The Role of the Pharmacies and Their Relationship with Citizens during the Covid-19 Emergency: The Italian Case History Download PDF

Journal Name : Suntext Review of Case Reports & Images

DOI : 10.51737/2766-4589.2021.027

Article Type : Research Article

Authors : Votta M1,*, Vitale M2, Cardillo M3 and Papavero M4

Keywords : Pharmacies; Pharmacists; Patients rights; Civic society; Italy; Covid-19 pandemic; Proximity; Local communities; Digital health; Pharmacy of services

Abstract

The Third Edition of the Annual Report on Pharmacy was born during the very particular context that we are all experiencing: the Covid-19 pandemic is putting a strain on healthcare systems worldwide, overburdening healthcare facilities and healthcare professionals, including pharmacists, who have been in the frontline against Covid-19, especially during the first and most critical phase of the emergency, which is the period taken into consideration by this Report realized by the Italian NGO Cittadinanzattiva [1,2]. What were the main critical issues that pharmacies had to face and overcome? How was their relationship with citizens shaped? What actions were implemented by pharmacies in order to guarantee protection and safety to both operators and clients? How promptly did they adapt to the numerous measures, and how did they manage - and before that suffer - the issue of the shortage of masks? In answering these and other questions, the 2020 edition of the Report offers a cross-section of the difficulties encountered in Italy both by pharmacies engaged in providing for an essential service in extremely critical operating conditions, and by citizens themselves in accessing and using the services provided in pharmacies. But also - and above all - the Report highlights the extraordinary ability demonstrated once again by pharmacies of being an irreplaceable garrison of proximity able to respond to the social and health needs of citizens.


Introduction

The Covid-19 pandemic has severely challenged the national, regional and local organizational systems all over the world, and has upset the usual processes of healthcare facilities, including community pharmacies, which have been - and continue to be – in the frontline against Covid-19, like all other healthcare professionals, and perhaps more exposed than others due to their diffusion on the territory and the high degree of proximity with citizens in the performance of daily activities that did not cease even in the first and most critical emergency phase. In light of this context, the Third Annual Report on Pharmacy entitled "The role of pharmacies and their relationship with citizens in the Covid-19 emergency" and coordinated by Cittadinanzattiva's Civic Evaluation Agency in collaboration with Federfarma and with the unconditional contribution of Teva, shows both the positive and negative sides of the health and social role played by pharmacies in responding to the needs of citizens and local communities in the context of the Covid-19 emergency. The aim of this article is to present the data emerged from the Report, which is the result of a survey addressed to pharmacies and one addressed to citizens, carried out between July and October 2020 [3,4].


Materials and Methods

The Civic Evaluation Agency of Cittadinanzattiva prepared a survey, in 2020, aimed at pharmacies and a survey aimed at citizens [5]. Data collection began at the end of July 2020 and ended in mid-October 2020. The 633 pharmacies that contributed to the annual survey are mainly located in northern Italy, in fact, 56% of the answers come from only 4 regions: Piemonte, Emilia Romagna, Lombardia, Veneto; while the territories of Trentino Alto Adige, Abruzzo, Molise and Val d’Aosta are scarcely represented. Almost 40% of the pharmacies involved are located in a subsidized rural or rural area, 17.4% within an area declared red during the pandemic. Moreover, half of the responses come from pharmacies that participated for the first time in 2020 to the Report on Pharmacy drawn up by Cittadinanzattiva, compared to a 37.9% of “loyalists” who instead have participated since its first edition. Finally, it is not to neglect that 56.7% of the pharmacies, involved or close to being involved in the Experimentation of the Pharmacy of the Services, stand out from the survey. The origin of the 664 citizens who responded to the survey results to be more balanced, compared to the data related to pharmacies, since the most represented regions are, in order, Campania, Lombardia, Piemonte, and Lazio. Among the poorly represented territories, we find again Valle d’Aosta, Trentino Alto Adige and Molise, followed by Basilicata. Most of the respondents are women (56.5%), while the most represented age groups are 51-63 years (30%), followed by 64-74 years (28.6%) and 31-50 years (24.5%). Basically, in 80% of cases, the citizens who responded come from non-rural and not declared red areas during the emergency (Figure 1).


Figure 1: The number of pharmacies and citizens involved in the two surveys. Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020.

The collected data does not claim to represent a scientifically representative statistical sample; however, this does not reduce the value of the monitoring and analysis process carried out. In fact, the survey itself can be considered indicative of the most relevant issues among those under investigation, and sufficient to develop proposals aimed at strengthening the role of the Pharmacy in its ability to respond to the social and health needs of citizens in the context of the Covid-19 emergency. For more details on the project, please refer to the relevant webpage [6].


Results

The survey addressed to citizens reveals how during the pandemic, even among the various difficulties due to contingency, the pharmacy was perceived as a "safe" place where to find useful information to deal with the health emergency. More than one citizen out of four has turned to their pharmacist for guidance on how to behave in case of possible symptoms of Covid-19. Instead, one citizen out of ten has fallen into the trap of fake news but has received useful information from their pharmacist on how to "unmask" them. Moreover, pharmacies have strengthened their home delivery and booking services for medicines, and, despite many difficulties, have been active in ensuring the availability of all the products needed by the population. Numerous criticisms, however, were also present. Some pharmacies (10.4% of the sample), often the smallest ones, located in areas where there have been greater inconveniences due to the high number of infections, were obliged to work with "closed doors" to ensure the safety of users, while still dispensing medicines and health products through a counter. Some were forced to cut services due to the emergency: 15.6% of pharmacies have suspended screening, 8.8% basic diagnostic tests/examinations, 7.9% services provided in the pharmacy by other health professionals. Still, the restricted access to pharmacies, in 63% of cases was not perceived by citizens as an additional difficulty in the context of the health emergency. On the other hand, 24,5% of the respondents argued that the new working hours and the “closed doors” function had repercussions, especially in terms of the services offered in the pharmacy. These access difficulties gradually decreased as the emergency phase has progressed, though they have not disappeared completely (for 27.2% of citizens) even in the post-lockdown period (Figure 2).

Figure 2: The graph shows the percentage of individuals who expressed themselves on the difficulty of accessing pharmacies in the lockdown and post-lockdown period along 2020. Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020.

Finally, citizens have highlighted also how, during phase one of the emergency, 90% of pharmacies had difficulty in procuring masks, 86% of them in providing for thermometers, saturation meters and alcohol, 73% reported shortages of disinfectant gel and 66% of gloves. Furthermore, 44.4% of citizens, in the first phase, struggled to find in pharmacies masks at reduced and fixed prices. The survey addressed to pharmacies shows instead the other side of the coin. There is an almost unanimous awareness among pharmacists that the pandemic has inevitably pushed the sector to supply responses to citizens’ needs, first of all of a social nature, and then also of a health nature. This fact finds substantial confirmation in the majority (56.8%) of the individuals who responded to the survey, who recognize that pharmacies have played, during the pandemic, both a health role, as a protection of the National Health Service (NHS), and a social role, as a point of reference for citizens and communities. That being said, only a third of pharmacists (34.3%) think that their role in the area during the emergency has been adequately recognized by institutions, while all the others are somewhat disillusioned in this regard, also showing some frustration. 

Figure 3: The graph shows the usefulness of pharmacies in providing for different services during the first phase of the pandemic. Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020.

On the contrary, the usefulness of the pharmacy is mostly consolidated in people’s perception: in providing advice/information (86.3% of citizens expressed themselves), in guiding at health facilities (71%), even in the observation of suspicious cases (59.2%), as well as for the more traditional activities of galenic production (63.9%) and of home delivery of medicines (78.3%). The positive side is that the pandemic still allowed the consolidation of agreements and collaboration between pharmacies and institutions (26.5%), civic/patient organizations (24.6%), private actors (11.1%) and other sector stakeholders (12.6%) (Figure 3).



Discussion and Conclusion

Cittadinanzattiva’s recommendations focus on expanding the services provided by pharmacies to enable them to act as a point of reference for the community and to improve their relationship with citizens. These are in line with the general recommendations put forward by the Pharmaceutical Group of the European Union in their “Position Paper on the Role of Community Pharmacists in COVID-19” [7]. The Paper highlights the need to call on governments to make health systems stronger and more responsive to patients’ needs by: expanding the role of pharmacies to ensure continuity of care and treatments; defining new models of care delivery with the support of integrated digital technology to treat patients as close to their home as possible; recognizing the value of pharmacies, that have been often the first line of advice, treatment, and referral during the Covid-19 emergency for many people both at the national and European level; and increasing investments in primary care. In Italy, the pandemic has particularly highlighted the fragility of an unbalanced system in the hospital field compared to territorial care, whose strengthening can no longer be postponed, starting with new organizational models to which we are all called to contribute. In this regard, focusing on the Italian case history, Cittadinanzattiva and Federfarma share the need - on one side - to implement definitively a planned but still not put into force arrangement (the so-called “Pharmacy of Services”) and - on the other side - to trace and carry out new scenarios for our NHS. For the first area, despite the difficulties that still characterize the operational context, it is important to restart the experimentation of the “Pharmacy of Services”, beginning from training courses necessary to allow pharmacies to provide for additional services of considerable social and health importance, especially in favour of the most vulnerable patients and with the aim of overcoming the inequalities heightened by the pandemic. This is the case of telemedicine services, of monitoring and support activities direct towards chronic patients, also in teleconsultation mode, and of prevention screenings, which must still be guaranteed to ensure an adequate level of protection of collective health. These are, therefore, services that cannot be separated from the implementation of the Electronic Health Record and, more generally, from investments for digital development. Concerning the new scenarios aimed at strengthening territorial assistance to support the needs of citizens and the NHS itself also during the pandemic, two main areas of intervention can be traced. Concerning the first area, as emerged by the Report, the vast majority of pharmacists (82.9%) agree upon the need of codifying new procedures for the ordinary management of activities. In particular, they refer to protocols for sanitation, cleanliness, aeration, and air-conditioning of spaces. More generally, in making an initial assessment of the impact of the pandemic on their businesses, pharmacies report that they had to face a series of difficulties and seize various opportunities for a restart (Table 1).

Table 1: The table points out to 10 difficulties and 10 opportunities the pharmacies had to – respectively – face and seize due to the Covid-19 pandemic. Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020.

The impact of the Covid-19 pandemic on the activities and services of pharmacies

10 difficulties

10 opportunities

Having to work always wearing the PPE

 Implementation of the dematerialized prescription

Having to ensure safety, for both operators and clients, even with limited space.

 Increasing the range of services offered for a definitive establishment of the community pharmacy

 Having to continuously adapt to new regulations and norms

Invest in digital services/telemedicine

 Continuous sanitation of all spaces

 Adapt operational and safety protocols

 Massive use of dematerialized prescriptions and, more in general, digital management

 Open up to the possibility of being involved in the administration of vaccines and rapid swabs

 Personnel Management

 Expand the ability of pharmacies to distribute medicines normally provided directly by public structures

 Procurement of PPE, especially if outside of the traditional distribution channels

 Affirm the role of the pharmacist on the topic of health education (for chronic patients and therapeutic adherence)

 Economic difficulties (drop in turnover)

Re-evaluation of galenic production

 Relationships with disoriented clients who in part struggled to adapt to new regulations

 Implement consulting on digital platforms and channels

 Sense of abandonment by Institutions

 Optimize home delivery of medicines

Among these, the expansion of the range of medicines provided by pharmacies following the transfer to this distribution channel of a share of the medicines that are normally provided directly by public structures, must be improved. This process started during the first phase of the health emergency, but only in a patchy way in the territory. Thus, it is necessary to accelerate the rhythm to facilitate citizens’ access to medicines, thanks to the proximity of the pharmacy, in order to reduce travel and gatherings in public health facilities. The second area of intervention is instead related to the active role of pharmacies in opposing the spread of Covid-19, with particular reference to the possibility of carrying out serological testing and rapid swabs in the pharmacy or through the pharmacy, also in the sight of interesting local experiences that could embrace the entire national territory, in order to lighten the organizational burdens depending on public structures, obviously guaranteeing the highest levels of security through specific protocols. The results and proposals put forward by the third edition of the “Annual Pharmacy Report” act as a useful public policy tool in showing the commitment insured in Italy by pharmacies during the health emergency generated by the Covid-19 pandemic. In this context, the fundamental objectives of the pharmacy network in our country were two: to ensure the safe supply of all medicines and essential health products to the population, in conditions of security for both citizens and healthcare workers; and to perform a function of support and orientation to the population also in response to the difficulties on the part of other public health centres to give adequate answers to the demand for health issues other than the Covid-19 emergency. These actions contributed to improving the relationship between the pharmacy and the citizen, in a perspective of mutual trust, exchange and collaboration, as well as enhancing good practices related to the role of the pharmacy as a reliable health center on the territory for citizens and communities.



Acknowledgement

All data shown in the present article comes from a broader civic survey, summarized in the “Third Edition of the Annual Report on Pharmacies”, realized in Italy during 2020 by the Civic Evaluation Agency of Cittadinanzattiva with the collaboration of Federfarma and Teva’s unconditional contribution [8].


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Abbreviations

NHS: National Health Service; PPE: Personal Protective Equipment.


References

  1. The role of pharmacies and their relationship with citizens in the Covid-19 emergency. Third Annual Report on Pharmacy.
  2. Cittadinanzattiva APS. Italian civic organization founded in Italy in 1978 and also active at the EU level since 2001 through its EU branch called Active Citizenship.
  3. Third Annual Report on Pharmacy in the time of the Covid-19 pandemic presented. The role of pharmacies and their relationship with citizens in the Covid-19 emergency.
  4. Federfarma, e la Federazione nazionale che rappresenta le oltre 18.000 farmacie private convenzionate con il Servizio sanitario nazionale in Italia.
  5. Cittadinanzattiva APS: Civic Evaluation Agency.
  6. Cittadinanzattiva APS: Third Annual Report on Pharmacy as a health center on the territory.
  7. Position Paper on the Role of Community Pharmacists in COVID-19 – Lessons Learned from the Pandemic, Pharmaceutical Group of the European Union: Position-Paper-on-on-the-Lessons-Learned-from-COVID-19.
  8. Third Annual Report on Pharmacy: The role of pharmacies and their relationship with citizens in the Covid-19 emergency.