This PhD project investigates how community pharmacists and community pharmacy users in Malaysia manage medication reconciliation and medication tracking within a healthcare system that does not separate the roles of prescribing and dispensing. Such an arrangement—where doctors can both prescribe and supply medicines—is common in low- to middle-income countries (LMICs) and introduces risks of incomplete records, medication duplication, and drug interactions. These problems are not purely technical; they are social, organisational, and cultural. When health systems focus only on digital health technologies without considering these human and systemic dimensions, they are bound to fail in practice.

Guided by Soft Systems Methodology (SSM), the study progresses through its seven stages, beginning with autoethnography and qualitative interviews to express the “problem situation” and map out the lived experiences of pharmacists and users. In Stage 3, these insights are abstracted into CATWOE root definitions, which clarify the Customers, Actors, Transformation processes, Worldviews, Owners, and Environmental constraints of each problem area. This structured lens exposes underlying system tensions such as policy gaps, professional boundaries, and cultural expectations.

Stages 4–6 apply the principles of Sociotechnical Systems Design (STSD) together with behavioural and system frameworks to develop, compare, and refine new design concepts. The COM-B model (Capability, Opportunity, Motivation–Behaviour) is used to understand what enables or hinders pharmacists and users from adopting safer practices, while the Systems Engineering Initiative for Patient Safety (SEIPS) framework examines how people, tasks, tools, environments, and organisations interact within pharmacy settings. Together, these frameworks ensure that proposed improvements balance both social and technical realities.

From this process emerge a series of sociotechnical design recommendations—including interoperable medication tracking systems, portable health cards and digital records, and policy reforms that would enable safer dispensing separation in the future. These recommendations demonstrate that sustainable change in LMICs cannot rely solely on technology or infrastructure; it requires alignment between human capability, organisational design, and policy context. The project contributes a systemic approach that bridges pharmacy practice, informatics, and design thinking to enhance medication safety and continuity of care across diverse healthcare settings.