Construction, Operations, and Sustainability of Maternal and Child Health Pharmacy Clinics in China: A National Multicenter Cross-Sectional Survey

Construction, Operations, and Sustainability of Maternal and Child Health Pharmacy Clinics in China: A National Multicenter Cross-Sectional Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Construction, Operations, and Sustainability of Maternal and Child Health Pharmacy Clinics in China: A National Multicenter Cross-Sectional Survey Yifan Li, Ran Wang, Xin Yu, Xin Feng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8425974/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Apr, 2026 Read the published version in BMC Health Services Research → Version 1 posted 10 You are reading this latest preprint version Abstract Background Pharmacist-managed clinics are being promoted nationally in China to strengthen pharmaceutical care, particularly maternal and child health (MCH). However, little is known about how these clinics are structured, staffed, financed, or sustained at a national level. This study examined the development, operational characteristics, and financial viability of MCH pharmacist-managed clinics in China. Methods A national, multi-center, cross-sectional survey was conducted from August to September 2025 among pharmacy department leaders from 150 medical institutions across 32 provinces. A validated 44-item questionnaire assessed institutional characteristics, clinic establishment, service delivery models, workforce composition, financial status, and operational challenges (5-point Likert scales). Descriptive statistics were used to summarize the clinical characteristics. Multivariable logistic regression identified factors associated with financial sustainability, defined as achieving a break-even or profitability. Results Ninety valid responses were analyzed (response rate: 62.7%). Among the institutions, 83.3% had established pharmacist-managed clinics and 57.8% operated dedicated MCH clinics. Most institutions (64.4%) provided services free of charge and 61.1% reported operating deficits. Annual patient volumes were highly variable (median 142; IQR 27.5–345.8), with nearly half of the clinics serving fewer than 100 patients per year. Major barriers include low patient willingness to pay and the absence of unified national charging standards. In the adjusted analyses, service charging was the strongest predictor of financial sustainability (aOR = 3.85; 95% CI: 1.88–7.89), followed by the inclusion of clinic activity in performance-based compensation (aOR = 2.15; 95% CI: 1.10–4.20). Institutional characteristics, clinical duration, and pharmacists’ seniority were not independently associated with sustainability. Conclusions MCH pharmacist-managed clinics have expanded rapidly nationwide, but the structural misalignment between policy-driven adoption and financial and workforce support has created significant sustainability challenges. Long-term viability requires coordinated reforms, including standardized fee schedules, integration of pharmacist services into insurance reimbursement, and strengthened institutional investment in the workforce and service pathways. These changes are essential to ensure that MCH pharmacy clinics can sustainably improve medication safety and health outcomes for mothers and children. Maternal and Child Health Pharmacist-Managed Clinics Pharmaceutical Care Health Services Delivery Financial Sustainability Health Policy Workforce Development Cross-Sectional Studies China Background Pharmacist-managed clinics represent an important evolution in pharmacy practice, shifting from product-oriented dispensing to patient-centered clinical care. Evidence demonstrates that such clinics improve medication safety, enhance adherence, and reduce healthcare costs by delivering structured, expert-led pharmaceutical services [ 1 ]. Specialized medication management is particularly important in maternal and child health (MCH). Pregnant, lactating, and pediatric patients frequently require pharmacotherapy and are often excluded from clinical trials, placing them at an elevated risk of adverse drug events and inappropriate medication use [ 2 , 3 ]. In China, national health system reforms, particularly the Healthy China 2030 strategy and the 2020 directive on rational medication use, have accelerated the establishment of pharmacist-managed clinics within hospitals. Many obstetrics, gynecology, and pediatric departments have subsequently developed MCH-focused pharmacy clinics to improve medication counseling and support safe prescribing [ 4 – 6 ]. However, the rapid expansion of these services has outpaced the development of standardized operational models, sustainable financing mechanisms, charging policies, and workforce requirements. Although the number of clinics continues to grow, no national-level health service evaluation has examined how these clinics are structured, staffed, funded, or integrated into routine care. Existing evidence is limited to single-institution reports that do not assess broader system issues, including financial sustainability, reimbursement pathways, performance incentives, patient demand, and regional variation [ 7 , 8 ]. This gap limits policymakers and hospital leaders’ ability to design evidence-based strategies for service planning, resource allocation, and long-term sustainability. Given the rapid but uneven development of MCH pharmacist-managed clinics, a comprehensive national assessment is needed to characterize their current status and identify the organizational and financial challenges affecting their implementation in China’s health system. Methods Study Aim, Design, and Setting This study aimed to evaluate the construction, operational characteristics, and sustainability of maternal and child health (MCH) pharmacist-managed clinics in China. We conducted a national, multi-center, cross-sectional survey from August 1 to September 1, 2025, following the STROBE reporting guidelines for observational studies. The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Gynecology Hospital, Capital Medical University (Approval No. 2024-KY-035-01). Electronic informed consent was obtained from all the respondents. Participants and Sampling Frame Directors of the pharmacy department were recruited from 150 medical institutions affiliated with the Women and Children Specialized Pharmacists Branch of the Chinese Pharmacists Association. Eligible respondents were required to (1) have administrative responsibility for pharmacy services, and (2) possess direct knowledge of their institution’s pharmacist-managed clinical operations. Directors from institutions without clinics were included to capture the perceived barriers. Questionnaires with more than 20% of missing data were excluded. Questionnaire Development and Validation This study employed a self-designed questionnaire (supplementary file 1). Data were collected using a structured 44-item questionnaire developed through 1) expert consultation involving five senior specialists in clinical pharmacy and MCH services and 2) review of national policy documents, relevant literature, and established frameworks for pharmacy services. Psychometric testing demonstrated strong reliability (Cronbach’s α = 0.87) and content validity (CVI α = 0.91). Questionnaire domains included: 1) institutional characteristics: hospital level, ownership, region, and bed capacity; 2) clinic infrastructure and workforce: year of establishment, physical space, number, and qualifications of pharmacists; 3) service delivery and operations: patient volume, service types, and charging policies; and 4) sustainability and challenges, assessed via 5-point Likert scales (1 = not important; 5 = extremely important). A pilot test of eight institutions was conducted to evaluate clarity and feasibility. Data Collection Procedures The survey was conducted using a secure online platform. The respondents were able to review and revise the entries before submission. All responses were screened for completeness. Minor missing data ( 20%) were excluded. Financial sustainability was defined as operating at break-even or generating positive net revenue, as reported by each institution. Statistical Analysis The data analysis was performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Normality was assessed using the Shapiro–Wilk test. Continuous variables are presented as means ± standard deviations (SD) or medians with interquartile ranges (IQR) and compared using t-tests, ANOVA, or Mann–Whitney U tests, as appropriate. Categorical variables were summarized as frequencies and percentages and were analyzed using Chi-square or Fisher’s exact tests. No sampling weights or regional stratification adjustments were applied, as the survey sought to describe observed patterns among participating institutions rather than produce population-representative estimates. For exploratory comparisons, clinics were categorized by establishment year (≤ 2022 vs > 2022) to examine whether earlier implementation was associated with higher service volumes or financial performance. To identify the independent predictors of financial sustainability (defined as break-even or profitability), a multivariable logistic regression model was constructed. Candidate variables were selected based on their theoretical relevance and univariate significance (P < 0.10). Multicollinearity was assessed using variance inflation factors (VIF < 5), and model fit was evaluated using the Hosmer–Lemeshow test. All statistical tests were two-tailed, and significance was defined as P < 0.05. Results Response Rate A total of 94 questionnaires were received from 150 invited institutions (response rate: 62.7%). After excluding incomplete responses, 90 valid questionnaires were included (effective response rate: 95.7%). Institutional Characteristics These institutions represented all 32 provinces in China (Table 1 : Characteristics of participating institutions ). Most of them were tertiary-level public hospitals (90%). Both institutional capacity and pharmacy workforce composition varied widely, with bed numbers and staffing levels ranging from small local centers to large academic hospitals. This heterogeneity reflects substantial differences in service scale, organizational resources, and maturity of pharmacy services across regions. Table 1 Characteristics of participating institutions (n = 90) Characteristic Category / Statistic n (%) / Median (IQR) Geographic distribution Eastern region 36 (40.0%) Central region 21 (23.3%) Western region 33 (36.7%) Institution type Tertiary specialized hospital 48 (53.3%) Tertiary general hospital 33 (36.7%) Secondary specialized hospital 7 (7.8%) Secondary general hospital 1 (1.1%) Other facility (local medical center) 1 (1.1%) Ownership Public institution 88 (97.8%) Private for-profit institution 2 (2.2%) Hospital capacity Bed capacity, median (IQR) 800 (400–1496) Pharmacy personnel Total pharmacy professionals, median (IQR) 47.5 (24.3–80.8) Educational background Doctoral degree holders, median (IQR) 0 (0–2) Master’s degree holders, median (IQR) 10 (2–21.8) Professional title Senior pharmacist, median (IQR) 1 (0–3) Deputy senior pharmacist, median (IQR) 4.5 (2–10.8) Intermediate pharmacist, median (IQR) 20 (9.3–34.8) Clinical pharmacist certification National certification, median (IQR) 6.5 (3.3–10) Provincial certification, median (IQR) 0 (0–0.8) Note: Data are presented as n (%) or median (interquartile range, IQR) unless otherwise specified. Pharmacy Clinic Establishment Among the 90 institutions, 75 (83.3%) had established pharmacist-managed clinics and 52 (57.8%) operated dedicated MCH specialty clinics (Table 2 : Establishment and operational characteristics of pharmacy clinics ). Insufficient pharmacist staffing and shortage of qualified specialty practitioners were the most cited barriers to clinical establishment. Charging practices varied considerably. Only a minority of clinics were charged for services (33.3%). Among institutions that charged fees, consultation prices were modest, generally ranging from ¥15 to ¥30 depending on pharmacist seniority. Most clinics reported operating at a financial deficit (61.1%). More than half of institutions (53.3%) lacked performance incentive mechanisms linked to clinic activity, indicating limited integration of pharmacy clinics into institutional financial and human resource systems Table 2 Establishment and operational characteristics of pharmacy clinics (n = 90) Characteristic Category / Description n (%) / Median (IQR) Pharmacy clinic establishment Institutions with established pharmacy clinics 75 (83.3%) Institutions without pharmacy clinics 15 (16.7%) Maternal and child specialty clinics Institutions with independent clinics and fixed scheduling 52 (57.8%) Motivations for establishing clinics Response to national policy initiatives 61 (67.8%) Enhancement of pharmacy discipline influence 58 (64.4%) Meeting specific patient needs 57 (63.3%) Improvement of medical service quality 54 (60.0%) Barriers among institutions without clinics (n = 15) Insufficient pharmacist workforce 11 (73.3%) Lack of qualified specialty pharmacists 9 (60.0%) Absence of clear service charging standards 6 (40.0%) Low patient demand or willingness to pay 6 (40.0%) Service fee structure All services provided free of charge 58 (64.4%) All services charged 30 (33.3%) Selective charging 2 (2.2%) Basis for fee determination (charging institutions, n = 32) Equivalent to physician consultation fees 15 (46.9%) Provincial/municipal health insurance regulations 12 (37.5%) Hospital-determined pricing 5 (15.6%) Consultation fee standards Senior pharmacists, median (IQR) 20.5 (13.75–30) Deputy senior pharmacists, median (IQR) 20 (11.6–30) Intermediate pharmacists, median (IQR) 15 (8–26.25) Financial sustainability Deficit operation 55 (61.1%) Break-even 32 (35.6%) Profitable 3 (3.3%) Note: Data are presented as n (%) or median (interquartile range, IQR) unless otherwise specified. Motivations and barriers allow multiple selections. Clinic Operations and Service Provision Across the 52 MCH clinics, the service types varied, with pregnancy medication consultation (17.3%), pediatric medication guidance (11.5%), and lactation-related counseling (9.6%) being the most common (Table 3 : Characteristics of maternal and child specialty pharmacy clinics ). The annual patient volume showed substantial variability (median 142; IQR 27.5–345.8). Nearly half of the clinics served fewer than 100 patients per year, whereas a small subset managed very high volumes (> 700 annually), highlighting significant differences in service uptake and clinic maturity across institutions and regions. Most clinics operate a limited number of weekly sessions and are staffed by small teams, typically three dedicated pharmacists, often with advanced degrees or senior titles. However, formal specialty certification remains uncommon. Table 3 Characteristics of maternal and child specialty pharmacy clinics (n = 52) Characteristic Category / Description n (%) / Median (IQR) Clinic service types Pregnancy medication consultation 9 (17.3%) Pediatric medication guidance 6 (11.5%) Lactation/pregnancy medication services 5 (9.6%) Annual patient service volume Median (IQR) 142 (27.5–345.8) 0–100 patients 25 (48.1%) 101–300 patients 13 (25.0%) > 700 patients 7 (13.5%) Clinic operation schedule Weekly clinic sessions (half-day units), median (IQR) 2 (1–5) Planned patient capacity per half-day session per pharmacist, median (IQR) 3 (1–5) Pharmacy clinic staffing Fixed clinic pharmacists, median (IQR) 3 (2–7) With deputy senior titles or above, median (IQR) 2 (1–3) With master’s degree or above, median (IQR) 2 (1–3) Clinical experience (years), median (IQR) 10 (6.75–12.25) Specialty certification Obstetrics/gynecology specialty pharmacist, median (IQR) 1 (0–1) Pediatric specialty pharmacist, median (IQR) 1 (0–1) Note: Data are presented as n (%) or median (interquartile range, IQR) unless otherwise specified. Service Content and Quality Assurance The most frequently consulted topics included adverse drug reactions, medication selection, dosing, drug interactions, and pregnancy/lactation-related medication safety. Commonly inquired medications were levofloxacin, ibuprofen, ribavirin, loratadine, and acetaminophen. Evidence-based resources were widely used, including international or national guidelines (85.6%), drug package inserts (83.3%), pharmacy databases (71.1%), and clinical research literature (32.2%). Standardized documentation practices varied across institutions: 35.6% provided structured forms for all first-visit patients, 26.7% used them selectively, and 22.2% did not use them routinely. Patient satisfaction assessments were conducted regularly in 10.0% of clinics and irregularly in 25.6%, with reported satisfaction levels generally high. Challenges and Barriers The institutions reported challenges across the four dimensions (Table 4 : Challenges in specialty pharmacy clinic development assessed across three dimensions) . External recognition and policy constraints, particularly the absence of unified charging standards and limited patient willingness to pay, received the highest severity scores, representing the most prominent systemic barriers to clinical development. Talent development issues and internal operational pressures, including heavy workloads and lack of performance-based incentives, were also consistently rated as significant challenges. In contrast, challenges related to service standardization scored moderately, indicating partial progress in workflow implementation but ongoing gaps in follow-up processes and continuity of care. Table 4 Challenges in specialty pharmacy clinic development assessed across three dimensions (5-point Likert scale, n = 90) Dimension Item Mean ± SD Service standardization Patient reception and consultation workflow 3.3 ± 1.5 Standardized documentation and record management 3.2 ± 1.3 Patient follow-up and continuity of care 2.9 ± 1.4 Talent development Lack of systematic pharmacist training programs 3.7 ± 1.2 Insufficient clinical practice skills among pharmacists 3.7 ± 1.1 Limited career advancement pathways in clinical pharmacy 3.6 ± 1.1 External recognition and policy environment Lack of unified national charging standards 4.1 ± 1.0 Low patient awareness and willingness to pay 4.1 ± 1.1 Inconsistent policy or regulatory support 3.9 ± 1.1 Internal operational and institutional support Excessive workload 3.9 ± 1.1 Lack of performance-based incentive mechanisms 4.0 ± 1.0 Insufficient research funding and institutional support 4.0 ± 1.0 Note: Ratings were based on a 5-point Likert scale (1 = not challenging, 5 = extremely challenging). Data are expressed as mean ± standard deviation (SD). Factors Associated with Clinic Establishment and Sustainability The clinic establishment rates did not differ significantly by hospital level (P = 0.106). Among the established clinics, those launched before 2022 had higher patient volumes and were more likely to charge for services (P < 0.01). Charging practices were strongly associated with financial sustainability, with clinics that charged fees being significantly more likely to achieve break-even or profitability (P = 0.002; Table 5 : Challenges in specialty pharmacy clinic development assessed across three dimensions ). In multivariable logistic regression, service charging remained the strongest independent predictor of financial sustainability (adjusted odds ratio [aOR] = 3.85; 95% CI: 1.88–7.89), and the inclusion of clinic activity in performance-based compensation was also a significant predictor (aOR = 2.15; 95% CI: 1.10–4.20). Structural institutional characteristics such as hospital level, clinic duration, and pharmacist seniority were not associated with sustainability, suggesting that financial and incentive mechanisms play a more determinant role than organizational scale or staffing profiles. Table 5 Univariate analysis of factors associated with pharmacy clinic establishment and operational outcomes Analysis / Variable Group 1 Group 2 P-value Part A: Factors associated with clinic establishment Hospital level Tertiary (n = 81) Secondary (n = 8) 0.106ᵃ Proportion with established clinic 60.5% (49/81) 37.5% (3/8) — Part B: Factors associated with operational outcomes (among established clinics) Annual patient volume by establishment year Established ≤ 2022 (n = 16) Established > 2022 (n = 32) 0.003ᵇ Median (IQR) 433 (195–1072) 112 (50–291) — Charging rate by establishment year Established ≤ 2022 (n = 16) Established > 2022 (n = 32) 0.005ᵃ Proportion charging for services 87.5% (14/16) 40.6% (13/32) — Financial sustainability by charging policy Charging clinics (n = 27) Non-charging clinics (n = 25) 0.002ᵃ Proportion achieving break-even or profitability 62.9% (17/27) 16.0% (4/25) — Note: Boldface indicates statistical significance (P < 0.05). ᵃ Chi-square test or Fisher’s exact test. ᵇ Mann–Whitney U test. Some subgroup counts may not total n = 75 due to missing data. Discussion Summary of Key Findings This national multi-center survey provides the first comprehensive examination of maternal and child health pharmacist-managed clinics in China. Clinics have been widely established across institutions; however, substantial heterogeneity exists in service models, staffing, patient volume, and financial performance. A central finding was the disconnect between rapid service uptake and fragile sustainability: over 60% of clinics operated at a deficit, and the annual patient volume varied widely, with nearly half serving fewer than 100 patients. The multivariable analysis showed that service charging and inclusion in performance-based compensation were the strongest predictors of financial sustainability. Organizational structural factors such as hospital level or pharmacist seniority were not independently associated with sustainability. Comparison with Existing Evidence Our findings are consistent with those of previous national surveys documenting the uneven development of hospital pharmacy services across China [ 9 ]. The clinic establishment rate observed in this study (83.3%) was higher than the estimates reported in general hospitals, suggesting that maternal and child health–specific policy initiatives may have stimulated earlier uptake and expansion in this sector. International evidence also reflects similar challenges in sustaining pharmacist-led clinical service. In the United States, multiple evaluations have shown that although pharmacist-led prescribing, chronic disease management, and primary care services can be both clinically effective and cost-effective, their scalability is constrained by inconsistent reimbursement pathways, limited billing mechanisms, and productivity expectations that do not adequately capture cognitive pharmacy services [ 10 – 12 ]. Comparable patterns have been observed in England, where pharmacy service delivery is strongly shaped by commissioning structures and payment models, underscoring how remuneration frameworks directly influence service volume and integration into routine care [ 13 ]. Even in highly specialized practice areas, such as palliative care, difficulties persist in defining, integrating, and funding pharmacist contributions within existing health system payment structures [ 14 ]. These global experiences highlight that the difficulty in establishing financially sustainable pharmacist-led services is not unique to China but reflects a broader structural misalignment between the clinical value of pharmacist interventions and the financial incentives that support them in many countries [ 15 , 16 ]. The weak alignment observed in our study, evidenced by the 61.1% deficit rate and low patient volumes in many clinics, mirrors these international patterns. Taken together, international comparisons reinforce a key message: while the clinical value of pharmacist-led services is widely recognized, their long-term sustainability depends on explicit and well-designed remuneration mechanisms [ 17 ]. Our study extends this insight to the MCH context in China and illustrates the risks of rapid institutional adoption in the absence of coordinated financial and policy supports. Interpretation and Underlying Mechanisms Several systemic and behavioral mechanisms may explain the misalignment between service expansion and weak financial performance. First, the structural financing constraints remain substantial. Pharmaceutical care lacks standardized billing codes and reimbursement pathways in China, limiting cost recovery and reducing institutional incentives for investment [ 18 ]. Second, organizational motivations were weakened by the absence of performance incentives tied to clinic output, a finding consistent with earlier evaluations of pharmacy service models [ 19 ]. Behavioral economics offers additional explanatory insights. Both administrators and patients may exhibit present bias, undervaluing services whose benefits accrue in the future rather than immediately [ 20 ]. For patients, this may manifest as a low willingness to pay for preventive counseling. For administrators, this may reduce the priority of resource allocation. Moreover, default bias likely contributes to underutilization; pharmacy clinics are not embedded as a routine step in the maternal care pathway, requiring additional effort from patients and care teams to engage with the service. These mechanisms suggest that the challenges observed are deeply rooted in system design and incentive structures, and not simply in clinic-level operations. Implications for Policy and Practice Strengthening MCH pharmacy clinics requires coordinated action from policymakers and institutions. At the policy level, establishing a national charging code for pharmacist consultations and integrating these services into medical insurance reimbursements would directly enhance sustainability. A large body of evidence supports the economic value of pharmacist-led care in chronic disease management and maternal health, demonstrating reductions in adverse drug events and healthcare utilization [ 21 ]. At the institutional level, hospitals may consider making pharmacist consultations a default component of maternity care pathways, an approach supported by evidence from other preventive health interventions. Linking clinical productivity to performance-based compensation could further enhance clinician engagement and promote service quality. The expansion of accredited training pathways and specialty certification programs in obstetrics, gynecology, and pediatrics may strengthen workforce capacity and ensure high-quality service delivery. Strengths and Limitations The strengths of this study include its nationwide coverage, collection of detailed operational and financial indicators, and a first-of-its-kind focus on MCH specialty clinics. However, this study has several limitations that must be acknowledged. Sampling bias: Recruitment through a professional WeChat group likely resulted in overrepresentation of institutions already engaged in specialty pharmacy practice. The clinic establishment rate reported here (83.3%) exceeds that documented in previous national surveys [ 6 ], indicating the participation of early adopters rather than a representative national sample. Cross-sectional design: Data represent a single point in time and cannot establish causal relationships between organizational factors and sustainability. Self-reported indicators: Operational and financial data may be subject to recall or reporting biases. Generalizability: Findings reflect better-resourced hospitals; the results may not apply to lower-level institutions. Economic outcomes not measured: Formal cost-effectiveness or budget-impact analyses were beyond the scope of this study, but are essential for informing reimbursement policies. Future research should incorporate stratified sampling to enhance representativeness, longitudinal designs to assess policy impacts, and rigorous economic evaluations to quantify the return on investment for MCH pharmacist-managed services. Intervention studies testing behavioral nudges, such as default scheduling or structured follow-ups, may also provide insights into improving clinical utilization and sustainability. Conclusion This national assessment shows that MCH pharmacist-managed clinics have expanded rapidly in response to policy initiatives, yet their development remains structurally misaligned with the financial and workforce support required for sustainable operations. Most clinics face persistent deficits, low patient volumes, and shortages of qualified personnel, reflecting systemic gaps rather than clinical shortcomings. To ensure long-term viability, national health authorities should establish unified charging standards and incorporate pharmacist consultations into insurance reimbursements. At the institutional level, hospitals must strengthen their workforce development and integrate pharmacy services into routine care pathways. Coordinated policy and organizational action are essential to transforming these clinics from policy-driven pilots into sustainable components of maternal and child health services. Declarations Ethics approval and consent to participate Ethics approval and consent to participate The study was performed in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Gynecology Hospital, Capital Medical University (Approval No. 2024-KY-035-01). Electronic informed consent was obtained from all the respondents. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Beijing Natural Science Foundation through the project “Development and Application of Perinatal Pharmaceutical Science Popularization Tools Based on Behavioral Economics Theory” (Grant No. 7244462), and by the Capital Health Development Special Project (Grant No. 2024-2-2115). Author Contribution LYF and WR designed the review, collected, analyzed, and interpreted the data, and wrote the review. YX designed the review, collected and checked the data, and wrote the review. FX designed the review and commented on the drafts of the previous version. All the authors have read and approved the final version of the manuscript. Acknowledgements None. Data Availability The datasets generated and analyzed during the current study are not publicly available because of institutional confidentiality and restrictions related to identifiable organizational information but are available from the corresponding author upon reasonable request. References Smith A, Nair DH, Smith ER, Wheeler TF, Smith LE, Russell BR, et al. University Pharmacy Clinic: Preventing Errors and Enhancing Lives Through Expert Medication Management. Pharm (Basel). 2025;13(1):24. Sema FD, Addis DG, Melese EA, Nassa DD, Kifle ZD. Prevalence and Associated Factors of Self-Medication among Pregnant Women on Antenatal Care Follow-Up at University of Gondar Comprehensive Specialized Hospital in Gondar, Northwest Ethiopia: A Cross-Sectional Study. Int J Reprod Med. 2020;2020:2936862. 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Supplementary Files SurveyInstrument.docx Cite Share Download PDF Status: Published Journal Publication published 22 Apr, 2026 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 19 Mar, 2026 Reviews received at journal 19 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviews received at journal 23 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers invited by journal 22 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Editor invited by journal 30 Dec, 2025 Submission checks completed at journal 29 Dec, 2025 First submitted to journal 29 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8425974","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":580901516,"identity":"a4acd452-e9ce-4fea-8493-638f9211f971","order_by":0,"name":"Yifan Li","email":"","orcid":"","institution":"Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yifan","middleName":"","lastName":"Li","suffix":""},{"id":580901517,"identity":"22526fd2-3f35-4272-86ad-9464d45f005b","order_by":1,"name":"Ran Wang","email":"","orcid":"","institution":"Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ran","middleName":"","lastName":"Wang","suffix":""},{"id":580901518,"identity":"ecddce56-35f0-4373-98ba-b7e3934c56da","order_by":2,"name":"Xin Yu","email":"","orcid":"","institution":"Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Yu","suffix":""},{"id":580901519,"identity":"c7b0bde6-ca0a-4e4a-b87c-62cd16c2439c","order_by":3,"name":"Xin Feng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBAC9gYQacDAw8bM//ABVNAArxaeAxA1MnzsPMwwpcRoYWCwkePnYZMgTgt77+HXPAV3gA7jPVbxo2ZbYgN78zYJhpo7uLXwnEuznGHwDKiFL+1mz7HbiQ08x8okGI49w6nFXiLHzOCDwWGgFgaz24wNQC1AEQnGhsO4bZF/Y2aQANVSDNYCFMGvRYLH+AHEFh4zZogtPAS08OSYMc4Aa2FLlgT6xbiNJ63YIuEYHi3sZ4w/8/w5bC/ff/jghx81t2X72Q9vvPGhBrcWIIBHB5QLIhLwaWBgYP6AX34UjIJRMApGPAAAxRhMtrCA5/EAAAAASUVORK5CYII=","orcid":"","institution":"Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xin","middleName":"","lastName":"Feng","suffix":""}],"badges":[],"createdAt":"2025-12-22 14:24:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8425974/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8425974/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-026-14586-z","type":"published","date":"2026-04-22T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":107929481,"identity":"6eb778a2-54b5-4300-be13-82281c956f7e","added_by":"auto","created_at":"2026-04-27 16:16:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":357984,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8425974/v1/872b12dc-f7f1-4dad-99ca-378265c3f227.pdf"},{"id":101398270,"identity":"a3a26f35-555c-45dc-85c1-a64d162ec740","added_by":"auto","created_at":"2026-01-29 09:40:35","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":41331,"visible":true,"origin":"","legend":"","description":"","filename":"SurveyInstrument.docx","url":"https://assets-eu.researchsquare.com/files/rs-8425974/v1/06f324b721c1ce31c9bdb031.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Construction, Operations, and Sustainability of Maternal and Child Health Pharmacy Clinics in China: A National Multicenter Cross-Sectional Survey","fulltext":[{"header":"Background","content":"\u003cp\u003ePharmacist-managed clinics represent an important evolution in pharmacy practice, shifting from product-oriented dispensing to patient-centered clinical care. Evidence demonstrates that such clinics improve medication safety, enhance adherence, and reduce healthcare costs by delivering structured, expert-led pharmaceutical services [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Specialized medication management is particularly important in maternal and child health (MCH). Pregnant, lactating, and pediatric patients frequently require pharmacotherapy and are often excluded from clinical trials, placing them at an elevated risk of adverse drug events and inappropriate medication use [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn China, national health system reforms, particularly the Healthy China 2030 strategy and the 2020 directive on rational medication use, have accelerated the establishment of pharmacist-managed clinics within hospitals. Many obstetrics, gynecology, and pediatric departments have subsequently developed MCH-focused pharmacy clinics to improve medication counseling and support safe prescribing [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the rapid expansion of these services has outpaced the development of standardized operational models, sustainable financing mechanisms, charging policies, and workforce requirements.\u003c/p\u003e \u003cp\u003eAlthough the number of clinics continues to grow, no national-level health service evaluation has examined how these clinics are structured, staffed, funded, or integrated into routine care. Existing evidence is limited to single-institution reports that do not assess broader system issues, including financial sustainability, reimbursement pathways, performance incentives, patient demand, and regional variation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This gap limits policymakers and hospital leaders\u0026rsquo; ability to design evidence-based strategies for service planning, resource allocation, and long-term sustainability.\u003c/p\u003e \u003cp\u003eGiven the rapid but uneven development of MCH pharmacist-managed clinics, a comprehensive national assessment is needed to characterize their current status and identify the organizational and financial challenges affecting their implementation in China\u0026rsquo;s health system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Aim, Design, and Setting\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the construction, operational characteristics, and sustainability of maternal and child health (MCH) pharmacist-managed clinics in China. We conducted a national, multi-center, cross-sectional survey from August 1 to September 1, 2025, following the STROBE reporting guidelines for observational studies. The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Gynecology Hospital, Capital Medical University (Approval No. 2024-KY-035-01). Electronic informed consent was obtained from all the respondents.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Sampling Frame\u003c/h3\u003e\n\u003cp\u003eDirectors of the pharmacy department were recruited from 150 medical institutions affiliated with the Women and Children Specialized Pharmacists Branch of the Chinese Pharmacists Association. Eligible respondents were required to (1) have administrative responsibility for pharmacy services, and (2) possess direct knowledge of their institution\u0026rsquo;s pharmacist-managed clinical operations. Directors from institutions without clinics were included to capture the perceived barriers. Questionnaires with more than 20% of missing data were excluded.\u003c/p\u003e\n\u003ch3\u003eQuestionnaire Development and Validation\u003c/h3\u003e\n\u003cp\u003eThis study employed a self-designed questionnaire (supplementary file 1). Data were collected using a structured 44-item questionnaire developed through 1) expert consultation involving five senior specialists in clinical pharmacy and MCH services and 2) review of national policy documents, relevant literature, and established frameworks for pharmacy services.\u003c/p\u003e \u003cp\u003ePsychometric testing demonstrated strong reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.87) and content validity (CVI α\u0026thinsp;=\u0026thinsp;0.91). Questionnaire domains included: 1) institutional characteristics: hospital level, ownership, region, and bed capacity; 2) clinic infrastructure and workforce: year of establishment, physical space, number, and qualifications of pharmacists; 3) service delivery and operations: patient volume, service types, and charging policies; and 4) sustainability and challenges, assessed via 5-point Likert scales (1\u0026thinsp;=\u0026thinsp;not important; 5\u0026thinsp;=\u0026thinsp;extremely important).\u003c/p\u003e \u003cp\u003eA pilot test of eight institutions was conducted to evaluate clarity and feasibility.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eThe survey was conducted using a secure online platform. The respondents were able to review and revise the entries before submission. All responses were screened for completeness. Minor missing data (\u0026lt;\u0026thinsp;5%) were managed with pairwise deletion for descriptive statistics, whereas questionnaires with major missing data (\u0026gt;\u0026thinsp;20%) were excluded. Financial sustainability was defined as operating at break-even or generating positive net revenue, as reported by each institution.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data analysis was performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Normality was assessed using the Shapiro\u0026ndash;Wilk test. Continuous variables are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD) or medians with interquartile ranges (IQR) and compared using t-tests, ANOVA, or Mann\u0026ndash;Whitney U tests, as appropriate. Categorical variables were summarized as frequencies and percentages and were analyzed using Chi-square or Fisher\u0026rsquo;s exact tests. No sampling weights or regional stratification adjustments were applied, as the survey sought to describe observed patterns among participating institutions rather than produce population-representative estimates. For exploratory comparisons, clinics were categorized by establishment year (\u0026le;\u0026thinsp;2022 vs\u0026thinsp;\u0026gt;\u0026thinsp;2022) to examine whether earlier implementation was associated with higher service volumes or financial performance.\u003c/p\u003e \u003cp\u003eTo identify the independent predictors of financial sustainability (defined as break-even or profitability), a multivariable logistic regression model was constructed. Candidate variables were selected based on their theoretical relevance and univariate significance (P\u0026thinsp;\u0026lt;\u0026thinsp;0.10). Multicollinearity was assessed using variance inflation factors (VIF\u0026thinsp;\u0026lt;\u0026thinsp;5), and model fit was evaluated using the Hosmer\u0026ndash;Lemeshow test. All statistical tests were two-tailed, and significance was defined as P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eResponse Rate\u003c/h2\u003e \u003cp\u003eA total of 94 questionnaires were received from 150 invited institutions (response rate: 62.7%). After excluding incomplete responses, 90 valid questionnaires were included (effective response rate: 95.7%).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInstitutional Characteristics\u003c/h3\u003e\n\u003cp\u003eThese institutions represented all 32 provinces in China (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003eCharacteristics of participating institutions\u003c/b\u003e). Most of them were tertiary-level public hospitals (90%). Both institutional capacity and pharmacy workforce composition varied widely, with bed numbers and staffing levels ranging from small local centers to large academic hospitals. This heterogeneity reflects substantial differences in service scale, organizational resources, and maturity of pharmacy services across regions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participating institutions (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory / Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%) / Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic distribution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEastern region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary specialized hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary general hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary specialized hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary general hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther facility (local medical center)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOwnership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic institution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (97.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate for-profit institution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBed capacity, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e800 (400\u0026ndash;1496)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy personnel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal pharmacy professionals, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5 (24.3\u0026ndash;80.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctoral degree holders, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaster\u0026rsquo;s degree holders, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (2\u0026ndash;21.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior pharmacist, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeputy senior pharmacist, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5 (2\u0026ndash;10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate pharmacist, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (9.3\u0026ndash;34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical pharmacist certification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNational certification, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5 (3.3\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvincial certification, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0\u0026ndash;0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Data are presented as n (%) or median (interquartile range, IQR) unless otherwise specified.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePharmacy Clinic Establishment\u003c/h2\u003e \u003cp\u003eAmong the 90 institutions, 75 (83.3%) had established pharmacist-managed clinics and 52 (57.8%) operated dedicated MCH specialty clinics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cb\u003eEstablishment and operational characteristics of pharmacy clinics\u003c/b\u003e). Insufficient pharmacist staffing and shortage of qualified specialty practitioners were the most cited barriers to clinical establishment.\u003c/p\u003e \u003cp\u003eCharging practices varied considerably. Only a minority of clinics were charged for services (33.3%). Among institutions that charged fees, consultation prices were modest, generally ranging from \u0026yen;15 to \u0026yen;30 depending on pharmacist seniority. Most clinics reported operating at a financial deficit (61.1%). More than half of institutions (53.3%) lacked performance incentive mechanisms linked to clinic activity, indicating limited integration of pharmacy clinics into institutional financial and human resource systems\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstablishment and operational characteristics of pharmacy clinics (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory / Description\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%) / Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy clinic establishment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutions with established pharmacy clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutions without pharmacy clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal and child specialty clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutions with independent clinics and fixed scheduling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (57.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivations for establishing clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse to national policy initiatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (67.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnhancement of pharmacy discipline influence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (64.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeeting specific patient needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImprovement of medical service quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers among institutions without clinics (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient pharmacist workforce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of qualified specialty pharmacists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsence of clear service charging standards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow patient demand or willingness to pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService fee structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll services provided free of charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (64.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll services charged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelective charging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasis for fee determination (charging institutions, n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEquivalent to physician consultation fees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvincial/municipal health insurance regulations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital-determined pricing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultation fee standards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior pharmacists, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.5 (13.75\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeputy senior pharmacists, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (11.6\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate pharmacists, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (8\u0026ndash;26.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial sustainability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeficit operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55 (61.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreak-even\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (35.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProfitable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Data are presented as n (%) or median (interquartile range, IQR) unless otherwise specified.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMotivations\u003c/em\u003e and \u003cem\u003ebarriers\u003c/em\u003e allow multiple selections.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinic Operations and Service Provision\u003c/h2\u003e \u003cp\u003eAcross the 52 MCH clinics, the service types varied, with pregnancy medication consultation (17.3%), pediatric medication guidance (11.5%), and lactation-related counseling (9.6%) being the most common (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cb\u003eCharacteristics of maternal and child specialty pharmacy clinics\u003c/b\u003e). The annual patient volume showed substantial variability (median 142; IQR 27.5\u0026ndash;345.8). Nearly half of the clinics served fewer than 100 patients per year, whereas a small subset managed very high volumes (\u0026gt;\u0026thinsp;700 annually), highlighting significant differences in service uptake and clinic maturity across institutions and regions.\u003c/p\u003e \u003cp\u003eMost clinics operate a limited number of weekly sessions and are staffed by small teams, typically three dedicated pharmacists, often with advanced degrees or senior titles. However, formal specialty certification remains uncommon.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of maternal and child specialty pharmacy clinics (n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory / Description\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%) / Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinic service types\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePregnancy medication consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (17.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric medication guidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLactation/pregnancy medication services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnual patient service volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e142 (27.5\u0026ndash;345.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;100 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u0026ndash;300 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;700 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinic operation schedule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeekly clinic sessions (half-day units), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlanned patient capacity per half-day session per pharmacist, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy clinic staffing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFixed clinic pharmacists, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith deputy senior titles or above, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith master\u0026rsquo;s degree or above, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical experience (years), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.75\u0026ndash;12.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty certification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetrics/gynecology specialty pharmacist, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatric specialty pharmacist, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Data are presented as n (%) or median (interquartile range, IQR) unless otherwise specified.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eService Content and Quality Assurance\u003c/h2\u003e \u003cp\u003eThe most frequently consulted topics included adverse drug reactions, medication selection, dosing, drug interactions, and pregnancy/lactation-related medication safety. Commonly inquired medications were levofloxacin, ibuprofen, ribavirin, loratadine, and acetaminophen. Evidence-based resources were widely used, including international or national guidelines (85.6%), drug package inserts (83.3%), pharmacy databases (71.1%), and clinical research literature (32.2%). Standardized documentation practices varied across institutions: 35.6% provided structured forms for all first-visit patients, 26.7% used them selectively, and 22.2% did not use them routinely. Patient satisfaction assessments were conducted regularly in 10.0% of clinics and irregularly in 25.6%, with reported satisfaction levels generally high.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eChallenges and Barriers\u003c/h2\u003e \u003cp\u003eThe institutions reported challenges across the four dimensions (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: \u003cb\u003eChallenges in specialty pharmacy clinic development assessed across three dimensions)\u003c/b\u003e. External recognition and policy constraints, particularly the absence of unified charging standards and limited patient willingness to pay, received the highest severity scores, representing the most prominent systemic barriers to clinical development. Talent development issues and internal operational pressures, including heavy workloads and lack of performance-based incentives, were also consistently rated as significant challenges. In contrast, challenges related to service standardization scored moderately, indicating partial progress in workflow implementation but ongoing gaps in follow-up processes and continuity of care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChallenges in specialty pharmacy clinic development assessed across three dimensions (5-point Likert scale, n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService standardization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient reception and consultation workflow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStandardized documentation and record management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient follow-up and continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTalent development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of systematic pharmacist training programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient clinical practice skills among pharmacists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited career advancement pathways in clinical pharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal recognition and policy environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of unified national charging standards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow patient awareness and willingness to pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInconsistent policy or regulatory support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal operational and institutional support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcessive workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of performance-based incentive mechanisms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsufficient research funding and institutional support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Ratings were based on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;not challenging, 5\u0026thinsp;=\u0026thinsp;extremely challenging). Data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFactors Associated with Clinic Establishment and Sustainability\u003c/h2\u003e \u003cp\u003eThe clinic establishment rates did not differ significantly by hospital level (P\u0026thinsp;=\u0026thinsp;0.106). Among the established clinics, those launched before 2022 had higher patient volumes and were more likely to charge for services (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Charging practices were strongly associated with financial sustainability, with clinics that charged fees being significantly more likely to achieve break-even or profitability (P\u0026thinsp;=\u0026thinsp;0.002; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e: \u003cb\u003eChallenges in specialty pharmacy clinic development assessed across three dimensions\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eIn multivariable logistic regression, service charging remained the strongest independent predictor of financial sustainability (adjusted odds ratio [aOR]\u0026thinsp;=\u0026thinsp;3.85; 95% CI: 1.88\u0026ndash;7.89), and the inclusion of clinic activity in performance-based compensation was also a significant predictor (aOR\u0026thinsp;=\u0026thinsp;2.15; 95% CI: 1.10\u0026ndash;4.20). Structural institutional characteristics such as hospital level, clinic duration, and pharmacist seniority were not associated with sustainability, suggesting that financial and incentive mechanisms play a more determinant role than organizational scale or staffing profiles.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate analysis of factors associated with pharmacy clinic establishment and operational outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalysis / Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart A: Factors associated with clinic establishment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary (n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.106ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion with established clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.5% (49/81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.5% (3/8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart B: Factors associated with operational outcomes (among established clinics)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnual patient volume by establishment year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablished\u0026thinsp;\u0026le;\u0026thinsp;2022 (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEstablished\u0026thinsp;\u0026gt;\u0026thinsp;2022 (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003ᵇ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e433 (195\u0026ndash;1072)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (50\u0026ndash;291)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharging rate by establishment year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablished\u0026thinsp;\u0026le;\u0026thinsp;2022 (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEstablished\u0026thinsp;\u0026gt;\u0026thinsp;2022 (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion charging for services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.5% (14/16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.6% (13/32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial sustainability by charging policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharging clinics (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-charging clinics (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002ᵃ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion achieving break-even or profitability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.9% (17/27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.0% (4/25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Boldface indicates statistical significance (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eᵃ Chi-square test or Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003cp\u003eᵇ Mann\u0026ndash;Whitney U test.\u003c/p\u003e \u003cp\u003eSome subgroup counts may not total n\u0026thinsp;=\u0026thinsp;75 due to missing data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSummary of Key Findings\u003c/h2\u003e \u003cp\u003eThis national multi-center survey provides the first comprehensive examination of maternal and child health pharmacist-managed clinics in China. Clinics have been widely established across institutions; however, substantial heterogeneity exists in service models, staffing, patient volume, and financial performance. A central finding was the disconnect between rapid service uptake and fragile sustainability: over 60% of clinics operated at a deficit, and the annual patient volume varied widely, with nearly half serving fewer than 100 patients. The multivariable analysis showed that service charging and inclusion in performance-based compensation were the strongest predictors of financial sustainability. Organizational structural factors such as hospital level or pharmacist seniority were not independently associated with sustainability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Existing Evidence\u003c/h2\u003e \u003cp\u003eOur findings are consistent with those of previous national surveys documenting the uneven development of hospital pharmacy services across China [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The clinic establishment rate observed in this study (83.3%) was higher than the estimates reported in general hospitals, suggesting that maternal and child health\u0026ndash;specific policy initiatives may have stimulated earlier uptake and expansion in this sector.\u003c/p\u003e \u003cp\u003eInternational evidence also reflects similar challenges in sustaining pharmacist-led clinical service. In the United States, multiple evaluations have shown that although pharmacist-led prescribing, chronic disease management, and primary care services can be both clinically effective and cost-effective, their scalability is constrained by inconsistent reimbursement pathways, limited billing mechanisms, and productivity expectations that do not adequately capture cognitive pharmacy services [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Comparable patterns have been observed in England, where pharmacy service delivery is strongly shaped by commissioning structures and payment models, underscoring how remuneration frameworks directly influence service volume and integration into routine care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Even in highly specialized practice areas, such as palliative care, difficulties persist in defining, integrating, and funding pharmacist contributions within existing health system payment structures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese global experiences highlight that the difficulty in establishing financially sustainable pharmacist-led services is not unique to China but reflects a broader structural misalignment between the clinical value of pharmacist interventions and the financial incentives that support them in many countries [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The weak alignment observed in our study, evidenced by the 61.1% deficit rate and low patient volumes in many clinics, mirrors these international patterns.\u003c/p\u003e \u003cp\u003eTaken together, international comparisons reinforce a key message: while the clinical value of pharmacist-led services is widely recognized, their long-term sustainability depends on explicit and well-designed remuneration mechanisms [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our study extends this insight to the MCH context in China and illustrates the risks of rapid institutional adoption in the absence of coordinated financial and policy supports.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation and Underlying Mechanisms\u003c/h2\u003e \u003cp\u003eSeveral systemic and behavioral mechanisms may explain the misalignment between service expansion and weak financial performance. First, the structural financing constraints remain substantial. Pharmaceutical care lacks standardized billing codes and reimbursement pathways in China, limiting cost recovery and reducing institutional incentives for investment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Second, organizational motivations were weakened by the absence of performance incentives tied to clinic output, a finding consistent with earlier evaluations of pharmacy service models [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Behavioral economics offers additional explanatory insights. Both administrators and patients may exhibit present bias, undervaluing services whose benefits accrue in the future rather than immediately [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. For patients, this may manifest as a low willingness to pay for preventive counseling. For administrators, this may reduce the priority of resource allocation. Moreover, default bias likely contributes to underutilization; pharmacy clinics are not embedded as a routine step in the maternal care pathway, requiring additional effort from patients and care teams to engage with the service. These mechanisms suggest that the challenges observed are deeply rooted in system design and incentive structures, and not simply in clinic-level operations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Policy and Practice\u003c/h2\u003e \u003cp\u003eStrengthening MCH pharmacy clinics requires coordinated action from policymakers and institutions. At the policy level, establishing a national charging code for pharmacist consultations and integrating these services into medical insurance reimbursements would directly enhance sustainability. A large body of evidence supports the economic value of pharmacist-led care in chronic disease management and maternal health, demonstrating reductions in adverse drug events and healthcare utilization [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the institutional level, hospitals may consider making pharmacist consultations a default component of maternity care pathways, an approach supported by evidence from other preventive health interventions. Linking clinical productivity to performance-based compensation could further enhance clinician engagement and promote service quality.\u003c/p\u003e \u003cp\u003eThe expansion of accredited training pathways and specialty certification programs in obstetrics, gynecology, and pediatrics may strengthen workforce capacity and ensure high-quality service delivery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThe strengths of this study include its nationwide coverage, collection of detailed operational and financial indicators, and a first-of-its-kind focus on MCH specialty clinics. However, this study has several limitations that must be acknowledged. Sampling bias: Recruitment through a professional WeChat group likely resulted in overrepresentation of institutions already engaged in specialty pharmacy practice. The clinic establishment rate reported here (83.3%) exceeds that documented in previous national surveys [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], indicating the participation of early adopters rather than a representative national sample. Cross-sectional design: Data represent a single point in time and cannot establish causal relationships between organizational factors and sustainability. Self-reported indicators: Operational and financial data may be subject to recall or reporting biases. Generalizability: Findings reflect better-resourced hospitals; the results may not apply to lower-level institutions. Economic outcomes not measured: Formal cost-effectiveness or budget-impact analyses were beyond the scope of this study, but are essential for informing reimbursement policies.\u003c/p\u003e \u003cp\u003eFuture research should incorporate stratified sampling to enhance representativeness, longitudinal designs to assess policy impacts, and rigorous economic evaluations to quantify the return on investment for MCH pharmacist-managed services. Intervention studies testing behavioral nudges, such as default scheduling or structured follow-ups, may also provide insights into improving clinical utilization and sustainability.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis national assessment shows that MCH pharmacist-managed clinics have expanded rapidly in response to policy initiatives, yet their development remains structurally misaligned with the financial and workforce support required for sustainable operations. Most clinics face persistent deficits, low patient volumes, and shortages of qualified personnel, reflecting systemic gaps rather than clinical shortcomings. To ensure long-term viability, national health authorities should establish unified charging standards and incorporate pharmacist consultations into insurance reimbursements. At the institutional level, hospitals must strengthen their workforce development and integrate pharmacy services into routine care pathways. Coordinated policy and organizational action are essential to transforming these clinics from policy-driven pilots into sustainable components of maternal and child health services.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthics approval and consent to participate The study was performed in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Gynecology Hospital, Capital Medical University (Approval No. 2024-KY-035-01). Electronic informed consent was obtained from all the respondents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was supported by the Beijing Natural Science Foundation through the project \u0026ldquo;Development and Application of Perinatal Pharmaceutical Science Popularization Tools Based on Behavioral Economics Theory\u0026rdquo; (Grant No. 7244462), and by the Capital Health Development Special Project (Grant No. 2024-2-2115).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eLYF and WR designed the review, collected, analyzed, and interpreted the data, and wrote the review. YX designed the review, collected and checked the data, and wrote the review. FX designed the review and commented on the drafts of the previous version. All the authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available because of institutional confidentiality and restrictions related to identifiable organizational information but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSmith A, Nair DH, Smith ER, Wheeler TF, Smith LE, Russell BR, et al. University Pharmacy Clinic: Preventing Errors and Enhancing Lives Through Expert Medication Management. Pharm (Basel). 2025;13(1):24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSema FD, Addis DG, Melese EA, Nassa DD, Kifle ZD. Prevalence and Associated Factors of Self-Medication among Pregnant Women on Antenatal Care Follow-Up at University of Gondar Comprehensive Specialized Hospital in Gondar, Northwest Ethiopia: A Cross-Sectional Study. Int J Reprod Med. 2020;2020:2936862.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph Davey DL, Bekker LG, Bukusi EA, Chi BH, Delany-Moretlwe S, Goga A, et al. Where are the pregnant and breastfeeding women in new pre-exposure prophylaxis trials? The imperative to overcome the evidence gap. Lancet HIV. 2022;9(3):e214\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu Y, Wang Z, Wu L. Research-Oriented Hospitals in China: A Bibliometric and Visualization Analysis Based CiteSpace. J Multidiscip Healthc. 2024;17:5277\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang X, Yili S, Dan M, Yan T, Xuelian Y, Liping D, et al. 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Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review. J Prim Care Community Health. 2022;13:21501319221084890.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasooly A, Pan Y, Tang Z, Jiangjiang H, Ellen ME, Manor O, et al. Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China. Int J Health Policy Manag. 2022;11(12):3019\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu JX, Modrek S. Evaluation of SMS reminder messages for altering treatment adherence and health seeking perceptions among malaria care-seekers in Nigeria. Health Policy Plan. 2016;31(10):1374\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCostello J, Barras M, Snoswell CL, Foot H. A post-discharge pharmacist clinic to reduce hospital readmissions: a retrospective cohort study. Int J Clin Pharm. 2025;47(5):1315\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal and Child Health, Pharmacist-Managed Clinics, Pharmaceutical Care, Health Services Delivery, Financial Sustainability, Health Policy, Workforce Development, Cross-Sectional Studies, China","lastPublishedDoi":"10.21203/rs.3.rs-8425974/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8425974/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Pharmacist-managed clinics are being promoted nationally in China to strengthen pharmaceutical care, particularly maternal and child health (MCH). However, little is known about how these clinics are structured, staffed, financed, or sustained at a national level. This study examined the development, operational characteristics, and financial viability of MCH pharmacist-managed clinics in China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA national, multi-center, cross-sectional survey was conducted from August to September 2025 among pharmacy department leaders from 150 medical institutions across 32 provinces. A validated 44-item questionnaire assessed institutional characteristics, clinic establishment, service delivery models, workforce composition, financial status, and operational challenges (5-point Likert scales). Descriptive statistics were used to summarize the clinical characteristics. Multivariable logistic regression identified factors associated with financial sustainability, defined as achieving a break-even or profitability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNinety valid responses were analyzed (response rate: 62.7%). Among the institutions, 83.3% had established pharmacist-managed clinics and 57.8% operated dedicated MCH clinics. Most institutions (64.4%) provided services free of charge and 61.1% reported operating deficits. Annual patient volumes were highly variable (median 142; IQR 27.5\u0026ndash;345.8), with nearly half of the clinics serving fewer than 100 patients per year. Major barriers include low patient willingness to pay and the absence of unified national charging standards. In the adjusted analyses, service charging was the strongest predictor of financial sustainability (aOR\u0026thinsp;=\u0026thinsp;3.85; 95% CI: 1.88\u0026ndash;7.89), followed by the inclusion of clinic activity in performance-based compensation (aOR\u0026thinsp;=\u0026thinsp;2.15; 95% CI: 1.10\u0026ndash;4.20). Institutional characteristics, clinical duration, and pharmacists\u0026rsquo; seniority were not independently associated with sustainability.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMCH pharmacist-managed clinics have expanded rapidly nationwide, but the structural misalignment between policy-driven adoption and financial and workforce support has created significant sustainability challenges. Long-term viability requires coordinated reforms, including standardized fee schedules, integration of pharmacist services into insurance reimbursement, and strengthened institutional investment in the workforce and service pathways. These changes are essential to ensure that MCH pharmacy clinics can sustainably improve medication safety and health outcomes for mothers and children.\u003c/p\u003e","manuscriptTitle":"Construction, Operations, and Sustainability of Maternal and Child Health Pharmacy Clinics in China: A National Multicenter Cross-Sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 18:56:18","doi":"10.21203/rs.3.rs-8425974/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T08:00:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T16:31:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315174408647338913052989080204617447530","date":"2026-02-19T16:13:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-23T07:51:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100929838286583384983701197436873422819","date":"2026-01-23T06:51:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T05:12:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T10:26:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-30T05:10:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-29T09:29:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-29T09:21:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f717f975-43c1-46ff-ba1c-b1bff36cd63b","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:16:05+00:00","versionOfRecord":{"articleIdentity":"rs-8425974","link":"https://doi.org/10.1186/s12913-026-14586-z","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-04-22 15:57:34","publishedOnDateReadable":"April 22nd, 2026"},"versionCreatedAt":"2026-01-28 18:56:18","video":"","vorDoi":"10.1186/s12913-026-14586-z","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14586-z","workflowStages":[]},"version":"v1","identity":"rs-8425974","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8425974","identity":"rs-8425974","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}