Strengthening Primary Healthcare through Accelerated Advancement of the Global Pharmacy Workforce (BMJ Open PDF)

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Open access Original research BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. Strengthening Primary Healthcare through accelerated advancement of the global pharmacy workforce: a cross-­ sectional survey of 88 countries Ian Bates ‍ ‍,1,2 Sherly Meilianti ‍ ‍,1,2 Lina Bader,2 Rishi Gandhi,1 Rachael Leng,1 Kirsten Galbraith ‍ ‍2,3 To cite: Bates I, Meilianti S, ABSTRACT Bader L, et al. Strengthening Objective Advancing the pharmacy workforce STRENGTHS AND LIMITATIONS OF THIS STUDY Primary Healthcare through contributes to strengthening primary healthcare and ⇒ This study is the most comprehensive to date ana- accelerated advancement of lysing stages of pharmacy advancement across 88 accelerating progress towards universal health coverage. the global pharmacy workforce: countries. a cross-­sectional survey This study aimed to identify key enablers to support policy development for national pharmacy workforce ⇒ The survey nature is self-­reported by participants, of 88 countries. BMJ Open 2022;12:e061860. doi:10.1136/ advancement. which may affect the validity of the findings; how- bmjopen-2022-061860 Design A cross-­sectional country-­level questionnaire was ever, the triangulation process through respondent distributed from July 2018 to March 2019. validation enhances the validity of the findings. ► Prepublication history and ⇒ The findings may be somewhat limited by the lan- Setting National-­level or country-­level pharmacy additional supplemental material guage and syntactical barriers for some countries in for this paper are available workforce development policy. Participants Professional leadership associations and completing the survey and providing relevant data. online. To view these files, please visit the journal online national agencies of the International Pharmaceutical (http://dx.doi.org/10.1136/​ Federation (FIP). The FIP global database included 129 bmjopen-2022-061860). countries. advancement in pharmacy practice could be adopted to Measures The questionnaire was designed to collate other countries to accelerate the progress of advanced Received 08 February 2022 data on the scope of advanced and specialist practice in Accepted 22 April 2022 practice globally. respondent countries. Multiple correspondence analysis and subsequent cluster analysis were conducted to explore the associations and patterns of country-­level INTRODUCTION attributes of systems in place for the pharmacy workforce WHO predicts a global shortfall of health- advancement in order to develop a general transnational care workers of around 18 million by 2030, model for country-­level advanced practice development. with the biggest impact in low-­income and Results Eighty-­eight countries (68.2% response rate) middle-­income countries (LMICs).1 Investing responded to the questionnaire. Factors that enhance in building health workforce capacity is and contribute to advanced practice policy development an essential (and non-­ contestable) factor include the country’s socioeconomic factors and the © Author(s) (or their availability of national practice advancement concepts. for enhanced delivery of primary health- employer(s)) 2022. Re-­use The essential advancement concepts include the care (PHC) and to achieve universal health permitted under CC BY-­NC. No availability of framework and professional recognition coverage (UHC).2 Strategies defined by commercial re-­use. See rights WHO for tackling this global issue include systems, programmes assisting advanced practice and permissions. Published by BMJ. development and workforce advancement and recognition implementing PHC programmes, country-­ 1 Department of Practice and opportunities. Cluster analysis identified three clusters of level tools for ensuring UHC and a global Policy, Faculty of Life Sciences, country respondents. First cluster included low-­income campaign to advocate for strengthening the UCL School of Pharmacy, and middle-­income with poor pharmacy advancement global health workforce.3 The pharmacy London, UK implementation, second cluster included a higher workforce is the third-­largest global regulated 2 International Pharmaceutical socioeconomic status with weaker pharmacy workforce health workforce. In nearly all countries, the Federation, The Hague, The advancement implementation and third cluster included Netherlands pharmacy workforce is the most accessible upper middle-­income to high-­income countries and high 3 Faculty of Pharmacy and health workforce for civil society and, as rates of pharmacy advancement implementation. Pharmaceutical Sciences, Conclusion The key factors identified in this study can such, is at the forefront of healthcare service Monash University, Parkville, be used to support a transnational approach to pharmacy delivery.4 5 Melbourne, Australia There is a need to describe and recognise workforce advancement. The three clusters identified Correspondence to highlighted that workforce advancement was not an an advanced practice role for pharmacists, in Dr Sherly Meilianti; exclusive trait of higher-­income countries. Lessons conjunction with enhancements in workforce ​sherly.​meilianti.​15@​ucl.a​ c.​uk from countries that have already adopted concepts of competencies.6 7As populations worldwide are Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860 1 Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. living longer, they do so with additional and often complex countries in professional recognition systems for the comorbidities, with increases in the use and complexity of advancement of practice, including development, defi- medicines and therapeutic strategies, most often within nitions and conduct.9 10 Some countries had developed more complex multidisciplinary team environments. competency development frameworks specific to the Trends such as pharmacist prescribing, in addition to advancement of pharmacy practice, demonstrating they therapeutic specialisation, are significant workforce are moving towards developing structures and guidelines development needs due to the increasing complexity for advancing and recognising practice beyond the early of medicines management for long-­ term conditions, career or foundation level.9 10 15 Despite the range of communicable disease and preventative healthcare.8 data gathered from this original survey, there remained Having national professional recognition mechanisms unanswered questions regarding factors associated with in place has shown benefits for the enhancement of the successful implementation of advanced practice path- career pathways, enhancement of service development ways. This paper presents a significant data extension and delivery (linked to career pathway) and profes- with a larger and more diverse sample base of 88 coun- sional esteem.9 10 It is also imperative to have workforce tries that aims to identify key enablers to support policy development mechanisms available to directly support development for national pharmacy workforce advance- the realistic achievement of PHC outlined in the Astana ment. Based on the key enablers or attributes identified, Declaration.8 United Nations (UN) indicator target 3.c the authors then developed a global template for realistic concerning a ‘substantially increase of health financing and impactful workforce advancement in a translation and recruitment, development training and retention of context. This global template is intended to be used to health workforce’, and pharmacists have been recognised support countries in assessing and evaluating their coun- as part of the health workforce (in addition to physicians, tries’ needs and is particularly aimed at LMICs. This study nursing personnel, midwifery personnel and dentists).5 will aid in identifying the support needed for countries The International Pharmaceutical Federation (FIP), wishing to introduce local advancement pathways for the the global professional leadership body, supports global pharmaceutical health workforce. The generation of an health through advancing pharmaceutical practice, evidence base for successful implementation of advance- sciences, workforce and education.11 In 2016, the FIP ment initiatives will enable an escalation of the processes started a programme of global workforce transformation for developing a global advanced health workforce to to meet the evolving complex health needs of popula- provide enhanced healthcare globally. tions, with the introduction of Pharmaceutical Workforce Development Goals.5 12 This has recently been further extended to incorporate practice transformation and METHODS innovation through pharmaceutical science, with new Survey development and distribution goals for practice and science merged with existing goals A cross-­sectional survey was developed from the previ- for workforce and education, under the umbrella of ously validated questionnaire on advanced and specialist the more comprehensive FIP Development Goals (FIP practice in pharmacy.9 10 15 Modifications included DGs).13 FIP DG 4 supports the concept of ‘advanced and language syntax adjustment and additional questions to specialist development’, including a recommendation expand data retrieval scope. The defined scope of this in the workforce element that ‘countries/territories and data retrieval survey was country-­level information on the professional member organisations should have education and extent and scope of advanced and specialist practice with training infrastructures in place for the recognised advance- a total of 12 questions. The survey items were mainly cate- ment of the pharmacy workforce as a basis for enhancing patient gorical (online supplemental table has a full variable list). care and health systems deliverables’.13 This goal sets out to The survey tool was available in English. ensure that pharmacy advancement and specialisation The survey was distributed to country-­level institutional/ is recognised and supported in all sectors of pharmacy organisational representatives (eg, professional leader- practice, including primary healthcare, where pharma- ship bodies, regulatory bodies, etc) from the FIP global cists serve as a first point of contact for many patients database (129 countries) between July 2018 and March and local communities. To support the achievement of 2019. Follow-­up reminders were sent over 3 months. this goal, the FIP has developed a validated tool, the FIP Global Advanced Development Framework, to support Data aggregation and data cleaning the professional development and recognition of the We conducted triangulation on any conflicting data in pharmacy workforce at the individual, institutional and order to verify a single country-­level dataset; identified national level.14 data discrepancies triggered recontact with the national In 2015, FIP conducted the first global survey to iden- agencies to seek clarification and resolution. Similarly, tify the status of advanced practice initiatives across incomplete responses on the survey were referred back countries.9 10 15 Across 48 countries, this study found to the responding agency and checked for completion. significant variations within terminology and definitions In addition to our survey data, we accessed secondary (scope of practice) of advanced practice and speciali- data sources on country demographics included country sation.10 15 The survey also reported variations between region based on WHO,16 country income levels based on 2 Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860  Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. the World Bank classification,17 country health systems Table 1 Sample responses, WHO region membership expenditure,18 community pharmacist workforce propor- categories and World Bank income category tions,19 pharmacist workforce density per 10 000 popula- Global distribution of tion19 and Health Access Quality Index.20 These variables Sample countries in each WHO relate to general economic and health climate, which WHO region distribution region membership may influence the development of advanced practice in membership (n=88) (n=194) a country (see online supplemental table). categories N (%) N (%) The resulting dataset was de facto categorical (nominal). Africa 17 (19%) 47 (24%) Some continuous variables (principally demographic) were subsequently categorised into ranked ordinal vari- Americas 13 (15%) 35 (18%) ables for analysis using descriptive dispersion measures. Eastern 12 (14%) 21 (11%) Mediterranean Data analysis Europe 28 (32%) 53 (27%) The analysis comprised descriptive reporting, multiple Southeast Asia 4 (4%) 11 (6%) correspondence analysis (MCA) of the categorical dataset Western Pacific 14 (16%) 27 (14%) and subsequent cluster analysis of the MCA outcomes. We used SPSS software version 26 (IBM, Armonk, New York, Global distribution of USA). Costa et al have used the combination of MCA and Sample countries in each World distribution Bank income category cluster analysis to explore associations of qualitative vari- Country income (n=88) (n=218) ables to healthy ageing.21 Both methods combined have level N (%) N (%) the advantage of displaying complex categorical associa- tions in visualised formats.21 We used this combination of Low 7 (8%) 31 (14%) MCA and cluster analysis to explore the associations and Low middle 20 (23%) 53 (24%) patterns of country-­level attributes of systems in place for Upper middle 23 (26%) 56 (26%) the advancement of the pharmacy workforce in order to High 38 (43%) 78 (36%) develop a general transnational model for advanced prac- tice development. MCA included all practice scope-­ related categorical responses, the WHO regional comparison and the World variables (n=12 variables, see online supplemental table) Bank membership categories. Our responses cover all six together with demographic/economic variables (n=6 vari- regions of WHO. The majority of respondents were from ables, see online supplemental table, resulting in a total Europe (n=28, 32%), while the lowest number of respon- of 18 variables). Following an inspection of the resulting dents came from Southeast Asia (n=4, 4%). Looking at initial discriminant measures, one highly discriminant the sample responses and the World Bank income level, variable (the WHO regions, which are highly associated most of the respondents came from high-­income coun- with health system economic factors) and two poorly tries at 43% (n=38), while 8% of responses came from discriminant variables were removed to optimise the low-­income countries (n=7). The sample responses model. Our final MCA model (using two resultant dimen- broadly show proportional generalisability of the country sions) had a total of 15 nominal variables. MCA’s output sample when compared with the WHO regions and the includes graphics for discrimination measures and a joint World Bank membership categories. plot of category points. A hierarchical cluster analysis of the object scores Multiple correspondence analysis obtained through the MCA model was conducted to The discrimination measures show correlations between classify subjects (countries) into groupings with similar clusters of variables and dimensions. A relatively large attributes for advanced practice. The clustering was discrimination value for a variable along a dimension based on Euclidian distances between objects in the indicates a greater influence along with the dimension.23 two-­dimensional model; Ward’s method was used, which Figure 1 shows the discrimination measures plot for each minimises the variance within the clustered groups.22 variable of the proposed MCA model. Variables marked with blue dotted lines (variables A–J) have larger discrim- Patient and public involvement ination coordinates along the abscissa (dimension 1). We did not include patients or the public in the study These variables tend to be variables that are subject to design, setting the research questions, interpreting or policy control in terms of workforce development (ie, writing up the results and disseminating the research. can be altered by policy innovation) and are related to conceptual attributes for the advancement of practice; we identified dimension 1 as ‘conceptualisation of advanced RESULTS practice’. Variables marked with red dotted lines (vari- Sample responses ables K–O) have statistical influence along the ordinate A total of 88 full country responses were included in the axis (dimension 2). These variables (such as pharmacist analysis (response rate 68%). Table 1 shows the sample density, World Bank class) represent the country-­ level Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860 3 Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. Figure 1 Discrimination measures plot. socioeconomic or demographic attributes and tend to be clustered together on the righthand side of dimension 1, more resistant to policy change; we identified dimension this indicates the presence of nationally available policy 2 as ‘socioeconomic factors’. and support available for structural advancement of prac- Eigenvalues for dimension 1 of the MCA result (4.637) tice, in contrast with left-­hand clusters with no access to indicate a greater weighting on this scale compared with identifiable concepts and support in those case countries. dimension 2 (2.977). This is also reflected in variance, Coded values along dimension 2 were dichotomised into with dimension 1 accounting for 30.9% while dimension 2 clusters of generally higher or lower attributes of socio- accounts for 19.8%; the overall model accounts for 50.8% economic and/or demographic measures (red circled of the total variance, indicating a reliable projection. clusters in figure 2). Using the MCA model outputs, attri- Figure 2 shows the joint category plot of the coded butes of pharmacy workforce development potential can values of the model variables, showing correlations now be associatively connected with current country-­level between variable values as well as their relationship to policy constructs within prevailing socioeconomic factors the model dimensions. It revealed four groups of vari- and access to, and implementation of, credible policy able items that tended to cluster. Along dimension 1 models for pharmacy workforce advancement. were the concepts and infrastructures for pharmacy workforce advancement, with clusters of presence/ Cluster analysis absence in sample countries divided by the abscissa (blue Using the MCA model outcome and object scores, a hier- circled clusters in figure 2). Where there are case values archical clustering analysis was conducted.24 The output 4 Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860  Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. Figure 2 The joint plot of category points. suggests a three-­cluster solution based on the coefficients These countries also tend to have much lower anglo- of the agglomeration schedule and gradient inflexion phone traditions. of the resultant scree plot. The three-­cluster solution in the scree plot was also reflected in the clustering dendro- gram; from this three-­cluster solution, case membership DISCUSSION for each proposed cluster was identified. Advancing the global health workforce is one of the Figure 3 shows a scatter plot of object scores associated strategies to strengthen primary healthcare. The 2018 with each of the sample case countries identified by the Astana Declaration further emphasised the pivotal role MCA model. Subsequently, overlay of the cluster analysis of the health workforce, including the pharmaceutical ‘cluster membership’ of the surveyed countries can be workforce, in primary healthcare access and delivery to identified (country cases identified with the three-­digit achieve universal health coverage by 2030.4 26 This paper country ISO codes).25 Table 2 expand on the attributes presented evidence on the attributes of national work- associated with each of the identified clusters. Gener- force development infrastructures in place for advancing ally, countries in cluster 1 (blue) were mostly lower to pharmaceutical workforce in the country. From the find- upper middle-­income countries; cluster 2 (green) were ings, we identified factors that enhance and contribute to of a higher socioeconomic status and cluster 3 (purple) advanced practice policy development, namely the coun- comprised mostly upper middle-­income to high-­income try’s socioeconomic factors and the availability of practice countries. Cluster 3 countries tend to differ as these are advancement concepts in the country. In terms of MCA more likely to have advanced practice scope policies in model dimension 1—conceptualisation of advanced place compared with cluster 1, and these latter countries practice—we found that ‘opportunities to gain formal have a greater anglophone tendency. Cluster 2 countries, recognition after registration’, ‘competency develop- although generally in higher socioeconomic categories, ment framework availability’, ‘professional recognition had mixed levels of practice advancement attributes. systems’, ‘definition of advanced practice or specialisation Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860 5 Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. Figure 3 Scatter plot of object scores (country ISO code used for labels). (scope of practice)’ and ‘support or programmes for advancement in pharmacy scope of practice; lessons can practitioners to develop advanced practice and special- be learnt from a systematic classification, and a transna- isation’, respectively have the highest associative value tional roadmap can be designed and adapted particularly (figure 1). This result shows that these concepts are for LMICs. It has been suggested that a change in phar- essential in advancing pharmacy workforce in the country macy education and a restructuring in legislation clari- respondents. From our findings, we proposed a global fying and protecting the roles of pharmacists may assist development roadmap for advanced and specialist prac- with narrowing the gap between the country clusters.27 tice to support country workforce self-­ assessment and In addition to various regulatory bodies, country-­ level self-­ diagnosed needs-­ assessments for progress towards national pharmaceutical professional leadership associa- achieving the FIP DG 4—advanced and specialist devel- tions are central in developing their respective workforces, opment (online supplemental figure). This roadmap supporting areas such as continuous professional devel- can be used as an evidenced-­based transnational tool for opment, legislation and guidelines and the implementa- health workforce transformation policy programmes. tion of tools to support pharmacists.10 15 It is important This study identified variation from a sample of 88 that these actions are made in conjunction with national countries on workforce development attributes related to frameworks for healthcare as well as the professional 6 Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860  Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. Table 2 Cluster attributes Variable and description Cluster 1 (n=25) Cluster 2 (n=26) Cluster 3 (n=37) Definitions 10% 30% 60% Countries that have an agreed definition of advanced practice and/or (n=4) (n=13) (n=26) specialisation (n=43). Framework 0% 36% 64% Countries that have a competency framework to describe advanced practice (n=0) (n=9) (n=16) and/or specialisation (n=25). Regulator responsible for recognition 10% 22% 68% Countries that the pharmacy regulator is responsible for recognition of (n=4) (n=8) (n=25) advanced practice and/or specialisation (n=37). Availability of professional recognition 0% 23% 77% Countries that have professional recognition of advanced practice and/or (n=0) (n=8) (n=27) specialisation (n=35). Formal academic pathways 11% 27% 62% Countries that have a formal academic pathway to advanced practice and/or (n=6) (n=15) (n=34) specialisation in your country (n=55). Support for specialisation and advancement 10% 25% 65% Countries that provide programme or support to assist practitioners in (n=4) (n=10) (n=26) developing specialised and/or advanced practice (n=40). Opportunities after registration 5% 25% 70% Countries that provide opportunities to gain a formal recognition in advanced (n=2) (n=11) (n=30) practice or specialised areas following initial registration and licensing as a pharmacist (n=43). Professional recognition credentials 4% 17% 78% Countries that credential postnominals to recognise advanced practice and/or (n=1) (n=4) (n=18) specialisation (n=23). Benefits 9% 17% 74% Countries that have tangible benefits for pharmacists being recognised as (n=4) (n=8) (n=34) specialists or advanced practitioners (n=46). needs of individual pharmacists. In this study, there has for competency development frameworks and profes- been some progress made from a smaller pilot sample sional recognition systems can be designed using existing of previous country responses9 10 with the early develop- evidence-­based mechanisms and shared using an ‘adopt ment of infrastructures for practice advancement, such as and adapt’ needs-­based approach for workforce devel- competency development frameworks, and by adopting opment policy implementation. The concept of a global and adapting ideas and resources of the frameworks from Workforce Transformation Programme to support coun- other countries. This shows the benefit of looking for a tries in leading the advancement of their national work- global template to support and share ideas across nations. force becomes a closer reality.28 An important finding from this study is that there is a key This study revealed three broad clusters of countries group of attributes that can describe workforce advance- with similar characteristics for advanced workforce devel- ment in the country respondents and be used as a collec- opment. Generally, cluster 1 countries mainly consisted tive measure of progress (figure 2, blue circle). The MCA of low-­income to middle-­income countries. They consis- and cluster analysis indicated this variable group was not tently showed less traction with workforce advancement fully associated with country-­level socioeconomic status indicators included in the analysis. Cluster 2 comprised (eg, figure 2, red circle), indicating that the concepts upper middle-­income countries with high rates of phar- of the scope of practice advancement do not need to be macy advancement implementation. Cluster 3 comprised limited by socioeconomic status. This suggests that we will high-­income countries but did not necessarily have high be able to facilitate mechanisms for shifting workforce traction with all of pharmacy advancement indicators. advancement attributes from ‘do not have an advance- Despite some countries in cluster 2 having a lower socio- ment concept’ to ‘having an advancement concept’ as economic status than those in cluster 3, they had still a low-­cost way of advancing the pharmacy workforce in adopted many concepts of advanced workforce practice. a country and hence accelerate workforce development This tends to indicate that the advancement of the phar- to meet the complex medicines-­ related challenges of maceutical workforce is not an exclusive trait of higher-­ primary healthcare across nations. We envision acceler- income countries. As pharmacists play a crucial role in ated workforce development progress as a ‘global advance- the provision of healthcare, particularly in primary care ment escalator’, with a resource focus on countries on settings, this study may open up the possibilities of accel- the far left of figure 2 to shift towards the righthand scale erated pharmacy advancement to countries regardless of of dimension 1. For example, transnational templates income level. Moreover, as pharmacists are increasingly Bates I, et al. BMJ Open 2022;12:e061860. doi:10.1136/bmjopen-2022-061860 7  Open access BMJ Open: first published as 10.1136/bmjopen-2022-061860 on 16 May 2022. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright. working more closely with other healthcare professionals, Contributors IB, SM, KG and LB conceived the study and designed the work. SM improved expert team working with pharmacists at the and LB conducted the data collection with input from KG and IB. IB, SM, RG and RL did the statistical analysis and interpretation of data for the work. IB, SM, RG advanced level would be beneficial as there would be an and RL wrote the first draft of the article. All authors critically reviewed the article, expectation that advanced pharmacists are competent in contributed to the interpretation of the findings and approved the final version of the direct patient care and in developing new patient care article. SM acts as guarantor. services related to medicines management.29 Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-­for-­profit sectors. Strengths and limitations Competing interests None declared. To the best of the authors’ knowledge, this study is Patient and public involvement Patients and/or the public were not involved in the most comprehensive to date analysing stages of the design, or conduct, or reporting, or dissemination plans of this research. pharmacy advancement between countries. This study Patient consent for publication Not applicable. has also provided information on associations with Ethics approval Formal ethical approval was not required as the data are neither country-­level socioeconomic status and the stages confidential nor commercially sensitive in the national domains; however, ethical of pharmacy workforce advancement. These find- oversight and approval was gained from the FIP Executive and Board structures ings may be somewhat limited by the language and and is on record. Participation in the survey was voluntary with no incentives, and professional leadership associations and other national agencies were free to syntactical barriers for some countries in completing choose not to provide data. the survey and providing relevant data. In addition, Provenance and peer review Not commissioned; externally peer reviewed. considering the survey nature is self-­ r eported by Data availability statement Data are available on reasonable request. The dataset participants, this may affect the validity of the results. analysed for the manuscript is available on reasonable request. The data dictionary However, the triangulation process through respon- is available on request to the corresponding author: ​sherly.​meilianti.​15@​ucl.​ac.​uk. dent validation enhances the validity of the results. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-­reviewed. Any opinions or recommendations discussed are solely those CONCLUSION of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content This study identified key factors to support a trans- includes any translated material, BMJ does not warrant the accuracy and reliability national approach to pharmacy workforce advance- of the translations (including but not limited to local regulations, clinical guidelines, ment for strengthening PHC programmes in order terminology, drug names and drug dosages), and is not responsible for any error to achieve UHC. The three clusters identified showed and/or omissions arising from translation and adaptation or otherwise. that workforce advancement was not an exclusive trait Open access This is an open access article distributed in accordance with the of higher-­income countries. Lessons from nations that Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-­commercially, have previously implemented concepts of advance- and license their derivative works on different terms, provided the original work is ment in pharmacy practice may support other coun- properly cited, appropriate credit is given, any changes made indicated, and the use tries to accelerate the progress of advanced practice is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. globally. This study further opens up other research ORCID iDs opportunities. Variables in the survey only elicited Ian Bates http://orcid.org/0000-0003-2219-5171 responses that reflected how much support is avail- Sherly Meilianti http://orcid.org/0000-0003-4023-0428 able for pharmacy workforce advancement in each Kirsten Galbraith http://orcid.org/0000-0003-1703-8307 country. As the research variables focused on nation- ally aggregated data and the presence or absence of key workforce indicators, levels of pharmacy advance- REFERENCES ment may not hold true for all areas within a country 1 World Health Organization. Urgent health challenges for the next (eg, in federated countries) or have direct traction decade, 2020. Available: https://www.who.int/news-room/photo-​ story/photo-story-detail/urgent-health-challenges-for-the-next-​ with the individual registered pharmacists themselves. decade [Accessed 21 Jun 2020]. There is an opportunity to investigate the proportions 2 World Health Organization. Declaration on primary health care Astana, 2018. 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