Article Type : Research Article
Authors : Votta M, Vitale M, Cardillo M and Papavero M
Keywords : Pharmacies; Pharmacists; Patients rights; Civic society; Italy; Covid-19 pandemic; Proximity; Local communities; Digital health; Pharmacy of services
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.
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].
The Civic Evaluation Agency of Cittadinanzattiva prepared a survey, in 2020, aimed at pharmacies and a survey aimed at citizens . 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 .
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).
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” . 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
Having to work
always wearing the PPE
Implementation of the dematerialized
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
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
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)
Relationships with disoriented clients who
in part struggled to adapt to new regulations
Implement consulting on digital platforms
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.
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
Each of the authors confirms that this manuscript has
not been previously published and is not currently under consideration by any
other journal. Additionally, all of the authors have approved the contents of
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NHS: National Health Service; PPE: Personal Protective