Relationship of culture and changing structure of pharmacy in a central-eastern European country, Hungary

RELATIONSHIP OF CULTURE AND CHANGING STRUCTURE OF PHARMACY IN A CENTRAL-EASTERN EUROPEAN COUNTRY, HUNGARY 1990. - 2007. dr. Szabolcs Dobson – dr. István Grabarits 1. Introducing Hungary Hungary is situated in Central-Eastern Europe. Its territory is about 93,000 km 2 , the size of population is slightly more than 10 million. The national language is Hungarian, a Finno-Ugrian language having in the EU two far relatives, the Estonian and the Finnish. The country is relatively evenly and densely populated unlike e.g. Norway. Therefore distribution of medicines has no geographical problems. Hungary became a member of the EU in 2004 along with Poland, the Czech Republic, Slovakia and Slovenia. The per capita GDP is about 60% of the EU average. The number of community pharmacies is about 2,100 in which about 4,700 pharmacists work along with more than 6000 pharmacy technicians. 2. Pharmacy as an academic profession in Hungary Until 1940 Hungarian pharmacists made a tyrocinal examination after which they continued their education with a 2-year-long university study. However, from 1940 university education became 4-year-long. From that year on pharmacy became a real intellectual, academic profession. From 1991 the university education is 5-year-long. Currently annually about 220 young pharmacists graduate in 4 medical universities. 3. Professional life in the socialist era In the 2. World War Hungarian pharmacies suffered heavy material damages. In the post-war period the country and the pharmacy network were relatively quickly rebuilt and the main pre-war professional associations, the Hungarian Pharmacists’ Association and the Hungarian Society for Pharmaceutical Sciences reorganized (but both were banned in 1949). A new chapter began in 1950 when the nationalization of pharmacies took place. State-owned pharmacy chains were created on a territorial basis (in each county plus the capital) and the former owners became subordinates. The coming decades were hallmarked by socialist economic and political principles. Even at the end of the socialist period, slightly more than 800 medicinal products were registered and a so called selective registration policy was in place in order to prevent overdependence on the West and due to protection of the home industry and cost-saving. At the same time compounding or magistral drug preparation was much more significant in some therapeutic areas then now. From this point of view socialism in a certain meaning of the word partially conserved the old drug-making traditions and mission of pharmacy. In this era, the Hungarian Society for Pharmaceutical Sciences (which was re-established in 1966 as an independent professional mass organization) was the one and only legal professional body uniting pharmacists working at universities, in community pharmacies, drug industry and hospital pharmacies, represented pharmacy to the state, organized continuing training courses and developed professional culture. 4. Political-economical transition to democracy and market economy In the socialist countries a radical political-economic transition started in 1989-1990 to democracy and market economy. The political system became basically identical to that of the traditional Western democracies. Along the transitory but significant economic decline and transformation, civil liberties, like freedom of speech, freedom of press, right to hold public meetings, etc) were restored. In 1989 the Hungarian Chamber of Pharmacy and in 1991 the Association of Independent Pharmacists (the biggest pharmacy owners’ association) were established and the Hungarian Society for Pharmaceutical Sciences continued to exist. Besides the opening of newly established pharmacies, in 1994 the privatization of pharmacies took place. The state-owned pharmacy chains disappeared and the privately-owned community pharmacy system was built on a legal basis similar to the one in place in Austria. 5. Professional culture in the socialist era The professional culture changed and developed in a controversial way. During nationalization in 1950 many valuable items (books/whole libraries, pieces of furniture, working tools) have been annihilated, stolen or simply thrown away. Pre-war professional organizations were banned. However, from 1950 the first ever Hungarian pharmaceutical continuing educational book serial was launched and from 1948 a continuing educational professional journal was published. A professional contest was established for young pharmacists which exists in our time, too. Continuing educational conferences and meetings were regularly organized. A postgraduate education system was instituted for specialisation, an analogue of the system for doctors. Many pharmacists made a scientific carrier. However, as the dynamics of book publication activity shows, development of pharmacy was more and more stagnant. Pharmacy was frozen in a basically chemistry and drug technology orientation and new trends like pharmaceutical care, patient-oriented pharmacy, patient education, although sporadically existed, could not develop). 6. Professional culture between 1990 – 2006 Privatization created a new situation in professional culture. On the one hand a new, wealthy layer of pharmacists was born who looked with the owner’s eyes on their pharmacies. This resulted in a huge development of material culture as can be seen in this photo of a pharmacy in the countryside before and after privatization. From the mid 1990s patient information journals were distributed in pharmacies after a new advertisement law made it possible to advertise OTC products for the public. Professional book publication activity increased. Many professional journals started. Each main professional organization has its own journal(s) (and now, of course, websites). A credit point-based continuing education system was established. Pharmaceutical companies and wholesalers became major sponsors of professional culture. Pharmaceutical care became a hot topic and from 2005 pilot pharmaceutical care studies started. Pharmacy has gradually transformed from product-oriented to patient and biomedicine-oriented and this re-orientation process was mirrored by the changing contents of the books. Taken together, this period, from 1994 to 2006 was the era the most significant development of pharmaceutical culture in Hungary ever. 7. Main factors determining (pharmaceutical ) culture - National language (big language/small language, language of one or more countries) - Size of the market (size of the population, number of pharmacies), ownership structure (market share of pharmacy chains, proportion of independent pharmacies) - Financial situation of the target group - Trends in and intensity of professional interest. About 20% of Hungarian pharmacies ordered any professional book between 2000 – 2005 which means 400 – 500 copies on average for every title. Consequently: - The national language and the size of the market are big enough to have some (although not very extended) pharmaceutical book publishing activity, but are not enough to publish specialised books, like e.g. chronopharmacology. - Furthermore, they are not enough to maintain profitable business with publishing houses specializing mainly on pharmacy. - The above problems are often bridged by sponsors. 8. Possible causes of low cultural interest - Pharmacy owners are mostly not engaged in professional activities in the narrow meaning of the word. Subordinates rarely buy books/journals and are not necessarily motivated in selfeducation - Sales margin has been reduced from about 25% in 1995 to about 17% in 2006 - There is no close relationship between financial success of the pharmacy and cultural level of the pharmacy staff - Basic questions: What is pharmacy? A shop or a healthcare institution? What is pharmacist? A salesperson or a healthcare professional? What is the individual coming to pharmacy? A patient, a customer or a consumer? - In many pharmacies technicians fulfil almost the same roles as pharmacists (e.g. contact with patients) - Cultural needs of pharmacists might be satisfied by credit point training courses - Contents of books and journals are not relevant enough to the everyday work - There is no real and generally acknowledged intellectual mission in community pharmacy. Pharmacists graduate as over-educated and work as intellectually underemployed. Pharmaceutical care still does not fulfil the role of a general mission. Will anything, anytime be a professional mission in community pharmacy? 9. 2006: liberalization of pharmacy From the autumn of 2006 a liberalization process started in Hungary: - Mandatory membership of the Chambers of Pharmacists and Doctors has been cancelled - Rules on establishment of new pharmacies were liberalized (regulations loosened) - Pharmacy chains can be organized - OTC drug sales outside pharmacies became legal Currently the cultural interest of pharmacists (membership in associations, book and journal sales and attendance of conferences) plummeted compared to the previous period. The political weight of professional associations is reduced. Due to economic and existential uncertainties no favourable change can be expected in the coming years. The question is that what will be the position of pharmacy chains in professional culture (organisation and financial support)? Finally, the most important question is: will there be anytime an everyday professional mission in community pharmacy which can serve as a compass and engine for development?