Time for Pharmacy Practice in Kenya to Catch Up with the World

Pharmacists are the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes. They do this by taking responsibility in the quality of medicines supplied to patients; ensuring that the supply of medicines is within the law; ensuring that the medicines prescribed to patients are suitable; advising patients about medicines, including how to take them, what reactions may occur and answering patients' questions. They achieve these objectives with the assistance of pharmacy technicians who perform non-core tasks that include receiving, arranging, assembling medicines for prescription, labelling and ordering of medications.

The Pharmacy and Poisons Act (Cap. 244) came into force in 1956 to control of the profession of pharmacy. At the commencement of the Act, only the holders of at least a bachelor of pharmacy degree or persons previously registered as ‘pharmacist’ by the Pharmacy and Poisons Ordinance (Cap. 128 (1948) (now repealed) irrespective of the qualifications held ('compounders', 'druggists', 'apothecarists', 'dispensers' etc), qualified to be registered as pharmacists. Between 1949 and 1978, only foreign trained persons could be registered as pharmacists, as there was no local university offering the training. In 2002, as an intervention to improve access to pharmaceutical services in underserved areas, an amendment was made to the Act to allow the Board to enroll ‘pharmaceutical technologists’ (Kenyan term Pharmacy Technicians). Under this intervention, the Board allowed pharmaceutical technologists of a certain experience to establish independent sole proprietor dispensing outlets.

The recent Health Laws (Amendment) Bill of 2018 published on 10^th of April 2018, initially appeared to the stakeholders (as it should) that it was making administrative changes to Pharmacy and Poisons Board, aligning it with MWONGOZO – The Code of Governance for State Corporations. It was not to be. Last week, the National Assembly at the committee stage of the Bill, essentially redefined the profession of pharmacy by introducing a ‘pharmaceutical practitioner’.

World over, only two cadres are known in pharmacy: a pharmacist and a pharmacy technician. Both of these cadres have routinely and erroneously been referred by the members of the public (and even the media) as ‘pharmacists’. The ‘pharmaceutical technologist’ title is a misnomer because a pharmaceutical technologist is a graduate-level industrial application scientist that in pharmaceutical manufacturing. It is worth noting that some jurisdictions, like the Republic of Uganda have ‘pharmacists’ and ‘pharmacy technicians’ but only pharmacists are mentioned in the law.

The title of a ‘pharmaceutical practitioner’ if passed, introduces ambiguity in law subject to varied interpretation. If it was intended to simplify the definition of a person authorised to practice pharmacy in Kenya and not to unify the pharmacist and ‘pharmaceutical technologist’ as one profession, it will fail because the title ‘pharmaceutical practitioner’ legally denotes equivalence and a ‘pharmacist’ is the professional in pharmacy practice. It casts the role and the legality of the para-professional into doubt during implementation.

If the purpose of the amendment was to increase access, the law already provided for this 2002. In any case this increased access has had its problems. There has been a rampant illegal licence renting to quacks since then (some are even published in social media). As the focus of these practices have been sales by any means to anyone, some of these medicines have ended up being used to ‘drug’ unsuspecting people and rampant abuse of prescription drugs by teens and young people.

The new law also expands, without applying any caution, a wholesale licence to the so called ‘pharmaceutical practitioner’. As much as Section 27 (1) and (2) still gives the Board the discretion to issue a licence, the amendment failed to recognize the regulatory role of a wholesale pharmacy practice. A wholesale practice performs pharmacovigilance, drug recalls and control of dangerous drugs; some which may have been observed by casual observers as ‘movement of boxes from one place to another’. It therefore defeats the purpose to licence such a function to a ‘pharmaceutical practitioner’, but require the practice to employ pharmacists to fulfil its objectives.

What will then be the future of enrolled ‘pharmaceutical technologists’? 

Going forward, we need to align pharmacy laws with the existing policies. The first Kenya National Drug Policy (KNDP) of 1994 sought develop pharmacy specialists to direct pharmacy practice, provide pharmacists who primarily delivers patient care and reintroduce pharmacy technicians to assist the pharmacist by carrying out non-clinical duties in a pharmacy. The policy spelt out provisions to allow the existing ‘pharmaceutical technologists’ to proceed to University and attain standards registerable by the Pharmacy and Poisons Board for practice as pharmacists. KNDP was succeeded by the Sessional Paper Number 4 on the National Pharmaceutical Policy which reaffirmed that pharmacy delivers to the Kenyan health system two outcomes: integrity of a pharmaceutical supply system and appropriate medicines use. These are the essential roles of a pharmacist – leadership and clinical – in pharmacy practice and healthcare in general.

Healthcare Professionals Strike or a Leadership Crisis?

Was the just ended healthcare professionals strike that ground the public healthcare system to a halt a mere strike or a severe leadership crisis in health?

On Tuesday, December 10 2013, just two days before 50th Kenyan Jamhuri Day, all healthcare professional unions went on an unprecedented national strike in the public sector to protest against devolution of the human resources for health and the manner in which the devolution was carried out.

The Centre for Pharmaceutical Excellence (CPE), a healthcare consultancy that promotes appropriate medicines use looked in depth on the real issues behind the crisis and made suggestion on the way forward during and way after the strike is over.

See it in the CPE media statement below:

~ The issues, the options and the way out ~

    17 December 2013

Executive Summary

The current healthcare crisis as a result of the strike by healthcare professionals could have been avoided. There has been a general misunderstanding and conflicting interpretation of the provisions of the constitution. There has also been a general lack of leadership, sense of urgency and common sense in the resolution of the healthcare professionals concerns. Now that we are in crisis, the general public needs to understand the underlying issues and the stakeholders who include the national government, the county government and the healthcare professionals themselves need to come together and bring this crisis to an end.

There are several options available for the resolution of this crisis and all are anchored in the law. The easiest and probably the most controversial option is finding a way to convince health workers to work with county governments under the existing arrangements. The second option is maintain the status quo and let the national government retain the health function until that time when all the transitional arrangements are complete. The third option is for national government to recognise health as a shared function between the national and county governments as stipulated in the Article 186 (2) of the constitution and lead the process to develop mutual agreeable governance structures under it. The fourth option is for the county governments to exercise extraordinary leadership and use the provisions of Article 187 of the Constitution; to voluntarily transfer the functions back to the national government for a limited period but still maintain the constitutional responsibility of the function and reserve the right to monitor performance or to withdraw the transfer at any time. The fifth option, which is very similar to the third option, is for both levels of government to use the provisions of Section 118 of the County Governments Act to manage health as a ‘shared service’ in an agreed timeline which is not even restricted to the constitutional transitional period of three years. The sixth option is to recognise all the healthcare providers previously employed by the public service commission to be on secondment as per Section 73 of the County Governments Act for the three year transitional period. The seventh and the final option is for the Parliament to use its constitutional powers, as provided by Article 261 of the Constitution, to extend any transition period by a further one year. Of all these options nothing stops the County Public Service Boards from employing their own healthcare professionals at any time based on their individual needs.

Contrary to what is widely thought, the Transitional Authority has very little role in the resolution this crisis, as much as they played a role in the creation of it. They however need to learn valuable lessons as they carry out the remaining functions to prevent as costly mistakes before their tenure ends. Proper interpretation and implementation of the constitution by the authorities, leadership, communication and effective change management are critical to ending the current crisis and preventing similar ones in future.

FULL TEXT ARTICLE

Introduction

The process of the implementation of the new constitutional dispensation has brought with it many challenges. There has been a considerable gain in bringing (or taking) public governance closer to the people. The County Governments have been formed and there is a new sense of responsibility in the delivery of services to the citizenry and the capacity to provide those services is expanding. And as with all good things, the implementation of the Constitution has resulted in the emergence of unforeseen challenges in the health sector.

The Kenyan public governance processes took a significant shift when the politician cabinet ministers exited the scene and entered the cabinet secretaries at the helm of ministries; the latter group being non-political technocrats sourced from a larger pool of experienced and accomplished professionals from both public and private sector. Within the national ministry of health organisational structure, there are, in addition to the cabinet secretary, the principal secretary, senior administrative secretaries and senior professionals in charge of different directorates, departments and units. This group based in Afya house, together, form the policy makers in the health sector. The constitution requires them to take charge of health policy, run specific national programs and the national referral hospitals; while the county governments deliver health services, including primary healthcare services, in the counties.

What the Constitution says

Chapter Four of the Constitution on the Bill of Rights, which outlines rights and fundamental freedoms, guarantees every person the right to the highest attainable standard of health as one of the basic economic and social rights (see Article 43 of the Constitution). These economic and social rights were even extended to emergency medical treatment; where every person in Kenya has a right of access in any healthcare setting in Kenya, including a private health facility.

The Chapter Eleven of the Constitution brought forth the county governments. It spells out the respective functions and powers of the national and county governments. It allows the national government to take up any function that has not been assigned by the Constitution. The Fourth Schedule of the Constitution has assigned the national and county government specific functions and responsibilities. Health as a function meets the definitions the Article 186 (2) of the Constitution because it has been assigned to both the national and the county governments; and therefore is subject to the concurrent jurisdiction of both levels of government. It is therefore inaccurate, and even unconstitutional, to state that health has been devolved to the county governments; just as it is inaccurate to say it is a national government function. The reality is that the health function has been shared between the national and the county governments. It was expected that the policy makers at the ministry of health were aware of these issues, had a well thought out policy framework, a sound communication strategy and were able to provide leadership in this time of change. The matters of legislations were not an absolute necessity for the smooth hand-over some of the health operations to the counties if all parties knew about it and its timelines in advance. The current ‘health care workers’ strike is, however, evolving to be a manifestation of a leadership crisis at national level of government.

The Issues

So, what then are the issues in the current health crisis that has resulted in all health professionals in the public sector going on strike in defiance and almost unanimously?  Is it the constitution? No. Is it the governors, their county executives or the county assemblies? No and a small yes. The governors have been trying to fill in the gaps when the national government failed to provide leadership. The governors, however, faltered when they pushed the national government through their council to transfer the function devolved to them by Schedule Four of the Constitution, some at a faster rate than originally intended. A section of them have further failed to build trust and confidence with health professionals with their utterances and actions in the period just before and during the strike. Is then the health care professionals? Of course not! They are just facing uncertain times and are victims of poor change management. It is even made worse by the common unchecked character of public servants in authority: propagating uncertainties, poor communication, withholding information and acts of intimidation by individuals, some who do not have a direct supervision relationship with the frontline healthcare professionals. To their own disadvantage, some healthcare professionals are perceived by the general public to have also contributed to the propagation of hate in their discussions in the social media. Their lack of restraint in dealing with people they need to work with then seemed to justify the corresponding lack of restraint by some figures in authority.

If it is not all these three mentioned above, then what is it that has caused the biggest health crisis to ever befall Kenya? The answer lies in Afya house. Afya house has propagated the chaos of the past, and the situation has been made worse by the leadership vacuum at its very highest echelons.

The entire crop of the policy makers in the Ministry of Health have been in a deep slumber for a long time. They have for a long time only preoccupied themselves with HR issues and little else; and it is unclear what their role will be going forward. Even the transitional period after the March elections did not wake this sleeping house from its deep slumber. The new head of the ministry, the cabinet secretary, has little more than common mwananchi conceptualisation of a good healthcare system. He is still learning about health and its policies in a period when he is supposed to be transferring functions that were traditionally coordinated by the ministry of health to the counties. He is not able to convince healthcare professionals in his arguments in the direction healthcare is taking. He does not seem to be able to foresee the expected successes of devolution of healthcare and its possible pitfalls. The general attitude of the health ministry under him of going with the flow does not help him connect with the healthcare professionals in such times of uncertainties as these. He believes that the County Governments Act provides adequate framework for the running of healthcare in the counties and that little else is needed. He, and the technocrats who fill the offices of Afya house, are yet to define what health policy is. In the process, this national ministry, has ended up presiding over the biggest confusion that healthcare has ever had in Kenya.

The counties do not have enough guidance and advice from the national ministry of health on how they should organise health services. Without proper healthcare standards and guidelines, the county governments are doing what they deem best. The net effect of this lack of leadership at the ministry level is the rolling out of services by the county governments as if there were no national policies and regulations governing health, in existence. Without the intervention of the healthcare professionals in this regrettable strike, this state of affairs was likely to persist and the national health status was set to decline. It would have been difficult to monitor the attainment of international health goals with the new silos of bureaucracy that would have been inevitably created with devolution.

The Way Out – options to consider

The health sector is too important a field to ignore or isolate any of its stakeholders, including the patients who are the ultimate consumers of healthcare services. We suggest the following options that the stakeholders (especially the ministry of health, the county governments and the healthcare professionals) must then jointly pursue to end the crisis and build a stronger and more responsive health system in the future:

OPTION 1: Convince health professionals to work with county governments under the existing arrangements

This will require a total change of tact on the authorities (national government and the county governments) and magnanimity on the health professionals’ side. The authorities must win the trust and confidence of the healthcare professionals. They must think out of the box and work out the formula in which health professionals are made the drivers of the healthcare both at the management and the service delivery level. In this regard, Machakos County and Kajiado County have been seen to be heading in the right direction. The healthcare professionals may however find this option unacceptable and risky for them, going by the history of MoUs and promises that are not kept in Kenya.

OPTION 2: Allow more time for the transfer of functions to the County Governments

This was a crisis that could have been avoided with proper change management strategy that allows adequate time for the most affected, the healthcare professionals, to understand and support the new system. We therefore suggest that the national government take up its share of the responsibility in health and manage the transition to the services to the counties for a period they will agree with the healthcare professionals, but must be equal or less than the three year period provided in the Constitution. Experts would suggest at least two financial years in the public sector where information flow and exchange is usually poor; to allow the employees time to encounter all possible work and career-related situations. In this period all the HR concerns and uncertainties like pending employee benefits, reporting relationships, promotions, trainings and terminal benefits will usually be addressed. Succession planning, training of interns and recruitment of entry level healthcare professionals will also have been put in place to build the confidence of the current and future employees.

OPTION 3: The national government could recognise health as a shared function of both governments as per the Article 186 (2) of the Constitution

The national government could initiate discussions with the county governments on a premise that health is a shared function and not an exclusive function of the counties. Since health policy is not defined in any way that is publicly accessible to all, both governments can share aspects of human resources for health (the healthcare professionals) as both health policy and health services issues. The national government can then have power of development, distribution and regulation of the health professionals while the county governments manage their day to day HR functions including running their payroll. The payroll of the intern doctors should however continue to be run by the national government to so that they can effectively carry out planning for the human resources for health.

The county governments exercise an extraordinary leadership in this matter as per Article 187 of the Constitution

This article allows the transfer back to the national government the health services function by the county governments by agreement for a limited period of time. The county governments will however still maintain the constitutional responsibility for the performance of the function or exercise of the power shall remain with the government to which it is assigned by the Fourth Schedule. They will have the right to demand for progress reports while the national government is temporarily carrying out the function and the specific. The healthcare professionals HR files will be kept by both the ministry and CPSB for this period and only by CPSB when the transition period lapses.

OPTION 4: National and County Governments to manage Health as a ‘Shared Service’ as per Section 118 of The County Governments Act

This option is very similar to the third option on the national government recognising health as a ‘shared function’. The Constitution recognises a ‘shared function’, while the County Government Act provides for a ‘shared service’. For the sake of this argument we will assume that the two avenues can seen as separate options, unless there is a contrary legal opinion. The county governments may enter into an agreement with the national government, to provide health services as the act allows an agreement to provide or receive any service that each county participating in the agreement is empowered to provide or receive within their own jurisdictions. In this scenario, the healthcare professionals are not involved directly but as interested parties or stakeholders. This provision does not have an imposed timeline but we still recommend it be within three years in the spirit of constitutionalism.

OPTION 5: To place all the healthcare professionals employed by the PSC on Secondment in the transition period as provided for in County Governments Act Section 73.

During this period, it shall be the responsibility of the national government to pay the salaries, remuneration, allowances and other benefits due to the staff seconded to a county government during the transition period. The County Public Service Board (CPSB) then manages these employees until the period of the secondment lapses, where they must then resign from the PSC and join CPSB if they wish to retain their current employment and benefits. The provisions of highly quoted Section 138 of the County Government Act on the arrangements for public servants appointed by the Public Service Commission apply.

OPTION 6: The Parliament could use its constitutional powers to extend the transition period by one year

The Constitution in Article 261 (2) allows the National Assembly by resolution supported by the votes of at least two-thirds of all its members, to extend the period prescribed in respect of any particular matter, including health, by a period not exceeding one year. This power can only be exercised once; and only in exceptional circumstances to be certified by the Speaker of the National Assembly. The Attorney-General, in consultation with the Commission for the Implementation of the Constitution, shall prepare the relevant Bills for tabling before Parliament, as soon as reasonably practicable, to enable Parliament to enact the legislation within the period specified.

Under these provisions, if the Parliament fails to enact any particular legislation within the specified time, any person may petition the High Court on the matter to make declaratory order or transmit an order directing Parliament and the Attorney-General to take steps to ensure that the required legislation is enacted, within the period specified in the order, and to report the progress to the Chief Justice. If Parliament fails to enact legislation in accordance with the high court order, the Chief Justice shall advise the President to dissolve Parliament and the President shall dissolve the Parliament. If Parliament has been dissolved in these circumstances, the new Parliament shall enact the required legislation within the periods specified in the Fifth Schedule beginning with the date of commencement of the term of the new Parliament. If the new Parliament fails to enact legislation in accordance with clause the same Article 261 of the Constitution, they will suffer the same fate as the dissolved parliament. And the cycle will go on and on. We however do not expect this to happen as healthcare is not an issue that a whole parliament could refuse to use its power and sacrifice their selves in the process.

Future directions

The health law would in the long-term fix the current and future challenges in the delivery of health services in the counties. The law could expand the national referral facilities to include those that have traditionally served larger populations and provided specialised services for patients within and beyond the county boundaries. This could then result in defining some of the current level 4 facilities, all level 5 and 6 facilities as national referral and teaching hospitals. This would allow counties to provide primary health and usual care and the national government to concentrate on providing specialised care.

Conclusion

 In conclusion, a major solution to all this is for the national government to provide leadership and enhance effective communication from now going forward. The health sector is in dire need of leadership to pull it out of the quagmire it finds itself in. The various stakeholders need to start communicating to resolve this crisis. A spirit of trust and mutual respect by the actors needs to take centre stage. If a good communication strategy existed, the current industrial action and the resultant health crisis could have been prevented. Proper interpretation and implementation of the constitution, leadership, communication and effective change management are critical to ending the current crisis and preventing similar ones in future.

The writers of the article are Directors of the Centre for Pharmaceutical Excellence.

For any correspondences, please call 0722-513770

Or email info@cpe.co.ke; sopanga@cpe.co.ke or tpanga@cpe.co.ke

MY VERSION OF A PHARMACIST CREED

Today I just want to think of my devotion to my profession.

I have to disclose though that I borrowed this heavily from the US Coast Guard.

'I am proud to be a Pharmacist.

I revere that long line of expert APOTHECARIES, COMPOUNDERS and PHARMACISTS who succeeded them as we know today, and who continue to evolve in new roles that I can only imagine now and those that I’m unable to yet; who by their devotion to duty and sacrifice of self have made it possible for me to be a member of a service honoured and respected, throughout the world.

I never, by word or deed, will bring reproach upon the fair name of my service, nor permit others to do so unchallenged.

I will always be on time for all my duties, and shall endeavour to do more, rather than less, than my share.
I shall, so far as I am able, bring to my seniors solutions, not problems.

I shall live joyously, but always with due regard for the rights and privileges of others.
I shall endeavour to be a model citizen in the community in which I live.
I shall sell life dearly to an enemy, but give it freely to rescue those in peril.

With God’s help, I shall endeavour to be one of His noblest Works...
A PROUD PHARMACIST IN KENYA'

James Macharias will always be our Health Secretaries until we put Our House in order

A distinguished banker was recently nominated by the president to be the cabinet secretary in charge of health. There has been uproar amongst us, the healthcare professionals, that 'outsiders' are being appointed to positions that should be the reserve of 'medical professionals'. Kenya Medical Association (KMA) responded almost immediately after the announcement. What was not clear was if KMA would have been happy still if the nominee was, let's say, a pharmacist.

I'm a pharmacist, and I really believe in us (all healthcare professionals). This view is not shared among the different cadres of health and healthcare professionals. Nurses are in support of the new secretary of health, not because they like him, but clearly because he is not the 'domineering self-centred all-important full-of-himself' doctor.

The society at large perception does not help us either. They visit public hospitals and wonder why they are that poorly managed. When they are told the top manager in the hospital is a doctor, they associate any failures with this individual. When hundreds of hospitals are managed in the same way, they conclude that this is just but the way doctors are trained - to care less and mismanage. When they hear billions that are squandered at the policy level, with little to show on the ground they write us off completely. Sooner or later,  our bad reputation flows upwards in the political circles, and end up at the president's desk. The president does not even need to depend on this information flow. Before he became the country's chief executive, he was first a Member of Parliament (M.P.) who gets information first-hand from constituents suffering from the healthcare we or we don't provide. The face of this poor healthcare is a the healthcare provider on the ground and his immediate manager, the Medical Superintendent or the DMoH (is that still their title?). 

So what do we need to do to get out of this?

First, let's dissociate ourselves from the greed, inefficiency and little concern for patients' welfare that has been associated with us. Let's shake off this tag - it begins with me and you today. Just having management degrees beefing up our CVs will not shake that tag. They will look past it and appoint others who they think have better clarity of purpose. We have just allowed ourselves to supervise failure for too long. We know the problem is bigger than us, but outsiders do not know that.

How do we turn this trend around, at least for 2018?

Let's write down indicators expected for change in health attributed to us and our presence before we consider other inputs that make healthcare. Let's be less wasteful. Let the few managers we have be exemplary. It begins with something as simple as this. What if from today we said we will not tolerate the bad septic hospital smells? Private hospitals have hacked it with the same amount of Jik and liquid soap that district hospitals buy. I'm yet to see/hear doctors, nurses or pharmacists saying enough of the pungent rotten smell of our wards and boycotting work until it is sorted. No one disinfects and clears patient vomit immediately it happens. Patient clothes are not disinfected and laundered. Soiled linen is left to culture more colonies of bacteria and putrefy further. Even the fact that the Medical Superintendent is a physician or surgeon doesn't seem to matter. If you condone it, you are part of it. If you tolerate these little avoidable discomforts, your value is revised downwards. It is those guys who fake it until they make it that will take up our jobs.

If you hang in there, in civil service, because of salary and nothing else, you are also in the same category. Opportunities are not for those who can clearly and passionately describe the problem; but for those who have a solution, however simple, in absence of other inputs (resources, equipment, money, medicines etc.) The fact that different health professionals are in constant collision and frustrate team work makes it difficult for the president to appoint one of them.

What do we do at Afya house? 

We are missing in action when it matters. We occupy spaces we do not deserve. Just as an example. The Chief Pharmacist is, in all my perception, absent. Yet he is supposed to be one of the top managers in pharmacy, and even a policy maker of the position equivalent to the immediate former posts of the Treasury and Devolution cabinet nominees at the Ministry of Finance. This means if the Chief Pharmacist knew what he was doing and his achievements could be seen and testified by all, then he could be appointed a health secretary. What’s more? We work in silos and secretly forward bills to the minister to be passed to laws without sharing with colleagues. We then expect other health professionals, affected by the laws we crafted in hush hush behind closed office doors, to obey and follow them without caring for their input. And they always turn out to be bad laws, no, terrible laws! 

We cede our power by accepting mediocrity. The question is, will the mediocrity continue to have an explanation or will we finally learn?

Chief Pharmacist: From my lips to God's Ears

If I became the Chief Pharmacist today, first I will create a crisis by refusing to be a registrar of a Board that is another full time job in itself. I will be happy to be an ex-officio member of the Board, and I must not go there all the time because I have qualified deputies. I will then lobby to my Minister (or is it cabinet secretary?) to go to parliament to reduce my roles, if he ever wants me to deliver.

Then, I will have a national pharmacy strategy that aims to improve health from my department’s perspective. My strategy will and should be feeding to the larger strategy of the ministry responsible for health, and not standalone. I will make sure every person contributing to pharmaceutical services: pharmacists, technologists and other techs, and subordinates know this strategy and they have memorized it in their brains and hearts.

 If there is no strategy in place when I step into office on my first day or if the current strategy is in conflict with national strategy, I'll start addressing by addressing that. I will work through deputies who will have all the power to do what they deem fit for pharmacy; I will only ask them to be accountable and put their money where their mouth is.

I believe in human resource. The pharmacists under me must be the most competent in the world. They must be good public speakers, must be able to educate patients and public on the health, they should be able to engage constructively on general health issues and they must be able to design, test, monitor and improve healthcare programs that work. They must know their patients, and they must address their needs, they must be able to communicate understanding to them, they must love them and they must follow them up longitudinally. I will have to sample reports of such on my desk. No training opportunity that can make them the best in the world as a pharmacist can be swept under the carpet by me, because I will have no carpet. All trainings will be on merit, and on value for investment. If you will not do, don’t be trained. If you promise to do, and you don’t; no mechanism to get the value back from you will I spare.

Then I will focus on the needs of Kenyan public, and what they need a pharmacist for. I will not accept pharmacists to do what the Kenyan public does not need them to. I will happily bring to an end the era of 'boss pharmacists' because that is not what the consumers of health that I'm accountable to need.

I will fight for, protect and give pharmacists a larger slice of training opportunities than was allocated. I will not allow others to steal the show, or let DMS or whoever that will assume the responsibilities of the current DMS know more about pharmacy than me. I will not miss his meetings because he intimidates me, but he may miss my meetings because he fears accountability.

 All I will need of the pharmacists I will do anything for is not to embarrass me with apathy, dishonesty with themselves, stealing, empty heads, divided or no loyalties, inability or painstakingly slow minds, poor decision making skills, poor or no customer care, purposeful stagnation, caggy or caged thinking, being experts of anything else other than pharmacy, lack of accountability and personal responsibility, not being able to take advantage of opportunities given and excelling etc etc.

 I will be quick to enforce sanctions as I do with rewards. Finally, I will be on a fixed non-renewable contract of five years (or even four) to give others with better ideas chance to lead. If people really liked me, and want me to go on, I will only accept an advisory position.

I will whisper to my successor that anyone who spends or plans to spend a quarter century in a position is nothing more than a space occupying lesion.

Response to 26 March 2012 Daily Nation article titled 'Policing the drugs business'

This post is a reply to an article on Daily Nation of 26th of March 2012.

The original article can be accessed via this link: http://www.nation.co.ke/Features/DN2/Policing+the+drugs+business+/-/957860/1373432/-/item/0/-/137y6o7/-/index.html

I have not read the print version of this article, but the author had not declared any potential conflict of interest that we the readers should consider when reading this article. Other than that I think the writer has a valid point, and Pharmacy and Poisons Board (PPB), the beneficiary of the TruScan technology needs to consider this as they go ahead and use this 'donation'. The Board members, who generally represent larger pharmaceutical sector, with heavy representation from the Pharmaceutical Society of Kenya (PSK), should be clear on what this scan technology can do and what it can't. That is why the PPB employs experienced pharmacists who should be able to use intuition, common sense, practice knowledge, well thought out drug policing strategies with a wide reach and finally the TruScan to identify the true counterfeits. I'm a pharmacist, and naturally I'm interested in knowing what technology the TruScan machine uses. Does it use infra red, MRI, UV or rapid chemical tests to identify active ingredients in a drug? If it does that, and that can be validated, then it is able to scan for the presence of the active medicine in any drug, brand or 'generic'. Is the 'analysis' that it does quantitative or qualitative? You need to know both attributes to declare a medicine a 'counterfeit'. In pharmaceutical science, too little of the right medicine is a bad thing and too much of it is still a bad thing.


 If the TruScan is not looking for an active ingredient, then is it scanning the primary and the secondary packages of the medicines to identify 'genuine packs'? And is knowing that just the pack is genuine good enough?


 Does TruScan just 'scan' Pfizer products, all the branded products, or it 'scans' all licenced for use and registered for trading pharmaceutical products? Who is the inventor of this technology? This is the kind of information that I was looking for when I chanced on this article, but did not find.


Remember, there is also competition between branded product manufacturers, and Pfizer here does seem to take up the burden of 'funding' an initiative that benefits all the multinationals whose products get faked. Why is it that it is only Pfizer which is purchasing this TruScan? Why would Pfizer fear generic products more than other manufacturers of branded pharmaceutical products, yet it has a wider range of medicines and still a respectable market share of each, and absolute market share for some? The article should either address Pfizer directly or generalize only when there is involvement of other multinational companies, otherwise the message will be construed to be views that are not necessarily objective.

It is my considered opinion that a counterfeit is that which claims to be what it is not. As a pharmacist, I do not perceive generics as counterfeits. I almost daily have to reassure a nervous client who has a mistaken idea of what generic drugs are, and educate them on the concept at the same time. I also know that it is the branded drugs, that many of us tend to rush to, that are the targets of the counterfeiters and not the generic brands.

I would then understand if the big pharmaceutical companies come together to address the problem that is unique to them. They lose the most to counterfeits, and gain the most if counterfeits are wiped off the pharmacy shelves. If people were to shift en masse and buy generic brands, the counterfeiters will go there. In Kenya now, generic brands, suffer the least when it comes to counterfeiting, and when it comes to fighting these counterfeits, it will make sense to focus on the branded products and get the companies affected on the board because they have everything to gain from such an initiative and so do the public.
A good every day example of counterfeiting are the paper currency notes counterfeiters and their motivation. They do not bother with a fifty shillings note: but they do fake the one thousand note where they are assured of higher returns if not, or before they are detected.

A survey preferably funded with public funds or by companies without their direct involvement in the processes, is welcome as the writer has suggested, identifying the true extent of the influence of counterfeit products in the market, its supply channels and its effect on public health. The survey should not just end there, but also suggest actions required to address the menace once and for all.

Pharmacists also know that just having a genuine product is not good enough. Before it gets to the right patient at the right dose and for the right medical condition, it must also be stored right. If a pharmacy does not store products in a way to preserve chemical integrity, buys from suppliers who don't do so, or worse still, buys from suppliers who they have no idea how they handle and store medicines, then the patients will still suffer, even when presented with a 'genuine product'.



Finally, I feel very uncomfortable with conversations that happen in virtually almost every pharmacy that this one medicine is 'original' that one 'is not'. Who will take up a product that is 'not original' even if the intention was to say this one is 'branded' and the other is a 'generic brand'? It is very unprofessional and not a priority conversation, when there are so many things to talk about that will benefit the patient the more: like the patient's medical condition; how to use the medicine and what to expect from the medicine. The patient is also supposed to be equipped with the knowledge on what to do if an expected positive outcome of the medicine does not occur or an expected negative outcome does occur!

A Challenge to 21st Century Kenyan Pharmacists who are still Sitting on the Fence

Pharmacy of today appears as a collection of disputatious factions and splinter groups still ‘a profession in search of a role’and a profession unable to choose from a bewildering variety of functions and unable to overcome a variety of ‘barriers to clinical practice’.


We will not solve this problem by introspection. It will not help to clarify, list, or debate more functions for pharmacy. The element that is missing as we define our role during this period of transition is our conception of our responsibility to the patient. Some pharmacists have not yet identified patient-care responsibilities commensurate with their extended functions, and the profession as a whole has not made CLEAR SOCIAL COMMITMENT that reflects its clinical functions. Some pharmacists will remain mired in the transitional period of professional adolescence until this step is taken.


Pharmaceutical practice must restore what has been missing for years: a clear emphasis on the patient’s welfare. Professional maturity has much in common with maturity as a person. One attribute common to both is a word view, an expectation that one thrives best by using one’s power t serve something bigger than oneself. Another attribute common to both is acceptance of responsibility for one’s actions.
Drugs do not have doses, patients have doses.



(Charles D. Hepler and Linda M. Strand statement back in March 1990 in an American Journal of Hospital Pharmacy)

LET US TALK PHARMACEUTICAL CARE!

BUILDING YOURSELF AS AN EFFECTIVE PROBLEM SOLVER

Pharmacy is built firmly on the concept of technical rationality. The idea states that practitioners are primarily problem solvers who select rational ways to serve particular purposes.

If I can use two words to describe what pharmaceutical care is, then I will say it is a RESPONSIBLE PROVISION. We provide treatment when we dispense medicines; it does not become pharmaceutical care until when we ensure that our dispensing is done responsibly. I do not want to bore you with the long definition of pharmaceutical care that has been repeated over and over, and has been ringing in the years of all pharmacists who want to understand what pharmaceutical care is; and how it can be implemented in their daily practice so that they can make the difference they have always striven to. It goes like this: Pharmaceutical Care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life.

Pharmaceutical care is essentially a process and is as follows:

Step ONE: Identify any DRUG-RELATED PROBLEM (actual or potential);

Step TWO: Resolve the DRUG-RELATED PROBLEMS that actually develop.

STEP THREE: Prevent all potential DRUG-RELATED PROBLEMS from developing


We usually start out with a lot of energy as rigorous ‘young’ practitioners, who are ready to solve well-formed problems (those that should be straight forward if all other practitioners did their part right) by applying theory and technique from systematic and scientifically derived knowledge. However as we become oriented to the ‘fuzzy” problems of daily practice, we find that the problems we encounter are not that straight-forward but rather “messy indeterminate situations”.

It does not take long for us, novice practitioners, to learn that we really don’t know how to solve many problems we face in practice. We learn quickly that defining the actual problem that needs to be solved is difficult and sometimes results in no clear solution.

Working Groups have been used in medicine (and pharmacy) for a long time to crack very important issues of practice that were not clear-cut from the outset. All of us know that all Cancer Chemotherapy protocols/regimens are product of focused Working Groups (or if you like Study Groups). A Pharmaceutical Care Working Group is an idea that has already taken off, and a handful of dedicated volunteer pharmacists will see to it that it changes the practice of clinical pharmacy in Kenya.

We will start from scratch and build working systems that pharmacists will rely on to practice. The moment we realized that no one but us can build our practice was the moment we decided to bid farewell to ambiguity. If only the vigour shown by these patriotic Kenyans can have a snowballing effect on every Kenyan pharmacist involved in patient care, and shake each and every barrier that has stood on our road to Pharmaceutical care!

The Pharmaceutical Care Working Group will provide a systematic method to collect and assess the clinical information used to determine patient’s problems and health needs. With repetition and practice, you can become proficient at “framing” the patient’s problems, achieving concordance with your own professional viewpoint and the patient. That is why it is called Pharmacy Practice!

HOW I WILL CONTRIBUTE TO ATTAIN THIS VISION FOR PHARMACY IN KENYA (See the vision in the immediate older post of this blog)

How can i contribute as an individual to attain this vision?

Individual level

 Ensure that all chronic care patients who are sent to me have an implementation (pharmaceutical care) plan for their treatment, follow up on them and track their future appointments so that I use that opportunity to evaluate treatment outcomes and set new goals.

 I will keep a register of all the patients I provide chronic care to be available for scrutiny by my peers and colleagues, so as to achieve a sustainable continuity of care.

 I will encourage the people who I will have the privilege to mentor, to embrace pharmaceutical care so that we can be members of a larger team who we can hand over care of our patients between us whenever we are not available to offer the essential service, with the goal of making sure that chronic care of patients is not an intermittent process but a long term continuous commitment.

 I will keep records of my interventions for scrutiny by me and my peers both for accountability and for opportunity for me and my peers to learn and improve our practice.

 I will teach, mentor and grow pharmacists younger than me to reach where I have not reached, to offer services that make more impact than I was able to, with or without compensation or remuneration of any kind.

 When my time comes I will provide leadership to pharmacists that will ensure that they realize their goals and have professional satisfaction.


As a member of team

 I will accept to carry out assignments and responsibilities assigned to me by my peers and professional colleagues that aim to improve the practice of pharmacy.

 I will be part of the process that ensures that there is a lifelong learning process going on for me and my fellow practitioners.

 I will take advantage of all opportunities to generate new knowledge in my area of practice and specialization, and target to carry at least one research or clinical audit each year which can be appraised by my supervisor.

 I will participate actively participate in a society, working group or an association that works to further the interests of the profession.


In the Regulation of Pharmacy Practice

 I will push for creation of working groups to come up with standards of practice for all the different specializations in pharmacy.

 I will call for the hospital pharmacy representative to the Pharmacy and Poisons Board (PPB) to buy the idea that regulation should always promote the provision of pharmaceutical care and ensure that the Board makes advancement of pharmacy practice a priority.

 I will mobilize the pharmacy practitioners and other stakeholders to keep the laws regulating pharmacy practice up to date and make the medicines that were registered after the last revision of Poisons List legal to be prescribed in Kenya.

o I will make my colleagues aware that the Poisons List Confirmation Order-which gave rise to a Poisons List [5] with two parts, (Part 1 and 2), in the Subsidiary Legislation to section 25 (Order under section 25) of the Pharmacy and Poisons Act-is now obsolete and need revision.

o That the revision of the list (addition or removal of medicines) together with its schedules be revised on an annual basis by pharmacists who have significant knowledge base and skills, and spend most of their time providing care directly to patients.

o That the reclassification of medicines from one prescription status to another is done in a structured way and the changes communicated efficiently to all pharmacists and other interested practitioners.


REFERENCES

1. New Statesman, 21 April 1917, article by Sidney Webb and Beatrice Webb quoted with approval at paragraph 123 of a report by the UK Competition Commission, dated 8 November 1977, entitled Architects Services (in Chapter 7).
2. Pharmaceutical Society of Australia: National Competency Standards Framework for Pharmacists in Australia 2010. http://www.psa.org.au/site.php?id=6782
3. Board of Pharmacy Specialties http://www.bpsweb.org/about/vision.cfm
4. Graham Copeland. A Practical Handbook for Clinical Audit. Clinical Audit Support Team, NHS http://www.wales.nhs.uk/sites3/Documents/501/Practical_Clinical_Audit_Handbook_v1_1.pdf
5. Pharmacy and Poisons Act, CAP 244 of the Laws of Kenya

MY VISION FOR THE CLINICAL PHARMACY PROFESSION

A pharmacy professional

A profession [1] is a vocation founded upon specialised educational training, the purpose of which is to supply disinterested counsel and service to others, for a direct and definite compensation, wholly apart from expectation of other business gain (Webb S, 1997).

Pharmacists are professionals who have the abilities and skills which are necessary to achieve outcomes related to:
• Providing pharmaceutical care to patients
• Developing and managing medication distribution and control systems
• Managing the pharmacy
• Promoting public health
• Providing drug information and education

While these outcomes seem easy to achieve, there is still a huge gap between what is expected of pharmacists [2] and what pharmacists actually achieve.

Clinical Pharmacist Training

The clinical component of pharmacist’s work need to improve the most and training for this role must meet the following objectives:
• to develop students' communication skills for effective interaction with patients and with practitioners of other health professions,
• to help students develop a patient awareness in the practice of pharmacy
• to enable students to integrate the knowledge acquired in course work prior to clinical exposure, and to apply it to the solution of real problem
• to develop students' awareness of their responsibility for monitoring the drugs taken by patients and,
• to help students become more aware of the general methods of diagnosis and patient care specifically related to drug therapy


Lifelong learning and professional growth

A good training in clinical pharmacy and the subsequent qualification as a practitioner is just but the beginning of a long journey towards developing competent professionals who will make an impact to the society. My desire is that pharmacists themselves will find it in their interest to develop, implement and sustain an internal mechanism where pharmacists’ knowledge, skills and attitudes are evaluated and improved.


Specialization

My vision for clinical pharmacy and pharmacy profession as a whole is that one day pharmacists will realize that it is not possible for an individual to accumulate enough knowledge in a lifetime to be an authority on all aspects of clinical pharmacy or general pharmacy. Some pharmacists have already realized this and are trying their best to fill the gap in the health care provision. The areas of specializations must however be relevant to the current needs, and must be continually reviewed to go with the times.


Certification

From patient to provider, the value of a certified practitioner registers throughout the health care continuum. This provides a legal basis and right to provide care in any clinical environment. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement.


How do we get there?

• The current clinical pharmacy training undergraduates are receiving in the University of Nairobi is much better than a decade ago; this is obvious when one engages a student on a clinical approach discussion. This needs to be sustained and even improved further.

• The undergraduate students in pharmacy should spend an extra year in training to be in line with internationally accepted standards for pharmacy training for students who have spent four years in high school or less than twelve years of pre-university education. This will give the pharmacists in training more time to accumulate knowledge, skills and attitude required to practice top level pharmacy.

• The internship should be done in areas where there is at least one preceptor per intern. The preceptor must have at least three years of experience in pharmacy practice post-registration and must be available at all times for consultation during the entire period of internship. The preceptor must demonstrate to have the knowledge, skills and attitudes required to train a highly motivated intern to have a successful professional life after registration before recertification.

• The pharmacist should be registered only if they pass pre-registration assessment that focuses on competencies expected of an entry level pharmacist. After that, annual practicing licence can be issued to a registered pharmacist without the need to sit for an exam, so long as there is evidence of continuous professional development (CPD) and the required CPD threshold has been achieved or exceeded.

• Only registered pharmacists should be allowed to practice pharmacy. Peer-led professional audits can be done on a regular basis to ensure that minimum standards required of a practice are maintained in all pharmacies.

• The current advanced training in clinical pharmacy needs to take at least 3 years with the pharmacist getting full residency status as their medical colleagues. The classes should be peripheral in term of time allocation, and real work environment practice to take the centre stage.

 The first half of the first year, can be fully academic, where an emphasis is placed on physiology, epidemiology, evidence-based healthcare and biostatistics. The second-half can the concentrate on pathophysiology, biopharmaceutics, pharmacokinetics, drug information and pharmacy management, toxicology, patient assessment, clinical chemistry and introduction to therapeutics and pharmaceutical care.
 The second year can be a year of problem-based learning where students need to build relationship with patients, other health care professionals and more importantly other pharmacists. The emphasis will be on the continuum of care, where there are multiple contacts between a student and an individual patient and student must have a plan for the patient who will be both in patient records and school of pharmacy records. The classes during this time will be mainly therapeutics, with numerous student presentations and faculty moderation. An adjunct class of advanced pharmacokinetics will be useful during this period. Some exposure to research methods can also be useful at this time
 The final year will concentrate on individual research work completion, more exposure to clinical areas of sub-specialization, and some level of participation in teaching more junior members so as to learn more. Communication and presentation skills, together with clinical audit [4] skills need to be enhanced at this stage. There should be evidence that the expected activities were actually carried out. Short-term exposure to other hospitals which are regional centres of excellence should be encouraged during this period.

• The newly qualified clinical pharmacists should practice for one year in the areas of their sub-specialty (residency) before they are awarded a board certification.

• The pharmacists to patient ratio should increase, and there should be presence of clinical pharmacists in all major specialties in major hospitals first, then to all other hospitals. The pharmacy specialist skills should not be spread thin, as there will be little or no overall impact. These specialists should be concentrated where they are needed most and should not be involved in primary care which registered pharmacists can provide with the help of lower cadre pharmaceutical professionals (technologists and technicians).

• The clinical pharmacists can harness their skills and knowledge by sharing information and experiences. They must have forums where they can communicate and influence the growth of the profession. Associations will leverage the growth of the profession by growing the capacity of the profession from within, and also by the lobbying forces outside the profession to further their interests.

• There must be a certification and recertification regulatory board [3] to certify pharmacists who meet the requirements to practice in their specialty areas, and prevent those who do not qualify from practicing.

• The clinical pharmacists should be able to motivate others to advance the practice of pharmacy. They should carry out clinical audits on a regular basis to demonstrate that the practice has improved. A clinical audit [4] is a cyclical process, involving the identification of a process to intervene, setting or adopting already available standards, comparing practice with the standards, implementing changes and monitoring the effect of those changes. Its purpose is to improve the quality of clinical care.

• There must be a standards body to force all healthcare providing institutions to meet certain minimum standards to be allowed to operate. Pharmacy practice can only excel if the pharmacists are well equipped to provide care.

REFERENCES
1. New Statesman, 21 April 1917, article by Sidney Webb and Beatrice Webb quoted with approval at paragraph 123 of a report by the UK Competition Commission, dated 8 November 1977, entitled Architects Services (in Chapter 7).
2. Pharmaceutical Society of Australia: National Competency Standards Framework for Pharmacists in Australia 2010. http://www.psa.org.au/site.php?id=6782
3. Board of Pharmacy Specialties http://www.bpsweb.org/about/vision.cfm
4. Graham Copeland. A Practical Handbook for Clinical Audit. Clinical Audit Support Team, NHS http://www.wales.nhs.uk/sites3/Documents/501/Practical_Clinical_Audit_Handbook_v1_1.pdf
5. Pharmacy and Poisons Act, CAP 244 of the Laws of Kenya