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Review Article

Hospital Pharmacy Services in Teaching Hospitals in Nepal:

Challenges and the Way Forward
P. Ravi Shankar, Subish Palaian1, Harish S. Thapa2, Mukhtar Ansari3, Bishnu Regmi4
Department of Pharmacology, Xavier University School of Medicine, Oranjestad, Aruba, 1Department of Pharmacy Practice, Gulf Medical University, Ajman,
United Arab Emirates, 2Department of Clinical Pharmacology, School of Health Sciences, Council for Technical Education and Vocational Training, 4Department of
Hospital and Clinical Pharmacy, College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal, 3Department of Clinical Pharmacy, College of Pharmacy,
University of Hail, Hail, Saudi Arabia

Abstract
In Nepal, a developing country in South Asia, hospital pharmacies in teaching hospitals faces a number of challenges. Design and location of
the pharmacy is inadequate, the pharmacy is often rented out to private parties, there may be a lack of separation of outpatient and inpatient
pharmacy services, medicines are not selected based on objective criteria, too many brands are stocked, pharmaceutical care services are
not provided, and pharmaceutical promotion is not regulated within the hospital premises. Furthermore, there is often a lack of pharmacy
management software to help dispensing, continuing pharmacy education is not provided, medicines are not compounded or packaged in house,
there are problems with medicines availability and medicine quality, and drug utilization studies are not linked with initiatives to promote the
rational use of medicines. In this article, the authors examine these challenges and put forward possible solutions.

Key words: Hospital pharmacy, Nepal, pharmacy care, South Asia

Introduction associated teaching hospitals in the region, this is becoming

Nepal is a developing country in South Asia situated between
two Asian giants, China and India. In 2016, the number of
medical schools in Nepal has increased to 20 as per the list
maintained by the Nepal Medical Council.[1] A well‑structured
and functioning hospital pharmacy could play an important
role in efficient drug supply and promoting the rational use of
medicines (RUM). Although all teaching hospitals of Nepal
have a pharmacy within their premises, the concept of “hospital
pharmacy services” exists only in a few. In this article,
the authors focus on challenges facing hospital pharmacy
services in teaching hospitals and put forward suggestions
for improvement. We believe many of these findings may
also be applicable to teaching hospital pharmacies in other
developing countries.
The authors have been involved with hospital pharmacies and
pharmacy services in Nepalese teaching hospitals for many
years. They were not able to come across articles providing
an overview of various challenges faced by teaching hospital
pharmacies in Nepal and suggestions to improve these
services. With an increasing number of medical schools and
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an increasingly important issue.
The authors conducted a literature search using the keywords
“hospital pharmacy services,” “teaching hospitals,” and “Nepal.”
Articles published between the years from 2000 to present
were included. The authors reviewed the published studies
and included those which provided insights into the working
of hospital pharmacies and associated pharmacy care services.
They also searched for publications by various governmental
and other organizations on this topic. Nepal also suffers from
occasional shortage of medicines due to transport disruptions.
We obtained articles dealing with this problem from the lay
press using Google Search Engine. We also consulted articles
dealing with hospital pharmacy services in teaching hospitals in
Nepal from the Drug Information Bulletin published by the Drug
Information Center (DIC) at Manipal Teaching Hospital (MTH)
Address for correspondence: Dr. P. Ravi Shankar,
Xavier University School of Medicine, #23,
Santa Helenastraat, Oranjestad, Aruba.
E‑Mail: ravi.dr.shankar@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and
build upon the work non‑commercially, as long as the author is credited and the new creations
are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Shankar PR, Palaian S, Thapa HS, Ansari M,
10.4103/2321-4848.196212 Regmi B. Hospital pharmacy services in teaching hospitals in Nepal:
Challenges and the way forward. Arch Med Health Sci 2016;4:212-7.

212 © 2016 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow

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Shankar, et al.: Hospital Pharmacy Services in Nepal; The Challenges
and also the Journal of Medicine use in developing countries
published by the Discipline of Social and Administrative
Pharmacy at Universiti Sains (University of Science) Malaysia,
Penang, Malaysia. The authors have long experience with
hospital pharmacies in Nepal, and their insights and experiences
were also utilized while preparing the manuscript.
The present article aims to provide the reader with an overview
of challenges facing hospital pharmacies in teaching hospitals
in Nepal and also put forward possible solutions using studies
from the scientific literature and personal observations and
experiences of the authors.
Design and Location of the Hospital Pharmacy
A hospital pharmacy is a place where patients not only obtain
medicines but also pertinent information about their proper
use. An ideal pharmacy should be centrally located, well
lighted, ergonomically designed, and capable of providing
patients with information about the safe and effective use
of medicines through pharmacist‑provided counseling. The
functions of billing, dispensing, and counseling should be
separated. A nontechnical person can handle billing leaving
the pharmacists free to carry out technical responsibilities. The
pharmacy should have a dedicated area for dissemination of
information about RUM to consumers.
Unfortunately, there are no specifications about the space
and design of hospital pharmacies at present. Hospital
administrators are aware of the revenue‑generating potential
of the pharmacy and would like to have the pharmacy at
a central location. However, this location may not have
adequate space and fulfill other requirements. Lack of
proper space and ergonomic working environment can lead
to an increased risk of medication errors. The Institute for
Safe Medication Practices of the United States identifies
improper communication such as bad handwriting, poor
verbal communication, drugs with similar names, missing
or misplaced zero and decimal points, use of nonstandard
abbreviations, poor drug distribution practices, complex or
poorly designed technology, access to drugs by nonpharmacy
personnel, workplace, and environmental problems that lead
to increased job stress, dose miscalculations, lack of patient
information, and understanding of their therapy as possible
reasons for medication errors.[2] Many of these are likely to
be present in Nepalese teaching hospital pharmacies also.[3,4]
The pharmacy at the MTH, Pokhara, has taken steps to reduce
medication errors. Three computer bills are created for each
prescription and are checked by three pharmacists before
dispensing.[5] Dispensing is done as per the batch number of
preparations. There are multiple windows within the pharmacy
with the prescription being received at one window, medications
being dispensed at a second window, and instructions for use
and cross‑checking being carried out at a third window.
Although the Ministry of Health and Population (MoHP),
Nepal, has already formulated “Hospital Pharmacy Guideline
2015” to ensure good quality hospital pharmacy services, most
Archives of Medicine and Health Sciences / Jul-Dec 2016 / Vol 4 | Issue 2
teaching hospitals do not run their own hospital pharmacy
services and meet the required specifications.[6] We feel that
the Department of Drug Administration (DDA), the National
Drug Regulatory Authority, should inspect hospital pharmacies
to check compliance with specifications before granting license
to operate the pharmacy.
Running the Pharmacy by the Hospital under
the Supervision of the Drug and Therapeutics
Committee
The authors of a recent article strongly recommend that
teaching hospital pharmacies should directly run by the
hospital under the supervision of the hospital Medicine (Drug)
and Therapeutics Committee  (MTC/DTC). [7] Unethical
promotion can be checked, service regulated, medicines
selected using objective criteria, number of brands restricted,
and pharmaceutical care services established.
“Hospital Pharmacy Guideline 2015” recommends all teaching
hospitals and government hospitals at various levels run their own
pharmacy under the supervision of the MTC/DTC. However,
there are challenges in implementing the guidelines. Starting a
MTC/DTC in all teaching hospitals is an important first step, and
many national workshops have been held to promote the concept.
Lack of Separation of Outpatient and Inpatient
Pharmacy
Separating the outpatient and inpatient pharmacy services has
many advantages. Compounding services can be started in the
inpatient pharmacy, and dosage forms and doses specific to
individual patients dispensed. Patient‑specific dispensing is
the most favored mode of drug distribution in hospitals for
inpatients and some teaching hospitals in Nepal, for example,
Dhulikhel Teaching Hospital and MTH, have adopted the
concept. This method of dispensing has several advantages
such as reduced medication errors, costs, losses and theft, and
improved productivity of health‑care professionals and better
quality of health care.[8]
Pharmacists at the outpatient pharmacy can devote more time
to patients who are not hospitalized and counsel them better
regarding the use of medications. At MTH, there are three
pharmacies, a bulk pharmacy, an inpatient pharmacy, and an
outpatient pharmacy. At KIST Medical College (KISTMC),
Lalitpur, Nepal, there are separate inpatient and outpatient
pharmacies, and efforts are underway to establish a
bulk pharmacy. DDA should develop guidelines specifying
separate pharmacies for outpatients and inpatients depending
on the number of hospital beds.
Lack of Objective Criteria for Selecting
Medicines and Too Many Brands in the Pharmacy
In many hospitals, medicines are selected based on the
recommendations of individual prescribers. This in turn may
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Shankar, et al.: Hospital Pharmacy Services in Nepal; The Challenges
depend on promotion by medical representatives (MRs)
during a particular time period. Furthermore, many brands
of a particular medicine are stocked in the pharmacy creating
problems with inventory management and ensuring the
quality of medicines. Arranging medicines in a manner easily
accessible to pharmacists is also difficult. An increasing number
of medicines and brands can increase the risk of medication
errors, especially with look‑alike and sound‑alike medicines.[4]
In the MTH pharmacy, the number of brands is limited to a
maximum of six, and medicines are arranged by therapeutic
category. Prescribers can recommend new generic medicines
or new brands of an existing medicine for inclusion in the
hospital drug list. The resources of the DIC are used for
evaluating the proposed medicine and comparing it to other
brands and existing medicines.[9] Patan Hospital (PH) also has
a form for adding new medicines to the hospital medicines
list.[10] KISTMC pharmacy follows objective criteria for
including medicines in the hospital medicines list.[11] The
criteria followed for selection are registration of the brand with
DDA, possession of good manufacturing practice certification
by the company, and cost. The pharmacy stocks a maximum
of two national and two international brands for each generic
medicine.
The recent draft guidelines of the MoHP and DDA recommend
limiting the number of brands available in the hospital
pharmacy to four. Central tendering and local procurement
have also been suggested for government hospitals to select
medicines at a competitive price. For private hospitals, pooled
procurement can be considered.
Lack of Pharmaceutical Care (Pharmacy
Practice) Services
Pharmaceutical care stipulates that all practitioners assume
responsibility for the outcomes of drug therapy in their
patients.[12] In Nepal, MTH was one of the first hospitals
to provide pharmaceutical care services. Medicines are
dispensed only with a valid prescription except in the case
of over‑the‑counter  (OTC) medicines.[13] The hospital has
created an OTC drug list specifying the medicines and
the quantities which can dispend without a prescription.
The department also provides drug information services,
operates a regional pharmacovigilance center, and provides
medication counseling services. Drug information services
are also provided at the Tribhuvan University Teaching
Hospital (TUTH). Nepal Medical College Teaching Hospital
operates a pharmacovigilance center. At KISTMC, medication
counseling services are provided, and medicine information
services are operating.[14] The department runs a regional
pharmacovigilance center under the national program.
Lack of access to objective, unbiased information about
medicines and therapeutics is a major problem in developing
countries[15] including Nepal. Certain DICs in Nepal have been
closed while others are facing problems in their functioning.
214
The DIC at MTH was functioning very well. The DIC
besides providing information about medicines was involved
in supporting medication counseling, pharmacovigilance
activities, continuing pharmacy education  (CPE) programs,
teaching students about drugs and therapeutics, and supporting
research.[16] The center also published a drug information
bulletin to disseminate objective, impartial information to
prescribers. Recently, however, the activities of the center
have been affected, and it has stopped publishing the bulletin.
Academic detailing (AD) has been defined as a form of
continuing medical education, in which a trained health
professional (physician or pharmacist) visits physicians in their
offices to provide evidence‑based information about medicines
and therapeutics.[17] AD is common in developed nations and
has been associated with improvements in the use of medicines
and reduction in cost.[18,19] In Nepal, AD is in its infancy. At
KISTMC, AD sessions had been conducted during 2008 using
a large group format. Informal feedback obtained from the
participants had been positive. The sessions and the medicine
information services had been well received and accepted as
a source of unbiased, objective information.[20] Unfortunately,
the initiative was not continued.
Thus, pharmaceutical care services are deficient or lacking
in many teaching hospitals. Possible reasons could be a lack
of MTC/DTC, renting the hospital pharmacy on contract to
the highest bidder, lack of commitment of the departments
of pharmacology and hospital pharmacy to RUM, and
lack of interest and commitment on the part of the hospital
management.
Lack of Regulation of Pharmaceutical Promotion
within the Hospital Premises
In Nepal, many urban areas are becoming booming markets
for pharmaceuticals.[21] Most teaching hospitals in Nepal allow
free, unrestricted access of MRs to doctors and administrators.
From our observations in different hospitals, we have noted that
pens, posters, calendars, diaries, and pen stands are common
gifts to doctors and residents.
PH in Lalitpur does not allow visits by MRs within the hospital
premises. In MTH, MRs can freely visit doctors, but the DTC
takes the final decision about inclusion of a particular brand
in the hospital pharmacy. In KISTMC, MRs cannot visit
prescribers individually. They can present their products to
a group of doctors, other prescribers, and faculty members
during a fixed time period each week.[22]
The Government of Nepal, DDA formulated a guideline
(Guidelines on Ethical Promotion of Medicine, 2007) to
promote ethical pharmaceutical promotion in the country.[23]
However, unethical pharmaceutical promotion has become
widespread and is a highly challenging issue in Nepal due to
extensive competition among the manufacturers and problems
with implementation of the guideline.[24]
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Shankar, et al.: Hospital Pharmacy Services in Nepal; The Challenges
The departments of pharmacology and hospital Pharmacy
should work on regulating pharmaceutical promotion
under the guidance of the hospital MTC/DTC. Prescribers
in developing countries lack access to objective, unbiased
information about medicines which can be provided by these
departments.
Lack of Dispensing Software
In Nepal, indigenously developed pharmacy software
is available to help in controlling inventory and billing
functions of the pharmacy. Dispensing software that can
assist the dispensing process and point out possible errors, and
drug–drug interactions are not yet widely available. Globally,
numerous pharmacy‑related software have been developed
for maintaining inventory, dispensing, calculating proper
drug dose, and checking for possible drug–drug interactions.
Dispensing software would be a major step toward reducing
dispensing errors and can contribute significantly toward the
safer use of medicines. A time and resource intensive activity is
customizing the software for individual hospitals in accordance
with MTC/DTC decisions.
Continuing Pharmacy Education
In Nepal, the majority of pharmacists in teaching hospitals are
diploma level pharmacists who have completed a 3‑year course
in pharmacy after passing their tenth standard or matriculation.
CPE programs are essential for pharmacists to maintain and
upgrade their knowledge about medicines. CPE programs are
conducted regularly at MTH for all hospital pharmacists.[16]
At KISTMC, a short course was conducted during the initial
days of operation of the pharmacy, but it has not been possible
to conduct further courses due to various reasons.
The department of hospital pharmacy should formulate a CPE
program for all hospital pharmacists, which can be periodically
restructured in the light of comments and suggestions from
the participants and assessment of its usefulness in improving
professional knowledge and practice. Inputs could also be
obtained from the department of pharmacology.
Lack of Compounding and in House Production
Facilities
Many medicine preparations, especially pediatric doses of
medicines and topical preparations can be compounded and
produced inside teaching hospital pharmacies. Production of
personalized medicine packs can lead to savings in cost and
reduce wastage of medicines. Pharmacies at TUTH, Dhulikhel
Hospital, and PH are compounding certain medicines.
Personalized medicine packs are, however, not being used
in Nepalese hospitals. The high cost of clean room facilities
and laminar air flow may be a hindering factor. Teaching
hospitals could come together to pool resources to construct
these facilities.
Archives of Medicine and Health Sciences / Jul-Dec 2016 / Vol 4 | Issue 2
Problems with Medicine Availability
Shortage and nonavailability of essential and lifesaving
medicines has been a major problem in Nepal. An often‑cited
reason has been nonrenewal of license by DDA and
consequent inability to import the medicine into Nepal.[25]
Medicines with low profit margin are manufactured by few
companies only and are especially prone to availability
problems. These problems should be discussed and sorted
out with DDA. Nepal recently has drafted a new constitution,
and some ethnic groups are unhappy citing their rights or
demands have not been significantly addressed. Therefore,
these groups and some political organizations have been
adopting repeated blockades and strikes to express their
dissatisfaction. This has affected not only the day‑to‑day life
of the people but also the health‑care system. In the recent
past, a long strike in the Terai (plain) region adjoining the
Northern Indian boarder led to a huge shortage of medicines
and medicinal products.[26]
Problems with Medicines’ Quality
Counterfeit products include drugs with the correct ingredients
in inadequate amounts or with the wrong ingredients, without
active ingredients, with insufficient active ingredient, or
with fake packaging and are a major problem in developing
countries. In 2001, it was reported that China had 1500 illegal
medicine factories. A  2002 study by government officials
showed that 9% of all drugs tested in India were substandard.[27]
Because of its proximity to counterfeit medicine producers,
Nepal may be at high risk.
Information on the extent of these medicines in the Nepalese
market is lacking. There are only a few laboratories testing
medicine quality. MoHP and DDA are proposing that 3% of
the total profit from medicine sales should be invested back
in quality assurance initiatives and imported medicines are
distributed through a single distributor only. A functioning
pharmacovigilance program will help in early identification
of adverse effects and nonresponse or inadequate response to
a particular medicine. A study by Gyanwali et al. pointed out
the availability of substandard medicines in Nepal.[28]
Linking Drug Utilization Studies with Measures
to Promote Rational Use of Medicines
Drug utilization studies help to obtain information on the
prescribing, dispensing, and use of medicines in the particular
teaching hospital and/or region. The data obtained can be
compared with international figures and problems in medicine
use identified. These problems can be addressed through
educational, managerial, and/or regulatory interventions.
The impact of these interventions can be measured through
further studies.
In Nepalese teaching hospitals, many drug utilization studies
have been carried out. However, linking the data obtained
from these studies to interventions to improve drug use has
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Shankar, et al.: Hospital Pharmacy Services in Nepal; The Challenges
been a challenge. The lack of a MTC/DTC or inadequate
functioning of an existing committee could be a possible
reason. Furthermore, it is challenging to convince clinicians
that use of medicines is below standard and can be improved.
Formation of a MTC/DTC and carrying out interventions
through the MTC/DTC can ensure greater acceptability and
success of interventions.
Hospital Pharmacies in Medical Colleges in
Other Countries
The authors have no personal experience about the situation in
teaching hospital pharmacies in other countries in the region.
A review of literature was done to obtain more information
about this topic. A study conducted in a private medical college
in India showed patients were not satisfied with the waiting
time at the hospital pharmacy.[29] In a teaching hospital in
South India, clinical pharmacy services have been provided
and have been assisting clinicians to improve drug therapy
and patient care.[30] The services were well received by the
health‑care providers. In a teaching hospital in the People’s
Republic of China, a mobile pharmacy service system was
used to deliver individual pharmaceutical care through text
messages to patients’ mobile phones.[31] These messages dealt
with reminders about medications, practical information about
medicines, and information about adverse drug reactions. In
Pakistan, pharmacists were concerned about their present
professional role in the health‑care system and their role in
improving patient outcomes.[32] A shortage of pharmacists in
pharmacies was also noted.
Implications for Patient Care
As mentioned throughout the manuscript, pharmacists, hospital
pharmacies, and pharmacy care services have an important
role to play in improving drug therapy, patient care, and
patient‑related outcomes in teaching hospitals. There have been
many studies exploring the role of pharmacists in improving
patient outcomes. Medication review by pharmacists, patient
counseling, and telephone follow‑up were associated with
a lower rate of preventable ADRs.[33] With the increasing
prevalence of chronic diseases, pharmacists with training in
clinical and behavioral skills will play an important role in
disease management.[34] Thus, knowing about the current status
of hospital pharmacies and of pharmacy care services will be of
importance to all clinicians and other health‑care professionals
in Nepal and in other countries in the region.
Conclusion
Various challenges are noted with the functioning of hospital
pharmacies in Nepalese Teaching Hospitals. Among these were
issues with the design and location of the hospital pharmacy,
leasing the pharmacy to the highest bidder, not running the
pharmacy under the supervision of the hospital DTC/MTC,
lack of separation of outpatient and inpatient pharmacy,
lack of objective criteria to select medicines, problems
216
with pharmaceutical care services, lack of regulation of
pharmaceutical promotion, problems with dispensing software,
and lack of CPE. There are problems with medicines availability,
issues with the quality of medicines, and with using data obtained
from drug utilization studies to improve the use of medicines.
The problems are multifactorial and are linked with unethical
drug promotion and lack of administrative commitments. The
authors have mentioned various measures that may help in
overcoming these problems. At present, scientific studies about
the challenges facing hospital pharmacies in teaching hospitals
are lacking. A questionnaire study can be considered among
senior pharmacists and hospital administrators in Nepalese
teaching hospital pharmacies to obtain objective information
about this topic. Closer cooperation among teaching hospitals
and with the national regulatory authority is required.
Acknowledgment
The authors would like to acknowledge Daya Ram Parajuli,
B. Pharm, M. Pharm (Molecular Pharmacology), PhD
Fellow  (Cardiovascular Research), Faculty of Medicine,
Nursing and Health Sciences, Flinders University, Australia,
for reviewing the initial versions of the manuscript and
suggesting modifications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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