This increased engagement in the medication use process requires pharmacists to undertake the assessment and evaluation of medication regimens, monitor regimens to ensure desired outcomes are attained, counsel to ensure medications are being used optimally, communicate with healthcare providers, and document care. In fulfilling this new and expanded role, pharmacists practice the fundamentals of patient care such as patient history taking, conducting basic physical assessment (i.e. vital signs) and assessing therapeutic markers for the purpose of monitoring medication safety and efficacy. The ultimate end product of the process is the avoidance of medication-related problems, thereby ensuring more positive patient outcomes^{2, 3}.

Community pharmacy practice evolved in the post Second World War period. In developed nations, evidence exists that pharmacists not only began to perform functions that were new to pharmacy, but they started innovating functions and captured their original contributions in health care system. The popular motto of "patient oriented practice" and "drug use control" came into practice. The traditional role of pharmacists to manufacture and supply of medicines has undergone a sea change. More recently, pharmacists have been faced with increasing health demands due to an ever growing and complex range of medicines, poor adherence to prescribed medicines that have forced the evolution of the pharmacist's role into a more patient centered approach⁴. In addition, the pharmacist assumes varied functions ranging from the procurement and supply of medicines to pharmaceutical care services thereby dispensing with knowledge and improving outcomes resulting in best treatment for patients.

In India role of community pharmacist is not so much recognized, and needs strong support from all stakeholders in fulfilling the same. However there is need for community pharmacist to understand the broder concept of public heath, which focus on improving heath at population level. Pharmacy is the application of scientific knowledge in the field of heath care, specifically drug and medicine⁵.

What is the need of community?

Health is a fundamental human right and that the attainment of the highest possible level of health is a most important worldwide social goal”. In addressing the main health problems in the community, Primary Health Care (PHC) must “…provide promotive, preventive, curative and rehabilitative services”. The Declaration states that PHC included at least “…prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries and the provision of essential drugs”. It recognized the role played by all health workers and the need for suitable training to enable these people to work as health care team to respond to the expressed needs of the community^{5, 6}.

Heath is a vital for ethical, artistic, material and spiritual development of man. In achievement in the health front is significant particularly in attaining the development indicators such as reduction in birth rate, death rate, infant mortality rate and increase in life expectancy. Our efforts have resulted in a discernible impart on mortality with steep declaim in the life expectancy at birth. There has been an improvement in India’s heath scenario; the much expected heath transition has happened. It is undeniable fact that Indian community pharmacists’ contribution to the healthcare has not satisfactory and has definite shortcomings as compared to western countries^{7, 8}. There are more than 6.0 lake approved community pharmacies (medical stores) in India. The community pharmacists provide only dispensing services within pharmacies. Many opine that presence of pharmacists in community pharmacies is merely to satisfy the current legal requirements. Community pharmacists merely count and pack tablets and capsules, and distribute these to consumers as with fast food outlets. In addition these services are provided by locums with little or no training. This is an urgent need to improve the heath infrastructure and heath care system in India if we have to need of our large populace⁹.

Why community pharmacist:

Pharmacy is the application of scientific knowledge in the field of healthcare, specifically drugs and medicines. A community pharmacist works within legal and ethical guidelines to ensure the correct and safe supply of medical products to the general public. They are involved in maintaining and improving people's health by supplying prescription medicines¹⁰. Community pharmacists have always played a role in promoting, maintaining and improving the health of the communities they serve. They are, after all, based in the heart of communities in rural as well as deprived inner city areas, in town centers and suburbs. Situated on high streets, in shopping centers and on housing estates, they gain a particular understanding of the needs of members of their communities through daily interactions with patients and customers¹¹. Community pharmacists are often patients first point of contact, and for some their only contact, with a healthcare professional. Engaging with communities through day-to-day activities, which might include the provision of advice to parents of young children, the care and support of drug miss users, visits to the homes of older and housebound people and advice on smoking cessation, pharmacists already make a significant contribution to public health. However, there is a need for community pharmacists to understand the broader concept of public health, which focuses on improving health at a population level. In addition, the new contract for community pharmacy will be an important vehicle for delivering public health services in community pharmacy.

To maintain, develop and support a stable pharmacy network to provide, in partnership with others a quality and comprehensive pharmaceutical service assuring the safe and effective use of medicines, minimizing barriers to provide equitable heath and social care to all. Community Pharmacies play an important role within the heath service and in the community as a whole^{12, 13}.

Health Development activities of community pharmacist

Decades ago, compounding was key to the pharmacist’s role. Majority of the medicines had to be prepared extemporaneously by the pharmacist and dispensed the same to the patient against prescription of a registered medical practitioner. The duty also included collection, storage and distribution of raw materials as well as labeling of dispensed medications. It was a time when unique ready-to-use medicine was not developed, drug targets were rare to find, medicinal dosages and drug delivery systems (DDS) were hard to optimize¹⁴.

As all we know, this situation has abruptly changed with the scientific revolution of pharmaceutical technology. The traditional manipulative expertise role of the pharmacist has been taken over by the modern advanced machineries and computers. The community pharmacists have lost control over so-called compounding role, and the role has changed to being focused not on the medicine itself but on the medicine user¹⁵.

Community pharmacy traditionally provides services in four core areas:

1. Treatment of common ailments: Advising on responsible self-care, selling appropriate OTC treatment and referring to other members of heath care team if necessary.

2. Provision of prescribe medicines for acute and long term condition. This also involves advising on correct use of the medicines or devices, helping patients to monitor the effects of treatment and working with the patient to ensure continuity of supplies.

3. Working with other health and social care professionals. Advising others on technical and clinical aspects of medicines.

4. Health promotion and disease prevention. Activities in this area including the direct provision of advice, access to information resources and delivery of specialist services such as smoking cessation programmes^{16, 17}.

Pharmacy New Contractual Framework for Community:

The researchers looked for evidence involving community pharmacists in the:

Ø promotion of health and well being;

Ø prevention of illness;

Ø identification of ill health;

Ø Maintenance of health for those with chronic or potentially long-term conditions^17,
18.

The new contract enables community pharmacies to contribute to National Health Service (NHS) service provision for patients, provide a more rewarding and stimulating working environment for the profession and reduce the burden of work currently carried by general practitioners (GPs)^{19, 20.}

An integral component within the NHS family, community pharmacies will:

· support patients who wish to care for themselves;

· respond to the diverse needs of patients and communities;

· be a source of innovation in the delivery of services;

· help deliver the aspirations within Designed for Life;

· help tackle health inequalities²¹

NHS Community Pharmacy Contractual Framework Enhanced Service – Minor Ailment Service: The community pharmacist will provide advice and support to people on the management of minor ailments, including where necessary, the supply of medicines for the treatment of the minor ailment, for those people who would have otherwise gone to their GP for a prescription²².

* Where appropriate the pharmacy may sell OTC medicines to the person to help manage the minor ailment

* The pharmacy will operate a triage system, including referral to other health and social care professionals, where appropriate.

Minor ailments are variously defined but are generally taken to include conditions that require little or no medical intervention^{22, 23}.

Established minor ailments schemes – using locally agreed protocols – have included:

_ Athlete’s foot

_ Bites and stings

_ Constipation

_ Contact dermatitis

_ Cough

_ Diarrhoea

_ Dyspepsia

_ Earache

_ Hay fever

_ Headache

_ Head lice

_ Mouth ulcers

_ Nasal symptoms

_ Sore throat

_ Teething

_ Temperature

_ Vaginal thrush

_ Viral upper respiratory tract infection (URTI)²⁴

Aims and intended service outcomes:

1. To improve access and choice for people with minor ailments by:

♦ promoting self care through the pharmacy, including provision of advice and where appropriate medicines and/or appliances without the need to visit the GP practice;

♦ operating a referral system from local medical practices or other primary care providers; and

♦ supplying appropriate medicines and devices (dressings etc.) at NHS expense.

2. To improve primary care capacity by reducing medical practice workload related to minor ailments^{25, 26}.

The role of pharmacists in National Rural Health Mission:

In India those most needing health care live predominantly in rural areas. Rural is a vast spread that covers not only the remote, but areas with varying levels of urbanization which will of course be the key trend as we proceed into 21^st century. The needs and service available will vary among rural areas and solutions must relate to local needs. There is an opportunity to do so in which pharmacists can have a role. In most rural communities, the primary issues are common - availability of drugs, doctors, prevention of ill health, promotion of good health and an environment that promotes culturally compatible well being²⁷. Generally, there is a mismatch between prevalence of disease and facilities for care between drugs availability and doctors. What is said to be available in public sector is poor and unreliable; what is offered in private sector is beyond reach and expensive. In this scenario, pharmacists often can substitute the gap as a first port of call and create the window of connectivity in drug supply, advice on its proper use and become a link between the community and health care²⁸

Therefore, there is a need for doggedly down staging knowledge about ill health and its ways and the role of preventive and personal care in remaining in good health and this is required by the community in culturally compatible term. Patients attach a great deal of importance to the receipt of good information about their medication –which means they are more likely to adhere to treatment. Pharmacists are excellently placed to be a ready source of this information – and because they are often the most readily accessible health professionals in rural communities, they are also in the position to provide regular patient follow-up during the first 2-3 months of drug therapy – again encouraging adherence to the treatment prescribed²⁹. Pharmacists are ideally a good link responsible for both succor in need and for business creation in a sense linking at the low end of the table commercial enterprise and community service. Their responsibility is to listen and check appropriateness of prescriptions, provide medicines and explain their proper use, all this at a reasonable cost. The role for pharmacists will only grow in a forward looking and self confident nation wanting to be a middle income country. One way is to establish and increase the reach of rural area pharmacies, accredit them into various grades, see them grow into a community resource and even over time with a facility for being a vendor of community health insurance through pharmacists. If hospitals do so in curative care why not pharmacists be a conduit for vending local community insurance. The opportunity would be available to integrate knowledge and action through vernacular translation made appropriate to local situations, thus helping community³⁰.

Role of community Pharmacist in the management of rational use of drug:

Pharmacists involved in a responsible manner leading to improved access to medicines at lower costs. Thus, four areas need to be developed in collaboration with the WHO by setting up task forces so that access to medicines through pharmacist improves^{30, 31.} These are:

1. Selection of medicines at different levels of health care:

Pharmacist knows more about medicines in terms of comparative use, cost, safety and efficacy. Pharmacists should play a vital role and take the lead³².

2. Quality of medicines:

Pharmacists can play a vital role in curbing the menace of counterfeit and substandard medicines. Basic Tests for Pharmaceuticals and Dosage Forms developed under the auspices of the WHO can and should be used especially in developing countries^33,
34.

3. Logistics of procurement, storage and distribution of medicines:

Pharmacists should ask themselves as to how and why medicines are not reaching almost 50% of the rural population, when cigarettes, tooth brushes, tooth pastes, etc. is readily available? The government is planning to outsource district health centers to NGOs. Pharmacists should use the opportunity and take up a few health centers to prove their role in procurement, storage and distribution of medicines³⁵.

4. Provide information on medicines:

Pharmacists should go straight to the public and provide information on medicines. People want to know about medicines that they are taking³⁸. They can go to special groups of people like the elderly who take many medicines for conditions like cancer, hypertension, diabetes, etc. and advise them on ways and means of reducing costs of treatment by rational use of medicines that are becoming costlier day by day and becoming difficult for them to buy out of their limited incomes and budgets. Pharmacists should think of changes in health care systems that are going to come^{36, 37}

Community pharmacists improve the use of intermediate care:

Community pharmacists have an important role to play, and improve the use of intermediate care, by helping elderly patients manage their medicines after discharge³⁸. Traditionally community hospitals have been associated with the long-term care of elderly patients. However, as pressure has increased on DGHs to optimize their use of beds, the role of community hospitals has changed to providing what is now termed intermediate care: "A short period (normally no longer than six weeks) of intensive rehabilitation and treatment to enable patients to return home following hospitalization, or to prevent admission to long term residential care; or intensive care at home to prevent unnecessary hospital admission³⁹."

Shortly before the patient was due for discharge a pharmacist produced an information leaflet for the patient which consisted of a "compliance grid" detailing what medicines would be prescribed on discharge, when they were to be taken and the general purpose of each medicine⁴⁰. The information leaflet formed the basis of a consultation with the patient to ensure that the patient knew what to take when they got home (and what not to take) and that they had an opportunity to discuss the risks and benefits of treatment with a pharmacist. The information leaflet was put together using a template for the grid and a database of files for each of the medicines used. We edited the standard drug files to suit the patients' medical conditions where necessary⁴¹. To keeps the information brief and relevant to each patient we kept the information disease specific. For example if a patient was prescribed a beta-blocker for hypertension, we did not include any information on angina. The leaflets were put together using a standard Word for Windows program by inserting the drug files into a template for each patient. The hypothesis that we were testing was that giving patients customised information on their discharge medication would reduce the mortality rate and readmission rate⁴².

Enhanced services: –

The specification for these services is agreed nationally but commissioned locally by Local Health Boards to meet the needs of the community. Services may include^{43, 44}:

· minor ailments management

· pharmacovigilance and ADR management

· reducing drug related problems in seniors

· prevention of poisoning

· diabetes screening

· substance misuse services

· disease specific medicines management services

· palliative care services

· emergency hormonal contraception service

· full clinical medication review

· care home services

· head lice management service

· smoking cessation service

· gluten-free food supply service

· needle exchange scheme

· Services to schools.

Tables 1: Community pharmacists should evaluate essential elements of a safe and effective medication use system

Element	Comments
1. Timely recognition of drug indications and other signs and symptoms relevant to drug use, along with accurate identification of underlying disease	“Correct” therapy for a late or incorrect diagnosis cannot improve a patient’s quality of life.
2. Safe, accessible, and cost-effective medicines	Safe and cost-effective (efficient) drug products must be legally and financially available.
3. Appropriate prescribing for explicit (clear, easurable, and communicable) objectives	Explicit therapeutic objectives simplify the assessment of prescribing appropriateness and are necessary for assessing (monitoring) therapeutic outcomes.
4. Distribution, dispensing, and administration of drug products with appropriate patient advice	This element encompasses ensuring that the patient has actually obtained the medicine, negotiating a regimen that the patient can tolerate and afford, ensuring that the patient (or caregiver) can correctly use the medicine and administration devices, and advising to empower the patient or caregiver to cooperate in his or her own care as much as possible.
5. Participation of patients in their own care (intelligent adherence)	The ambulatory patient or caregiver should consent to therapeutic objectives and should know the signs of therapeutic success, side effects, and toxic effects; when to expect them; and what to do if they appear.
6.Monitoring (problem detection and resolution)	Many problems can be detected before they become adverse outcomes or treatment failures.
7. Documentation and communication of information and decisions	Documentation and communication are necessary for cooperation in a system.
8. Evaluation and improvement of products and system performance	Practice guidelines, performance indicators, and databases are useful approaches to achieving and maintaining improved system performance (outcomes).

Tables 2: Summary of health promotion activities provided in community pharmacies

Area	What can community pharmacy offer?
Asthma	Pharmacists undertake routine follow-up of asthma patients. Community pharmacy-led medicines management services for asthma, check medication usage and give advice on managing their condition. The condition can be managed with a combination of medication and environmental control.
Cardiovascular Disease	Community pharmacists collaborate with doctors in order to detect early warning signs for cardiovascular diseases. For example pharmacists measure blood pressure, cholesterol levels, weight and blood sugar levels to detect risk factors for cardiovascular disease.
Diabetes	Health monitoring to detect risk factors for diabetes and run pharmaceutical care programmes for people with diabetes. Participation in campaigns to raise awareness of the importance of retinopathy screening. Sustainable medicines management services to diabetic patients. Community pharmacy-led medicines management services for diabetic patients.
Hypertension	Community pharmacists offer blood-pressure monitoring services to patients. For example patients showing signs of hypertension are provided with advice on lifestyle changes and when necessary are referred to their physician. High blood pressure can often be reduced through simple lifestyle changes such as reducing salt and fat intake, not smoking, undertaking regular exercise and only consuming moderate amounts of alcohol.
Accidents	Medication reviews and provision of advice to patients on the side effects that some medicines have on the risk of falls. Participation in campaigns to raise awareness of ways, to prevent falls in the home.
HIV/AIDS	Community pharmacists are involved in the fight against the spread of HIV/AIDS. Pharmacists take part in health information campaigns to raise awareness of HIV/AIDS and provide accurate information on the disease and its transmission. There is as yet no cure for HIV/AIDS, although modern medicine can now manage the disease in many patients. Preventing the spread of HIV/AIDS is therefore of vital importance for public health.
Contraception	Community pharmacists participate in health information campaigns on emergency contraception and offer contraceptive advice. Community pharmacists provide advice on and access to emergency hormonal contraception and pharmacists undertake special training in counselling citizens on contraception.
Immunisation	Involve community pharmacy in campaigns to raise awareness of ‘flu’ vaccinations. Consider a community pharmacy-based immunisation programme integrated with the local NHS ‘flu’ campaign
Smoking cessation	Community pharmacy-led smoking cessation services, as part of the integrated network of specialist NHS smoking cessation services. Community pharmacists run health promotion campaigns on the dangers of Tobacco. Pharmacists cooperate with health authorities to warn citizens of the dangers of smoking and provide practical advice to encourage smokers to kick the habit. Smoking related diseases place a huge burden on healthcare systems across world because smokers suffer higher rates of cancer, and smoking is a risk factor for many diseases including hypertension, asthma and coronary heart disease.
CHD	Participation in health promotion and education to promote smoking cessation, healthy eating, etc. Integration of community pharmacy screening services s part of NHS screening services for those at risk of CHD. Community pharmacy-led medicines management services for CHD patients, hypertensive patients.

It is envisaged that the contract framework will develop over time, to keep pace with the changing needs of patients and the NHS. This gradual contract development may for example see some Advanced or Enhanced services becoming part of the Essential category⁴⁵

We will support and encourage community pharmacists to:

• Work with local communities to develop services tailored to their particular needs;

• Develop health promoting pharmacies, including community outreach and offering the opportunity for other professions to provide their services there;

• Make optimal use of their specialized knowledge of medicines, leading to safer and more effective use…

• Participate in co-ordinated health promotion programmes …

• Develop as a public health resource, by establishing a community-based indicator which records relevant self care data...

• Target the medicines education and advice needs of those who are most at risk from the adverse effects of medication directly or through those who care for them^{46, 47};

… Clearly there is much to gain by exploiting the opportunity that the community pharmacy-public interface presents, to offer health promotion in a care environment.

CONCLUSION:

Our aim is to maintain, develop and support a stable pharmacy network to provide, in partnership with others, a quality and comprehensive pharmaceutical service assuring the safe and effective use of medicines, minimizing barriers to provide equitable health and social care to all. “Community pharmacy will offer an open door to the health service providing upto-date, quality and focused care, based on individual and community need. The community pharmacist will be recognized as the medicines expert working as an integral part of the health and social care team, freely accessible to everyone.” Today the professional role of the community pharmacist is changing from a focus on preparation, dispensing and sale of medications to one in which pharmacist assist the public heath to get the best possible result from medications through patient education, physician consultation, and patient monitoring. The role of community pharmacy is to act in an important and responsible manner for the propagation of national health programmes.The way Indian community pharmacists motivate in safeguarding that the modern medicines consumed have the intended effect will help them attain an appreciable position in the health care system of our country.

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Received on 11.08.2009

Accepted on 12.09.2009

Research Journal of Pharmaceutical Dosage Forms and Technology. 1(2): Sept.-Oct. 2009, 87-93