Unpacking the Community Pharmacy Structure in Japan
Key takeaways:
Japan actually has two types of places for medications — drugstores and pharmacies. Drugstores only carry over-the-counter (OTC) medications, while pharmacies only carry prescription medications.
Japan doesn’t have pharmacy technicians. Pharmacists dispense all the medications, and there are usually multiple pharmacists working at the same time.
Pharmacists in the community setting primarily only fill prescriptions and provide OTC counseling and recommendations. They don’t give vaccines, check blood pressure or cholesterol, or provide other clinical services.
Community pharmacies are the ones that dispense medications to patients who are not hospitalized or in nursing facilities. I’ve always been interested in how community pharmacies operate in other countries because it gives us a chance to view our own system in a new light, exchange ideas, and find opportunities for improvement.
In this new GoodRx series, we’ll look at community pharmacies around the world, and as you’ll see their basic definition only tells part of the story. There is a rich diversity of ways in which countries provide prescriptions to their citizens, and in this first post we’ll look at Japan.
Japan’s healthcare and pharmacy systems are very different from those in the United States. In this post, we’ll look at some of the most notable differences. (I’ll also include the Japanese terms for those of you learning to speak the language, like me.)
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Japan is a country with which I have some experience. My wife is from Hiroshima, and we’ve been there numerous times. I also had the opportunity to interview Dr. Megumi Howard, PharmD, a resident at Swedish Medical Center and also a licensed pharmacist in Japan. The interview provided a richer look into Japanese community pharmacies.
How are Japan’s community pharmacies set up?
Japan has two types of places that we can consider community pharmacies. The first is a drugstore (ドラッグストア) that only sells over-the-counter (OTC) medications. They hire pharmacists who don’t dispense prescriptions. Instead, they provide recommendations and have a counseling station in the middle of the OTC section. An example of this kind of store is Zag Zag (pronounced “zagu zagu” in Japanese). Zag Zag looks very much like a chain drugstore in America, except without the pharmacy.
More recently, Japan has created an “OTC counselor” position for nonpharmacists to provide some of these services. These individuals don’t go to pharmacy school, but they take a certificate course offered by the country’s Ministry of Health, Labour, and Welfare.
The second place is sometimes translated as a pharmacy (“chouzai yakkyoku,” or 調剤薬局) and only dispenses prescription medications. They have virtually no front-end merchandise, and the buildings are very small. (The Hikami Pharmacy is an example of a typical prescription-only pharmacy in Japan.) I asked Dr. Howard if the owners ever thought about carrying front-end merchandise. She explained that because patients only think about going to those pharmacies when they have a prescription, the pharmacy wouldn’t be able to sell very much.
How do Japan’s community pharmacies function day to day?
One major difference from the United States is that prescription refills don’t exist in Japan — although there’s been some discussion of implementing them. There’s a system of partially filling a prescription (“bunkatsu chouzai,” or 分割調剤), which could in theory make it the same as a refill system. But according to Dr. Howard, it’s not commonly used. Also, she said, patients don’t receive a year of medicine under this system, but could receive a 90-day supply that is split into 3 separate 30-day supplies at the pharmacy.
Unlike the United States, Canada, and much of Europe, the role of the pharmacy technician doesn’t exist. Only pharmacists are allowed to dispense medications, often with multiple pharmacists working at the same time. On average, pharmacists dispense fewer prescriptions per day in Japan. Insurance is billed once at the end of every month, and Dr. Howard said that sometimes pharmacies will then be faced with rejections for medications they’ve already dispensed.
She also noted liquid medications are uncommon in Japan. But every pharmacy has a machine to measure powdered medications that are dispensed in unit-dose packaging to patients. In turn, the patients mix it with water before taking it. Tablets and capsules are both purchased from the distributor and dispensed in boxes with strips of envelopes — not in bottles. This is similar to the adherence packaging that is becoming popular in the States.
Finally, patients keep a medicine booklet (“Kusuri techou,“ or 薬手帳) to record of all their prescriptions, although this is now also being kept electronically. Each time a prescription is filled, a sticker is placed in the medicine booklet with all the information so the patient has their medication history. Dr. Howard used this booklet for medication reconciliation when she worked in the hospital in Japan. She said that they’re particularly helpful in the case of a natural disaster. Patients receive a small discount for bringing the booklet to the pharmacy, and most patients are compliant.
How does the community pharmacy system in Japan compare with the U.S. pharmacy system?
Pharmacists in the community setting only fill prescriptions and provide OTC counseling and recommendations. They don’t give vaccines, check blood pressure or cholesterol, or dispense medicines without a prescription. According to Dr. Howard, pharmacists also don’t have the authority to switch generic brands of the same medication. Some Japanese pharmacists I have spoken with feel like pharmacy practice in Japan is behind what it’s in America, and would like to see legislative changes to expand their practice.
Despite Japan’s sluggish vaccine approval and rollout — partially due to a critical shortage of staff trained to give vaccines — Japan’s regulatory agency, the PMDA, was still resistant to allowing pharmacists to administer vaccines. In May 2021, Japan authorized lab staff and paramedics to give vaccines but was debating whether to allow pharmacists to do so. Dr. Howard reports the regulator ultimately decided not to give the authority to pharmacists.
Salaries for pharmacists are another point of contrast; they’re much lower in Japan. (Take this job, for example, offering 4.5 million yen, or roughly $45,000 per year.) Lower salaries, in addition to the limited scope of practice for pharmacists compared with other countries, are both reasons some pharmacists in Japan are interested in practicing overseas.
How is patient adherence different in Japan vs. U.S. pharmacy?
One study found that 58% of patients were nonadherent to their medications. However, the authors found this to be similar to nonadherence rates reported in studies conducted in other countries. This is also similar to the United States, which has an adherence rate of about 50% to chronic medications.
Regardless of differences in adherence, Japan and America have a lot of potential for pharmacists to play a role in improving adherence. For instance, we know that adherence packaging, medication synchronization, and 90-day supplies improve adherence rates. And pharmacists are central to implementing all of these initiatives.
The bottom line
With no pharmacy technicians, no refills, a separation between OTC sales and prescription dispensing, and a more limited scope of practice than the United States, Japan has a markedly different system for community pharmacies. The two nations have the opportunity to improve patient adherence rates, and pharmacists may be central to achieving that goal.
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