A scenario-planning approach to human resources for health: the case of community pharmacists in Portugal
Human Resources for Health
A scenario-planning approach to human resources for health: the case of community pharmacists in Portugal
Joo Gregrio 0
Lus Velez Lapo 0
0 WHO Collaborating Centre for Health Workforce Policy and Planning, International Public Health and Biostatistics Unit, Instituto de Higiene e Medicina Tropical , Rua da Junqueira n100, 1349-008 Lisbon , Portugal
Background: Health workforce planning is especially important in a setting of political, social, and economic uncertainty. Portuguese community pharmacists are experiencing such conditions as well as increasing patient empowerment, shortage of primary care physicians, and primary health care reforms. This study aims to design three future scenarios for Portuguese community pharmacists, recognizing the changing environment as an opportunity to develop the role that community pharmacists may play in the Portuguese health system. Methods: The community pharmacist scenario design followed a three-stage approach. The first stage comprised thinking of relevant questions to be addressed and definition of the scenarios horizon. The second stage comprised two face-to-face, scenario-building workshops, for which 10 experts from practice and academic settings were invited. Academic and professional experience was the main selection criteria. The first workshop was meant for context analysis and design of draft scenarios, while the second was aimed at scenario analysis and validation. The final scenarios were built merging workshops' information with data collected from scientific literature followed by team consensus. The final stage involved scenario development carried by the authors alone, developing the narratives behind each scenario. Results: Analysis allowed the identification of critical factors expected to have particular influence in 2020 for Portuguese community pharmacists, leading to two critical uncertainties: the Legislative environment and Ability to innovate and develop services. Three final scenarios were built, namely Pharmacy-Mall, e-Pharmacist, and Reorganize or Die. These scenarios provide possible trends for market needs, pharmacist workforce numbers, and expected qualifications to be developed by future professionals. Conclusions: In all scenarios it is clear that the future advance of Portuguese community pharmacists will depend on pharmaceutical services provision beyond medicine dispensing. This innovative professional role will require the acquisition or development of competencies in the fields of management, leadership, marketing, information technologies, teamwork abilities, and behavioural and communication skills. To accomplish a sustainable evolution, legislative changes and adequate financial incentives will be beneficial. The scenario development proves to be valuable as a strategic planning tool, not only for understanding future community pharmacist needs in a complex and uncertain environment, but also for other health care professionals.
Community pharmacists; Human resources for health; Pharmaceutical services; Scenario planning; Portugal
Community pharmacists role in global health systems
Human resources are the present focus of attention in
health systems strengthening and public health policies
[1-3]. This is partly due to the increase of chronic
conditions and the emergence of interprofessional models of
practice that aim at transforming the daily care for
patients with chronic illnesses from acute and reactive to
proactive, planned, and population-based . Most
successful chronic illness interventions include major roles
for non-physicians such as pharmacists and nurses [5-7].
Community pharmacies and pharmacists are in a
privileged position within health care systems due to their
professional training and easy accessibility (i.e., in most
high streets), which could contribute to more reliable
monitoring of medication use and patient counselling, as
well as health promotion and education [8,9].
For pharmacists, this new role towards a more
patientcentred care has become a new paradigm of pharmacy
practice, leading to the development of patient
information services, pharmaceutical care services, and the
development of a clinical role for community pharmacists
[10,11]. The work of Hepler and Strand , in the early
nineties, was a milestone in this change, pointing out to
the delivery of longitudinal advanced medication-related
services, the rise of professionals level of responsibility,
and the development of cooperative relationships with
other health care professionals as essential features to
this new role. However, this movement toward
patientcentred care in community pharmacy has been taking
longer than one would expect back in the nineties, much
influenced by inner organizational barriers as well as several
external factors such as the economic and legislative
context, commercial pressures, government politics and/
or policies, technological innovations, new therapies,
support from other professionals, health system integration,
and the personal attitudes of pharmacists and pharmacy
Community pharmacists workforce in Portugal
Portuguese community pharmacists have followed the
global trend for an extended practice. Community pharmacists
in Portugal serve the public in independent shops, the
community pharmacies. The installation of community
pharmacies is regulated by the government, establishing
the minimum distance between pharmacies and
number of inhabitants serviced. The number of pharmacies,
now close to 2,900 in total, has increased 9.5% since
the turn of the century, with an average of 24 new
pharmacies per year . From 2007 onwards, changes
in legislation allowed for non-pharmacist ownership, a
decrease in the population base from 4,000 to 3,500
inhabitants per pharmacy per county, and a shorter
distance between pharmacies from 500 m to 350 m. This
political measure had impact in that year, with a rapid
increase of pharmacies, but quickly stabilized.
Pharmacies have a National Health Service (NHS) contract for
dispensing medicines, establishing prescription
medicines profit margins and co-payments. Apart from
dispensing, none of the new services is supported by NHS
remuneration. To cope with this, pharmacies may offer
services such as smoking cessation, minor ailment
schemes, and adherence support services, all of which
are supported by the patients direct payments .
During the early 21st century, Portuguese pharmacies
have implemented pharmaceutical care programs for
hypertension and diabetes with the help of professional
organizations such as the National Association of
Pharmacies (ANF), a pharmacy owners organization. The
program for diabetes was financially supported by the
NHS from 2006 to 2009. At the time, a maximum of
400 pharmacies were doing patient follow-up, with an
average of three patients per pharmacy . After the
cancelation of NHS financial support of these
programs, most pharmacies terminated the provision of
the service and stopped with patient follow-up. Since
then, many pharmacies have broadened their services
to other services provided by different professionals
such as nutritionists, podologists, or nurses in an
attempt to have more revenue to face the present
Community pharmacists represent almost two thirds
of the total pharmacist workforce mandatorily
registered in the Pharmaceutical Society (OF) . By the
end of 2012 there were 7,716 registered community
pharmacists . These are mostly young professionals
(67% less than 45 years old), 80% of which are women.
The total number of community pharmacists has
increased 74% between 2000 and 2009, with an annual
average of 340 newcomers [19,20]. This sharp rise was
a direct consequence of the increase in the number of
pharmacy degrees offered in private and public
universities. For instance, in 2010 there were more than 1,100
new students enrolled, a 6.5% increase when compared
with 2008 admissions . In the same period, the
number of pharmacy technicians working in
community pharmacy dropped by 25%, mainly due to the
oversupply of pharmacists [19,20]. The ratio of pharmacists
per pharmacy has increased between 2000 and 2010,
with an average above 2 since 2005, leading to 68
pharmacists per 100,000 inhabitants [20,22], which can be
considered a homogenous geographical distribution,
although with a greater concentration in the Lisbon and
Porto metropolitan areas [14,19,20,23]. Due to the
decrease of pharmacy technicians, pharmacists then started
to have increasingly technical tasks to perform, since
the development and implementation of new services
was not widespread. With the onset of the economic
crisis of 2008, low salaries and unemployment, especially
among recently graduated pharmacists, started to become
a reality .
The need for strategic planning in community pharmacy
The shortage of primary health care (PHC) physicians,
the economic and political uncertainty deriving from the
economic crisis that started in 2008, and the primary
health care reform currently developing in Portugal, are
all contributing to a changed climate and have created
an opportunity to rethink the role of community
pharmacists within the Portuguese health care system.
Strategic planning is essential to assess the efficiency of
human resources and health services, since it is an effective
tool to address innovative solutions within health systems
[25-27]. Although the organizational environment is
recognised as an important factor in health care services
functioning and development, external environment continuous
modifications challenge decision makers and practitioners.
For health professionals, this environment could be
described by a constant technological evolution, a growing
search for patient-focused care, and empowerment of
citizens, particularly in terms of health knowledge . For
community pharmacists, the changing environment and
the shifting in health care demands is pushing them to a
continuous adaptation process and a more advanced role in
patient care .
Due to these uncertainties, which limit the capacity to
predict and plan the needed resources accurately, there is
now an opportunity to delve more deeply into Portuguese
community pharmacists future through a thinking exercise
supported by the development and analysis of strategic
scenarios [30-32]. Undertaking a strategic thinking approach
allows for the analysis of different possibilities, without
excluding those that seem unlikely. Recent approaches to the
issue of pharmacists future have focused on workforce
supply and demand [33-35], while others have proposed
scenarios to depict what the profession could be in the
future, from the perspective of interviewed experts [36,37].
This last case inspired our work since a flexible approach
is used and a creative attitude is promoted towards a future
vision on the pharmacist profession.
The aim of this study was to develop future scenarios
for the community pharmacist profession in Portugal. To
achieve this, two main objectives were considered: (i) to
analyse the possible evolution of community pharmacists
role in the Portuguese health care system by building and
studying three different scenarios and (ii) to identify the
main driving forces and related uncertainties.
Strategic scenario analysis does not aim to predict the
future. Instead, it aims to construct stories for the future
that contribute to the better understanding of the external
environment in which an organization is operating in
order to support strategic decisions, anticipate difficulties,
and assess an organizations business positioning [38-41].
Scenario development is a validated and useful
methodology, where each scenario can be regarded as a strategic
case or as a branch of a decision tree . Its use
extends from academic research to more practical issues as
business and public administration . Scenarios are the
archetypical products of future studies, as they facilitate
both the possibility for a deeper and more creative
thinking about the future (reducing the risk of being surprised
and unprepared) while, simultaneously, enabling the
enhancement of the collective awareness (and preparation)
over multiple plausible circumstances .
Besides an organizational and business strategy, this
methodology has also been used in prospective research
of academic medical organizations and professional
pharmacy-related groups [36,37,44]. For this work, it was
decided to use the community pharmacists perspective.
Although pharmacies and pharmacists are closely linked
entities, this distinction is essential since the
developmental paths of both bodies do not necessarily overlap.
The method proposed and used by Lapo and Thore
was followed . This method condenses the 10-step
method of Schoemaker  into three stages (Figure 1)
that yield a set of three scenarios which represent three
different future possibilities. The three scenario
development stages are presented in detail below.
First stage literature review
In this first stage, the authors thought of relevant questions
to support and motivate the scenario development process.
For instance, What will be the need for community
pharmacists in the future?; Is it possible to establish and
sustain a new role for community pharmacists within the
health care system?, If so, how can community
pharmacists integrate the PHC network?; What might happen to
the newly graduated pharmacists coming to a labour
market that is increasingly saturated? A scenario horizon was
also defined. For this study, we selected the 2020 horizon.
Ten years is considered a good enough timescale within
policy-making, avoiding difficulties in participants
To perform the literature review, PubMed database and
Google Scholar were searched using the following strings:
community pharmacist role, community pharmacy
future, pharmaceutical services, pharmacy scenarios,
health services innovation, and pharmacy information
technologies. This search retrieved 167 articles on the
global community pharmacists role, its evolution, barriers
and facilitators to professional development, and future
market trends such as the challenges of population ageing
or the use of information technologies (IT). The
information collected was used to prepare a review to inform the
Figure 1 The three stages of scenario development as proposed by Lapo and Thore .
next stage of scenario development. Besides the
qualitative information, quantitative information related to
Portuguese community pharmacists was obtained from
the official Medicine Statistics reports, available from
the regulatory agency (INFARMED) [19,20], as well as
complementary information from the OF and the ANF
Second stage scenario development workshops
The second stage comprised two face-to-face
audiorecorded workshops, each with three hours duration.
The workshops took place in two different days with the
participation of a workgroup that included the first author,
a community pharmacy specialist, and a scenario developer.
To complete the workgroup, pharmacy and health
management experts were invited. A total of 10 experts were
invited, 6 of which accepted the invitation (Table 1). These
were selected by convenience, using academic experience
and professional experience as the main criteria.
Academic experience was assessed by relevant publications in
the field of community pharmacy. The professional
experience was assessed by years of practice and/or
ownership of community pharmacy listed on the online CVs.
Having community pharmacy experience or health market
knowledge in Portugal and being an academic was
considered a major asset, although it may be considered a bias
toward academia; only one expert was personally known
by the researchers. None of the invited experts was an
Table 1 List and characterization of expert informants present at the workshops
P Present at the workshop.
Professional and academic experience
Doctor of Pharmacy (PhD), Associate Professor in Social Pharmacy, expert in Pharmacist
communication, Community pharmacy co-owner
Doctor of Pharmacy (PhD), Assistant Professor, expert in Pharmaceutical Care
Master in Health and Development (MSc), Community Pharmacist specialist; study main author
Doctor of Systems Engineering and Health informatics (PhD), Assistant Professor, expert in
scenario design and trained facilitator
Manager, Regional Access Manager for a multinational pharmaceuticals company
Master in Public Health, Community Pharmacist, expert in Pharmaceutical Care, Community
Pharmacist, Executive Director of a public primary health care centre cluster
active representative of a professional organization, thus
avoiding possible conflicts of interests. Considering
previous pharmacist scenarios analysis reported in the
literature [36,37], it was decided that the 8 person group was
enough to accomplish our goals.
The workshops were recorded using a digital recorder
with participants verbal consent obtained prior to the
workshops. The recordings were transcribed and thematic
analysis performed. The first workshop was meant for
context analysis and design of draft scenarios, while the second
workshop aimed at scenario analysis and validation.
According to Godet , the first interaction with
experts should start with a short seminar to acquaint all
participants with the purposed tools and concepts that
will be used in the scenario development process. After
this introduction, a presentation was made, highlighting
the main findings from the literature review, namely on
workforce, economic, technological, political, and
demographic trends. Next, the process of collecting
information started using the thematic brainstorming technique:
the experts were asked to imagine different possibilities
for community pharmacists future role based on
whatever their perceptions were on the influence of the
literature review findings. This approach allowed a free
flow of ideas and discussion, without the boundaries of
an interview and conventional reflection. These findings
were then summarized into several themes, which is
necessary to identify critical uncertainties. Critical
uncertainties are environmental factors considered to have an
influence in the progression of the theme under analysis
. To do so, we asked the participants to vote on the
two themes that they thought would be the most
influent for the proposed scenario horizon. These themes
were then condensed into two major critical
uncertainties that will work as the scenarios driving forces, to
develop an initial draft version of the scenarios discussed
in the end of the first workshop .
To prepare the second workshop, a story for each of the
draft scenarios was written, combining the analysis of the
workshops recording and the selected driving forces. On
the second workshop, both the initial draft scenarios and
driving forces were checked for consistence and
plausibility. This was done by expert consensus. If a scenario or
driving force was deemed to be unlikely or if it was
incoherent, it would not be considered for further
development. Next, the gap between present and future was
fulfilled by participants discussion aiming to reach a
narrative of a consistent set of events that would lead to the
Third stage scenario analysis
This third and last stage of the scenario design process
was carried by the authors alone. The workshops
recordings were transcribed and the information collected
was combined with information gathered in the
literature review to redesign the final set of scenarios, with
the corresponding narratives. The narratives are
hypothetical stories of the future built by the authors, based
on the trends that the invited experts feel that some
uncertainties might have on the years to come, their impact
on the community pharmacy workforce and on the
health system in general.
This study was performed in strict accordance with
the good research practices and code of ethics of
Instituto de Higiene e Medicina Tropical, Universidade Nova
de Lisboa, Portugal. The protocol was approved by the
Ethics Committee of Instituto de Higiene e Medicina
Tropical, Universidade Nova de Lisboa (Permit Number:
During the scenario workshops, several themes considered
to be relevant to community pharmacists role in the
Portuguese health care system were debated. A final
voting identified the critical ones. The following descriptions
for each of the critical uncertainties were suggested.
This was considered the main driver for professional
development and professionals satisfaction, being also the
driver for service differentiation between pharmacies. The
experts further considered that there would be more
sophisticated services in the future, which will be essential
for customer retention. The concept of a health care
mall, where customers and patients would have access to
several health care services provided by different
professionals (e.g., nurses, nutritionists, podologists, etc.), was
considered highly plausible. When discussing pharmacies
sustainability, the participants belief was that pharmacies
would only offer additional services if or when they were
Economic environment and financial situation of the
The participants agreed with the concept of pharmacies as
small enterprises, particularly dependent on NHS
cofunding. Presently, pharmacies are facing decreasing profit
margins, with new remuneration models that are mostly
strangling the smaller pharmacies. The participants
perceptions about this issue were that pharmacists clinical
intervention would be in jeopardy as the financial
situation of the pharmacies deteriorates, blocking the eventual
development of a new role. To counter the decreasing
budget trend, pharmacies would be forced to address and
improve their management and search for alternative ways
of funding. One identified alternative was the clustering of
pharmacies, which is already emerging.
Political will and NHS reorganization
This theme emerged associated with the fundamental idea
of a legislative change that would consent new roles to
develop. It was recognized that political will is influenced by
several aspects, such as the countrys economic and
financial situation, pressure from social and economic lobbies,
health care professional groups, but also by the
relationship between the government party and the main
professional organizations, ANF and OF. The awareness of a
recent phenomenon pharmacists unemployment also
emerged as a pressure factor for the politicians and
professional organizations. Bearing in mind the most
significant pharmaceutical policy and economic change in
recent years the loss of pharmacists property rights and
pharmacies exclusive rights in over-the-counter medicines
sales the participants acknowledged that if the economic
situation continues to deteriorate, a change in pharmacy
legislation will be inevitable, i.e., there will be pressure to
change the minimum distance between providers and
adjust the population density limits, allowing for a horizontal
and vertical integration of the community pharmacy
market. There is also the possibility that the current NHS will
suffer liberal reforms, reducing medicine reimbursement
and limiting patient purchases.
Patients and clients
The participants considered that the patients perceptions
of health care and consequent behaviour influence the
demand of products and services. The current economic
setting is forcing many patients to choose lower-priced
products and fewer services. This effect will influence
prices policies in order to lower medicine costs even more,
through patients advocacy groups and other associations.
It was considered that the relatively low health literacy of
Portuguese patients is an impediment for pharmacy
extinction. However, the use of the Internet as an information
channel for health issues is growing not only in younger
age groups, but also in elders too, a group where chronic
diseases are prevalent. This fact, alongside with the
perceived early adoption of new information technologies by
the Portuguese population, makes Internet based health
care and pharmacy services very likely and promising in a
Professional organizations role
Most workshop participants were certain that the two
main professional organizations (ANF and OF) would still
be very strong actors in shaping the community
pharmacist role, although the ANF will be more dedicated to
protect business interests while the OF will maintain the
defence of a professional point of view. This will probably
happen, assuming that non-owner pharmacists do not
necessarily support ANFs points of view and strategy. The
ANF has been advocating the implementation of a new
practice model since the late nineties with the OF also
supporting this change. However, ANFs economic power
and political influence still places it as a main stakeholder
in this arena, with participants recognizing that in the
future, it would be better for the profession to keep the OF
as the main stakeholder to clearly separate the business
interests of pharmacies from the professional interests of
non-owner pharmacists. Besides this, the role of academia
was also deeply discussed. It was recognized that academia
will have an important role in defining pharmacist
education and thus, their specialization toward a patient centred
Primary health care reform
The present reform is promoting the harmonization of
clinical procedures between primary and secondary
health care, and this will also influence pharmacies
organization, management, and positioning. The
integration of a pharmacist in PHC centres teams emerged
as a possibility. Depending on the functions performed
(e.g., disease management versus medicine use
management and logistic support) there could be a stronger
link with the local community pharmacies to better
integrate the patients in the health care network. To
make this possible, participants suggested pharmacists
should acquire new communication skills to better
work with other health professionals, and taking into
account factors such as lobbying, trust between
professionals, and cultural issues.
From the several themes discussed that were not
considered critical uncertainties, it is worth to highlight
themes such as absence of a community pharmacist
career, implying that the professional development is
nonexistent and the specialization occurs mainly within the
practice setting; technological innovations will surely play
a major part in shaping the future pharmacists role, but
could have their potential hindered by most patients low
IT literacy; the inconsistency of services between
pharmacies was identified as one barrier to the dissemination
of new forms of practice, contributing to a low speed of
diffusion of innovations.
To start the scenario design process it was necessary to
condense the critical uncertainties into two driving forces.
The first driving force was named Legislative
environment, comprising the critical uncertainties Political will
and NHS reorganization, and Economic environment.
Two extremes for this driving force were considered,
namely one with little or no change in the legislative and
economic environment, and the other comprising both
pharmacy market and health care system liberalization.
The second driving force was named Ability to
develop services, condensing the critical uncertainties
Financial situation of the pharmacies and Patients and
clients. The extremes for this driving force were low
innovation versus high innovation that enables new
service development. The first was due to the absence of
incentives, lack of demand, and lack of pharmacies
financial capacity, resulting in a low development of new
services. The second emerged from greater customer
demand, resulting in an increased need for differentiation
between pharmacies as a means to expand their client
base and profits.
After the driving forces were fully defined and
validated by the experts, it was possible to design the
following final scenarios (Figure 2).
In the Pharmacy-Mall scenario, new pharmacies
opening and ownership will have been completely liberalized,
but with no significant modification in the way
pharmacies are paid for their services. Remuneration will come
entirely from the profit margins on the sale of medicinal
products. There will be no governmental attempts to
improve services development or payment for the existing
ones. As the profit margins improve, due to the
horizontal and vertical integration of pharmacies into chains,
pharmacies owners will not feel the need to innovate,
thus keeping a low development of new pharmaceutical
services. The demand for pharmaceutical services will
also remain low. There may be pharmacies in the
Internet, providing medicines to patients who cannot or do
not want to visit the pharmacy to fill their prescriptions.
In the e-Pharmacist scenario, besides pharmacies
ownership liberalization, there is the possibility of health system
Figure 2 Final community Pharmacists scenarios.
liberalization, i.e., greater opportunities for health services
personalization. In this sense, it will be beneficial for the
citizens to have a health insurance or a subsystem of care.
In this scenario, pharmaceutical care services become the
main source of revenue for pharmacies. Pharmacies will be
mainly supported by private health systems, thus
encouraging the development of additional pharmaceutical
services. Community pharmacists, skilled in the provision of
services beyond medicine dispensing, will be subject to a
strong demand. They will be recognised for the economic
and clinical value in the services provided and the impact
on patients quality of life will be definitively proven.
Service innovation will lead to a broader utilization of IT:
proactive community pharmacists will be showing leadership
on the use of information systems for provision of health
care, managing virtual spaces, such as electronic cabinets,
where all the disease and therapeutic management will be
accomplished. e-Pharmacists will manage patients health
information and the interaction with PHC physicians and
other health professionals using digital and IT resources.
Reorganize or Die
In the Reorganize or Die scenario, no significant
legislative changes will have occurred, other than cutting profit
margins. The current trend for decreasing profit margins
will continue, forcing pharmacies to look for other sources
of revenue, including reorganizing in groups of
pharmacies. This will help survival and will maintain the
pharmacies minimum profit level and costs controlled. The
development of services will take place based upon the
need to differentiate between pharmacies, implementing
strategies to increase their products and services demand.
In this scenario, pharmaceutical services would only exist
if supported by individual payers, without any financial
support from the health systems. Most pharmacies will
have their own Internet site; however, since there will be
no legislative change, dispensing prescription medicines
will still be performed in the traditional way. The websites
will be more dedicated to the sale of over-the-counter
products and provision of general health information.
From the analysis of our set of scenarios, it seems that
the most promising future for community pharmacists
in Portugal is the provision of pharmaceutical services
that go beyond medicine dispensing.
Comparing this set of scenarios with others found in the
literature, namely the scenarios suggested by Norgaard
et al.  for Danish community pharmacists, we can
conclude that much of the trends that led to the
development of their scenarios are still very much present today,
leading us to believe that the transition in pharmacist role
is universal but has been much slower than expected. In
that work, five scenarios were developed using a different
methodology. Apart from the No future scenario,
which is a worst case scenario, that we did not consider
developing, there are several common aspects with the
remaining scenarios. Their Uncertain future scenario is
closely related to our Pharmacy-Mall. However, aspects
of their IT expert and Provider of individualised
information and future role developer scenarios are included
in the e-Pharmacist scenario, with some other aspects
being included in the Reorganize or Die. This may stem
from different methods approaching the scenario
development, as the perception of pharmacists role is very similar
in both countries. Although different in their context,
these scenarios show some intriguing trends in spite of
the Danish scenarios lack of a clear scenario horizon.
The trend towards the use of technological solutions to
assist pharmacists work is present as is the fear of
becoming less important in the health system.
The choice of the two driving forces from the themes
discussed was a critical step in the definition of our
scenarios. They were discussed and validated by the experts
at the beginning of the second workshop. For the first
driving force, Legislative environment, the decision was
supported by the perception that the most important
change in the pharmacy sector in Portugal, and also in
Europe, is the liberalization of pharmacies ownership and
installation [23,47,48]. Although some authors found that
restrictions to free pharmacy installation are limiting
innovation , other studies suggested that the current
legislation on pharmacy installation ensures equity of
access and the quality of medicine dispensing as long as the
presence of a pharmacist is mandatory [47-49]. Experts
recognition that these contrasting views stem from the
political environment, supported the integration in this
driving force of the issues of political will and economic
environment. The second driving force Ability to
develop services, intends to reflect the competency, will
and vision of a pharmacy owner to develop and
implement innovative services. The experts considered that
the development and implementation of
pharmaceutical services is critical for pharmacy differentiation and
sustainability, which in turn impacts on the community
pharmacist role. It also acknowledges that pharmacy
owners will only have interest in implementing services
that will be profitable, with adequate service
remuneration as an essential requirement for ensuring service
diffusion and adoption, as described in the literature
[13,48]. It is expected that pharmacy owners will adopt
this new practice, especially in a context of economic
constraints. However, the lack of business skills and
openness to innovation could represent a barrier to this
process of change.
The final three scenarios represent obvious implications
and consequences, which are summed up in Table 2.
The Pharmacy-Mall scenario is the one that offers
community pharmacists fewer chances for professional
development, besides representing a likely sharp decrease
in workforce numbers (Figure 3). The potential oversupply
of pharmacists and rising unemployment will contribute
to the increasing number of professionals leaving the
country, seeking new job opportunities, professional
development, economic stability, and job satisfaction .
Others will quit the profession, choosing another career
outside community pharmacy . In a scenario where
big profit-driven pharmacy chains will emerge, conflicts
are expected between business objectives and pharmacists
interventions, namely free of charge patient counselling.
This can have negative consequences on professional
satisfaction and community pharmacists work conditions
[52,53]. For patients, the advantage of this scenario is the
reduction of medicine prices, due to greater vertical and
horizontal integration and additional competition .
For the health system, this scenario could bring important
savings in medicine expenditures, as it has been observed
in countries with a similar model. Nevertheless, the
downside is a reduced accessibility to medicines, especially in
remote and rural areas [47,48].
Table 2 Implications and consequences of the different scenarios
Demand for community pharmacists
Main functions and responsibilities
Supervision of dispensing processes
Main skills to acquire/improve
Human resources and pharmacy
Clinical pharmacy and pharmacotherapy
Advanced information technologies
Primary health care integration
Multidisciplinary teams and polyclinics
In the local health units
Figure 3 Evolution of the ratio of pharmacists per pharmacy in each scenario.
The e-Pharmacist scenario represents a best case
scenario. The numbers of community pharmacists per
pharmacy will keep rising, ensuring that a significant part of
the trained pharmacists is still absorbed by the community
pharmacies market (Figure 3). However, it is crucial for
pharmacy professionals to promote a greater collaborative
work culture, both inside and outside the pharmacy. This
scenario implies a greater collaboration with general
practitioners and nurses, and probably some changes in
working regulations. With more information to share, the use
of IT is an evident solution that will continue to be
explored [54,55]. For patients, this may be a valuable
scenario since there is the possibility of remote disease and
therapy management, associated with better health
outcomes, less general practitioner visits and other health
care system savings [6,56,57]. It is likely that an improved
accessibility will increase patient satisfaction. For the
health care system, a real integration of community
pharmacists in the PHC network would possibly increase the
costs of care. However, the efficiency increment and the
reduction of other costs would be relevant to those
financing the health system, without affecting the quality of
pharmaceutical services provided [58,59].
In the Reorganize or Die scenario, customer
relations management competencies are the most valuable
asset a pharmacist can have. A solid education in
marketing and quality of services will be extremely
important to increase demand for the products and services
each pharmacy is willing to provide. For patients, this
scenario is not as valuable as others, since they will be
considered as consumers rather than actual patients
using a health service. In this sense, not everyone will
have access to pharmaceutical care services, depending
on the services available at each pharmacy and on the
individual means to pay for services. Since funding of
pharmaceutical services will be largely dependent on
patients, the overall equity of the health care system
could be endangered, since most of the people who
might need pharmaceutical care may not be able to
afford it. As far as the health care system is concerned,
besides the lower equity, the absence of community
pharmacists integration in the PHC network will limit
the gains in efficiency associated to pharmaceutical care
From scenarios to reality roadmap to develop
pharmacists new role
One can argue that to sustain the benefits of the
envisioned change, an integrated and longitudinal perspective
of services provision should be considered, requiring
event registering, comprehensive data analysis, and
interactive dialogue with patients, i.e., enabling a more
sophisticated use of information systems. Health care services
should be based on health knowledge, people, and
technology supporting health care processes. Future
pharmaceutical care services should be developed to first deliver
valued information to patients and health professionals.
This could only work if community pharmacists assume
their role as caregivers, supported by adequate
information systems, developing caring abilities, and also taking
responsibility for patients therapeutic results, which is
essential to the practice of pharmaceutical care and other
professional services . However, this patient-centred
practice will also require curricula adaptation towards
clinical practice [62-64], without losing sight of all issues
related to drug discovery, development, delivery, and use,
from applied pharmacology to pharmacoepidemiology.
Information systems will have an important impact on
the definition of new roles for community pharmacists
[10,65-68]. The proper use of technological solutions
could relief pharmacists workload, sparing time to
perform pharmaceutical care functions. These functions will
be supported by new technological solutions such as the
remote monitoring of patients [56,69,70].
The relation with other health professionals is also
essential to the diffusion of this new kind of practice
and for the real integration of community pharmacists
in primary health care. Firstly, the role of pharmacy
technicians has to be clarified. Nowadays, pharmacists
are the larger workforce in Portuguese community
pharmacy, being required to perform activities that
could be performed by technicians with more
efficiency. In an exploratory study made recently, Lapo
et al.  found that pharmacists and technicians are
doing the same activities, with pharmacists spending
40% of their time on non-professional tasks. From these
findings, it is clear that a better organization of internal
functioning of pharmacies is needed, with precise role
definition, delegation of tasks, and supervision
mechanisms in place if Portuguese community pharmacists
want to move beyond medicine dispensing.
A good interprofessional relationship with physicians
is an important factor in integrating pharmacists in the
PHC network as are interpersonal skills and an
adequate communication with all elements of the health
care team [72-74]. However, the relationship with
physicians is frequently reported as a major barrier to the
development of pharmacists new roles in the community
[75,76]. Moreover, nurses have taken roles in primary care
provision that could be performed by pharmacists, and
this evolution within the health care team is something
that community pharmacists should take into account
[77,78]. It is important for the community pharmacists to
be aware of other health professionals competencies and
skills and vice-versa, probably through educational sharing
at the university level, in order to stimulate synergisms
which best serve the community health needs.
This kind of study is particularly important to generate
new research questions that will help design the best
strategies to enforce an effective change in Portuguese
community pharmacists role. Below are some examples
of possible questions that followed the scenario analysis.
Emerging research questions
What will the impact of the International Monetary
Fund/European Central Bank Memorandum of
Understanding in the pharmacy business be;
What impact will the reorganization of the
community pharmacy sector in the role of the
community pharmacist have;
What will the future needs of community
pharmacists in Portugal be;
What expectations do the community pharmacists
have for their future;
What services will patients really need from
Are todays community pharmacists curricula
adapted to future practices;
What would the impact of a community pharmacist
working in PHC, either in a health care centre or in
a health care trust, be;
What new information technologies may be used,
how should these be used, and what impact will
they have in developing new services.
Further, it will be interesting to define a set of indicators
that enables the monitoring of community pharmacists
role evolution. The information gathered in this indicators
would help to support better policy making and human
The scenarios here depicted do not intend to predict or in
any way define the future of Portuguese community
pharmacists. Rather, they should be seen as a way to frame
possible futures, in order to stimulate new forms of
practice and prepare the best strategies in an ever-changing
society . Bearing this in mind, the choice of two
driving forces and the use of a 2 2 matrix may result in a set
of arbitrary scenarios. If other driving forces were chosen,
different scenarios would be designed. With the
methodology described herein we intended to choose the driving
forces that seemed to better frame all possible futures,
considering them as a starting point instead of a fully
This methodology is somewhat subjective, which results
in a process easily weakened by some traps that are
usually related either to the way this process is conducted
inside an organization (team composition; brainstorming vs.
interviews) or to the scenarios time frame (short-term vs.
long-term). One of the most common traps that
planners face when developing scenarios is to consider the
scenarios as a fixed prediction of the future or to bet in only
one scenario, instead of looking at alternatives. The
scenario analysis is a flexible process meant to be adjusted to
future developments. All these difficulties were considered
as a natural part of a scenario planning such as this, but
they can also be seen as a weak point of this methodology.
The use of scenario analysis in a strategic thinking process
has demonstrated to be of value while planning for future
human resources and other policy issues. It creates a good
setting for stakeholders to be more involved, and discuss
and study common issues. With the present scenarios, it
is possible to anticipate future community pharmacists
needs, at market and educational level, thus providing
valued information to health regulators and planners.
From these scenarios, it is clear that the foreseen changes
in pharmacy practice will potentiate the development of
new roles for Portuguese community pharmacists in the
future health care system. The new role will require
significant legislative changes, adequate financial incentives and
other behavioural changes, namely an entrepreneur
mindset and innovators dynamics. Ideally, the new role will
balance the traditional dispensing with a clinical orientation,
emerging from pharmaceutical care practice and disease
managing programs. Defining a model to finance these
services will be vital to preserve community pharmacists
contribution and the overall equity of the Portuguese health
Changing all parties perceptions, from patients to other
health professionals, health authorities, and community
pharmacists, is critical for embracing a new paradigm in
pharmaceutical services provision. In this collaboration,
properly designed information systems and technologies
will have a very important role, opening the opportunity
for community pharmacists to assume true responsibility
for patient and disease management.
The practice change will imply new ways of working
and interacting with patients, physicians, and other PHC
professionals. The envisaged practice change, proposed by
the prospective scenarios, would only be effective if all
involved professionals are included. The professional
organizations have now to show leadership and coordinate
strategies to ensure that the new practice might reach all
practitioners in a near future for the benefit of the health
JG carried out the literature review, conducted the scenario workshop
sessions, collected and interpreted data, and drafted the manuscript. AC
carried out the final revision for important intellectual content. LVL
conceived the study, participated in its design and coordination, and helped
to draft the manuscript. All authors read and approved the final manuscript.
Part of this research was funded by Fundao para a Cincia e Tecnologia
under the number PTDC/CCI-CIN/122690/2010. The authors acknowledge
with thanks all the pharmacy experts for their invaluable participation in the
scenario workshops, and the key informants who so willingly contributed to
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