1.1 New entrants

The increasing number of new community pharmacies, especially those opened by young, inexperienced pharmacists was a major concern. The common sentiment was that these pharmacists are likely to indulge in price war and undercut the market in order to gain a foothold in the sector, especially those with adequate financial backing. Another worrying trend was them overloading customers with products to maximise their profit margin.

“The price throwing had thrown a lot of the margin off so it’s actually quite bad. More pharmacists coming up and opening new shops around the area… they want to compete with the older pharmacies. Therefore price is the only thing they can compete on, cause experience wise they can’t.”

Some respondents suggested that the number of new pharmacy undergraduate intakes should be closely monitored and planned, and the scope/area of job opportunities for pharmacy graduates expanded to solve the perceived over-population of pharmacists in the community sector, particularly in the absence of dispensing separation. They also advocated for the enactment of zoning rules to prevent new community pharmacies opening in close proximity to an existing pharmacy.

“We are hoping that in an area they probably need to limit [number] of pharmacy that can be established within a [certain] distance… there are more and more pharmacies being opened that it can be next to you.”

1.2 Emergence of government supported competitors

The consent given by the government to set up community pharmacies in the vicinity of public hospitals was another source of consternation. The location offered an unfair privilege in accessing prescriptions written by government doctors intended for purchase in the private sector. In Sarawak, these pharmacies are owned by the Hospital Workers’ Cooperative, and it was deemed unethical for government officials to have direct commercial interest in the community pharmacy business.

“At the moment the Kop-Sihat (Hospital Workers’ Cooperative) are launching a retail pharmacy in the general hospitals, and these pharmacies will be a bigger threat to all the retail pharmacies in the near future… they are getting a much more lower pricing compared to the majority of the retail pharmacies.”

2.1 Absence of dispensing separation

The majority of the respondents lamented the continued absence of dispensing separation in Malaysia, which resulted in a lack of prescriptions for them to dispense. They felt that the situation is detrimental to the health of the population by depriving them from getting medicine use and safety counselling. Respondents also had to face daily dilemmas regarding the sale of controlled medicines without prescriptions; their desire to be ethical clashing with their altruism to fulfil the needs of customers and ensuring business survival.

“We have a lot of rural customers requesting for urgent supply of Poison B (Prescription Only Medicines)… sometimes we really need to juggle how we want to swing between [following] the law and breaching the law. So what should we do? We really, at the moment, we really don’t know.”

The respondents hoped that the government can be a fairer referee in the on-going deliberation regarding dispensing separation, as they seemed to favour the medical doctor profession.

“We had been talking for so many years, and now, before we want to implement it (dispensing separation), medical profession come in with a lot of condition and so on… government must come in because there’s a commercial interest involved.”

They also advocated for an increased range of pharmacy only medicines (known as Poison C), perceiving the current list as being too limited. Suggestions include maintenance medicines for customers whose disease and medicine dosage had been stabilised. The creation of an emergency supply category, enabling them to legally dispense a limited supply to customers who ran out of their medications was also suggested.

2.2 Rules and regulations without empowerment

Additional restrictions, including the outlaw of sponsored signboards and sale of items not related to the profession were proposed by the government in an effort to maintain the professional image of community pharmacies. Inspections and covert operations by pharmacy enforcement officers are also held frequently to ensure compliance with prevailing laws. Respondents felt that these restrictions may be unwarranted without the provision of corresponding compensatory concessions to sustain their livelihood.

“They say in the near future pharmacy will be barred from selling items that are not related to health… if cannot sell how can we do business?… We didn’t sell any illegal things, unless like if we sell cigarettes, that they can say pharmacy can’t sell.”

Dissatisfactions were also raised regarding the inability of the government to act against pharmaceutical suppliers who offer unfair bonus schemes. General practitioners in Malaysia enjoy better purchase discounts and exclusivity for selected items compared to community pharmacies, and thus they can sell medicines at cheaper prices. This discriminatory practice still exists despite the distribution of Good Pharmaceutical Trading Practice Guidelines to all stakeholders by the Pharmaceutical Services Division that prohibit this practice.

“What we know, some big company, they are biased. They give certain items only special for doctors and then we pharmacy, we couldn’t sell it… and then also doctors or certain big players of pharmacy they can enjoy special bonus. It’s very, very unfair, especially for us independent small pharmacies.”

3.1 Distorted expectations on pharmacists’ roles and jurisdiction

There are still confusion among customers regarding the exact roles of community pharmacists in the Malaysian healthcare system. Some of them cannot differentiate between the distinct roles and jurisdiction of doctors and pharmacists.

“There are so many times where patients just come in, have their blood pressure tested, and they just ask for medications like that.”

Customers also often demand prescription medicines from community pharmacists without a prescription. This expectation is caused by the fact that there are numerous community pharmacists who actively supply them even though it is against the law. The situation is so entrenched that pharmacists who did not concede to the requests of their customers have their pharmacies branded as not being a ‘proper’ pharmacy.

“Customers with no prescriptions… they will say this is not a proper pharmacy, and then they say ‘your shop so big [how come] this thing never sell’, and then they say other people sell to me.”

3.2 Poor knowledge on medicine use

Lack of knowledge among customers visiting community pharmacies about health and medicine use was also an important challenge faced. Very often, customers fail to differentiate between symptoms and illness, and grasp that for certain illness numerous medications are needed for successful treatment.

“Usually they thought that taking a single type of medicine will be sufficient, but sometimes when there are a lot of problems, a lot of symptoms, they actually need more than one type of medicines… They always thought that they will be okay after only taking one or two types of medicines.”

Customers are also prone to identify their medicines based on the shape and packaging rather than the active ingredient. They often cannot accept substitutions (ie generic medicines) offered by pharmacists, even though the substitute contains similar active ingredient.

“Most of the people they still used to this pre-packed type of [extemporaneously prepared] cream. So they demand it, even though we give them the same ingredient type of the [commercially] ready made tube cream, they still refuse to use.”

4.1 Increasing costs

Many community pharmacies experienced a slowdown in business due to the introduction of Goods and Services Tax (GST), high foreign exchange rate and economic uncertainties. When the GST was first introduced in April 2015, the prices of most items sold in community pharmacies increased, as a lot of medicines were initially taxed. The concurrent weakening of the Malaysian currency resulted in further price increases, as most medicines are imported.

“The challenge that we face for this year, very obvious, actually started end of last year and this year is increase of cost of medication. Not just medication, also supplement, basically everything, due to the drop of the Malaysian currency, and the economy is not very good, the GST.”

4.2 Decreasing sales

The negative economic sentiments also reduced the spending power of customers, rendering them being more price conscious. An increased tendency of customers telephoning or dropping in just to enquire about prices was observed. Community pharmacists were generally unhappy with this emphasis on price, as it distracted the customers from learning more about proper use of medications.

“They even go on the telephone and just ‘how much do you sell this? How much do you sell that?’ They do telephone shopping. So as a result when they come in only talking about price, they divert us from our role as a professional.”

The respondents were also worried that the economic slowdown impacts their customers’ optimisation of health. Instances of customers not being able to afford the medicines needed, delaying treatment and stopping their consumption of health supplements and vitamins were noticed.

“You see them come in with 5, 10 [MYR] (1 MYR = 0.23 USD, February 2017) to get a medication. They have cough, flu, fever, everything but with 5 or 10 [MYR]… so it’s quite hard sometimes to dispense so we select the more urgent treatment.”

5.1 Financial capital and cash flow

A large financial capital is required to operate and manage a community pharmacy. Prudent financial and cash flow management is also essential to ensure business survival. In particular, a lot of considerations are involved in stock purchases, as community pharmacists need to order based on customer demand patterns to reduce wastage.

“Especially financial aspects…need a lot of funds to manage a shop… sometimes we can’t afford to buy certain items, due to lack of funds. As a consequence we can’t fulfil the requests of the customers.”

They also need to juggle between buying large enough quantity to enjoy cheaper prices without tying too much of their capital in the stock and thus affecting cash flow. For those operating in rural areas or independent pharmacies, this is a more pronounced problem as pharmaceutical companies and suppliers preferred community pharmacies to take larger stock quantities to offset transportation costs.

“Some company, because we are further away [in a rural area], they will tend to encourage us to take a bigger load, so when we want to take on a bigger [load], our company will need more funds to pay for this stock.”

5.2 Staffing problems

Most respondents work as the sole pharmacist in their community pharmacies. The long hours (some works for over 55 hours a week) led to them being mentally tired and having less time to spend with their families. The recent move enabling government employed pharmacists to be locums at their pharmacy was a welcome respite and positively received. They also wished that private sector pharmacists have the choice to be a full-time locum, whom they can hire as needed on a short notice. It is currently not possible due to the pharmacy specific nature of Malaysian practicing license.

“It’s another idea as well to actually not fix a pharmacist at a pharmacy. It’s better off to make sure that there is pharmacist at the pharmacy at all times, but it doesn’t have to be one pharmacist at one place.”

A lot of respondents faced difficulties in recruiting and retaining competent auxiliary staff. Pharmacy assistants in community pharmacies are often trained up from scratch by the community pharmacists themselves. It took approximately six months of training for them to be competent. Unfortunately, it is hard to find candidates with sufficient basic education and skills, especially in the rural areas. Retaining pharmacy assistants also proved to be hard, and most community pharmacies have high staff turnover rate.

“Staff do come and go and sometimes after we trained up like 4 or 5 months, they probably want to switch job…and that’s why we do get quite a high turnover rate, like I would say maybe every 6 to 18 months.”

5.3 Non-professional responsibilities

Independent community pharmacists reported spending a significant amount of their time dealing with non-professional work. They have to do stock management, ensure proper recordings of controlled substances, renew their licenses and dealing with the provident funds and social security contributions of their staff. The amount of paperwork increased substantially after GST implementation due to the fillings needed to be done for rebates.

“Major issue will be paperwork and red tape…currently the major thing is customs. Most of them will be GST registered because we want to get the [rebate] back. So that adds on a lot of work… we have corporate body that we need to registered… a lot of paperwork compared as to before.”

6.1 Lack of concrete coping strategies

Most community pharmacists did not have concrete strategies to counter the challenges faced by them in managing their community pharmacies. Some of them felt that current challenges are still manageable. In contrast, the majority of respondents claimed they were overwhelmed with the day-to-day management of their pharmacies to the extent of not having the time and energy to actually plan a strategy.

“If I managed to recruit staff then I will. Without staff I cannot do anything, even cleaning the store I already feel [tired].”

6.2 Improving service provision as a coping strategy

For community pharmacists with a strategy in mind, most of them centred on improving customer services or increasing the range of professional pharmacy services provided. Developing a closer relationship with customers by being attentive to their needs was seen as important to attract customers.

“My best strategy at the moment is to provide a good service to my customers. When I provide them with the knowledge, then they usually tend to come back again.”

Hiring pre-registration pharmacists (PRPs) was integrated by some community pharmacists to be part of this strategy, as having another pharmacist is particularly helpful in service expansion. This is possible as PRPs in Malaysia can conduct professional activities independently as long as their preceptors are satisfied with their competence. Some respondents also sought to increase public awareness about their pharmacy by conducting road-shows and free health screenings; however, this move was only taken by a few pharmacies and offered for a short duration.

“It (free screenings) will help them open up more, come and seek for advice, details on these medicines like there’s any certain condition they cannot control… they will feel welcomed.”

6.3 Operationalisation of strategy

The intention of some community pharmacists to operationalise their strategies was however, curtailed by the current negative economic outlook. Due to narrowing profit margins, they do not have the time to focus on service provision/expansion nor making major changes like renovating the pharmacy and purchasing equipment for a new service. For example unique services like asthma management require additional physical space and a nebulizer machine.

“Not at the moment, based on the present economic situation. I think times are pretty [tough], though even we might have the ideas, but we wouldn’t be able to do it yet.”

The lack of an adequate healthcare system, particularly dispensing separation and a national health insurance financing system, also limits their options to make changes. Community pharmacies currently exist at the periphery of the system, with their roles and potential contributions unfamiliar to many.

“Actually the biggest problem still stemmed from the overall government system… so if there are no changes in the system, I think it’s difficult for us to make any major changes.”

“With a proper health system in the country, where people can get the medications from the pharmacy at a reduced prices, and the government tops up on that, that will also help.”