Introduction

Community pharmacies are the first point of contact between clients and the health system in many countries, especially where the availability of public health services is limited [1]. As such, pharmacies across the world have played an important public health role during the COVID-19 pandemic, supplying essential medicines and personal protective equipment (PPE), conducting consultations for clients with mild symptoms and referring more serious cases, delivering information on disease prevention, contributing to COVID-19 surveillance, and ensuring the continuity of care delivery [2, 3]. In performing these activities however, community pharmacists may face a high risk of contracting the virus due to prolonged contact in the workplace with clients and colleagues, who may be infected [4]. Further, they can experience additional challenges due to lockdown measures and shortages of medicines and other supplies such as PPE [5, 6].

Aware of these challenges, professional organizations in the pharmacy sector have issued COVID-19 contingency plans to help their members during the current pandemics and any future outbreaks. In 2020, for example, the International Pharmaceutical Federation (FIP) published a detailed document containing relevant information and guidelines for the pharmacy workforce [7]. Similar documents were drafted by organisations at the regional level, such as the Federation of Asian Pharmaceutical Associations [8]. Guidelines were also developed at the national level by, for example, the National Health Service (NHS) in the United Kingdom [9] and by professional pharmacy organisations in Pakistan [2], Malaysia [10], South Africa [11], and the Philippines [12], to name a few. Despite these initiatives, however, several surveys have reported a general lack of access to information and training among pharmacists during the COVID-19 crisis [4, 13–16]. Furthermore, the experiences of pharmacists and pharmacy technicians during the pandemic have only been documented in a few studies. As a result, the generation of guidelines for pharmacists has tended to proceed without in-depth understanding of the needs and perspectives of these frontline workers.

Considering these issues, we conducted a qualitative study to explore the experiences and challenges of pharmacists and pharmacy technicians working during the COVID-19 outbreak in Indonesia, a country that has recorded more than four million cases and 150 thousand deaths since the start of the pandemic [17]. Besides the substantial health and economic burden, severe disruptions to health service delivery have been reported in Indonesia [18–20], including the closure of primary health centres (puskesmas) and hospitals in areas with widespread infection of local health workers [21]. In this context, community pharmacies have played an important public health role, serving their communities under challenging circumstances. Thus, gaining a better understanding of the challenges they have faced and coping strategies implemented is critical to inform national guidelines and prepare for future emergencies.

Methods

Results

In the sections below, we present the findings structured around the main themes. Where appropriate, anonymised citations are included to illustrate key points and are referenced by the unique identifier IDI-n. In total we conducted 21 in-depth interviews with participants recruited from 16 provinces (Table 1). Most participants were pharmacists that had been working in the same establishment for at least three years. The age range of the study sample was 26–51 years. Apart from a pharmacy technician employed in a large retail chain, all participants worked in independent small pharmacies which have less than 11 staff.

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Table 1. Characteristics of participants.

https://doi.org/10.1371/journal.pgph.0000606.t001

Discussion

Most participants in our sample coped well with the unprecedented challenges posed by COVID-19, implementing preventive measures and adapting their business model to the changing circumstances. The shift to remote sales and home delivery allowed many pharmacies to continue operating, and even increase their sales due to greater demand for medicines and PPE.

Nonetheless, significant operational challenges emerged. Despite preventive measures implemented in pharmacies, many participants were concerned about the increased risk of infection due to prolonged interactions with clients, many of whom were suspected to be contagious. Importantly, as documented in other countries [4], there was a general perception that these risks were not sufficiently recognized by the government.

Frequent stock outs of face masks, hand sanitizers, and medicines were reported in many pharmacies. While this has been a global challenge also affecting doctors and nurses [33], it has been particularly acute in low- and middle-income countries, like Indonesia, where supply chains are more vulnerable to fluctuations in the availability of imported products and raw materials [34]. Similar to findings in Serbia [5] and Ethiopia [35], some pharmacists were worried about the lack of face masks for their personal use and safety. Participants also noted that these supply disruptions led to steep price increases especially for vitamins and face masks, as found in other countries [6, 36]. Pharmacists in our study reported frequent stockouts of vitamins. This is likely to have been driven by advice from the Indonesian government to take multivitamin supplements to help strengthen immune system response to COVID-19 (21).

Our findings invite some reflections for policy, practice, and research. Our study clearly indicates that measures to ensure the safety of pharmacy personnel must be strengthened. While pharmacists in our sample had access to training materials and updates on COVID-19 from professional organizations, government guidelines and safety protocols targeting community pharmacies were not widely circulated. Second, frequent stock outs of key products in some pharmacies highlights the need for constant monitoring of sales data to avoid supply shortages and price increases [37]. Additionally, monitoring the sales of particular products such as vitamins, cough medicines, antivirals and antipyretics could also serve to support the national system of syndromic surveillance [38], as seen in other countries [39]. To achieve this goal, effective oversight of the supply chain and regulations should be in place. In the United States, for instance, the Food and Drug Administration adopted a flexible approach to allow for the local production of face masks during the pandemic [40]. Alternatively, the government of Taiwan applied restrictions on the quantity face masks which could be purchased by individual citizens during the pandemic [41]. Governments can also mandate greater public disclosure of prices for pharmaceutical products in high demand during pandemics, as was the case in Rwanda [6].

Moreover, there is little doubt that the increase in online sales has helped sustain supplies of products and consultation services amid the pandemic. However, this practice is not without its challenges. Concerns have been raised in other countries about potential hazards associated with online sales of medicine, with little or no oversight from the authorities [42]. Thus, a stronger regulatory framework and some forms of quality control should be introduced. In some European countries, for example, the following information must be included in the parcel together with the medicines purchased online: information on the pharmacy, a notice that medicines cannot be sent back (except if defective), the list of pharmaceutical care services offered after dispensing and any information required for their responsible use [43]. On a related note, our study also suggests that the pandemic resulted in a steep increase in the demand for antibiotics, despite these medicines not being recommended for the management of COVID-19. Given the harmful consequences of this practice on antimicrobial resistance [44], the government should consider implementing additional measures to monitor antibiotic use and promote antibiotic stewardship during the pandemic. This is in line with wider calls to better integrate private providers including community pharmacies into the health systems of LMIC in order to tackle ongoing threats such as antimicrobial resistance [45].

Taken together, our findings suggest that during the COVID-19 pandemic, community pharmacies in Indonesia have fulfilled an important public health role, supporting the continued supply of medicines and services, advising clients on disease prevention and management, promoting preventive measures, and even countering the proliferation of false or inaccurate information from social media. This is in keeping with a recent review, which highlighted the potential for ‘multilevel’ engagement of pharmacists during the COVID-19 pandemic, from disease education and counselling to active surveillance of suspicious cases [46]. And yet, similar to findings in Pakistan [47], some participants noted that more guidance and a clearer regulatory framework are needed to support pharmacies and enable them to contribute to pandemic response efforts. Indeed, limited coordination and recognition of the important role of the private sector, including pharmacies, has been a long-standing challenge to effective public health action in many countries, and has been a major shortcoming of pandemic preparedness in the past [48] and during the COVID-19 crisis [3, 49–51]. In a study in Puerto Rico, for example, pharmacists were resentful and outraged they were excluded from all government schemes aimed at recognizing and incentivizing essential workers and health professionals, despite providing continued service since the start of the COVID-19 pandemic [3]. In contrast, evidence suggests that countries that have engaged with the private sector, through for example, purchasing arrangements or the rapid adaptation of existing policies around the management of drug supplies [37], have been able to implement more effective COVID-19 response measures [52]. For example, during the COVID-19 pandemic, the government of Iran established a public-private partnership with the country’s biggest online retailer, Digikala, to promote the sale of products in high demand during the pandemic through their platform, free of charge [53]. Other countries have issued novel legal provisions to extend the role of pharmacists during the pandemic including authorisation to: prepare disinfectants; renew prescriptions for chronic diseases; fill pro auctore and pro familia prescriptions (i.e. for themselves and for some family members); perform COVID-19, influenza and Group A Streptococcus screening tests; and administer vaccine [54]—actions that are worth considering in the Indonesian setting during the current pandemic and for future public health crises.

Conclusion

COVID-19 has increased the recognition of the critical role that community pharmacies play in the health system. Our study provides novel insights on the views and experiences of these frontline health care providers during the pandemic. While some community pharmacies have managed to maintain, and even increase, their services using e-commerce and other remote sale strategies, several key challenges to maintaining quality service provision have emerged. While pharmacists were exposed to an abundance of information on COVID-19 through various online sources, concerns emerged about the circulation of inaccurate information through these channels. Frequent stockouts and a steep increase in the price of medicines and other supplies also arose as key challenges. Lastly, participants expressed that their contributions and vulnerabilities during the COVID-19 pandemic have not been sufficiently recognized by the government. Thus, further attention to these issues should be given in future research and policy in order to better understand the role of the pharmacy sector during public health emergencies. A more comprehensive study involving all categories of stakeholders (including informal drug outlets, suppliers, and representatives of professional organisations) would be a useful follow-up to this study, providing key evidence to inform operational guidelines and regulatory frameworks for pandemic preparedness.

Supporting information

Acknowledgments

We thank the Indonesian Ministry of Health, Indonesian Pharmacist Associations, Indonesian Pharmacy Technician Associations at the national, provincial, and district levels, and participants involved in this study.