Practical tips for the pharmacists in the public hospitals

The pharmacists in the public hospitals are probably the best face of pharmacists as professionals to the general public. If we want to have a leverage, then we must start reforms here.

You are a pharmacist, and in the public sector having just completed your internship, and in very high spirits that your 12 months of wait has finally ended. You have just been employed, and once again you have applied for job as a pharmacist confirming among other things that your grandparents were a Kenyans, and you went through some primary school with an odd name like, Amaiya Primary School. You get an appointment letter within minutes of your application, signed on the behalf of PS by a guy who can write but cannot talk. You accept the appointment in yet another letter and the whole choreographed process is completed within 30 minutes. You start celebrating the 'efficiency' in which your application was processed. Your celebration is however cut short by the posting order that catapults you to Isiolo District Hospital. And as you will soon discover, you, indeed, were very lucky to be taken there and were a decision away from being deported to Marsabit. Not that Marsabit does not deserve a good person, but there seems to be no mechanism to compensate the extra costs that such a person incurs, as well as the hardships experienced. At least for Isiolo, that is the where tarmac ends and gives way to lorry-buses for those going beyond. There really must be a dark lining for every silver cloud! Did I say silver?

Well, you arrive to Isiolo within a fortnight with your posting letter to beat the deadline for reporting because you really need that salary-it is not much as far as your bills are concerned-but it keeps you going as you are waiting for better options to come your way. You check around the town, and discover that this is not a place for you. The hospital buildings are far much more nicely finished that any building you can see around, and look very new. Surely, CDF must have transformed this country or is it the so many NGOs that clutter the region. You brush off the thought and settle for the more weighty matters at hand. Some Mbuva guy has condemned you to this place, and he is not about to change his mind soon, or he might and think there is service need in Marsabit. This must be the wrong province to be in, you think, that it is easy to be in Machakos as it is easy to be in Kagundo, Meru or Marsabit.

You grudgingly accept to work here, and console yourself that it is not busy after all, and you can always create time for yourself to do other things. You also discover that all your medical superintendant is interested in, is your physical presence in the hospital for sufficiently long time for his hospital management team meetings and for his regular hospital staff returns to higher levels of the bureaucracy. There are no tangible targets set for you by the man behind the desk who deported you to Isiolo. He does not even give you management support thereafter for whatever reason. No amount of communication and good work you do will move him. The only communication you will probably get from him thereafter, is through another posting order, or in some odd mistake-finding mission by the people who have a ‘chief’ as part of their titles. The very person who does not come to your side when you need them most in the field, will come breathing fire on your neck, in a clear show of deep seated and long standing frustration (I wonder how one can be in both situations at the same time!) than genuine interest for efficiency. Surely, somebody must be making the hell out of their lives in Afya house, that I’m almost tempted in my child self not to hope to be in that house when I grow up, unless all I want is to unleash terror that has been building up inside me on others. As I had hinted, they may never visit you. Probably, the big bosses up there do not provide adequate funds for 'supportive supervision' as the small bosses do down here. So, it is actually lose-lose situation for us all, and for that we at least have something in common in this system. If they actually visit, then count yourself lucky, and chances are this might never happen to you again for the time you will be in civil service, unless you are in Tigoni or Kiambu that are a stone-throw away from Nairobi.

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We all know that a civil service job is not your dream job, but there must be something you can do in the when you are still there. One of the best legacies you can leave behind is to put the pharmacy profession a step ahead so that younger pharmacists can find a better environment. You know that you had a million ideas on how you can transform pharmacy, and yourself, on the day that your pharmacy school dean recommended that you should be awarded a pharmacy degree by your university. So what can you do to make your while worthwhile?

You can start by first learning the systems, in your new workplace. You were probably in a referral hospital for your internship, or you just did not take your hospital internship seriously. It is understandable; interns can be absolved for reeling in their newfound status, and be allowed to party while it lasts. But now things are more serious, and the profession depends on the decisive steps that you take. You realise, that as much as the private sector pharmacy practice is completely different from the public sector, the private sector terms of service is actually pegged on that of the public sector.

After learning the systems (for your efficiency), you start the hard work that you know clearly will impact on your future, whether in the public or private sector. What do you do next? Here are some tips for you.

• Change the rules for the access of medicines in the hospital by the patients.

The truth here is, actually, you are not changing things but you are just doing what was supposed to be done in the first place. They are actually very basic rules, that make huge impact on the image pharmacists project to others. The rules include, but are not restricted to the following:
No one should be dispensed a medication for speculative purposes, but only on what it is indicated for.
Observe the rule of the right drug for the right patient in the right dose for the right duration.
No one, not even the hospital staff who will prove to be your biggest headache of all time, should be exempted from this rule.
Keep your eye on the fast moving commodities, and especially those that are of high market value.
Analyse all the data you generate and make useful conclusions on them. Like, do not just fill the mandatory antibiotic registers, for drug accountability purposes only. That is what was expected of a pharm tech or a data clerk, but not a pharmacist. A pharmacist should be able to process information they generate to guide policy making. Predict antibiotic resistance patterns from them by matching, the indication with drug choice, dose and the duration of treatment. And when you find a problem, present it in your hospital CMEs.
Finally, and please, for goodness sake, don’t steal drugs. Pharmacists simply don’t do it. It is very petty. Period. I suggest any suspected essential medicines thief should be up for disciplinary committee with a view to permanently deregister them. Please, if you must steal, steal government’s time and not its commodities.

• Be pro-active to a extend of being branded a ‘busybody’ by your detractors

Can you believe this? You can actually be a pain in the *** to an extent that everybody wishes you were on leave, or better still transferred to a faraway place, especially if you are tough on money and budgetary issues. Read all the regulations on prudent use of hospital funds, those that are collected locally as well as those that are provided for centrally. Your main supplier of essential medicines and medical supplies (KEMSA) will probably not provide for all your basic pharmaceutical needs. That is where hospital funds come in. You probably don’t know that you should be allowed to spend 75% of your collections on your pharmacy. You also probably do not know that you can only get your pharmaceuticals from those suppliers who tendered for them and were given tenders at the district level.
What may even be more shocking, is money allocated to pay your pharmacy debts not reaching the supplier if you don’t follow them actively. Civil servants were made to be pushed, and they are always looking for sources of dirty money, searching for one loophole after another, so start closing loopholes that are touching on your work lest it might be difficult for an outside eye to separate the wheat from the chaff. You are too fresh, too proud and in another league to allow yourself to be enrolled into such dirty games; so push them aside and do what you know is good. There are a million clean ways for a pharmacist to make monumental amounts of money. Ask around, and you may discover your store man or whoever clerk is assigned to process payments to the suppliers, is sitting on the payment vouchers, because a bribe has not been paid. Shame such people in front of everyone, if they consistently frustrate those that you need to function well; your suppliers.

• Do constant research

One classical situation is that of the paediatric wards constantly complaining that a specific brand of broad-spectrum antibiotic injection like Ceftriaxone in the right peadiatric doses is not working at all. The department in such cases may specify that the Rocephin brand be ordered for the patient. While such claims may be correct, wouldn’t it be prudent that you carry out a small study to confirm or rubbish such claims?

You can take the following steps in your small research:

 Take one vial of the powder for reconstitution, reconstitute the injection yourself in the pharmacy, and note any unusual observation for injections.

 Go through the patients file in the ward and check for the provisional diagnosis and steps taken so far by the primary doctor.

 Note the dose prescribed for the diagnosis and the duration of treatment ordered

 Observe as the drug is administered during ward treatment sessions to see if the right dose is administered in the right way

 For high treatment failure rates, document the antibiotic sensitivity tests (if they are done). Consider misdiagnosis or too little amount of drug if the suspected bacteria are even mildly sensitive to the drug. If resistant, then consider wrong drug choice or poor drug quality.

 Note if more than one clinician on more than one occasion complain about the product. Be very certain that the complaint is credible.
A credible complaint is always due to a first-hand experience and not from hearsay or unverifiable ward gossip. Make sure the complaint is not an unjustified push for branded products that are costly to the hospital in the long run and are unsustainable. I know of a situation where erroneous information spreads like wild fire and nobody takes time to validate the information. A fallacy in that situation can end up being taken as the truth.

 In your desperate attempt in defence of your faulty product, (it really has to be a product that you believe in or so you thought) you could issue another batch of the same product (if you have) and note if there is difference. Sometimes the defect could be restricted to just one batch of the product.

 Now try another brand and rest your case. Either way, you will have already done your research if you had not figured out that yet if you go through all these steps. And with your findings, you will be able to intervene authoritatively.

 Compile your evidence and present them a hospital forum for continuous education.

 Send your samples to a national quality control laboratory (for a nominal fee to the hospital) to ascertain if the percentage of the drug to the label claim. If the percentage ends up being above 100%, then you have more nuts to crack; it had better be much less than 100% to fit your theory. Thankfully, the NQCL should be able to do for you some qualitative analyses that may go a long way to quench your thirst for excellence.

Someone else with more suggestions can add in the comments.