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Introduction: The Most Accessible Clinician You Never See
In the sprawling urban neighborhoods of Lagos, the dusty trading posts of northern Kenya, and the hillside villages of Uganda, there is a healthcare professional who requires no appointment, no referral, and often, no payment for consultation. They are open on weekends, after hours, and during holidays. They know their patients by name, understand their family histories, and are trusted implicitly by the communities they serve. The global healthcare landscape is shifting from a product-centered model to a patient-centered clinical approach. Central to this evolution is the
They are community pharmacists, and across Africa, they are the forgotten frontline of primary healthcare. Community pharmacists are among the most accessible healthcare professionals worldwide. Their role has significantly evolved due to:
- Physician shortages
- Increasing burden of chronic diseases
- Demand for decentralized primary healthcare
Globally, pharmacists now contribute to primary healthcare delivery, including prescribing, screening, and preventive services. However, Eastern Africa (Like Rwanda, Kenya, Uganda, Tanzania) largely maintains a restricted scope, limiting pharmacists' contribution to health systems despite growing needs.
Recent data from Nigeria reveals a striking pattern: nearly 60 percent of patients seek advice from pharmacists before visiting hospitals [8]. This statistic, emerging from a March 2026 stakeholder engagement organized by the Association of Community Pharmacists of Nigeria (ACPN), confirms what health systems researchers have long suspected that the neighborhood pharmacy is often the first, and sometimes only, point of contact between citizens and the formal health system.
Yet despite this proximity and trust, the community pharmacist in most African countries operates with a scope of practice that would be unrecognizable to their counterparts in the United States, Canada, the United Kingdom, France, or Australia. While pharmacists in Western nations increasingly prescribe medications, manage chronic diseases, and function as integrated members of primary care teams, their African colleagues remain constrained by regulations written in an era when the pharmacist's role began and ended at the dispensing counter.
This article offers a comprehensive comparative analysis of community pharmacists' scope of practice in Eastern Africa against global standards. Drawing on updated 2025-2026 data, systematic reviews, and policy documents from multiple jurisdictions, it examines the gaps, identifies the barriers, and charts a path toward full implementation of expanded pharmacy practice. The stakes could not be higher: in a region facing critical health worker shortages, rising burdens of non-communicable diseases, and persistent antimicrobial resistance, unlocking the full potential of community pharmacists may be one of the most cost-effective investments available to health systems.
Defining the Full Scope of Practice
The Evolution of a Profession
To understand what is possible, we must first understand how the pharmacy profession has evolved globally. Fifteen years ago, a community pharmacist's role in the United States was limited to dispensing medication. Five years ago, it expanded to include administering routine vaccines. Today, according to a January 2026 analysis in the NEJM Catalyst Innovations in Care Delivery, the trajectory points toward a future where pharmacists conduct minor acute illness evaluation and treatment, chronic disease prevention, and complex disease management including independent medication prescribing [2].
This evolution, which the NEJM Catalyst authors describe as well under way in many other countries, responds to a fundamental reality: primary care systems are under unprecedented strain. Physician shortages, aging populations, and the rising burden of chronic disease have created gaps that traditional delivery models cannot fill. Community pharmacies, with their accessibility, extended hours, and embedded community relationships, offer a solution that requires no new infrastructure only policy reforms and investments in workforce development [2].
The Elements of Full Scope Practice
What constitutes full scope of practice for community pharmacists? Full scope of practice refers to pharmacists practicing to the maximum level of their training and competency, including:
- Independent or collaborative prescribing
- Vaccination and injectable administration
- Chronic disease management
- Laboratory testing and interpretation
- Minor ailment management
- Medication therapy management (MTM)
- Health promotion and screening
Countries such as Canada, the UK, and parts of the USA have institutionalized these roles. Based on international standards and the frameworks emerging in leading jurisdictions, we can identify several core elements:
The United Kingdom leads in this domain. From September 2026, all newly qualified pharmacists in England will enter the General Pharmaceutical Council register as independent prescribers [4]. The NHS Community Pharmacy Independent Prescribing Pathfinder Programme, already operational in selected sites, enables pharmacists to manage hypertension, conduct hormone replacement therapy (HRT) reviews, and optimize lipid management. Early results are promising: by August 2025, 251 patients had been seen through the south west London pathfinder sites, with 96 percent indicating they would like more clinics available in pharmacy settings [10].
Australia is advancing rapidly as well. In South Australia, Regulation 17A of the Controlled Substances (Poisons) Regulations 2011 now permits authorized pharmacists to prescribe certain Schedule 4 (Prescription Only) medicines, provided they are included on a public register and comply with the Community Pharmacist Prescribing Code [5]. The code specifies training requirements, clinical practice guidelines, and conditions for prescribing, creating a structured pathway for role expansion.
The United States is progressing unevenly but decisively. In Washington State, Substitute Senate Bill 5924, passed during the 2026 regular session, explicitly expands the legal definition of pharmacy practice to include limited diagnosing and prescribing or ordering of drugs and devices . The legislation explicitly states the legislature's intent to improve patient outcomes for behavioral and physical health by permitting pharmacists to practice at the top of their education, training, and experience [9].
In Canada, pharmacists are authorized to renew existing prescriptions in limited circumstances and may adapt the formulation, regimen, duration, or route of administration of medication [3]. These adaptations, while falling short of full independent prescribing, significantly reduce the burden on primary care and improve patient convenience.
The Competencies Underpinning Expanded Practice
Expanded scope is not simply a matter of regulatory permission; it requires corresponding competencies. A systematic review published in Pharmacy in November 2025 analyzed 23 studies of pharmacist prescribing and identified four thematic clusters: expanding clinical roles and self-perceived readiness; regulatory frameworks; inferred competencies; and implementation barriers [6].
The competency framework that emerged distinguishes between micro-skills patient assessment, application of clinical guidelines and macro-capabilities such as clinical judgment, accountability, and reflective practice [6]. These capabilities cannot be assumed; they must be developed through structured training, supervised practice, and continuing professional development.
Importantly, the review found that pharmacist prescribing is safe and patient-centered when supported by regulation, structured training, and systemic integration [6]. Safety concerns, while legitimate, are addressable through well-designed systems rather than serving as an insurmountable barrier to role expansion.
The Eastern African Reality
In high-income health systems, the Scope of Practice has expanded to include independent prescribing, chronic disease management, and advanced point-of-care testing. To reach these standards, African practitioners must prioritize
For instance, while global models utilize pharmacists as primary leads in cardiovascular health, African pharmacists are just beginning to adopt standardized protocols, such as those found in this
Global Leaders (USA, Canada, UK, France, Australia)
Key Features- Prescribing authority (independent or collaborative)
- Vaccination programs (routine and travel vaccines)
- Chronic disease clinics (hypertension, diabetes, asthma)
- Laboratory services (ordering/interpreting tests)
- Medication adaptation & renewal
- Reimbursement systems for clinical services
Eastern Africa (Rwanda, Kenya, Uganda, Tanzania)
Current Scope- Dispensing and supply of medicines
- Basic patient counseling
- Limited participation in public health campaigns
- Minimal involvement in clinical decision-making
- Antimicrobial stewardship participation
- Health education
- Limited screening programs
- Prescribing authority
- Diagnostic testing
- Clinical service reimbursement
- Integration into primary healthcare teams
.png "Community Pharmacists Scope Comparison: Eastern Africa vs Global Standards")
The Current Scope: A Snapshot
Against this global backdrop, the scope of practice for community pharmacists in Eastern Africa appears strikingly limited. While precise regulations vary across Kenya, Uganda, Tanzania, Rwanda, and Ethiopia, common patterns emerge.
In most Eastern African countries, the pharmacist's legally defined role centers on dispensing medications according to prescriptions issued by authorized prescribers. Patient consultation, while common in practice, occurs in a regulatory vacuum neither explicitly authorized nor prohibited, but certainly not structured or reimbursed as a formal health service.
The contrast with global standards is most stark in prescribing authority. No Eastern African country currently authorizes community pharmacists to independently prescribe medications, even for minor ailments. While some pharmacists may informally advise patients and recommend non-prescription products, the boundary between legitimate advice and illegal prescribing remains poorly defined and inconsistently enforced.
Chronic disease management, where it occurs, is informal and undocumented. A pharmacist may counsel a regular customer with hypertension about medication adherence, check their blood pressure if a device is available, and offer lifestyle advice but these activities are not recognized as formal health services, are not recorded in any health information system, and are not eligible for reimbursement.
Vaccination services, while growing in some countries, remain exceptional rather than routine. The infrastructure for pharmacist-administered vaccination cold chain capacity, training, liability protection, and reimbursement mechanisms is largely absent.
The Awareness-Implementation Gap
The most troubling finding from recent research concerns not what pharmacists are permitted to do, but what they actually do particularly around antimicrobial dispensing. Expanding the scope of practice is not without its hurdles. Without robust regulatory frameworks, there is a heightened risk of
A systematic review of antimicrobial stewardship practices in sub-Saharan Africa, published in January 2026, assessed 26 studies conducted between 2010 and mid-2024 [7]. The findings are sobering. While community pharmacists, accredited drug dispensers, and patent medicine vendors are generally aware of antimicrobial resistance and the principles of antimicrobial stewardship, non-prescription antibiotic dispensing remains highly prevalent, with a median rate of 67.5 percent [7].
This is not a knowledge gap; it is an implementation gap. Pharmacists know that dispensing antibiotics without a prescription is wrong, contributes to resistance, and violates regulations. Yet they do it anyway, driven by economic pressures (refusing a sale means losing a customer to a competitor), patient expectations (customers demand antibiotics and will go elsewhere if refused), and weak regulatory enforcement (the probability of consequences is low).
The review found that very few studies reported concrete antimicrobial stewardship interventions, and implementation is consistently undermined by weak regulatory enforcement, economic pressures, and entrenched dispensing practices despite adequate knowledge [7].
This gap between awareness and practice has profound implications for scope expansion. If pharmacists cannot be trusted to adhere to existing regulations around antibiotic dispensing, how can they be entrusted with broader prescribing authority? The question is not rhetorical, and it demands an answer grounded in systemic analysis rather than professional defensiveness.
The Nigerian Case: Progress Amidst Constraints
Nigeria, while geographically West African, offers insights relevant to the Eastern African context. In March 2026, community pharmacists convened in Abuja for a strategic stakeholder engagement organized by the ACPN and the Community Pharmacists Assessment and Career Progression Institute (CPACPI) [8].
The central agenda was the CPACPI framework a structured professional pathway designed to move community pharmacies beyond their traditional role of dispensing medicines toward providing broader services including preventive care, disease management, and maternal and reproductive health support [8].
The framework introduces a five-level professional progression ladder:
- Community Pharmacist
- Senior Community Pharmacist
- Community Pharmacy Specialist
- Community Pharmacy Senior Specialist
- Community Pharmacy Consultant
This structure links career advancement with measurable clinical outcomes, mentorship, and regular professional appraisal, aiming to improve service quality and strengthen the health workforce [8].
The framework has already gained international recognition after being presented at the global congress of the International Pharmaceutical Federation in Copenhagen, where it was described as an innovative model for advancing pharmacy practice .
Yet the challenges remain substantial. The ACPN has called on government institutions and lawmakers to provide the policy and legislative support needed to implement the framework [8]. Without enabling regulations, reimbursement mechanisms, and integration with the broader health system, even the most elegant professional framework cannot translate into changed practice.
The Pharmacy as Healthcare Hub Vision
The vision articulated by Nigerian pharmacists resonates across the continent: transforming community pharmacies into key healthcare hubs capable of delivering a wider range of primary healthcare services [8].
This vision recognizes the unique position of community pharmacies. They are everywhere in urban centers, rural towns, and peri-urban settlements. They are accessible without appointments, during hours when clinics are closed. They are trusted, often more than distant and impersonal health facilities. And they are staffed by professionals with extensive training in pharmacology, therapeutics, and patient communication.
The question is not whether community pharmacies could serve as primary healthcare hubs. The evidence from high-income countries demonstrates conclusively that they can. The question is what it will take to realize this potential in Eastern African contexts, where regulatory frameworks are weaker, health systems are more fragmented, and resources are more constrained.
Comparative Analysis of Scope Elements
To make the comparison concrete, the following table analyzes specific elements of pharmacy practice across Eastern African countries and comparator jurisdictions, based on available data and regulatory frameworks.
| Scope Element | Eastern Africa (Typical) | USA (Leading States) | Canada | United Kingdom | Australia | France |
|---|---|---|---|---|---|---|
| Independent Prescribing | Not authorized | Limited authorization (e.g., state-level protocols such as WA State SB 5924, 2026) | Limited (primarily adaptation-based prescribing) | Full authorization for qualified pharmacists (from Sept 2026) | Authorized for selected Schedule 4 medicines (e.g., South Australia) | Limited |
| Prescription Adaptation | Not authorized | Authorized under collaborative practice agreements (CPAs) | Authorized (dose, duration, formulation, renewal) | Authorized | Authorized under protocols | Limited |
| Minor Ailment Management | Informal, non-regulated | Expanding across states | Formal, publicly funded programs | Fully established (e.g., NHS Pharmacy First) | Established | Limited |
| Chronic Disease Management | Informal only | Expanding (e.g., hypertension, diabetes management) | Limited but structured in some provinces | Formal pharmacist-led services (e.g., hypertension, lipid management, HRT) | Emerging | Limited |
| Vaccination Services | Rare / pilot-based | Routine (influenza, COVID-19, travel vaccines) | Routine | Routine (NHS-led programs) | Routine | Limited |
| Point-of-Care Testing (POCT) | Variable, largely unavailable | Expanding (e.g., COVID-19, strep, HbA1c) | Common | Common | Common | Limited |
| Diagnostic Authority | None | Limited diagnosing authority in some states (e.g., Washington State) | Not formally defined | Limited (linked to prescribing rights) | Not formally defined | None |
| Formal Recognition in Health System | Minimal integration | Growing integration into primary care | Established | Fully integrated within NHS | Established | Limited |
| Reimbursement for Clinical Services | None | Emerging (insurance-based models) | Available in some provinces | Established (NHS-funded services) | Available in selected programs | Limited |
| Structured Competency Framework | Emerging (e.g., Nigeria CPACPI model) | Established national frameworks | Established | Established (GPhC, NHS frameworks) | Established | Established |
This comparison reveals the magnitude of the gap. In every dimension of expanded practice, Eastern African pharmacists operate with a fraction of the authority granted to their counterparts in leading jurisdictions. The gap is not incremental but fundamental a difference in kind rather than degree.
The Regulatory Architecture Deficit
Underpinning these specific gaps is a broader deficit in regulatory architecture. In jurisdictions with advanced pharmacy practice, scope expansion occurs within a framework of enabling legislation, implementing regulations, competency standards, training requirements, and quality assurance mechanisms.
South Australia's approach illustrates the model. Expanded scope is legally enabled under the Controlled Substances (Poisons) Regulations 2011, with specific provisions (Regulation 17A) authorizing pharmacist prescribing [5]. An implementing code the Community Pharmacist Prescribing Code sets out detailed requirements for pharmacists, prescribing, training, and the specific Schedule 4 medicines that may be prescribed, including any restrictions or conditions [5]. A public register of authorized pharmacists enables verification of credentials and prescription authenticity [5].
This layered architecture statute, regulation, code, register creates the conditions for safe, accountable expansion. Each element addresses a specific risk: the statute grants authority, the regulation specifies parameters, the code provides detailed guidance, and the register enables transparency and verification.
Eastern African countries lack most of these elements. Pharmacy practice acts, where they exist, were written in an era when the pharmacist's role was assumed to be dispensing. Regulations have not kept pace with evolving professional capabilities. Competency standards for advanced practice are absent. Public registers of qualified professionals, while sometimes maintained, are not integrated with prescribing authority or prescription verification.
Filling this regulatory architecture deficit is the foundational task for any jurisdiction seeking to expand pharmacy scope. Without it, expanded authority risks becoming unaccountable authority a danger for patients and a vulnerability for the profession.
Gaps and Barriers in Eastern Africa
A. Regulatory Barriers
- Restrictive pharmacy laws
- Lack of prescribing frameworks
- Absence of national scope expansion policies
B. Workforce and Training Limitations
- Insufficient clinical training
- Lack of leadership development
- Limited postgraduate specialization
C. Health System Constraints
- Poor integration into primary care
- Physician dominance in clinical decision-making
- Weak interprofessional collaboration
D. Financial and Structural Barriers
- No reimbursement for cognitive services
- Retail-focused pharmacy model
- Limited infrastructure (labs, digital systems)
E. Perception and Awareness Issues
- Public perception of pharmacists as dispensers
- Policymaker under-recognition of pharmacists' potential
Benefits of Full Scope Implementation
The case for expanding pharmacists' scope of practice rests on multiple pillars: improved access, reduced costs, enhanced quality, and strengthened health systems. Each deserves examination in the Eastern African context.
Improved Access to Care
Access is the most intuitive benefit. In regions where physician density is low often below 1 per 10,000 population in rural areas pharmacists represent a distributed, accessible clinical workforce that already exists. No new training institutions are required. No new facilities must be built. No new recruitment campaigns are needed. The pharmacists are already there, in their communities, practicing at a fraction of their potential.
Expanding pharmacist roles leads to:
- Better chronic disease control
- Improved medication adherence
- Reduced hospitalizations
Studies show expanded roles significantly improve outcomes such as asthma control and medication adherence.
The NEJM Catalyst analysis emphasizes this point: expanded pharmacy scope would help to relieve pressure on primary care, control costs, improve outcomes, and increase access to essential services, particularly in rural communities [2]. For a patient with hypertension in a Kenyan village, a monthly trip to a district hospital may require a full day, transportation costs, and lost wages. A visit to the local pharmacy, where the pharmacist is authorized to check blood pressure, adjust medications, and provide refills, transforms chronic disease management from burdensome to sustainable.
The numbers from the NHS Pathfinder Programme are instructive. By August 2025, 251 patients had been seen in pharmacy settings for conditions that would otherwise have required general practitioner visits [10]. The 96 percent patient satisfaction rate with patients indicating they would like more pharmacy-based clinics confirms that this model meets patient preferences, not just system needs [10].
Reduced Burden on Overstretched Systems
Health systems across Eastern Africa face impossible demands. The physician-to-population ratios are among the lowest globally. Nurses and clinical officers manage workloads that would be unthinkable in high-income countries. Referral hospitals are overwhelmed with patients whose conditions could have been managed at primary level.
- Pharmacists serve as first point of contact
- Reduced burden on physicians
- Improved rural healthcare access
Every condition managed by a pharmacist is one less condition consuming physician time. Every prescription renewed without a physician visit frees appointment slots for more complex cases. Every patient educated about self-management by a pharmacist reduces the likelihood of costly complications and emergency visits.
- Task-shifting reduces workload on doctors
- Shorter waiting times
- Cost-effective care delivery
The NHS explicitly frames its Independent Prescribing Pathfinder Programme as a response to growing pressures in primary care [10]. For patients not eligible for pharmacy review, the programme still supports general practices by increasing overall system capacity, as a proportion of patients are managed in pharmacy settings [10]. This is not substitution but supplementation a way to multiply the effectiveness of the existing workforce.
Economic Efficiency
The economic case for expanded pharmacy scope is compelling, though specific data for Eastern Africa are limited. In high-income countries, the savings accrue through multiple channels: reduced physician visits, lower facility costs, avoided transportation expenses, and fewer lost work hours.
- Reduced healthcare costs
- Improved productivity
- Optimized workforce utilization
For health systems operating on constrained budgets, the cost-effectiveness of pharmacist-delivered care is particularly attractive. Pharmacist salaries are typically lower than physician salaries. Pharmacy infrastructure already exists and is privately financed. The marginal cost of adding clinical services to existing pharmacy operations is modest compared to building new clinics or hiring new physicians.
For patients, the savings are equally real. A consultation with a pharmacist is typically free or low-cost, compared to physician consultation fees, transportation costs, and time away from work or family responsibilities.
Quality and Safety
The safety of pharmacist prescribing is no longer speculative. The November 2025 systematic review concluded that pharmacist prescribing is safe and patient-centered when supported by regulation, structured training, and systemic integration [6].
Safety is not automatic, but it is achievable. The key elements are well-understood: clear protocols defining what pharmacists may and may not do; training requirements ensuring competency; supervision and support mechanisms for complex cases; and data systems enabling monitoring and continuous improvement.
For conditions like hypertension, where treatment follows standardized protocols and monitoring is straightforward, pharmacist management may be as safe as physician management and potentially safer if improved access leads to better adherence and follow-up.
Antimicrobial Stewardship
The antimicrobial stewardship crisis in sub-Saharan Africa with non-prescription dispensing rates exceeding 67 percent [7] is often cited as a reason not to expand pharmacist authority. The logic seems compelling: if pharmacists cannot be trusted to follow existing rules, why give them more authority?
But this logic may be backward. One reason for non-prescription dispensing is the absence of legitimate pathways for pharmacists to respond to patient needs. When a patient presents with symptoms suggesting a minor infection, the pharmacist faces a choice: refuse, and send the patient away empty-handed (likely to seek antibiotics elsewhere, possibly from an unqualified vendor), or dispense without a prescription, violating regulations but potentially meeting a genuine health need.
- Expanded vaccination coverage
- Enhanced antimicrobial stewardship
- Better epidemic response capacity
Formal minor ailment schemes create a third path. The pharmacist can assess the patient, determine whether antibiotics are indicated, and if so, provide them under clear protocols with documentation, patient education, and follow-up. This legitimate pathway reduces the pressure for illegitimate dispensing and brings antimicrobial use into the regulated system where it can be monitored and stewarded.
The systematic review's finding that implementation is consistently undermined by weak regulatory enforcement, economic pressures, and entrenched dispensing practices [7] suggests that the problem is systemic, not individual. Addressing it requires systemic solutions of which expanded, structured practice authority is one component.
Professional Fulfillment and Workforce Retention
The human dimension of scope expansion matters. Pharmacists are highly trained professionals who, in most Eastern African contexts, practice far below their capabilities. The resulting frustration contributes to burnout, emigration, and departure from the profession.
Expanded scope offers the possibility of professional fulfillment of practicing at the top of one's license, using clinical skills acquired through years of training, and experiencing the satisfaction of direct patient care. The CPACPI framework in Nigeria explicitly links career progression with measurable clinical outcomes, mentorship, and regular professional appraisal, helping to improve service quality and strengthen the health workforce [8].
For health systems struggling to retain skilled professionals, this intrinsic motivation matters. A pharmacist who feels valued, challenged, and effective is more likely to remain in practice and in country.
Overcoming Challenges for Full Implementation
The benefits of expanded scope are clear, but so are the challenges. Translating aspiration into reality requires addressing multiple barriers systematically. Full implementation of an expanded scope requires more than just policy changes; it requires infrastructure.
Regulatory Reform
The foundational challenge is regulatory. Most Eastern African countries operate under pharmacy laws and regulations that predate the modern conception of pharmacists' clinical role. These frameworks must be revised to explicitly authorize expanded practice not just by removing prohibitions but by creating enabling structures.
The South Australian model offers a template. Authorizing legislation creates the possibility; implementing regulations specify the parameters; detailed codes provide guidance; public registers enable accountability. Each layer builds on the previous, creating a coherent architecture for safe expansion.
Regulatory reform also requires addressing the tension between professional advancement and public protection. Expanded authority must be accompanied by enhanced accountability clear standards, meaningful oversight, and effective enforcement. Professional bodies have a critical role in shaping these frameworks and demonstrating that the profession can regulate itself effectively.
Competency Development
Authority without competence is dangerous. Expanding pharmacists' scope must be accompanied by investments in competency development, both pre-service and in-service.
The competency framework emerging from the systematic review [6] provides guidance. Micro-skills patient assessment, guideline application must be systematically taught and assessed. Macro-capabilities clinical judgment, accountability, reflective practice must be cultivated through supervised experience and continuous professional development.
The CPACPI framework in Nigeria [8] represents one approach to structured competency development. Its five-level progression ladder links career advancement with demonstrated competence, creating incentives for continuous improvement and recognizing achievement.
But frameworks alone are insufficient. They must be backed by training programs, assessment mechanisms, and quality assurance systems. They must be accessible to pharmacists across diverse practice settings, including those in rural and remote areas. And they must be sustainable funded through mechanisms that do not depend on donor projects or short-term initiatives.
Health System Integration
Expanded pharmacy practice cannot succeed in isolation. Pharmacists must function as part of integrated health systems, with clear referral pathways, shared information, and collaborative relationships with other providers.
The NHS Pathfinder Programme explicitly situates pharmacy prescribing within an integrated workforce model in primary care [4]. The programme aims to enable Integrated Care Boards to commission pathways that widen access to care and tackle health inequalities by using the unique footprint that community pharmacy creates in local neighbourhoods [4].
This integration has multiple dimensions. Clinical integration requires clear protocols for when pharmacists should manage patients independently, when they should consult with other providers, and when they should refer. Information integration requires systems for sharing patient data across settings, ensuring that all providers have access to the information they need. Accountability integration requires clear lines of responsibility and mechanisms for coordinating care across providers.
In Eastern African contexts, where health information systems are often fragmented and interoperability is limited, achieving this integration will require substantial investment. But the investment is necessary; expanded pharmacy practice without integration risks creating parallel, uncoordinated care rather than strengthening the system as a whole.
Reimbursement Mechanisms
For expanded practice to be sustainable, it must be reimbursed. Pharmacists cannot be expected to provide clinical services without compensation, and health systems cannot rely on volunteerism to deliver essential care.
Reimbursement mechanisms vary across jurisdictions. In the NHS model, pharmacy clinical services are commissioned by Integrated Care Boards and reimbursed through the Community Pharmacy Contractual Framework [4]. In Australia, specific services may be reimbursed through public or private insurance. In the United States, reimbursement is evolving through Medicare, Medicaid, and commercial insurance.
In Eastern Africa, where insurance coverage is limited and out-of-pocket payments predominate, reimbursement mechanisms must be adapted to local realities. Options include:
- Public financing through government budgets, targeting priority services (e.g., hypertension management, family planning)
- Social health insurance where schemes exist, covering pharmacy services as part of benefit packages
- Community-based financing through mutual health organizations or other local mechanisms
- Appropriate user fees with exemptions for vulnerable populations
Whatever mechanism is chosen, the principle is clear: if pharmacy services are valued, they must be funded. Reliance on pharmacists' goodwill or cross-subsidization from product sales is unsustainable and inequitable.
Addressing Antimicrobial Resistance
The antimicrobial stewardship crisis cannot be ignored in any discussion of pharmacy scope expansion. The 67.5 percent non-prescription dispensing rate documented in the systematic review [7] is a stain on the profession and a threat to public health.
Expanded scope offers both risks and opportunities regarding antimicrobial resistance. The risk is that broader prescribing authority could increase inappropriate antibiotic use if not accompanied by robust stewardship. The opportunity is that structured minor ailment schemes could bring antibiotic dispensing into the regulated system, replacing illegal, undocumented dispensing with legal, documented, and stewarded practice.
Realizing the opportunity requires several elements:
- Clear protocols defining when antibiotics are and are not indicated for common conditions
- Training in antimicrobial stewardship principles and application
- Documentation requirements enabling monitoring of prescribing patterns
- Feedback systems providing pharmacists with data on their prescribing compared to peers and guidelines
- Enforcement for persistent non-compliance
The systematic review's finding that implementation is consistently undermined by weak regulatory enforcement [7] highlights the importance of the last element. Regulations without enforcement are merely suggestions, and suggestions are insufficient to change behavior in the face of economic pressures and patient expectations.
Technology and Data Systems
Modern pharmacy practice depends on technology. Electronic health records, clinical decision support systems, e-prescribing, and data analytics enable safe, efficient, and accountable care.
In Eastern African contexts, technology infrastructure is often limited. Pharmacies may lack computers, reliable internet, or electricity. Health information systems may not extend to the pharmacy sector. Interoperability between pharmacy systems and other health records is rare.
Investments in technology and data systems are essential enablers of expanded practice. These investments need not replicate high-income country models; mobile-based solutions, offline-capable systems, and appropriate technologies can achieve many objectives at lower cost. But some level of digital infrastructure is non-negotiable for safe, accountable expanded practice.
Professional Identity and Culture
The most subtle but perhaps most important challenge concerns professional identity and culture. Many pharmacists trained in traditional dispensing roles may not see themselves as clinical practitioners. Many may lack confidence in their clinical abilities. Many may resist the additional responsibilities and accountabilities that expanded scope entails.
The CPACPI framework explicitly addresses this dimension, aiming to improve professional confidence among pharmacists working in private practice [8]. The framework's emphasis on mentorship, regular appraisal, and structured career progression recognizes that professional identity is not fixed but developed through experience and recognition.
Cultural change takes time. It requires leadership from professional associations, modeling from early adopters, and reinforcement through education and practice. But it is essential; expanded scope imposed on unwilling practitioners will fail, regardless of regulatory permissions.
Multi-Stakeholder Collaboration
Finally, expanded pharmacy practice cannot be achieved by pharmacists alone. It requires collaboration across multiple stakeholders: government ministries, regulatory bodies, professional associations, educational institutions, other health professions, payers, and patients.
The ACPN's March 2026 meeting exemplified this collaborative approach, bringing together "government agencies, regulatory bodies, development partners, professional associations and private sector organizations [8]. The resulting communiqué urged legislators to provide institutional backing while also encouraging pharmacy owners and individual pharmacists to participate in professional development programs [8].
The systematic review's conclusion emphasizes that successful implementation requires training, funding, acceptance, and integration [6] each of which demands action from different stakeholders. Training requires educational institutions. Funding requires payers and governments. Acceptance requires other health professions and the public. Integration requires health system leadership.
A Roadmap for Eastern Africa
Drawing on the comparative analysis and implementation challenges discussed above, what might a roadmap for expanding pharmacists' scope in Eastern Africa look like?
Phase 1: Foundation Building (Years 1-3)
The initial phase focuses on creating the enabling conditions for expanded practice:
Regulatory Review and Reform: Conduct comprehensive review of pharmacy laws and regulations to identify barriers to expanded practice. Develop amendments authorizing structured scope expansion, drawing on international models. Create regulatory architecture statute, regulations, codes, registers for safe implementation.
Competency Framework Development: Adapt existing competency frameworks (e.g., from the systematic review [6]) to Eastern African contexts. Define competencies required for various levels of practice. Develop assessment mechanisms.
Stakeholder Engagement and Consensus Building: Engage government, regulators, professional associations, other health professions, and patient groups in dialogue about expanded practice. Address concerns, build trust, and develop shared vision. Learn from Nigeria's CPACPI stakeholder engagement model [8].
Pilot Design: Design pilot programs for specific expanded services (e.g., hypertension management, minor ailment treatment) in selected pharmacies. Develop protocols, training materials, and monitoring systems.
Phase 2: Piloting and Learning (Years 2-5)
The second phase tests expanded practice in controlled settings, generating evidence and refining approaches:
Pilot Implementation: Launch pilot programs in diverse settings urban and rural, public and private, standalone and integrated. Provide training and support to participating pharmacists.
Data Collection and Evaluation: Collect rigorous data on processes, outcomes, safety, and patient experience. Compare pilot sites with control sites. Identify what works, what doesn't, and why.
Refinement and Adaptation: Use pilot findings to refine protocols, training, and implementation approaches. Address unanticipated challenges. Build evidence base for scale-up.
Antimicrobial Stewardship Integration: Ensure pilots incorporate robust antimicrobial stewardship elements. Document impact on prescribing patterns and resistance-related outcomes.
Phase 3: Phased Scale-Up (Years 4-8)
The third phase expands successful approaches more broadly:
Regulatory Implementation: Implement regulatory reforms enabling expanded practice beyond pilots. Establish registration systems for authorized pharmacists.
Training Scale-Up: Integrate expanded competencies into pre-service pharmacy curricula. Develop continuing professional development programs for practicing pharmacists. Train sufficient pharmacists to meet demand.
Reimbursement Mechanisms: Establish sustainable reimbursement for clinical services. Integrate pharmacy services into health financing mechanisms public budgets, insurance schemes, or appropriate user fees.
Health System Integration: Develop referral pathways, information sharing mechanisms, and collaborative practice arrangements. Ensure pharmacists function as part of integrated primary care teams, not parallel providers.
Monitoring and Quality Improvement: Establish systems for ongoing monitoring of expanded practice prescribing patterns, patient outcomes, safety events. Use data for continuous quality improvement.
Phase 4: Full Integration (Years 7-10)
The final phase achieves full integration of pharmacists as clinical practitioners within health systems:
Universal Access: Ensure all communities have access to pharmacies providing expanded services. Address geographic and economic barriers.
Advanced Practice Pathways: Develop pathways for advanced practice pharmacists with specialized competencies in areas like chronic disease management, mental health, or HIV care.
A broader scope of practice allows pharmacists to intervene in critical areas like mental health and substance abuse. This includes addressing the
Research and Innovation: Establish research programs evaluating impact and identifying innovations. Contribute to global evidence base on pharmacy practice in LMICs.
Regional Harmonization: Work toward regional harmonization of standards and competencies, facilitating mobility and mutual recognition.
Conclusion: The Time for Change
Ultimately,
The distance between these two visions is not measured in kilometers but in policy decisions, regulatory reforms, and investments in people and systems. It is a distance that pharmacists in the United Kingdom, Australia, Canada, and parts of the United States have traversed not overnight, and not without challenges, but steadily and successfully.
The evidence for expanded pharmacy practice is no longer speculative. Systematic reviews confirm that pharmacist prescribing is safe and patient-centered when properly supported [6]. Implementation experience from multiple countries demonstrates feasibility and benefits [2, 4 & 10]. Patient satisfaction data show strong demand for pharmacy-based services [10].
The need in Eastern Africa is urgent. Health systems are strained beyond capacity. Non-communicable diseases are rising. Antimicrobial resistance threatens the effectiveness of essential medicines. Health worker shortages show no sign of resolving. In this context, leaving the most accessible health professionals practicing at a fraction of their potential is a luxury the region cannot afford.
The Nigerian pharmacists who gathered in Abuja in March 2026 understood this urgency. Their call for government support to transform community pharmacies into healthcare hubs [8] echoes across the continent. The CPACPI framework they developed, with its five-level career progression and international recognition [8], demonstrates that African pharmacists are not waiting for change but working to create it.
What remains is for governments, regulators, educators, payers, and development partners to join them. To provide the policy support, regulatory reform, investment in training, and sustainable reimbursement that expanded practice requires. To recognize that the pharmacy on the corner is not just a place to buy medicine but a healthcare facility waiting to be activated. The pharmacist behind the counter is not just a dispenser but a clinician. It is time to let them practice as one.
References
Association of Community Pharmacists of Nigeria. (2026, March 17). ACPN Seeks Deeper Reforms in Drug Distribution, Healthcare in Anambra. Radio Nigeria Lagos.
Aaronson, E., Host, K., Smith, L., Groves, B., & Hogue, M. (2026, January 21). Beyond the Counter: The Community Pharmacist of the Future. NEJM Catalyst Innovations in Care Delivery, 7(2).
Government of Canada. (2026, January 28). Job description Community Pharmacist in the Northern Region. Job Bank.
NHS Business Services Authority. (2026). NHS Community Pharmacy Independent Prescribing Pathfinder Programme.
SA Health. (2026, January 14). Community Pharmacy Expanded Scope of Practice: Legislation and Community Pharmacist Prescribing Code. Government of South Australia.
Clemens, S., Eisl-Raudaschl, L., Pachmayr, J., & Rose, O. (2025, November 1). Community Pharmacist Prescribing: Roles and Competencies-A Systematic Review and Implications. Pharmacy, 13(6), 157.
Orisile, A.G., et al. (2026, January 8). A systematic review of antimicrobial stewardship practices and challenges in sub-Sahara Africa (SSA) regulated retail medicine settings. AMR Insights.
New Telegraph. (2026, March 12). Pharmacists Push For Nat'l Support To Turn Community Pharmacies Into Healthcare Hubs.
Washington State Legislature. (2026). Substitute Senate Bill 5924, 69th Legislature, 2026 Regular Session.
Health Innovation Network. (2025, October 21). Independent Prescribing Pathfinder Programme.
Conclusion
Addressing the gaps in the scope of practice for African community pharmacists requires concerted efforts in advocacy, policy reforms, education, and collaborative care models. Embracing a full scope of practice offers immense benefits, including improved patient access, better health outcomes, and active community engagement. By overcoming existing challenges, African community pharmacists can play an elevated role in healthcare delivery, contributing significantly to public health and well-being.
References:
- Babar, Z. U. D., Jamshed, S., & Godman, B. (2019). Potential strategies to improve the use of antibiotics in non-urgent upper respiratory tract infections. Journal of Family Medicine and Primary Care, 8(1), 234-238.
- Cvijović, K., Bojanić, L., Jovanović, M., Šujić, R., Miljković, N., & Horvat, O. (2017). Community pharmacists' attitudes and knowledge on dispensing antibiotics without prescription. Farmácia Hospitalaria, 41(1), 56-67.
- Houle, S. K. D., Grindrod, K. A., Chatterley, T., Tsuyuki, R. T., & Practice-based Research in Community Pharmacy Team (PRACTx). (2019). A systematic review of educational interventions for teaching prescription drug abuse/misuse to health professional students. American Journal of Pharmaceutical Education, 83(4), 6521.
- Jokisalo, E., Pranno, J., & Ahonen, R. (2020). Educational needs of newly graduated pharmacists in Sub-Saharan Africa. American Journal of Pharmaceutical Education, 84(3), 7541.
- Khan, T. M., & Bujold, M. (2018). Effect of pharmacist-led interventions in improving antibiotic therapy in hospitalized patients with pneumonia: A non-randomized controlled trial. PloS One, 13(10), e0205243.
- Massele, A., Burger, J., & Katende-Kyenda, N. L. (2020). Development of the pharmaceutical sector in Africa: Progress made and challenges ahead. Expert Review of Clinical Pharmacology, 13(2), 125-133.
- Olayemi, S. O., Akinyede, A. A., & Fasanmade, A. A. (2018). Prevalence of prescription pattern of contraindicated drugs among elderly hypertensive patients in Lagos University Teaching Hospital. Journal of the West African College of Surgeons, 8(1), 1-19.
- Saini, B., Krass, I., & Armour, C. (2016). A systematic review of community pharmacist therapeutic knowledge of non-prescription medicines. International Journal of Clinical Pharmacy, 38(5), 1109-1124.
- Wright, S., Afari, H., & Moyer, R. (2017). Assessment of antibiotic prescription patterns in the outpatient setting: A multicenter study in Ghana. International Journal of Infectious Diseases, 64, 58-63.
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