Malaysia's Healthcare System Under The Covid-19 Pandemic

There are numerous pharmacy related topics for presentation and further exploration, ranging from medication safety and pharmaceutical advancements to pharmacy ethics and patient counseling. However, for my personal study I chose to analyse the system of Malaysia's healthcare system before and during the COVID-19 pandemic. 

In December 2019, SARS CoV-2, which stands for severe acute respiratory syndrome coronavirus 2, a newly contagious zoonotic illness began to spread from China to neighbouring nations. This infection mostly transmitted by person-to-person through respiratory droplets created by exhalation during breathing, sneezing, coughing, or even speaking. After a few months, the illness's worldwide expansion had approached 100 nations, prompting the WHO to categorize the sickness as a pandemic. One of the first preventive steps taken by several governments throughout the world was the entire shutdown of cities, often known as lockdown. The lockdown is predicted to minimize COVID-19 transmission, resulting in fewer new cases, hospital admissions, intensive care unit admissions, and maybe a lower fatality rate. The COVID-19 pandemic management and outbreak control would be incomplete without the participation of pharmacists. The International Pharmaceutical Federation (FIP) emphasized the critical role that pharmacists must play throughout the epidemic by publishing several guidelines about instructions and information concerning COVID-19 outbreaks.

Malaysia's healthcare system is divided into two tiers: public and private. Everyone has access to the public system, meanwhile the private system mostly serves the metropolitan population and those with the financial resources to pay for healthcare. The Ministry of Health (MOH), the Ministry of Higher Education (MOHE), or the Ministry of Defence are in charge of government-run healthcare institutions (MOD). Hospital pharmacy is a subset of pharmacy that is integrated into the care of a medical facility including hospitals, outpatient clinics, poison control centres, drug information centres, and residential care facilities. Hospital pharmacy is referred to a health care service that includes the art, practice and profession of selecting, preparing, storing, compounding and dispensing medicines and medical devices. The profession also involves advising patients and other healthcare professionals on the safe, effective and efficient use of medicines. To provide different set of services in an efficient manner, the pharmacy department in a hospital can be split into three broad sections: inpatient pharmacy, outpatient pharmacy, and medical store.

Malaysia's Healthcare System Before COVID-19 Pandemic

Supply chain management comprises material selection and supplier selection, purchase, reception, control, and organization of materials in stock, storage, dispensing, and assistance to the target public. All actions linked to drug management and supply chain must be carried out in accordance with established rules and best practices, with only certified and professional personnel involved. For greater compliance with current standards, facility-specific policies and procedures including SOPs should be designed and followed. When medications are delivered from the supplier, pharmacists are subjected to acceptance testing to ensure they does not get low-quality items. If there are any error in the distribution of medicines and devices, it can make serious problems to hospital and patients.

Inpatient pharmacy services primary function is to deliver drugs to warded patients using a variety of mechanisms. The example of inpatient pharmacy services is parenteral nutrition, extemporaneous preparations, cytotoxic drug reconstitution and drug information services. The duty of hospital pharmacist is to recommend and dispense individualized drug administration methods and doses. Hospital pharmacists can provide information on potential adverse effects and ensure that medications are compatible with other medications. They will frequently observe the effects of treatments to ensure that they are effective, safe, and appropriate for the user. Because hospital pharmacists must collaborate closely with other members of staff such as physicians, nurses, and dieticians, information must be communicated in a clear and understandable manner. To avoid any confusion, medication charts serve as an important source of information and an effective means of communication between hospital pharmacists and other members of the medical team. Next, they should keep track of which patients are being discharged and to review the discharge report. This necessitates the pharmacist inspecting the patient's drug file to check that the prescription dispensed corresponds to the medication listed in the discharge statement. 

The out-patient pharmacy's primary function is to provide drugs to discharged in-patients or out-patients who visit a doctor at the hospital clinics. The primary strategy entails having patients to physically come and get their drugs on a monthly basis. The length of a pharmacy session may vary depending on the hospital, since it is determined by the stock of pharmaceuticals offered to patients at each visit. There are also a variety of value-added service (VAS) mechanisms available for refilling prescription drugs such as drive-through pharmacies. However, VAS is not available at most hospital and may vary depending on the appropriateness and the patients' medications. For example, not all pharmaceuticals, particularly cold-chain and liquid dose medications, can be transported by courier services. In addition, it offers medication counselling which includes everything that happens during a medication review. Meanwhile, the drug information center is available to respond to questions from healthcare providers and the general public, developing guidelines, conducting pharmacy and therapeutic committee activities, educational activities, conducting studies and reporting adverse drug reactions. 

Malaysia's Healthcare System During COVID-19 Pandemic

During the COVID-19 pandemic, the supply chain management is critical which need continuous monitoring. The hospital’s pharmaceutical and medical logistics pharmacist at the medical store should facilitates the purchase of protective gear to protect healthcare professionals, such as personal protective equipment (PPE), medical disposables, hand sanitizers and others. The PPE includes Tyvek suits, 3-ply surgical or medical masks (ear loop or tie on), respirator masks (medical or particulate), medical cap, head cover, face shield, googles, plastic aprons, surgicalisolation gowns, disposable gloves, leg covers, shoe covers and waterproof boots. There was a global scarcity of PPE during the first wave of COVID-19 in Malaysia, so PPEs sewed by healthcare personnel and non-governmental groups are donated to hospital and evaluated by pharmacists to confirm the quality. Furthermore, a PPE tracker—an online spreadsheet is used to update their daily PPE balance. The pharmacist may also stock up on alcohol-based hand sanitizers. Self-production in large quantities is done to alleviate shortages, meet rising demand, and cut costs. Additionally, the lockdown imposed on the majority of countries has made it difficult for pharmacy departments to get medical supplies especially drugs for the treatment of COVID-19. Hence, pharmacists should update details of daily drug consumption and maintain continual contact with state pharmacy departments to procure medicinal supplies for routine usage in their hospitals. Commencing in April 2020, Pharmacy Information Systems (PhIs) is used for the reporting and monitoring of daily stock balance status at MOH sites because majority of COVID-19 medicines and antivirals were used off-label, including hydroxychloroquine (Plaquenil), azithromycin (Zithromax) and so on. 

To minimize overcrowding and medication refill time, changes were made to outpatient pharmacy services. Pharmacy value-added services (VAS) are implemented where patients may collect their medications through the Pharmacy counter appointment-based system, Medicines by Post, Drive-through Pharmacy (Farmasi Pandu Lalu), Locker4U, and the Integrated Drug Dispensing System (IDDS). However, pharmacist will analyse the case before dispensing medication using VAS. When there are changes in pharmacotherapy, patients are still advised to visit the pharmacy for a scheduled medication collection and counselling. Instead of receiving a one- or two-month supply of drugs, patients are given three months' worth of medication to reduce the number of trips required. The patients' waiting area has been adjusted to meet the physical distancing standard (1 m), and pharmacists working at the counter must wear a face shield over a surgical mask and keep a safe distance from patients. 

The inpatient pharmacy services are carried out as usual but with extra precautions method. This involves sanitising their work spaces on a daily basis, wearing PPE, and rotating danger leaves to reduce contact. Meanwhile, other strategy likes use of PhIS allows for online prescriptions, drug supply, medication administration, and counselling recording. The medication distribution technique was altered from a unit-of-dose to a unit-of-use system, and the frequency of medicine delivery was lowered from daily to three times per week. Medication is delivered to wards through a cleaned work space, and unused drugs are decontaminated with a 70% alcohol solution. Besides, quarantine units should be available even if a hospital is not treating COVID-19 patients. The in-patient pharmacy staff must guarantee that these wards receive enough pharmaceutical supply and maintain minimum exposure between ward staff and pharmacy team. All COVID-19 wards have been denied medicine administration through a medication trolley. Instead, all prescriptions are placed in a single-use plastic zipper bag containing a one-week supply of orally given drugs and a three-day supply of injectable meds for each patient.

Case conversations between pharmacists and physicians, which were formerly done at the bedside, are now held away from patient cubicles to limit interaction time with patients. Ward pharmacists have taken the initiative to provide COVID-19 patients with remote pharmaceutical care by examining medication records via the PhIS. If any pharmaceutical-related difficulties are recognised, interventions are carried out by interacting with prescribers in the wards by phone call, video conference, and messaging via WhatsApp. On the other hand, clinical pharmacists will participate in weekly online talks with other healthcare providers where patient cases are summarised, discussed, and intervention is provided as needed. Pharmaceutical care concerns including medication therapy, dose, length of treatment, results, and adverse drug reactions connected to COVID-19 patients are submitted by clinical pharmacists to the PhIs to update Malaysia's COVID-19 management standards. Next, videos and QR codes with connections to instructive e-pamphlets were created as part of the e-counseling resources. Phone and video call therapy were also used to assure the continuation of critical therapeutic services while also ensuring the safety of both patients and pharmacy workers.

Conclusion

When administering any medicine, it is critical to ensure that the appropriate patient, dose, method of administration, time, drug, information, and paperwork are followed. The hospital pharmacist's role is broad and may entail a variety of responsibilities such as creating drug regimens that are tailored to the needs of each patient, assisting health care providers in making drug-related choices, compounding drugs for hospital usage and educating people about their medications and how to use them. They also need to plan and administer all sourcing and procurement, conversion, and healthcare-related logistics management tasks. It is also important to coordinate and collaborate with channel partners, which might include suppliers, middlemen, third-party service providers, and customers. When hospital was designated as a COVID hospital, pharmacists need to adjust their daily routines to better serve the pharmacy department and the hospital as a whole. Pharmacists must modify their routine to adjust to the 'new norm' way of life by avoiding 3Cs (crowded locations, confined areas, and close talk) and practicing 3Ws (wash, wear and warn). Some of the problems they faced were staggered working hours to ensure social distance is practiced, limited evaluation of patients in the ward with no participation in clinical rounds with the physicians, insufficient evidence for COVID-19 therapy and medication delivery and charting accuracy in the wards.