DISPENSARY SEPARATION : PERCEPTIONS OF THE PUBLIC VISITING PRIMARY CARE CLINICS IN MALAYSIA

Over the years, the rights of pharmacists as health care professionals have been a controversial topic in the medical field. Pharmacists worldwide have always been independent in being able to practice medicine in their own way and have been given exclusive dispensing rights to distribute drugs and medicines to patients. In Malaysia, however, this is not the case. The overwhelming opinion has been that pharmacists are losing their dispensing rights because doctors are earning more. The current study was carried out in view of recent debates regarding the implementation of a dispensary separation policy in Malaysia. The main objective of this study was to gain an understanding of the views of and challenges experienced by the public in regards to the implementation of this type of policy. The overall results of this study show that dispensing rights are still viewed with mixed feelings. Study subjects reported believing that pharmacists were capable of dispensing medication but that they lack the confidence to make changes within the existing system. When their conditions were not severe, respondents indicated that they preferred the old system where doctors prescribe them with medicine and they subsequently visit the pharmacy. In conclusion, the majority of interview participants were of the opinion that maintaining the current system would benefit them holistically. In this study, input from a total of 929 respondents was gathered via a structured survey conducted throughout Malaysia. The study findings were also supported by data obtained during interviews carried out with 350 informants regarding their views of the implementation of dispensary separation in Malaysia.

Over the years, the rights of pharmacists as health care professionals have been a controversial topic in the medical field.Pharmacists worldwide have always been independent in being able to practice medicine in their own way and have been given exclusive dispensing rights to distribute drugs and medicines to patients.In Malaysia, however, this is not the case.The overwhelming opinion has been that pharmacists are losing their dispensing rights because doctors are earning more.The current study was carried out in view of recent debates regarding the implementation of a dispensary separation policy in Malaysia.The main objective of this study was to gain an understanding of the views of and challenges experienced by the public in regards to the implementation of this type of policy.The overall results of this study show that dispensing rights are still viewed with mixed feelings.Study subjects reported believing that pharmacists were capable of dispensing medication but that they lack the confidence to make changes within the existing system.When their conditions were not severe, respondents indicated that they preferred the old system where doctors prescribe them with medicine and they subsequently visit the pharmacy.In conclusion, the majority of interview participants were of the opinion that maintaining the current system would benefit them holistically.In this study, input from a total of 929 respondents was gathered via a structured survey conducted throughout Malaysia.The study findings were also supported by data obtained during interviews carried out with 350 informants regarding their views of the implementation of dispensary separation in Malaysia.

INTRODUCTION
The healthcare system in Malaysia has experienced great changes during the time since the establishment of its first hospital -Taiping Hospital -in year 1880.Currently, there are 139 government hospitals and 2,836 health clinics serving the public as frontline

Global Overview
In year 2000, the government of the Republic of Korea implemented a separation reform with three main goals in mind.First, it aimed to reduce the over-use of pharmaceuticals by doctors, identified as occurring mainly due to economic incentives to dispense high margin drugs, commercial incentives that influenced the types of drugs dispensed and over-use of antibiotics.Second, the reform also aimed to improve patient rights for information, as the type, quantity, treatment period, and side effects of drugs may frequently not be explained by doctors.Third, the policy also aimed to improve the efficiency of the drug industry and drug distribution by reducing the mechanisms that drove manufacturing companies to encourage the prescription of high-margin drugs by dispensing doctors and increasing research and development (R&D) activities to improve the quality of drugs (Organisation for Economic Co-operation and Development [OECD] 2003).
However, these noble goals have yielded mixed outcomes and triggered a series of reviews for several reasons.In terms of benefits, the policy was found to have improved the professional specialisation of doctors and pharmacists and decreased inappropriate prescriptions and antibiotic use over a period of one year.However, on the other hand, the policy failed to achieve progress in several areas.First, the third goal of improving the drug industry failed to achieve the desired outcomes of producing better domestic manufacturing output in terms of quality and improving the distribution network for generic prescriptions, as many doctors preferred to dispense the more expensive branded pharmaceuticals.Instead, the reform benefited foreign drug manufacturers and helped them gain extensive market shares over a short period of time while increasing the cost of pharmaceuticals for

Dispensing Separation
Malay J Pharm Sci, Vol. 16, No. 1 (2018): 23-35 patients.Second, the numerous strikes initiated by doctors over their loss of professional role, power and economic incentives triggered repeated reviews of consultation fees by the government, thereby effectively increasing the medical costs for patients by more than 40.0%over a period of less than 15 months (OECD, 2003).In summary, while the reform resulted in some progress, its overall impacts on patients were negative; however, both doctors and pharmacists appeared to be better off following the reform.
In year 2005, the United Kingdom revised their health act to include a dispensing doctor service as part of a hybrid system developed for the convenience of patients, specifically those who have difficulties obtaining medications from pharmacies and residents of rural areas where pharmacies are scarce (Department of Health: Medicines and Pharmacy, 2012).Similarly, in Canada, physicians have been allowed to dispense medications under certain circumstances by a 2007 revision of the Health Professions Act (Health Professions Act 2009).
Table 1 shows a comparison of the health expenditures (percentage on gross domestic product [GDP]) in Asian countries practicing dispensary separation (DS) and countries that have not adopted DS.Table 1 clearly reflects that no major significant difference in health expenditure has been identified.Compared to countries such as Malaysia, Thailand and Philippines, countries that practice DS, i.e., South Korea, Taiwan and Japan, were observed to have a much higher percentage of their GDP representing health expenditures.

METHODS AND SUBJECTS
This study, which uses both quantitative and qualitative methodology, was conducted among patients who sought medical treatment at participating private clinics nationwide.In Malaysia, there are 6,589 private clinics currently registered with the Ministry of Health, Malaysia to provide outpatient medical treatment.Among these clinics, 125 sites were randomly selected after taking into consideration the location of the private clinics to ensure an even distribution between urban and rural areas.An invitation to participate in the survey and 20 copies of the structured questionnaire were sent to the selected private clinics.Of the 125 selected sites, 98 private clinics responded and agreed to participate.The completed questionnaires were returned after two weeks by the enumerators who were assigned to collect the data.
Malay J Pharm Sci, Vol. 16, No. 1 (2018): 23-35 A self-administered structured questionnaire developed by Hassali et al. (2009) was adapted for use in this study.The questionnaire collected information on the sociodemographic background of the participants, namely age, sex, ethnicity, education level, employment status and average monthly income.The second section consisted of five items designed to elicit participants' responses to the implementation of a dispensing separation policy in Malaysia.The last section contained 19 statements intended to assess the level of agreement regarding dispensing separation among respondents using a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree).Participants were briefed about the study using an information sheet, and their consent to participate voluntarily was requested.Participants were assured of their confidentiality and allowed to withdraw from the study at any time.Since the questionnaire was adopted from Hassali et al. (2009), the content validity of the questionnaire was established based on a review of the literature.The researchers also provided the combined questionnaire to five lecturers in the field of health sciences to check its validity.Questions regarding the suitability of the questionnaire items were verbally asked by each validator and upon the provision of satisfactory answers by the researcher, the go-ahead was given to conduct the study.
In total, surveys were collected from 1,004 patients.However, 75 patients were excluded from the final analysis due to various reasons, including high numbers of missing values, incomplete questionnaires, and withdrawal from the study.Data management and analysis were conducted using IBM SPSS, version 22.0 (IBM Corporation, Armonk, New York, USA) and descriptive statistics were performed.

RESULTS
A total of 929 respondents with a mean age of 36.0 (Standard Deviation [SD] = 11.5) years were recruited over a period of one month (Table 2).The age of the respondents ranged between 15 and 84 years, but those aged between 19 and 30 years constituted the majority of participants (37.1%).There were more female than male participants (59.7% vs. 40.3%).In terms of ethnicity, most respondents were Malay (69.2%), followed by Chinese (13.2%),Indian (9.1%) and other ethnicities (8.5%).
The majority of participants were married (70.8%) and full-time employees (73.4%).The literacy level among the participants was high, with only 0.5% of the respondents reporting that they did not attend school.Most respondents had a tertiary education and at least a diploma (45.4%), while the second largest group comprised those with a secondary education (42.3%).The disparity in monthly income was large, with 9.1% of participants reporting that they had no income, while some other respondents earned as much as RM40,000.00a month.The majority of participants earned below RM3,000.00 (58.0%), and the mean income was RM2,543.15 (SD = RM2,879.89).
Table 3 shows the responses towards implementation of a dispensing separation policy in Malaysia among participants.The study revealed that as many as 93.1% of respondents disagreed with the implementation of dispensing separation in Malaysia.Similarly, a large proportion of participants were unwilling to obtain medications prescribed by a doctor from a pharmacy (84.2%).The respondents also had the opinion that medical doctors were more reliable than pharmacists in explaining the uses and side effects of medicines (89.6%).

Dispensing Separation
Malay J Pharm Sci, Vol. 16, No. 1 (2018): 23-35  As shown in Table 4, the respondents' perceptions of dispensing separation were also explored.Most of the respondents agreed that having two professionals review medications would increase medical costs (94.2%).In addition, they agreed that it may be difficult to find a pharmacist during the night (96.8%).The respondents also "agreed" or "strongly agreed" that the medicines prescribed by doctors may not be available in nearby community pharmacies (96.1%).A more direct question regarding whether respondents would support the implementation of a dispensing separation policy in Malaysia showed the majority respondents were against the policy, with 95.9% responding that they would "agree" or "strongly agree" with item 12.
In addition, the majority (95.5%) of participants agreed that dispensing separation would not reduce the cost of medical care, as highlighted by their responses to item 14.The respondents also show a strong affinity towards getting their medications prescribed and dispensed at a clinic (98.6%), as indicated by their responses to item 16.When asked whether they agreed with the statement, "Medication errors could not be completely avoided, even if medications were dispensed by a pharmacist", 96.3% agreed or strongly agreed that these errors could not be completely avoided.Overall, most respondents (96.5%) felt that the current system was adequate and practical, as shown by their responses to item 19.

Interview Results (Patients)
The study also complemented the survey data with data obtained during patient interviews carried out in a total of 11 states and a federal territory in Malaysia: Kedah, Pulau Pinang, Perak, Selangor, Negeri Sembilan, Melaka, Johor, Pahang, Terengganu, Kelantan, Sarawak and Wilayah Persekutuan.The convenience sampling methodology was employed for the interview phase of the study, whereby doctors in the respective clinics indicated that they were interested in having interviews carried out with patients in their clinics.The classification of the clinics in each state that participated in the interview phase is listed in Table 5.
Table 5: Total number of clinics according to their classification.

Category Total numbers of clinics
Urban 12

Semi urban 12
Rural 12 In-house 12 A total of 350 informants were interviewed during the interview phase.An average of 6-10 informants were interviewed in each clinic, depending on the patient load at the time of the interview.
The following questions were asked during the interview, and feedback was elicited from patients of various racial, educational, age, and regional backgrounds: 1. How do you think the implementation of a dispensary separation policy would affect the public at large?
2. Do you think the implementation of a dispensary separation policy would have an effect on the general cost of medication for the public?
3. Who would you be comfortable talking to about your medication?
4. If a medication error occurred or if your symptoms were not relieved after taking your medication, do you think that having to consult with two parties during subsequent medication management would pose an inconvenience for you?
5. What are your thoughts regarding the implementation of a dispensary separation policy in the country in the near future?
The results of the interview indicated that a total of 343 informants (98%) felt strongly that it would be a greater inconvenience for the public at large to visit to two places for medical care rather than just one place, as was currently practiced.More than half of these respondents, totalling 195 informants (56.9%), had sought treatment for their children.This group (parents) felt that it would be extremely stressful to bring a sick child to two places for care, a process that would be even more difficult if the closest pharmacy was not within the vicinity of the clinic visited.Some informants also reported that they travelled via public transportation to visit clinics and that it would be very troublesome and costly for them to take public transportation to two places.However, the remaining seven informants (2%) felt that the implementation of a DS Policy would not impact care, as they had received care in countries employing a DS system while studying abroad.However, when the interviewer asked the proximity of their primary care clinic and community pharmacy, all of them replied that it was on the same block.
For Question 2, a total of 295 informants (84.3%) reported that they believe that medical costs for patients would, in general, increase instead of decrease when other hidden costs, such as gasoline, parking and, most importantly, time costs, were considered.The remaining 55 informants (15.7%) felt that purchasing medication from pharmacies would reduce the total cost of medication.
When asked with whom they would feel most comfortable discussing their medication, a total of 322 informants (92%) felt that they would prefer to speak to a doctor instead of a pharmacist for confidentiality reasons.Of the participants, 34.3% raised a concern that in the event that a condition was a private matter (i.e., a sexually transmitted infection [STI], gynaecological problems or fungal infection) and the prescription was brought to a pharmacy, the pharmacist might ask them further questions in regards to their condition in public and within hearing distance of other customers, thereby making them feel very uncomfortable.The remaining 28 informants (8%), who were all males, felt that they would not have any problem speaking to either a doctor or a pharmacist regarding their medication.
For Question 4, all 350 informants (100%) felt that if a medication error occurred or their condition did not improve after the first visit; it would definitely pose an inconvenience, as they could not be sure which party was at fault.Participants also felt it would be Malay J Pharm Sci, Vol. 16, No. 1 (2018): 23-35 inconvenient to have to consult two parties regarding medication management.A total of 180 informants (51.4%) also raised concerns regarding the possibility that both parties would feel that the error resulted from the care provided by the other party and inquired what they, as non-medical professionals, would do in that case.
For the last question, a total of 345 informants (98.6%) felt strongly that Malaysia was neither logistically nor strategically prepared to have a DS system implemented in the near future.They reported that in the event that a DS Policy was implemented, pharmacy outlets should be located next to clinics to avoid inconveniencing the public.Some of the common issues that were shared by many of the informants in the study were as follows: 1. Would a DS system require for pharmacy outlets to be open 24 hours?2. During the festival season, if a clinic is open and a pharmacy outlet was closed or vice versa, would it be an inconvenience for patients to travel out of their neighbourhood for medical treatment?
3. Many rural areas still do not have community pharmacy outlets.
4. The implementation of a DS policy would likely be a great inconvenience for patients who depend on public transportation.

Interview Results (Stakeholders)
Four human resource managers who reported sending their employees for panel treatment, four retail pharmacists and four medical representatives were also interviewed.These respondents were also selected using convenience sampling methods.
For this component of the study, the interviewer asked only two questions: 1. What are your thoughts regarding dispensary separation policies?
2. Do you think we are ready for a dispensary separation policy to be implemented in this country?
The responses for Question 1 indicated that all four Human Resources (HR) personnel were completely against the implementation of a DS system, as they felt strongly that this system would increase the likelihood that employees seeking treatment may abuse time-off policies.They reported that many employees take time off, i.e., two hours, to see a doctor in the event that they are not feeling well and voice concerns that if the employees were required to see two parties, then the organisation would have to consider providing them with more time off work, which some employees may abuse if they see both parties within two hours.In addition, they also felt strongly that the current panel system has already been comprehensively developed, and in the event that a DS policy was implemented, this may require them to revise their policies regarding staff benefits and standard operating procedures (SOPs) related to medical treatment.The four retail pharmacists, however, had mixed feelings regarding the implementation of a DS policy, as they had not yet been exposed to the contents of policy and felt that community pharmacy outlets may also have problems in terms of revising SOPs and require some training and planning prior to DS implementation.However, they also expressed they were open to the idea of a DS system.For the medical representatives, all four of them felt that DS policy implementation would have an effect on their profession, as each of them covered general practitioner (GP) clinics
As for Question 2, all four HR personnel felt that a DS Policy was not currently implementable in the country, as they felt that employers were definitely not ready for this policy to be implemented in the near future.The retail pharmacist also felt that more planning should be completed prior to DS implementation and believed that the policy should not be implemented in the near future, as many parties were still undecided regarding its implementation.As for the medical representatives, they also felt that we were not ready for the system and expressed a belief that the policy may benefit some parties but have a huge significant negative impact on other parties.

DISCUSSION
The findings of this study were relatively consistent with those of a previous study conducted by Hassali et al. (2009) using a similar tool, which indicated that 73.2% of 1,000 people surveyed in Penang disagreed with implementation of a similar policy.These findings were likely observed because the current practice of having a general physician prescribe and dispense medications has been in place for a long time, and people may not be ready for an abrupt change in an already adequate system (Hassali et al. 2009).Asian countries, such as Taiwan, South Korea, Japan, Indonesia and India, that have had similar systems in place for some time have been reported to experience challenges associated with its actual implementation, largely due to public rejection because the system's effectiveness at improving the quality of medical care and decreasing health expenditures has been inconclusive (Chou et al. 2003;Kweon et al. 2002;Shim and Son 2013;Yokoi and Tashiro 2014).
Although no comprehensive information regarding the structure of a dispensing separation policy in Malaysia has become available to the public, feedback from participants indicated that they anticipated more problems than solutions to arise if a policy if implemented.Among these concerns, the inconvenience of visiting two places when seeking medical care, the availability of prescribed medications in pharmacies, and the closure of pharmacies during public holidays were raised repeatedly during data collection.Some of these issues were not unfounded, as they have been highlighted previously in the literature.A study conducted in Osaka City, Japan by Ooe (2007) found that closures of private pharmacies during the Bon holidays caused some patients to be unable to obtain their medications after receiving medical consultations at private clinics.In addition, these logistic shortcomings may create an unnecessary burden for those who have mobility issues, such as the elderly, the disabled, those who live in rural areas and those who rely on public transportation.
Concerns regarding medication errors that may occur if general physicians continue to dispense medications were almost non-existent among the respondents, as they expressed a relatively strong faith in the professionalism of their doctors.It may be also inevitable that medication errors occur, regardless of the dispensing party.This finding is consistent with the results of a previous study conducted in Pulau Pinang, which reported that 55.1% of participants felt that having a community pharmacist dispense medication would not reduce medication errors (Hassali et al. 2009).Additionally, the respondents also had the perception that were a dispensing separation policy to be implemented, the cost of medical care would increase and the process of receiving care would become Malay J Pharm Sci, Vol. 16, No. 1 (2018): 23-35 more complicated and troublesome.These perceptions were in contrast with the findings of previous studies, which showed that medical costs decreased by as much as 30.0%when dispensing separation policies were implemented (Kaiser and Schmid 2013;Yokoi and Tashiro 2014).However, as the policy for Malaysia is still in draft form, whether actual implementation would decrease medical costs remains to be seen.

CONCLUSION
In this study, the public's unwelcoming perceptions of the implementation of a dispensing separation policy were readily apparent.Several key obstacles that were highlighted in this study need to be thoroughly addressed if a DS policy is implemented.Given the strong opposition against its implementation, it is critical that more studies be conducted to determine the public's acceptance level, and should repeated local studies indicate that similar trends have continued to occur, it is crucial that the government and policymakers respect these findings and consider the needs of the public when implementing a DS policy.It would not be meaningful to introduce a policy that may not improve the quality of medical care in the long run for the public at large and benefit only certain parties.The aftermath of Korea's reform should provide clear warning signs to the Malaysian government, suggesting that they reconsider their plan to embark on dispensing separation unless better solutions are in place to counter the policy's potentially tremendous shortcomings.

Table 1 :
Comparison of total health expenditures (% of GDP) between Asian countries with dispensing separation and without dispensing separation policy year 2012.

Table 2 :
Sociodemographic background of respondents.

Table 3 :
Responses to dispensing separation.

Table 4 :
Perception of dispensing separation.