs, in order to improve the effects of PhC services³⁰.

Regarding postgraduate training, and according to the plans of study of the 146 universities with information available in their websites, 25 (17.1%) of them offered postgraduate courses associated with the patient care area; 7 of these (31.8%) had accreditation. In Brazil, it was worth highlighting the specializations in PhC, Clinical Pharmacy, Hospital Pharmacy, Pharmacy Prescription, as well as masters in PhC. On the other hand, Argentina (Universidad de Córdoba), Uruguay (Universidad de Uruguay) and Venezuela (Universidad Central de Venezuela) offered specializations in Hospital Pharmacy. In the same line, Bolivia (Universidad Mayor de San Andrés), Honduras (Universidad Nacional Autónoma) and Mexico (Universidad Veracruzana) had offers for master courses in Clinical Pharmacy. As well as the specialization in Hospital Pharmacy, the Universidad de Panamá also offers master courses in: Clinical Pharmacy, with emphasis on PhC; Oncology Pharmacy and Palliative Care, and Management of Pharmacy Services, with emphasis on patient care services.

The Universidad de Chile offers a doctorate in Pharmaceutical Sciences, with professional degree in Pharmaceutical Care, Clinical Pharmacy, and practice in Community Pharmacy; similarly, the Universidad de Antioquia in Colombia offers doctorate (and master) programs in Pharmaceutical and Food Sciences, with emphasis in PhC. The Universidad del Atlántico offers the specialization in Clinical Pharmacy, and the Universidad de Cartagena, a master course in Pharmaceutical Care.

Perspectives / challenges in teaching PhC in Latin America

Even though some successful experiences have been published regarding PhC teaching and major changes in study plans, there is limited bibliography supporting the inclusion of PhC teaching in Latin America. However, when the information is complemented with that available in the websites of the universities with pharmacy programs, there is a significant improvement in the scenario, caused by the detection of a noticeable increase of the inclusion of PhC teaching in Latin America, either specifically or with similar subjects. However, it is necessary to harmonize concepts and practices, in order to collect overall orientations and optimize PhC teaching. In this sense, the following can be highlighted, regarding the recommendations of the document generated at the SimpoDader 2016¹³ (Table 2):

Table 2 Perspectives in Pharmaceutical Care training in Latin America, according to the third Workshop-Conference of the Forum for Pharmaceutical Care in Community Pharmacy (PhC-CP Forum)¹³  

PhC: Pharmaceutical care.

In Latin America, there is evidence of the incorporation in the study plans for the pharmacy program of subjects such as Community Pharmacy, Pharmaceutical Care, Clinical Pharmacy, PhC, Hospital Pharmacy, among others. However, very few programs have included curricular practices allowing students to have an early interaction with patient care reality, as recommended by renowned organizations¹³. Brazil, followed by Colombia, are the countries that include this type of practices; though the five programs recently recorded in Colombia are not reflecting this recommendation, which could be due to the lack of professionals with a postgraduate degree in PhC in the health institutions or certified fields of practice, such as university hospitals.

Continuous education programs are a key factor in Pharmacy education, as well as in the strengthening of the necessary skills and permanent learning in order to improve PhC services. Besides, there is evidence of the efficacy of pharmaceutical interventions which combine the use of Information and Communication Technologies (ICTs), continuous education programs, and networking among Pharmacists and other healthcare professionals.

Brazil is the Latin American country with the highest evidence for PhC teaching through the use of ICTs and simulation. Overall, the use of ICTs is promoted throughout the world at all levels; however, in the specific case of Pharmacy services, this is a road still to be travelled, and, at Latin American level, still to be implemented.

In the Latin American plans of study, it was not possible to find evidence of subjects associated with Implantation Science, Information Sources and Scientific Evidence, as recommended by the SimpoDader 2016¹³. However, these could be incorporated in some of the micro-curricula. Besides, no available information was found about contents of social drivers of health, interculturality, dispensing to patients with special needs, interprofessional education, social pharmacy, and PhC for special populations¹³.

In Latin America, Hospital Pharmacy has experienced a major growth in recent years⁸. However, postgraduate training is limited in most countries; additionally, no postgraduate training accreditation is required for the practice.

Accreditation is the tool used by High Education institutions in order to promote an improvement in the quality of education. Besides, it is an instrument that supports the quality of the institutions and the education programs offered. In the 9^th Pan American Conference on Pharmaceutical Education, proposals were generated, and there was emphasis on the importance of accreditation for pharmacy degrees in Latin America⁵¹. This review detected that only 37.9% of universities, according to the information in their websites, offered accredited pharmacy programs. Therefore, this is a matter which requires more work oriented to meet this purpose.

Remote (virtual) teaching is used in some Latin American countries in order to meet the needs for training in High Education. However, in the pharmaceutical setting, similarly to other healthcare professions, it is necessary to remember the contribution by practice, face-to-face activity, and interaction of students with patients, institutions, and other health-care professionals, as drivers for the development of healthcare skills.

The use of active teaching-learning methods promotes the training of students who are able to solve problems, and are responsible and committed with their humanistic training²⁰. Equally, the use of the Participative Action-Research shows the need to train students and Pharmacy professionals regarding the know-how with social function²⁸. As well as offering education with enterprising spirit and motivated by learning and re-learning, this strategy contributes to training Pharmacists who are responsible with their profession and their own lives²⁸. In this context, identifying ways of learning can be used to define better strategies in the teaching-learning process, thus promoting the acquisition of professional skills by High Education students.

Recommendations

The training process in the healthcare area must be oriented towards meeting the needs of health systems and patients. In this sense, internship programs are the most common strategy in order to link education with health systems²⁵. Besides, there is a need to generate and implement curricular guidelines that will strengthen the development of patient care skills in Pharmacy programs²⁵. Overall, the majority of Pharmacists in Latin America need to be prepared for the changes demanded by PhC practice. For this, universities play a major role in the development of the profession and its practice⁵². Additionally, success cases in PhC teaching could be extrapolated to other Latin American countries.

In general, clinical training of the Pharmacist at graduate level seems to be limited; therefore, specialization is seen as an option in order to improve pharmacist performance in the patient care area. In this sense, specialized training for Pharmacists must include real clinical practice, strengthening skills and the confidence by Pharmacists in order to interact with patients and other health professionals, effectively contributing to achieve better health results. However, the offer must be improved in the Latin American context, because only 16.3% of the 146 pharmacy programs accessed on-line have this type of continuous training. In this sense, despite the advances and developments in PhC research, particularly in Brazil and Chile⁴⁷, it is necessary to work in order to strengthen research and the visibility of the results achieved with this practice^53,54, which should be promoted by a higher post-graduate training.

University training in graduate and postgraduate pharmacy must continue with the accreditation and re-accreditation processes, as a way of continuous improvement. Additionally, it is necessary to generate more options for postgraduate training on PhC. For this aim, universities must achieve coordination with the needs of health institutions. Besides, it is necessary to associate qualified professionals with practical experience, who will enable said connection and, therefore, the generation of projects targeted to identify and use solutions to the problems of patients and the health system.

On the other hand, in Latin America it is necessary to connect training with the statements in the forum for PhC teaching in university, held in Spain: 2016 International SimpoDader¹³, which highlighted the need to structure educational plans with contents of direct application on patients, encouraging an early contact of students with patient care reality. In this sense, there is a specific proposal by consensus about the minimum contents for PhC teaching⁵⁵. Table 3 describes some recommendations targeted to promote the incorporation of PhC teaching to practice:

Table 3.  Recommendations for incorporating pharmaceutical care teaching to practice 

PhC: Pharmaceutical care.