Table 3 Stakeholders' perceptions of the legal framework and organizational practice, related to implementation problems

Adequate rule

The standards for the certification of hospitals by the General Health Council and the chapter of hospital pharmacy of the FEUM Supplement (fifth edition 2014) were the rules mostly identified as adequate by the participants (F, S)

Rule absence

The General Health Law/Health Products Regulation. It does not recognize the pharmacist as a professional of the health team (S, A)**

FEUM Supplement. Lack of legal framework for some pharmaceutical services (F)

Inadequate rule

The General Health Law/Health Supplies Regulation. The figure of the health manager (called responsible sanitario) is not suitable for the implementation of HPS (F). No difference specified between private and hospital pharmacies (S)

FEUM Supplement. Lack of clarity in concepts (F). Consistency problems with the COFEPRIS pharmacy verification card (F). It is a non-binding standard (F, A). A low-profile law, consider a change in secondary legislation necessary (S, F, A, O)

National Model of Hospital Pharmacy. It is voluntary (S, A). Not updated (S)

Contradictory rule

The General Health Law / Health Supplies Regulation. It only requires the health manager (called responsible sanitario) to monitor the legal sale of controlled medicines (S)

FEUM Supplement. It is not aligned with the Mexican General Health Law or its Regulations (S). To achieve the changes proposed in the FEUM Supplement requires a budget (O)

Regulation by COFEPRIS / Health Verification Act. Conceptual and process discrepancies with the CSG and FEUM Supplement (F) standards

Weak rule enforcement

The General Health Law / Health Supplies Regulation. Weak organizational and management capacity in hospitals, so instead of demanding compliance with the legal framework, this is only encouraged (S). Problems in supervising the assignment and fulfilling the functions of the health officer (F)

FEUM Supplement. Lack of penalty for non-compliance / is not binding (F, A)

Regulation by COFEPRIS / Health Verification Act. Lack of a requirement for the implementation of HPS (F, A). Staff may not be adequately trained in evaluating HPS (F)

Weak organizational capacity

At the health system level. Decentralization complicates the homogeneous implementation of new service delivery models (S). The fragmentation of the health system increases the number of service delivery models (S). The lack of hospital pharmacists at various levels of decision-making (F). Poor continuing education by universities, colleges or associations (F, A). Corruption problems in different instances (A, F, O)

At the hospital level. The area to which the pharmacy service belongs influences the implementation of HPS, historically it has belonged to the area of material resources or the administrative area of the hospital (O, F). Inadequate levels of recruitment and wages for pharmacists (O, F). HPS's permanence may be subject to the decision of the hospital director (A, F). Resistance to change by members of the health team and hospital managers (F). Lack of financing for the implementation of some services (F)

At the pharmacy service level. Insufficient number of hired pharmacists (O, F). The need for pharmacists with leadership and management skills (S, F). Pharmacists must have the necessary skills to develop HPS

Dysfunctional inter-organizational relationships

At the hospital level

Problems of prioritization of services and activities between pharmacy staff and the hospital authority (F). Lack of hospital director support (F, A, O). Lack of support from the area manager (F)

Externally

Lack of adequate training of human resources in terms of HPS. Few universities train pharmacists with a focus on health sciences (O). NGOs do not make common cause on HPS (F, O). Internal struggles pharmaceutical guild produces a weak organizational capacity (S, O, A, F)