Spotlight on Barriers to Pharmacists as Vaccination Providers

Considering not only the imperative of improving vaccination coverage but also the overall evolution of pharmacy as a profession towards a broader role primary health care, health promotion and disease prevention, it seems logical to expand the scope of practice of pharmacists to include a series of vaccine-related roles and particularly the administration of vaccines. 

However, this is an evolution that might not be immediately and universally understood or welcomed by several groups, including other health professions, the public or even some pharmacists themselves. 

Several barriers to pharmacists as vaccination providers have been identified. Counteracting these arguments with evidence of impact is a critical and ongoing activity to ensure pharmacists are accepted as vaccination providers in all settings and all jurisdictions 

The arguments presented below are often without foundation, often not based on fact, or are addressed by the imperative to build a sustainable framework for pharmacist vaccinators, including undergraduate education and ongoing professional development. What is important is to identify the barriers and arguments, compile the evidence and impact of pharmacists as vaccinators and the benefits this brings, so as to advocate effectively. 

Arguments sometimes used against pharmacists gaining vaccination authority 

Arguments used by other healthcare professions 

1. Fragmentation of care 
   1. It would lead to incomplete medical records/incomplete patient history
   2. Health care should be led by general practitioners 
   3. Doctors will have to manage the ill effects of pharmacist vaccination 
   4. It would only shift the demand but not improve vaccination coverage 
2. It would be a lost opportunity for a holistic health care approach by doctors 
3. Vaccination payments sustain general practice services 
4. There is a finite supply of vaccines that would be spread too thinly across vaccination providers 
   1. This would disadvantage patients 
   2. Pharmacists would waste vaccines on healthy people 
5. It is too costly to extend national cold-chain distribution service to pharmacies 
6. Lack of competence of pharmacists: 
   1. Pharmacists are not trained in anatomy or public health 
   2. Pharmacists have no experience in managing anaphylaxis 
   3. Pharmacists cannot provide confidentiality 
   4. There would be no follow-up of patients 
   5. Pharmacists have no such training at undergraduate level 
   6. It is outside the scope of practice of pharmacy 
   7. Theoretical training is no substitute for real-life experience 
   8. The public cannot trust quality or competence in pharmacy 
   9. There would be an increased risk of shoulder injuries from incompetent vaccinators 
7. Inappropriate facilities/lack of privacy in pharmacy 
8. Pharmacies are profit-driven corporations 
   1. Pharmacy is retail, not health care 
   2. Waste of limited supplies on inappropriate patient groups 
9. Vaccination rates are as good as anywhere — pharmacy participation is not necessary 
10. There is no evidence that pharmacist vaccination improves overall coverage

Arguments used by pharmacists 

1. Vaccine administration is outside our scope of practice — pharmacists reluctant to touch patients 
2. Vaccination cannot be integrated into the pharmacy workflows 
3. It would introduce a distraction from core function of dispensing and medicines management services 
4. It is economically unsustainable 
5. It requires too much upfront investment in consultation room, fridge space, training, adrenaline pens etc.. 

Arguments used by the public/media 

1. Vaccines do not work 
2. The urge to improve vaccination coverage is a conspiracy driven by the pharmaceutical industry 
3. The side effects of vaccine are worse than the illness being prevented  

Arguments used to gain and support pharmacy vaccination rights 

1. Health care should be multidisciplinary and interdisciplinary — and have the patient’s best interest at its centre. 
2. There is no “fragmentation of care”, because pharmacies and the location of the premises are an ideal extension of healthcare systems and part of the healthcare team attending to each patient. The important element is that pharmacists have read-and-write access to patients’ immunisation records, as this enables them to record vaccinations and monitor vaccination coverage, and to measure the impact of their services. Also, when pharmacists have access to vaccination records, they can remind patients of their next vaccination needs, even when patients visit the pharmacy for other reasons 
3. Pharmacists are knowledgeable about communicable diseases, vaccines and immunology, and can offer information and education to patients, and actively dispel myths and prejudices against vaccines through evidence-based advice. 
4. Pharmacists are competent to administer vaccines and will only provide the service once they have received certified training for doing so. This includes the management of potential adverse events, such as anaphylaxis. In addition, anaphylaxis is an extremely rare reaction, and some countries where pharmacy-based vaccination has been available for several years have never had a single case of anaphylaxis. 
5. Pharmacists who receive certified training for administering vaccines are at least as competent as other healthcare professionals to deliver this service and manage any potential adverse events. 
6. Pharmacy is a well organised and dynamic profession, and its professional organisations have the capacity to reach out to practitioners, train and certify them, and engage practitioners to adopt this new role. 
7. The role and scope of practice of community pharmacists is increasing to include a number of health promotion, disease prevention and disease state management services, aside from dispensing medicines and ensuring their responsible use. Community pharmacies function as a gateway and an integral part of healthcare systems. Their services contribute to improving the efficiency and sustainability of health systems, namely by preventing the saturation of other parts of the system, such as GP offices and emergency rooms. When necessary, they refer patients to other healthcare professionals or facilities. 
8. Pharmacists are experts in medicines and in conveying advice in lay language and using different communication methods (e.g., oral, written, pictograms, different languages, etc.) 
9. Pharmacists are familiar with the religious and cultural diversity of their communities. They address concerns and beliefs in a respectful manner and even develop materials addressing specific groups in the community. 
10. Pharmacists can organise community reach-out activities and campaigns to inform and advise about vaccines in schools, community centres, workplaces, etc. 
11. Pharmacists are highly trusted professionals, and one of the most accessible health care providers, with widespread presence across territories and convenient opening hours for both working and non-working patients. 
12. Pharmacists are bound by a code of ethics: not only are their priorities to serve the healthcare needs of patients and contribute to the efficiency of health systems, but their professional ethics guide their access to and use of sensitive patient data. 
13. Pharmacies follow good practice standards with regards to their facilities, ensuring patient privacy and appropriate storage conditions for all medicines, including those that require strict cold-chain management. In addition, pharmacies have the infrastructure, equipment and logistics in place to store and handle such products. 
14. In many places, pharmacies are connected via electronic network systems that allow them to receive and access instantly information about vaccines, notifications of quality problems or recalls, shortages of vaccines, etc. 
15. Patients value the ease of access to pharmacies when they need to be vaccinated and informed, and are often willing to pay for the service if it saves queuing, waiting times and taking time off work to visit a health care centre or GP. In addition, people visit a pharmacy far more often than they visit a physician’s office, which offers more opportunities to be reminded about vaccination and actually be vaccinated, and particularly to identify risk group patients. 
16. The high accessibility of community pharmacies is not only about their territorial distribution, but is also about the close relationship they establish with the surrounding community. 

Pharmacy-based vaccination is not a speculative or risky project with no evidence regarding its social value: it exists in at least 36 countries around the world according to FIP data from 2020. Ten respondents (2 from upper-middle income and 8 from high-income countries or territories) reported that the service is reimbursed by public health systems, and five reported the existence of reimbursement by private health systems. In addition, pharmacists play a role as vaccination advocates and educators in at least 34 countries. Enabling legislation to introduce it is being considered in an additional 16 countries.  

Barriers and enablers identified during the Transforming Vaccination Globally and Regionally Series 3 events 

Event 3.1: Regional needs and drivers for transforming vaccination: Europe 

1. Pharmacists are important actors in making vaccines and vaccine information available to the public 

2. Developing vaccination qualifications to make pharmacists competent to administer vaccines is a key factor for transforming vaccination 

3. Best practice sharing can help with bringing about change at national level  

4. Advocating about the advantages that diversifying the provision of immunization services through the involvement of pharmacists can add is an important tool for bringing about change   

5. Collaboration between health care professionals is an enabler that should be utilised  

Event 3.2: Regional needs and drivers for transforming vaccination: South East Asian Region 

1. Identification of needs in the Consideration for transforming vaccination. 

2. Preparedness to rule out COVID-19, planning for COVID-19 vaccine deployment. 

3. The Vaccine Readiness Assessment Tool (VIRAT) transformation to all countries by Ministries of Health with support from WHO and UNICEF. 

4. Immunization through the existing health care system like Hospitals, Dispensaries, Paramedics etc. 

5. Roll out Vaccine cold chain management logistics, well trained human resources by FIP developed training programs. 

6. A proactive healthcare professional, preferably a pharmacist will have a huge impact on the likelihood of a patient to be vaccinated.    

Event 3.3: Regional needs and drivers for transforming vaccination: Eastern Mediterranean 

1. Lobbying decision makers & legislators, including the involvement of international organisations to support the position of local pharmacist organisations.  

2. Creation of guidelines for vaccination by pharmacists, framework for pharmacists’ roles within the health system, and accredited training at the same time as point 1, so that pharmacists are qualified and ready to contribute the moment that legislation catches up.  

3. Inclusion of international organisations – WHO, UNICEF, and FIP – in the process of lobbying decision makers & development of training was a consistent theme.  

4. Addressing opposition from others within the healthcare sector is an important part of removing barriers  

5. Addressing vaccine hesitancy is an important aspect of improving vaccine uptake for all people, and is especially important in areas where reactions to vaccine programmes may be violent.  

Event 3.4: Regional needs and drivers for transforming vaccination: Western Pacific 

1. Advocacy: Support from regional and global agencies is helpful in convincing domestic stakeholders.  

2. Training and certification: Pharmacists have significant relevant knowledge which means additional training to satisfy credentialing as a vaccinator is not excessive.  

3. Legislative issues. This is the impediment that has greatest variability across the Region with each country a unique situation.   

4. Step wise roll out. Once vaccination by pharmacists is approved and initiated, a staged increase in the range of vaccines and the age range of recipients should be applied.  

5. Public and healthcare professionals’ acceptance: Data that shows pharmacist vaccination leads to an increase in the percentage of the population vaccinated can be used to counter the medical profession’s argument that pharmacists are encroaching on their role.  

Event 3.5: Regional needs and drivers for transforming vaccination: Africa 

1. Vaccination by pharmacists is permitted in Kenya, but not permitted in Cameroon nor in Ghana. It is not officially permitted in Algeria though practiced by some community pharmacists. 

2. Importance of advocacy to politicians, other healthcare professionals and stakeholders on the added value of pharmacists in vaccination coverage  

3. Importance of education to empower pharmacists as accountable 

4. Vaccination by pharmacists must be legislatively recognised and financially compensated to be sustainable.  

Event 3.5: Regional needs and drivers for transforming vaccination: The Americas 

1. In a country where immunization services have been introduced in community pharmacies, the contribution to improve the vaccination rates of non-obligatory vaccines have been achieved (like flu vaccine). 

2. Pharmacist must be in the pharmacy, with suitable training (both at graduate or continuous education level) 

3. Several countries expressed the importance of moving move forward to introduce immunization services in community pharmacies 

4. To introduce immunization services requires a legislative framework, training opportunities for the pharmacist and technical requirements for the pharmacy (patient records and keeping the cold chain suitable). 

5. It is important to learn/know international experiences of immunization services in community pharmacies, and how these could be transferred to local needs.