INTRODUCTION:

Education is one of the most powerful instruments for reducing poverty and inequality. Education is equally key to enhance competitiveness in the global economy. It is a means to promote individual, social, professional and economic development and it shapes the difference between the worlds of today and that of tomorrow. The issue of quality in education becomes therefore an essential concern, not only to those directly involved in the formal educational processes (such as students and educators), but also to society as a whole, policy-makers, professional bodies, parents and other stakeholders. In addition, one of the major changes to deeply mark the 21^st Century has been the shift from a social attitude of independence to one of interdependence between individuals, organizations and societies. The world has become increasingly aware that mutual understanding and partnerships are essential in every aspect of life, if we are to optimize the results of human Endeavour and improve quality of life for every citizen. In health care particularly, the need for professional interdependence has become increasingly apparent, as new priorities in public health and new demographic trends emerge, generating the necessity for multidisciplinary approaches involving all health care providers as well as social scientists and practitioners. Also, due to great developments in scientific research and the increasing (and changing) social demands in terms of health-care, the profession of pharmacy has been forced to undergo a radical process of evolution with great shifts in its public mission in the last hundred years.

Having changed firstly from the formulation to the dispensing of medicines, the role of the pharmacist has more recently evolved towards direct patient care and the assurance/optimization of therapeutic results. However, pharmacists maintain a level of expertise about drugs that is valuable at all stages of the development, production and delivery of medicines. In this scenario, it becomes clear that pharmacy education needs to react to and even anticipate professional and social change, renewing its mission in terms of graduate profiles and learning objectives. Here again, interdependence and partnership amongst all stakeholders in pharmacy education has become a necessity, in order to ensure positive development. It is now clear that all stakeholders, including students, have a responsibility to encourage and facilitate change and must show leadership in the movement for an improved pharmacy education.

The aim of this review to state the international point of view of pharmacy students on essential developments in pharmacy education and, more importantly, to provide students, educators and other stakeholders with a valuable resource for positive change in pharmacy education at local, regional, national and/or international level.

AN EVOLVING PROFESSION - CHALLENGES AND RESPONSIBILITIES:

Challenges to the Pharmacy Profession from Rising Pharmaceutical Demand:

In the 21^st century, in all parts of the world, priorities and challenges facing pharmacy and healthcare in general have changed considerably. The World Health Organization estimates that by 2020, leading causes of the burden of diseases are likely to be ischemic heart disease, depression and road traffic accidents, while health trends are likely to be dominated by four factors: the ageing of the world's Population, the unfolding of the HIV epidemic, the epidemic of tobacco-related mortality and disability and the expected decline in childhood mortality from infectious diseases. Pharmacy, as a profession has its own obstacles in trying to meet these challenges. Recruitment is a significant problem both in developed and developing countries in all fields^3-6. The total number of drugs is constantly increasing, and the cost of drugs for many illnesses is beyond the budget of huge numbers of payers, especially in developing countries. Countries struggle to make quality drugs available and affordable, and this may mean seeking to achieve national self-reliance in pharmaceutical production, despite opposition from license holders⁷. Elsewhere, community pharmacies are forced to rely on the sale of OTC medicines, due to opposition to separation of prescribing and supply from the medical profession⁸. Primary health care has been recognized as the way to reach the WHO 'Health for All' target and the role of pharmacists in this context needs serious attention. Each country faces its own unique combination of assets and challenges.

Student Responsibility:

Pharmacy students themselves may not react to changes in the positive manner that they were intended. They must assume responsibility for their own futures and attempt to contribute in a constructive and mature manner to educational development. The openness and accessibility of the faculty staff will help this. Students must recognize that the quality of their education is dependent on previous improvements and it is their duty therefore to work for further benefits for the next generation. Change, though often uncomfortable, is essential to progress and students should welcome it in this context.

Professional Leadership:

The quality of professional practice must be unquestionable, and should stand up to analysis at any stage. Even with the highest standards of current practice, the rapid pace of change in healthcare systems means that contemporary practice in many areas is not entirely reflective of the direction in which the profession is moving. In these situations, professional bodies must show leadership. Once students are committed to pharmacy as their chosen course, ample opportunity must be provided for them to hear about and experience examples of top quality innovative practice. Students should be shown the opportunities which exist to take initiative, to be responsible and dynamic, to move pharmacy towards an exciting future in all fields. This kind of work can be included as part of the curriculum, extra-curricular lectures/symposia, competitions, publications, practice, visits etc. Keeping students informed of the work of the professional organizations is an excellent way to give them a feeling for the issues and responsibilities in their profession. If pharmacy is to survive, pride and enthusiasm in the profession must be cultivated in students from the very first day of the Programme.

EVALUATION FOR QUALITY AND POSITIVE CHANGE:

Consideration of our evolving profession suggests that the evolution process in pharmacy is unique to each environment and the professional profile of the pharmacist in that area. Consequently, it becomes apparent that no one system of pharmacy education is universally valuable. Harmonization of education is only valuable in so far as it guarantees quality in pharmacy graduates regardless of their place of study. It is therefore vital that each learning institution develops its own plan for continuous quality development specific to the faculty or school of pharmacy in question, taking into account local conditions, needs and primary expectations8. The establishment of complete clearly stated goals/intentions that are widely known and exist with reasonable consensus across students, staff and other stakeholders including patients, is crucial to the continued success of any educational Programme. Educational goals must be clear and specific and stated in useful terms, regarding skills, attitudes, knowledge and values. All evaluations must compare actual to desired performance and establish plans to bridge the gap^{10, 11}.

LEARNING PROCESSES AND OUTCOMES:

Teaching and Learning Approaches:

Educational re-orientation in pharmacy is necessary in many schools and the strategies by which students learn, as well as the context for the learning process should be a primary focus for review. The concepts of "learning" and "teaching" are two aspects of the educational process that are often mistaken and too often, teaching, rather than what students actually learn, tends to be emphasized when pedagogical reform is planned or made. Orthodox lecturing and other passive teaching methods do not encourage adaptation to new situations in professional life or inter-relation of knowledge from different areas. Also, individuals who experience an orthodox education generally do not have the orientation for life-long learning as a means to continuous professional development. What society needs are pharmacists who can provide rational and adequate solutions to individual health problems. For that, pharmacists should be able to assess problems competently and have the skills to find the available knowledge and process it through a multidisciplinary approach. There are learning methods and teaching approaches that can better provide students with the skills, attitudes and knowledge they need to achieve these skills. Innovative methods develop graduates' skills in understanding and processing information and provide them with orientation for life-long learning.

Assessment of Learning Outcomes:

Assessment methodologies must be coherent with the learning process that was practiced and they play an important role in defining how students will approach their learning and establish their objectives. Assessment cannot be regarded as an end in itself, but as a vehicle for educational improvement, and must reflect an understanding of learning as a complex process that is multidimensional, integrated, and revealed in performance over time. There are many useful tools for improving the quality of learning that do not require major changes, and should be an increasing feature in educational processes. Active participation of students should be encouraged. For this educators should be given adequate pedagogical training and should accept new educational approaches which prove to be beneficial to students' learning.

Ø Educators should also be approachable and available as experts and mentors to advise and assist students in their studies when required

Ø Adequate study literature should be made available to students in order to help them actively study and process the information they receive from the educator

Ø Laboratory classes and practical activities should lead students to develop such skills that will enable them to deal with real problems and propose effective solutions for them.

Ø Project and research work should be promoted, as it enables students to work both independently and in groups and challenges them towards independent thinking

Ø Co-operative projects and activities with students from other health professions should be a regular feature in educational programmes, as these contribute to breaking down the communication barriers that are currently found in healthcare practice

Ø Practical experiences facilitated by professionals should be introduced in the curriculum, in an increasing level of complexity, to facilitate the contact between the student and the professional practice^12-14.

Student and Staff mobility:

One other aspect that can have great influence on the graduate's profile is the learning environment. In particular, the exposure of individuals to a variety of educational/ practical experiences has a significant impact in their adaptability to different situations, both professionally and in life. In this context, student and staff mobility programmes should be promoted, as they represent an experience that complements the educational process itself.

CONTENT OF PHARMACEUTICAL EDUCATION:

In considering the content and therefore the mission of pharmaceutical education, it is useful to reflect on the service that pharmacy provides. The pharmacy profession plays a major role in the discovery, development, production and distribution of drug products and in the creation and dissemination of related knowledge. In addition to these traditional roles, pharmacists are becoming increasingly involved in direct patient care and are taking responsibility for the resolution of drug therapy problems of individuals¹⁵.

Foundation:

Pharmacy education is responsible for preparing students to enter into a career in medical field and function as professionals and responsible citizens in changing healthcare systems. Fulfilling these functions requires a dynamic, challenging, and comprehensive curriculum, which includes a foundation in the biological, biomedical, clinical, pharmaceutical and physical sciences, clear focus on application and use of knowledge in practical settings, and a general education in healthcare systems, ethics, management, professional issues, communication, and practice skills. Among other healthcare providers, pharmacists are unique in their detailed and comprehensive understanding of physical, chemical and biological interactions on the outcomes of drug therapy. Pharmacists in all settings require an understanding of the chemistry of drug entities, the delivery characteristics of dosage formulations, the disposition of drugs within the body, the physiological and pharmacological outcomes of drugs' interactions and aspects of modern drug development and production that are the basis for expertise in all aspects of medication.

Inspiring Learning:

A variety of methods must be used to teach the context of each topic both in terms of how the knowledge was generated and how it can be applied in practical situations. Applied subjects such as clinical therapeutics and industrial syntheses; for example, should not only be included, but should be taught in parallel with the corresponding basic science subjects (pharmacology and pharmaceutical chemistry) in order that students be challenged to consider the broader relevance of their study. It is important that the concepts and principles of and commitment to lifelong continuing education and professional development should be introduced in undergraduate courses and supported throughout a pharmacist's career. In addition, the pharmacy curriculum should equip students with the skills that they need in order to learn throughout their professional lives. In other words students must learn how to learn. Part of this ability comes with practice, and as such is a function of the educational process itself, but it is important that students are confident and capable in managing information.

Communication and Language Skills:

Since pharmacists work directly and closely with members of the public in many settings, pharmacy students must be comfortable and capable in communicating about health with non-experts. They must be given the training that is necessary to work effectively with patients, to listen and elucidate primary drug-related needs and expectations and to impart information. In the context of cultural diversity in many countries, and increasing professional mobility, students should be facilitated and encouraged in the learning of languages in addition to their own. They should gain some understanding of how to approach the variety of cultures and social groups in which they may work in the future, as well as some knowledge of the ways in which various cultures deliver and respond to healthcare. The curriculum should also provide grounding in the concepts of management and leadership and the necessary skills to effectively use resources, physical, fiscal and human.

Healthcare Organization:

In order for pharmacists to fulfill their roles and responsibilities in society, graduates will require a broader knowledge of the healthcare system and environment in which they will function. They should learn how healthcare is organized, delivered and financed in their own country and gain a broad comprehension of innovations, issues and developments in healthcare worldwide. They should understand the challenges facing healthcare both locally and globally, and the factors that influence its delivery and effectiveness, including the major causes of morbidity and mortality, primary and secondary care and the balance between them, public health initiatives, pharmaco and health economics, how research is organized and financed, and economic issues for individual patients. They should have an initial understanding of epidemiology and its relevance to population based treatment guidelines, prevention programmes and public health education.

Professional Uniqueness and Interdependence:

Within the context of emerging developments in healthcare, future professionals are likely to be required to function, communicate and work effectively in multidisciplinary teams. Therefore, comprehension of the intertwining roles of each healthcare professional and the pharmacists' place within the healthcare team is essential, as understands differing perspectives, and professional and legal obligations. In order to be able to function confidently and effectively in such settings however, students must gain a sense of professional identity and pride over the course of their education. Professional identity cannot be taught in a specific course or lecture and yet may be considered crucial to the motivation of individuals and therefore the success of the profession. If it is apparent however, in the attitude of the staff and how they relate to the students, in the very atmosphere of the learning institution, and encouraged by the example of professionals, it will be passed on to the students, who will lead the profession in the future.

Practical Knowledge:

Experiential education (through practice periods, internships etc) is a fundamental part of the educational experience of future pharmacists, and in many ways, one of the most important aspects of the undergraduate training. Indeed, when arranged carefully, with trained tutors and assessed in ways appropriate to the setting, the practice period offers a vital reinforcement of many of the concepts described above. It is during this time that the students are presented with the most powerful example of what it means to be a pharmacist, how the profession works, how knowledge is applied, how to act in a professional manner etc., in a real setting. A good curriculum will help to develop students' own values and skills, but good experience in practice will cement those values and skills. The practice period should form part of the undergraduate programme and be organized by the learning institutions in co-operation with professional and where necessary, governmental bodies. Given the wide variety of professional settings in which pharmacists are found, at least some of the practice placements should offer the chance of training in any of these areas in order that students might form some idea of their own career preferences. A positive practice experience is also a powerful catalyst for increased student learning and for this reason we conclude that it is not ideal to have the apprenticeship only at the end of the training, but that periods of practice should be spread throughout the programme as well as at the end. Experience should be offered in real life practice environments, with other healthcare professionals (both pharmacists and others) where students can learn from qualified mentors in the nurturing environment of supervised training. Ideally, students in later years who are expected to contribute as full time staff members during their practice placements should be supported where feasible with a basic wage.

Incorporating Change:

All of the above must be considered important for the formation of well-rounded pharmacists, and we recognize that in some cases this might require a longer undergraduate course. Such an extension should be welcomed where necessary to include these elements, but we believe that in many cases a full review of the curriculum will allow for positive change without requiring an extension. Many universities maintain traditional syllabi, with over-emphasis on some chemical and technological subjects, long botany courses or less relevant information. As the amount of knowledge increases overtime, selection of the most important and most relevant information becomes even more necessary. It is worth remembering too, that an in-depth understanding of scientific method and reason in a few applied areas can be more valuable than a breadth of understanding of too many different subtopics. It is the responsibility of each professor to ensure that his/her lectures keep pace with developments in knowledge and practice.

Flexibility and Choice:

While a broad undergraduate education is necessary to provide future pharmacists with the essential formation for working in a variety of different roles, students should be given the opportunity to gain a deeper understanding of areas that interest them particularly. We believe that the pharmaceutical curriculum should consist of a core curriculum to be undertaken by all students, followed by a period in which the students could in effect choose their own subjects, from a predetermined list of options. Allowing flexibility in this way would make students aware of all of the topics covered above and ensure that many graduate roles could be catered for. They would have the chance to be educated particularly for their preferred working field, but could also gain some preparation for others. Such a model would make the curriculum more inspiring and interesting for students without being prohibitive in length and would provide an ideal foundation for competitive and adaptable pharmacists ready for the needs and challenges of the future^15-18.