Community pharmacies have quite a distinct and unique position in healthcare delivery system as they are the first and/or final contacts between patients and drugs in majority of cases [1]. This importance is augmented by their large extent and magnitude of operations, serving to millions of patients every day. However, an important fact to consider is that these outlets are working mainly as business entities and not as healthcare providers. All over the world, community pharmacies act on a business model but they are regulated by health laws. The problems lie in ambiguity in laws and their implementation, not in pharmacies being run as a profit oriented profession. [2]. Inherent with their unique characteristics, many irrational drug use problems have cropped up at these outlets, including self medication, antibiotic prescribing, inappropriate use of antidiarrheals and steroids, sale of less than prescribed quantity of drugs specially antibiotics and poor drug storage practices. Other common problems include limited counselling, attempts to diagnose and treat almost all conditions despite having no expertise. This problem is compounded by the confidence with which they execute this process for the multitude of patients [3]. The people who are dealing with these patients are normally pharmacy assistants, dispensers and those with lower secondary school qualifications and no formal training [1,3-5]. However, they feel confident while dealing with patients and patients also show trust on their suggestions and seek medical advice directly from these community pharmacies because they are faster and less expensive than the physicians’ [4].

The professional services and activities of the pharmacist have considerably evolved in the last decades. Today, the main health-related activity of a pharmacist is to ensure quality of dispensing [6]. The role of pharmacists in dispensing medicines is very important and all the resources involved in patients care, up to the point of dispensing, may be wasted if dispensing is erroneous. World Health Organization, (1988) recognizes and advocates the role of pharmacist as ‘seven star pharmacist’ who is a care giver, decision maker, communicator, leader, manager, lifelong learner and a teacher. Thus putting him/her in a unique position in health care system for performing these roles [7].

The role of pharmacist is usually laid down in the drug laws of a particular country, thus making it possible for the community to get lawful benefit of the pharmacist’s presence in health care system. The pharmacist is required to procure good quality medicines from the right source, store them as per their specifications, dispense them in a lawful and professional manner when required, communicate vertically with the physicians and ensure that the patient uses his medications as per advise and monitor their therapy [6].

Currently, the professional role of pharmacist in hospitals and community pharmacies is switching from dispensing and sale of drugs, to patient counselling globally [8]. Two states North Dakota and Florida in USA, allowed independent prescribing to pharmacists [9]. Pharmacists were included in primary care services in Scotland, to promote access to services[10]. Pharmacists are switching from supply and distribution to medicines management services in New Zealand, United Kingdom and Australia. Pharmacists are looking forward to prescribe medicines independently in UK [11]. Major reforms of separation of drug prescribing and dispensing, according to which the physicians and the pharmacists both can prescribe and dispense drugs were implemented in Korea [12].

In developing countries, due to lack of qualified personnel, direct access to pharmacists in all the areas is not possible. Thus, the quality of pharmaceutical services in a given region becomes dependent on the availability of a pharmacist. It is a well known fact that the conditions of pharmacy practice differ among countries and also vary between different areas within the same country. This is due to the number of pharmacists being lower than required. The direct supervision of pharmaceutical products by the pharmacist can be beneficial in ensuring the provision of high quality services to the patients [13]. There is a wide variation in dispensing time from a minimum of 20.5 seconds to a maximum of 222 seconds, being significantly longer in private than in public pharmacies [14-17]. Many dispensing workflow procedures are not consistently followed by all pharmacy employees. Poor dispensing practices are manifested by errors occurring in the transcription stage, incomplete dispensing, lack of proper counselling about drugs sold, drugs not being labeled and different drugs being mixed in the same package [1,17-22]. Drug sellers often fail to adequately counsell their customers in certain settings and no counselling is provided at all [18,23-28]. Customers are rarely informed about the precautionary measures and adverse effects of the drug [29-32], thus pharmacies are being underutilised with respect to their capacity to deliver health promotion advice.

Regulations regarding prescription drugs are generally not respected in developing countries, and one of the most worrisome issues concerning irrational drug use is the free availability of over-the-counter drugs [33,34]. The problem of dispensing POM drugs as OTC, in many countries, has been highlighted. Drug sellers not only prescribe and dispense drugs to their customers but also they do it with great confidence [25,26,35-42]. The appropriateness of prescribing by dispensers or self-medication by patients is far from acceptable [34]. Dispensers hardly ask questions about the illness, and historical information obtained is inadequate to determine the nature or severity of disease or appropriateness of therapy [3,4,26,28,32,37].

Majority of the customers visiting pharmacies seek care for ARI, fever, pains and diarrhea. Other conditions for which customers seek care at pharmacies and drug stores include loss of appetite, dyspepsia, rashes, wounds, hookworm, emergency contraception, STDs, skin infections (scabies), eye and earache [43]. The quality of case-management in the retail sector leaves much room for improvement and depends on the knowledge and the manner in which private drug sellers treat their customers [44,45]. Pharmacy employees dispense a wide variety of drugs, ranging from simple OTC drugs, NSAIDs, antibiotics and steroids, usually in small doses [46-49] and they, at times, administer injections to patients in their retail outlets [44]. The findings of studies show that the dispensers attend to their customers and provide treatments with a friendly attitude, but most of them prescribe ineffective, inappropriate, and dangerous drugs, in inadequate dosages with little or no counselling. Such practices were observed for diarrhea [4,25,38,40,50-53], ARI [43,46,48,52], malaria [29,42-44,49,52,54], back pain [39,47], and STDs [27,47,55,56]. It is surprising that the patterns of drug sellers’ prescribing mimics the prescribing trends of GPs much more closely than the doctors prescribing in hospitals [4,57]. Another observation is that drug sellers at pharmacies prescribe and sell drugs similar to those that they have learned by filling physicians prescriptions as reported in a study from Iran [58]. With scarce resources and easy accessibility of drug sale outlets in developing countries the role of pharmacist needs to be emphasized for safe and effective use of medication through these evolving roles, thus helping in the achievement of millennium development goals [59,60].

Pharmaceutical care is regarded as an important component of good pharmacy practices but it has been ignored by the dispensers, stakeholders and researchers in Pakistan. There are very few studies which focused at the practices of community pharmacies in Pakistan and just one intervention study with a very small sample size is available. Limited studies have been designed to explore the role of pharmaceutical care at community pharmacies in Pakistan. Studies conducted in other countries provide some insight on this issue, though the difference in the healthcare systems makes it difficult to extrapolate the results to Pakistan’s setting [39,60,65,66]. Health system research focusing on current dispensing practices with sound study design is needed to explore this issue to its full extent in Pakistan. This requires multi stake holder’s collaboration in designing and executing a well thought-out, scientifically sound study design, with quantitative and qualitative tools and provision of ample funding.

The current paper highlighted that quality of services provided at community pharmacies in Pakistan is not satisfactory. Absence of qualified people, lack of provision of advice and lack of professionalism by the dispensers, ambiguity of laws and their implementation are the main reasons for the poor quality of services offered at community pharmacies. The provision of information is scanty and reflects on the poor communication of dispensers with the patients/customers. Sale of POM, including antibiotics and narcotic medicines without prescription, is a common practice. Drug safety issues, inadequate number of legally qualified persons, lack of history taking, inappropriate treatment and lack of counselling are the most immediate concerns to be addressed. Thus it becomes important to critically evaluate and document the various gaps in the current dispensing practices at community pharmacies which are required to guide researchers and policy makers to look into the situation from a broader perspective to improve current pharmacy practices and pharmaceutical care at community pharmacies. However, innovative approaches are required to design appropriate interventions, policies and ways for their effective implementation, to utilize the maximum potential of community pharmacies in provision of better pharmaceutical care at the community pharmacies in Pakistan.