Hospital Pharmacy Practice in Namibia: Part 3

Welcome Back!

Thank you for checking out this final installment of my blog! In the previous two posts, I talked about the scope of my project, Namibia, the public- and private-sector hospital systems, healthcare access, information management, and process innovations. In this post, I'll be discussing the most prominent themes regarding challenges I observed in the hospitals I visited, as well as my thoughts on enabling future improvements in practice.

Major Themes: Resource Constraints

Budgeting is a notable source of stress for just about any organization. In the brainstorming phase of any project-based work I've done in the past, regardless of the institution or project, phrases like "well, if we had more money or some additional people" always seemed to come up when discussing the possibilities. Given the universality of this theme, I wasn't surprised to see it surface in Namibia. However, the extent of the resource constraints they faced in these hospitals went beyond any of the challenges I have seen elsewhere. It was inspirational meeting the pharmacists who got up every day to meet these challenges head-on, and to give their best to using what they had to help the patients in their community.

Most hospitals I visited faced financial challenges. The public sector's challenge was related to the set amount of funding they received from the government, while the private sector's challenge had to due with the difficulty of remaining profitable in a country where only a minority of patients will seek care from their sector on top of the usual competition between private institutions. The most notable manifestation of this funding shortage was a lack of adequate staffing. In my last post I mentioned the example of a hospital with 2 pharmacists who serve 2,000 patients per day; while this was the most extreme case, it did paint an accurate picture of how busy pharmacists were in the country, since most sites had a total of 1-3 staff members for the whole pharmacy department. It was not uncommon to see waiting rooms with upwards of 100-200 patients outside the pharmacy waiting for medications. This also meant that the pharmacists were sometimes unable to get involved in the areas they would like, such as in-patient clinical work and attending ward rounds with the other healthcare providers. If they had too many outpatient prescriptions to fill to leave the dispensing area of the pharmacy, that meant they spent their day dispensing since there were patients there who would likely become disheartened and leave if they had to wait too long for the pharmacist to return from other areas. Staffing also affected the hours of operation. In all of the sites I visited the hours were 8am-5pm; all of the pharmacy needs that occurred overnight required that nurses retrieve medications from the emergency pharmacy storage cache, and doctors called the pharmacists at home if they had questions. No other pharmacy services ran after hours or on weekends.

Another resource, which I realized I have taken for granted in my pharmacy intern experience in the US, was space. This was a challenge in the public sector in particular, where it was frequently the case that the hospital was designed without the pharmacy's/pharmacist's needs for space in mind. Some sites explained that the hospital was actually built without a pharmacy originally, with the intent that patients would go elsewhere for medications, so they'd had to repurpose the existing space when the pharmacy service was established. In some cases that had gone well based on the ability to convert other rooms, but in other hospitals the pharmacy ended up in what used to be a supply closet. In other scenarios, the builders and architects had simply forgotten the space was supposed to be there, and they ended up converting part of the parking lot into a pharmacy, or perhaps a small patient room. In one case, the pharmacist had so little space that boxes of medications were stacked from floor to ceiling and she had to shuffle sideways between these towers of boxes to get what was needed. In another case, the pharmacist said if he ordered just the minimum amount of each type of medicine that was used in one month, that would fill his entire stock room three-fold over, and that's not leaving any space for isles to move around. As a result, he had to store most of their stock outside in a small fenced-in area that prevented theft; he acknowledged this was clearly not ideal, but given the choice of not enough medicines vs. medicines outside, he went with medicines outside. The result in both of these cases was the need to order very small amounts of each medicine nearly every day, which resulted in frequent medication stock-outs where patients couldn't be helped that day. In addition, this meant the pharmacist was spending far more time on managing their inventory than they would need to if they had a little more room.

Society's Understanding of the Profession

In my own experience in the US, pharmacy is a relatively misunderstood profession. The average person usually seems to know about the dispensing role pharmacist's play since that is the role where most people would have interacted with a pharmacist, but they don't know about the other valuable clinical services pharmacists provide. Many people who don't work in healthcare may not know that pharmacists also perform valuable services in a hospital like dosing medications used in inpatient wards, providing recommendations for drug therapy to physicians, answering drug information questions for healthcare providers, monitoring drug levels and clinical response, and checking prescriptions to prevent prescribing errors or drug-drug interactions from reaching/harming patients.

I found this lack of transparency/common misunderstanding of clinical roles to be similar in Namibia, but perhaps to a greater extent. Other types of healthcare providers also didn't tend to know much about what pharmacists are trained to do beyond dispense medicines, and I learned that since there is currently not a pharmacist on the health council, the Ministry of Health was often unclear of pharmacy services or their funding needs compared to professions like medicine and nursing. Society's limited understanding of the profession seemed to cause difficulties in expanding the pharmacist role into additional clinical areas, as well as preventing the pharmacy departments in the public sector from receiving adequate government funding needed to do so.

That being said, there was a great desire among the pharmacists themselves to "practice at the top of their license" and utilize all of their training. It was commonly expressed by the sites that a large amount of the job is inherently related to dispensing and stock management. This does make sense, since without the medicine in hand the other services wouldn't be possible, and if they don't make it to the patient, the clinical knowledge also doesn't help. The pharmacists viewed these two areas as the absolute necessities for the profession, and while funding often allowed them to do little more than focus there, they knew the potential was there to make a difference in other areas of patient care if they could get time for more clinical engagement.

Sharing of Information & Best Practices

One of the most uplifting parts of this project for me was the realization that while there are many long-term opportunities to improve the practice of pharmacy in Namibia which require greater financial resources, there are also near-term, tangible improvements that would be enabled by gathering and sharing information about current pharmacy practice in the country. I spoke in my last post about certain process improvements and operational efficiencies that Namibian pharmacists had come up with to free up their time to expand their role further into clinical practice, reduce medication errors, and ultimately extend their ability to help more patients. Sharing these practice-enhancing innovations will be valuable, since they not only work in theory but in practice in similar environments with the same resource constraints in Namibia. This continued knowledge sharing is something we're excited to continue with going forward.

Beyond dissemination of the project's observational findings on process improvements and best practices, we will also be able to provide the participating sites with advice on areas of prioritization to focus their future resources on. Due to the project's confidentiality needs, our specific findings captured by data gathered with the survey tool cannot be shared here, but the root-cause analysis they enabled was helpful in locating the source and nature of prevailing practice challenges. Long-term, the hope is that having well-defined areas of resource prioritization based on this root-cause analysis alongside increased transparency to the profession and its current workforce capacity-building opportunities will enable donor organizations to effectively fund projects which improve the state of hospital pharmacy services in Namibia.

Farewell!

Thanks again for reading my blog! I hope you've enjoyed hearing about my experiences in Namibia, learning about its healthcare system, and of course about Namibian culture. I will miss Namibian/polychronic time, carving tagua nuts, the food (especially "fatcakes"), and most of all my new friends and colleagues. I know a piece of my heart will always stay in Namibia, so I made an effort in my final weeks to reconnect with the people I'd met in my stay to say my farewells. I had the opportunity to reconnect with Alfons, the tagua nut carver I'd met in my first week, who gave me a very touching souvenir. He made me this very special piece based on my interest in traveling around the world and working to improve the health of the people in it:

A tagua nut carved by Alfons. I had the chance to visit him a couple more times and chat about what I'd been up to and what new carvings I'd made, which he enjoyed seeing. He said since I'm so interested in traveling the world, I needed a souvenir to remind me of the future, not just my time in Namibia. He carved me this nut which had an incredible map of the world! The other side has an inscription that reads "Dr. Mason Benjamin, 'I was there' - Namibia 2018" with a few blank areas to carve the names/dates of places I visit in the future.

P.S. - Attention Travelers!

While the majority of my time in Namibia was spent working on the data collection project I was sent to accomplish, I did try to make the most of the weekends falling outside of the project-related travel. I thought I should share one of the most unique experiences I had, for those who may someday be interested in visiting the country. I've always loved animals, and as a little kid The Lion King was one of my favorite movies. I went on a couple of short safari drives into the bush, and saw some incredible sights that made a childhood dream of mine come true! I loved seeing this lion relaxing in his natural habitat, and he seemed very curious about what I was doing there (or maybe I just looked tasty, who knows). It was sort of like being in very large, two-way zoo, and I've never experienced anything else like it. I would highly recommend that anyone who loves travel and animals try to make it to Namibia if they have the chance! Etosha National Park and Erindi Game Reserve were the two places I made it to, which are each a several hour drive north from Windhoek, but well worth the time. I have more photos than I know what to do with, and incredible memories that'll last a lifetime.

In lieu of another sunrise/sunset, I thought I would share one of my favorite memories from the trip: here's a picture of me and my new friend, Simba. It was cool to see this young, male lion from so close! 

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This internship was sponsored by the William Davidson Institute as part of its Global Impact Internship Program, in collaboration with the WDI Healthcare Research Initiative, International Pharmaceutical Federation (FIP) and the University of Namibia School of Pharmacy.

My Last Weeks in Kenya

Andrea Arathoon – University of Michigan School of Public Health

Twelve weeks went by faster than I anticipated. August 3^rd was my last day at Jacaranda Maternity, and after traveling for a couple of weeks, I’m now back in Ann Arbor.

In my last post I described how we would be testing an outpatient checklist for prenatal visits for two weeks, in the hopes of making any changes after the testing period and then implementing it.  After the two weeks ended, I had a feedback meeting with the nurses to understand how the implementation was going. During this meeting, the nurses explained that the checklist was repetitive and redundant, and added more work to every patient visit. After talking to the senior management team, the decision was made to go back to the previous patient file and use the checklist template for when the clinical part of the EMR is implemented in the future.

However, the patient reminders are still being utilized at every prenatal care visit and have simplified the check-in process for patients in the clinic, reminding receptionists of the tests that patients need to be completed before their appointment with the nurse or the physician. Staff is pleased with this implementation and report that it’s making their lives easier by reminding them of what needs to be done.

Reflecting on my time in Nairobi, I believe I learned much more than I had previously anticipated. I was fortunate to work with a team of passionate, highly motivated nurses, as well as an empathetic and dedicated group of leaders. I was given the freedom to test and implement new ways of doing things, and although not everything turned out as I expected, it was a great learning experience overall. I brushed up on my clinical skills by observing clinicians at the hospital, learned about healthcare policy in Kenya, and developed a relationship with the organization that I hope will last for years to come. I also picked up a few words in Swahili, with the help of the staff members at Jacaranda Maternity.

Although I’m back in the US, I am still working on a marketing project with Jacaranda Maternity. This consists of rebranding the hospital, reviewing the mission, vision and values of the organization, and making sure that communications within the organization and with patients are consistent and well percieved.

My time in Kenya also allowed me to make new friends. I was lucky to have three other interns from different schools working in Jacaranda’s sister organization (JHSL), and we had the chance to travel to different parts of the country during the weekends. We took a trip to Lake Naivasha, where we visited Hell’s Gate National Park and Crescent Island. We also took a day trip to Lake Nakuru and went to Lamu for a weekend. During a holiday, I visited Ol Pejeta Conservancy, where I had the opportunity to interact with the last two Northern White Rhinos in the world. After my internship, I also traveled to Amboseli National Park, The Maasai Mara National Reserve and Naboisho Conservancy, where I had the chance to meet people from the Maasai tribe, arguably the most famous tribe in Kenya.

Overall, I am very happy with my summer in Kenya at Jacaranda Maternity, and am grateful for the opportunities I was given to challenge myself, expand my skills, and have new experiences.

 Admiring one of the last Norther White Rhinos in Ol Pejeta Conservancy

Baby giraffe at Crescent Island, Naivasha

Our vehicle for the weekend in Lamu, a dhow

Having fun with our guides during my trip to Naboisho

The gorge at Hell's Gate National Park

Lake Nakuru

Naboisho Conservancy

Amboseli National Park, with Mount Kilimanjaro in the back

Retrospective on Energy as a Service

Matthew Carney - Ross School of Business & School for Environment and Sustainability

Namaste! With my internship now over, it’s a perfect chance to reflect on my summer and how my first year at Michigan led to this opportunity. Like many students, I came to Michigan without a firm idea of where exactly I wanted to go professionally. I knew I wanted to do something in the realm of sustainability, but I struggled to decide which problem I wanted to focus on. Renewable energy? Clean water? Waste? Poverty? Forest degradation? These were all significant areas to focus on, but I still felt like I hadn’t quite scratched my itch.

Thankfully, my vision became clearer as the year wore on and I began to reconsider energy not as a product to be sold - but a service to be provided. Working with institutions like the William Davidson Institute helped me understand that we shouldn’t limit ourselves to thinking that the benefits of renewable energy are realized when the lights turn on. Particularly in emerging markets, new sources of renewable energy can have a significant positive impact beyond reducing carbon emissions.

Subsistence farmers in rural Nepal provide a stark reminder of this fact. These farmers spend hours each day farming their land by hand, and struggle to produce enough crops to feed themselves - much less sell for profit. Additionally, tasks such as irrigating land and grinding crops into flour are extremely manual labor-intensive and incur significant opportunity costs due to how time-consuming they are.

Access to solar-powered mechanization can help these farmers in numerous ways. First, improved agricultural productivity means that farmers can produce more crops with less effort, ensuring they not only have enough food for themselves but also have crops they can sell to earn income. Secondly, reducing the number of manual labor hours needed to tend the farm leaves individuals, particularly women and children, free to pursue other income-generating opportunities. From an environmental perspective, the adoption of modular solar power can also meet these farmers’ needs while reducing the incentive for capital-intensive, environmentally unfriendly electrification infrastructure projects.

Overall, I was very lucky to spend my summer working with a company that helped me see the positive trickle down effects energy access can have in emerging markets. I’m grateful for the experience WDI provided because I know this experience will provide a new lens for how I approach the upcoming year at Ross and my career interests.

Updates from the Final Stretch

Rebecca G-K - University of Michigan Ross School of Business and Medical School

It is hard to believe how fast the summer (or rather, winter here in the southern hemisphere) has flown by and I now find myself wrapping up loose ends to finish my project. The main goal of the internship was to work with Plan to develop a new approach to measuring the impact of their programs, with a specific focus on tracking gender equity initiatives. Until now, the organization has tracked, in addition to some qualitative interviews with participants, numbers: the number of workshops on early childhood facilitated with parents, the number of girls who were trained in digital advocacy, the number of community members who attended a community event. The question guiding our work this summer was: what good is it to reach thousands of girls if the programs aren’t changing their lives positively? We needed a systematic approach to approximate the effects on participants’ wellbeing.

We began by visiting Plan’s recently revised theory of change to map out the intended outcomes of Plan’s work. It was a complex undertaking because Plan has many different projects that take place in four different regions of the country and for youth ranging from ages 5 to 20. As is typical of many non-profit organizations, over time the programs shift and evolve based on the funding climate and specific interests of corporate sponsors. One of our main challenges in the beginning was deciding whether or not we could make one streamlined tool that could be applied to every Plan program. All of our iterations began with the three program areas of the new Plan strategy: Lead (advocacy and leadership skills), Thrive (preventing violence), and Decide (sexual and reproductive health); does each of these program areas deserve its own evaluation tool? After many discussions and literature searches, we decided to pare the tool down and collect data on the core outcomes that are shared among all of Plan’s work (such as self-efficacy and beliefs regarding gender equality).

This was only the beginning, however! The following weeks involved testing the survey questions to make sure participants would understand the questions as they were intended. We spent a lot of time breaking down words like “advocate” and defining exactly what would be considered “violence” or “harassment.” The final product is still a work in progress, as it will continually be improved with each cycle it is used. However, it represents a step forward in understanding the impact that Plan programs have on girls and their communities.

(I can't post photos from this process due to Plan's child protection policy, so I'll post some of my other activities below).

Design Thinking workshop with Plan 

Another highlight from the last month was a Design Thinking workshop, conducted by LiveWork Brazil, for the Plan team to develop several innovation projects that have been in the pipeline.

Essential tool of design thinking: Post-It notes
We even received tips on peeling post-its so they retain their "stick!" 

I was lucky enough to join Plan employees from different regional offices and functions, board members (one of whom, it turns out, is married to a Ross MBA alum!), and community members in a 2-day design extravaganza. Groups of 5-6 focused on a question related to an opportunity or challenge for Plan, and conducted interviews to gain new perspective. My favorite part of the workshop was brainstorming solutions using exercises like “How would the United Nations solve this problem? What about Disney? Google? What is the worst idea you can possibly come up with?”

Sharing our rapid-fire brainstorming ideas 

São Paulo - Worth a visit! 

This may be my last blog post before the summer comes to an end, and I would be remiss not to include a plug for visiting São Paulo. Sao Paulo is often skipped over by tourists, on their way to Rio or Iguazu Falls, and underappreciated by business travelers. The city gets a bad rap for being a concrete jungle, with high-rise buildings as far as the eye can see stretching out in every direction. However, it is a bustling, vibrant, diverse megacity  that can somehow feel like a friendly small town despite its population of 12 million. A few reasons to visit:

On Sundays, the a main street is closed to cars and filled with street artists, food stands, and families strolling. 

A free music show at a photography museum downtown 

An early 5:30pm sunset on Paulista Avenue 

Dumplings at the Liberdade Sunday market. Liberdade neighborhood is home to the largest Japanese population outside of Japan

Quintessential São Paulo is sitting at a sidewalk table at a "boteco" diner-like restaurant with friends and ordering manioc fries or fried cheese snacks and ice-cold drinks

Ibirapuera Park is where families congregate on Sundays to picnic and exercise

Impressive samba moves

If you like jazz or bossa nova music, give samba a listen! This is a song by Moacyr Luz and Wilson das Neves, performed by Chico Aguiar Médico.

Listening to samba music with full participation of the crowd: an unforgettable experience 

Personal Development Week at EBC

Nadia Putri - Ross School of Business

When EBC's General Manager asked me to organize training for recently-promoted supervisors during the rest of my time in Desa Ban, I was perplexed. What should I talk about and share with them in 10 days straight?!

The objective of her request was to get the employees used to the idea of strategic thinking, effective discussions, etc. Most of them came from the lowest level of employment at EBC. Some started the job not knowing how to use computers and now have to process data in Excel. They were hired for manual labor, paid by the kilograms or daily. Thus, it is a challenge to switch from an output-oriented work mindset to a more strategic work mindset. We hope to embed in their minds that they have bigger responsibility now, which is to coordinate, collaborate, and work across departments.

Considering all of these and after brainstorming with the head of people operations at EBC, I designed a one-week program called "Personal Development Week" for ~15 supervisor-level employees, including factory supervisors to headmaster of EBC's preschool. With "action-based learning" in mind, I created training-workshop program. Training is when I presented some tools related to the topic, whereas workshop is a stage for them to put these tools into practice.

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Training & Workshop 1: Public Speaking & Feedback Giving

In the first training set, I shared some tools on how to present your thoughts/ideas in a structured manner and deliver constructive criticism that provides learning insights for the recipients. During workshop the next day, I asked them to present a work problem that they're facing in front of their peers for 3 minutes. Their peers, in turn, provided feedback on their performance.

Whenever I bumped into them in the hallway, they would come up to me saying they're "very nervous about tomorrow's speech". I took every opportunity to remind them that this is just to increase their confidence, get them used to speak in front of a big group, and gain feedback from the audience. It's not to criticize or show their flaws, but to keep practicing!

Rinna Kustiana explained problem she's facing in her department

At the end of the workshop, one of them asked "when's the next time we do this again?"

Training & Workshop 2: Problem Solving & Effective Team Discussion

In the following training set, I partnered with one employee from people operations to present the material. He presented how to do critical problem solving and how to navigate teams with different POVs. We picked two best presenters from public speaking workshop, split the audience into 2 random groups, and assigned them with one of the best presenters' problems. During the workshop, we let them work in their respective team to brainstorm, discuss, and come up with recommendations to solve the problem.

Team 2 during problem solving workshop at factory's gazebo, surrounded by lush scenery

We gave them 1 hour to meet, yet we went a bit over because the discussion was so fun and insightful!

Training & Workshop 3: Presenting with Visual Tools

Finally, the last set of the training should put a bow on this one-week program. I shared some tips and tools to structure and design slide deck using PowerPoint. On the final training day, they will work in teams to create their slide deck, present their findings to the other team, and critique each other's recommendations! This final day serves as an opportunity to showcase everything they have learned this week.

Team 1 creating their slide deck to present their recommendations for AnaKardia preschool

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I was nervous about how this one-week program will turn out. It's never done before at EBC, especially since the employees have to take some time off work to attend a class every single day. But, this pilot training received very positive feedback! Post-training survey says that they wished they had more time during the training/workshop, and would like to join more similar training in the future

I was not expecting a major shift in the training participants only after attending a one-week training. I wanted them to experience and most importantly: enjoy the learning process, and luckily this mission was accomplished. I hope this training will continue and can be opened to a wider audience at the factory.

As the old saying goes, Rome was not built in a day. But I'm glad I took part in laying the foundation of something great in Desa Ban, East Bali.

Training participants and I at the end of our last workshop

Hospital Pharmacy Practice in Namibia: Part 2

Mason Benjamin - School of Pharmacy

Welcome Back!

Hello, and welcome back! Last time I covered my initial perceptions and what it's like to travel around Namibia. Before I dive into the detailed observations, I wanted to dedicate this post to discussing the healthcare system in Namibia. 

The Public- & Private-Sector Payment Systems

The first thing that stood out to me, as someone coming from the US, was how interesting the healthcare system design is in Namibia due to having both a public and private sector. In the US, I was used to having one set of healthcare facilities that everyone can use where payment details are different from one patient to another (based on their insurance and financial situations). In Namibia, there are instead two sets of healthcare facilities, and the payment process instead varies based on facility type.

Because there are two types of hospitals, public and private, it's not at all uncommon to see billboards like this with directions to four different healthcare facilities all on the same sign post. The prevalence of healthcare facilities here in Windhoek is incredible! In addition to these hospitals, there are also many smaller health clinics serving patients in the area.

The public-sector hospitals are predominantly paid for by the government using taxes which pay the salaries of the hospital employees as well as for most of the costs for supplies, medicines, and facility maintenance. These facilities charge only a nominal fee (N$ 8.00, which is ~$0.60 USD) to visit the hospital, and medications are given to the patients free of charge. Hospitalizations and longer admissions will cost slightly more (up to N$ 50.00, or ~$3.75 USD), but if the patient cannot pay the fee to visit or to be admitted, they are still taken care of free of charge. Certain sites told me that they would occasionally make notes to track who hasn't paid in a while to discourage abuse of this system, but that they never really deny patient's healthcare access. Because they are extremely inexpensive (and free, if need-be) the public sector facilities are the most commonly-utilized source of healthcare facilities in Namibia by the majority of the population.

The private sector has a very different operating structure, which I have found to be extremely similar to that used in the US. These hospitals do not receive funding from the government, and instead receive payment from patients' insurance companies if applicable, or else charge high out-of-pocket fees for their service. Namibia has a population of only ~2.5 million people (vs. ~326 million in the US), and only a small proportion of the population has private insurance or coverage through their employer. As such, to make their business model sustainable with such a (comparatively) small number of people using them, private hospitals must charge substantially higher prices than the public sector for medical care and medications which makes the prices roughly comparable to those in the US. I was told that a surgery could easily cost between ~$20,000-250,000 USD, and it might not be uncommon for someone to pay ~$15-30 USD for a prescription co-pay (it was unfortunately not possible to get many "average" estimates, since the cost varies by patient depending on their insurance, but one pharmacist who had formerly practiced in the US said it's surprisingly almost identical). These facilities are generally only used only by wealthier patients with insurance, but they do sometimes treat critically-ill, uninsured patients transported from a near-by motor vehicle accident or medical emergency. In these emergencies, they generally do not charge the patient a fee for their services (unless the person has insurance and elects to stay in that hospital), but instead triage them until the patient is in stable condition, and then transfer them to a public-sector facility whenever possible.

In both facility types, pharmacists are relied upon to treat both patients admitted to the hospital, as well as patients who walk in from the community for their primary healthcare needs. The ambulatory care burden from outpatient is generally about three fourths of the cases they see, and both sectors reported finding it difficult to attend ward rounds and get further involved in the inpatient care due to such a high degree of outpatient (walk-in) cases that need their continued attention. The one exception was that certain private hospitals only treated inpatient cases if the pharmacy was owned by the hospital, rather than by a pharmacist (it is a law in Namibia that non-pharmacist-owned pharmacies cannot dispense medication to patients not admitted to that hospital). Both hospital types serve patients with a variety of chronic diseases, though care for HIV and TB is generally managed by public-sector hospitals and health clinics.

Healthcare Access, In Context

For the most part, private-sector facilities have a reputation for having nicer facilities (in terms of space and cleanliness), lower wait times, access to more types of medicine (including Brand-name drugs), and an overall higher quality of care and customer service. While in contrast public sector facilities have longer wait times and fewer treatment options, their main advantage is in still being able to provide access to any patients that need care, regardless of their financial situation. The pricing models used by the public- and private-sector hospitals mean that a person's socioeconomic status (SES) generally dictates where they receive care, and so individuals with higher SESs will often receive better care and customer service than those with lower SESs do (as is unfortunately the case in many countries, the US included). It is relevant, in this context, to mention some of Namibia's recent history and the current economic situation most Namibians face, discussed below.

Namibia (formerly South West Africa) won its independence from South Africa 28 years ago, up until which time the apartheid system of racial segregation redistributed property and financial resources from the majority black population to a minority of white citizens. It additionally prevented black citizens from owning land or securing desirable, high-paying jobs (among many other non-financial discriminatory provisions). While these laws were abolished upon Namibia gaining its independence in 1990, there was no direct or immediate transfer of wealth back to the populations who had been disadvantaged, leaving a majority of the population in poverty contrasted by a small number of extremely wealthy individuals. Namibia has made an effort to combat this issue, and there are now progressive wealth transfer policies in place. The "upper 10%" of Namibians (by income) pay approximately 70% of the country's taxes, and many unemployed Namibians survive using money that is redistributed from a portion of this pool. Despite this policy, unemployment rates hover around 40-50% and the country ranks 2nd on the World Bank Gini Index (meaning it is considered to have the 2nd-least-equal wealth dispersion of any country, faring better only than its neighbor and former ruler, South Africa). This is largely because of how few years have passed since Namibia gained independence, and because of how much work lay ahead of their new government at that time.

Taking into account the country's history, I'm impressed by how well the country is recovering, and how far Namibia's healthcare system has progressed in so little time. While the distribution of choice and preference in healthcare access is not yet perfect, there are areas where I think Namibia is actually doing a better job delivering care than nations like the US are. During my time here, I have commonly reflected on the ~10% of uninsured Americans who are sometimes entirely unable to access healthcare resources due to cost barriers, as well as their many insured peers who are still discouraged from seeking care based on the cost of their copays or coinsurance. Compared to the system I grew up using, I think it's incredible that despite its recent past, every person in Namibia already has the right to basic healthcare access, and no patient will be turned away for financial reasons.

I should also mention, while often the private sector earns its reputation for offering a higher quality of care, this is not always the rule. In fact, it was a public-sector facility which received the award for the country's best hospital from the Ministry of Health & Social Services. The head pharmacist at this hospital was incredibly proud of the quality care they provide, and his desktop background was a picture of him shaking hands with the American Ambassador when he visited to congratulate them on the service distinction. Aside from this site, there were also other hospitals where I felt that the care seemed similar, regardless of facility type. In certain comparisons, I thought the differences were predominantly cosmetic (in that the private-sector facility might have a better-looking or newer building, however, the actual services received differed mostly based on the average patient wait-time).

Here I am (2nd from the right) in Namibia's top-ranked hospital, Oshakati State Hospital, with their head pharmacist, Walellign, Liv, and Moses (from left to right). In addition to his pharmacy training, Walellign has both a management and leadership degree, and you can tell! This place was incredibly well-run, and he had an amazing talent for motivating his staff and cultivating pride in their work.

Also in Oshakati, Walellign introduced a suggestions book where patients can offer their advice for the pharmacy (and hospital at large) to improve their delivery of care. This book was well-used!

Here is a page in the suggestions book at Oshakati. While flipping through, it was incredible how I couldn't find a single "suggestion," but instead pages after pages of compliments on how well they are doing! Apparently before the new management arrived, wait times were longer, patients didn't get the same attention from the pharmacist, and their access to medicines was sporadic. With his leadership and hard work, the place was transformed in a way that the community loves!

Differences & Similarities: Medication Access

There are a handful of major differences between the way private- and public-sector hospitals operate, although I've found in my interviews that they surprisingly face similar challenges. Medication access is one of the bigger examples I've seen. Both facility types listed this as one of their biggest concerns, and yet the source of their problems are different.

Public-sector hospitals order their medications from a Central Medical Store (CMS), and these medications are paid for by the government. One of the largest complaints I heard at multiple public hospitals was that stock-outs (a period where a given medicine is unavailable for purchase) are far too frequent, and they wish they had more autonomy in their ordering process and in what medicines they are able to request. When asked about their facility's biggest strengths, many public hospitals spoke about medication-sharing alliances with neighboring facilities, which are needed to overcome these scenarios (notably, private sector facilities mentioned a similar strategy for handling their drug shortages).

Private-sector hospitals order their medications from private wholesalers, which are similar to CMS, though often higher-priced. This difference in vendor types confers them the ability to order a wider variety of medicines, including Brand-name drugs and more expensive drugs, but due to a lack of drug price regulations in Namibia, they frequently end up ordering similar drugs as the public sector (based on the cost) but may pay a higher price. Private-sector facilities also face a challenge in obtaining certain medication types based on the laws here. For example, medication for malaria can be purchased in bulk and stored for future use by public-sector facilities, and so is generally readily available. In contrast, private-sector facilities must file paperwork in advance of procuring medicine for each of these prescriptions on a patient-by-patient basis, and can only purchase the amount to treat that patient. Sometimes this process can take long enough that the patient dies before they can be treated if they were not able to visit a public-sector facility with the drugs available. There is also unfortunately a lesser business incentive for pharmaceutical manufacturers to register their medicines for use in Namibia than exists in other countries, based on Namibia's small population, so some drugs are unavailable for import in the private sector. The process to get a new drug registered can take upwards of a year, which patients may not have.

Information Management Systems & Record-Keeping

The way health information is managed in Namibia has so far stood out as one of the biggest areas where my initial expectations and experiences have differed. 

From my research before traveling to Namibia, I expected to see facilities who used paper records for patient health information, especially in the public facilities. While I was not surprised to observe this in practice at each of the public-sector hospitals I visited, I was surprised by the nature of information transfer and recording. I had imagined that the pharmacy or hospital would probably keep paper records of the patients who visited on file for use in future treatment, similar to how paper records were kept by my own pediatrician's office back home before they adopted a computerized system. However, it turns out that the majority of public hospitals don't keep any notes about their patients. Rarely, a particular ward will keep its own treatment notes, but these are not accessible if the patient is admitted to a new ward on a return visit. Instead, the common practice is that patients will carry around paper "health passports," which have a written list of medical conditions, hospital/clinic visits, allergies, and which medications they are taking. 

The health passport system solves the problem of information transfer between one facility to the next if the patient moves or is admitted to a different hospital. However, it also relies on them retaining these records, and remembering to bring them to the hospital (which is not always realistic in the case of emergencies). Unfortunately, patients will commonly lose their health passports, in which case all of their medical information is gone. They may also leave the hospital and forget the health passport, especially if the wait time is too long. At one site, I saw ~300 health passports in the "lost & found," which will likely never be reunited with their owner. The health passports which do survive multiple decades, due to being made of paper, are usually relatively deteriorated. They can become extremely difficult to read over time from all the fold lines, accumulation of dirt, and stains or rips that tend to accumulate. These scenarios can make it difficult for doctors and pharmacists to make educated treatment decisions, and is an area where many pharmacists expressed a desire for change.

While the health passport system is used for most medical conditions, there is actually a separate, computerized system to handle anti-retroviral therapies (ARTs) used to treat HIV, as well as for tuberculosis (TB) which is commonly observed in patients with HIV due to TB's ability to exploit weakened immune systems. This separate system was developed to address the high burden of HIV seen here, as up to 1 in 6 adults in Namibia is infected with HIV. To reduce the stigma these patients face, there is almost always a separate ART pharmacy at a separate location from the main hospital pharmacy so that patients' HIV statuses are not discussed in front of the general population who may be less understanding, and so they are not seen picking up their medicines by people they may know. There is a computerized system where treatment records are kept to assess whether or not patients have been adherent to their treatment regimen, which determines the quantity of medicine that the patient will be discharged with. For example, patients with over 95% adherence will generally receive three months of medicine, but (to reduce wastage in the context of drug shortages) patients with poor adherence will receive fewer. Patients at these facilities will receive education on the importance of regularly taking their medication, and often these hospitals and clinics will host educational seminars for the community where large groups of patients receive health information and get support from others who have experience living with the disease. Overall, there is an extremely positive perception of this system from the pharmacists here, and in the interviews I conducted, many of them mentioned wishing that this electronic record-keeping would extend to all other medical conditions as well.

Another surprise I encountered was that despite the paper system, many public facilities do have access to a computer. Some sites used it to answer clinical drug therapy questions by searching online, or to access Namibia's online dashboard of current medication availability. Other sites without internet access still used computers to keep track of the medication stock they had on-hand, or to print prescription labels from a template (to save themselves the time of hand-writing medication labels or instructions all day). 

The private sector's record-keeping was slightly different. They generally did not rely on health passports, but instead kept computerized patient visit records. Given these facilities' overall similarity to facilities in the US, I imagined that they may use the computers in a similar way. However, it turned out that while visit records are kept, most of these computer systems were designed to help with billing and stock management, rather than clinical decision support. Some private hospitals kept treatment records of visit summaries that could be used by doctors and pharmacists to make clinical decisions when patients return, but they did not have the ability to quickly check things like drug-drug interactions or treatment guidelines from within their system.

Going Above & Beyond

As part of this project, which is focused on building pharmacy's workforce capacity, one of the most important questions to ask during my site visits has been, "what do you think can be done to make pharmacy services improve in Namibia?" The most common thing I heard, both from the private and public sector, were the need for additional human and financial resources. The public sector sites said that the government is able to give them enough funding to continue to function, but not enough funding to improve their services (which they would like to have to invest in new technologies or to hire more personnel). The private sector said essentially the same thing, though the cause of their financial issues was related to remaining profitable despite having competitors in a country where only a small percentage of the population can afford their care. As a result, both types of sites said staffing was a huge issue holding them back. For the same reason, one of the largest sources of attainable improvement was personal innovation and process improvements which didn't require additional resources. These types of changes required that individual pharmacists go above and beyond their job description to make a difference. 

I was continually impressed by the improvements these pharmacists mentioned making. One example is Oshakati State Hospital, a major hospital where 2 pharmacists serve over 2,000 patients per day! The pharmacist I spoke to said that it was not only important to improve the efficiency of their operations, but fully necessary for their continued survival as an institution due to what an incredible workload they had to meet. To reduce the number of medication errors, they instituted an assembly  line where a medication packer fills medication sachets, a pharmacy technician checks this supply and labels it for the patient, and the pharmacist oversees the final product, ensures that the prescription makes sense, and counsels them. This workflow allows multiple pairs of eyes to pass over each prescription, and has greatly reduced the frequency of medication errors their hospital sees. They also reorganized their outpatient pharmacy so that instead of being stored alphabetically, drugs are first classified by disease state (for instance, all of the blood pressure medications are grouped together). This helps the pharmacist quickly determine what alternatives are available and in stock if the patient is contraindicated from receiving a drug, or in times where a medication is out of stock. It also reduces the likelihood of medication errors resulting from "look-a-like, sound-a-like" drugs being mistakenly swapped (for instance by accidentally giving the patient hydroxyzine, used for anxiety, instead of hydralazine, used for high blood pressure and heart failure, which can happen if they are right next to each other on the shelf). According to this site, patients in this country rely on their pharmacist loving pharmacy. If the pharmacist isn't willing to go beyond their job roles, the quality of care will deteriorate and they will suffer. Many sites echoed this sentiment, and agreed that you had to use what little autonomy you had to make improvements, otherwise the public would lose faith in the profession and stop coming.

Not only are the innovations I'm seeing at individual sites attainable improvements that I'll be excited to share with the other sites as part of this project's results dissemination, but they are also things I'll have to suggest in my own career. I'm glad I've been taking notes from the start, and amazed every time I look back through the data we've collected how many great insights and ideas the pharmacists here have come up with!

A Taste of the Culture: Namibian Time

I didn't want to conclude this post without a section on culture, so I figured I'd discuss what has been the biggest adjustment for me coming from the western world. At home, I'm used to schedules and planning being fairly exact. If I have a meeting at 2:00pm, I anticipate that it will start within a couple minutes of 2:00pm, and I would be stressed out if I wasn't there by 1:55pm. That's not been the case here, since the cultural view of time is much more approximate.

In anthropologic terms, there are cultures with "monochronic time," and cultures with "polychronic time." In monochronic time, 2:00pm has one meaning (hence "mono-"). In polychronic time, 2:00pm means 2:00pm, but it can also just as easily mean 2:15pm, 2:45pm, 3:30pm, or "sometime in the afternoon." In essence, it has several, looser meanings (hence "poly-"). People regularly arrive after the time that was set, but this is usually not viewed as "late," and would not be interpreted as rude or disrespectful by most people. 

As someone traveling around the country with two Namibians to interview other Namibians, I have not experienced any meeting occurring "on-time" so far. It has ranged from 30 minutes to 6 hours after the planned interview time, and in several cases we have needed to reschedule to a later day. While this has made it more difficult to keep to a tight travel schedule between regions, it has made the overall experience much less stressful since everyone's schedules are more flexible. The way businesses operate in Namibia (and in most of Africa, I'm told by my colleagues here), is that they 1) accept that things come up and so plans may change, and 2) that you shouldn't be too stressed out to interact with or help people. I was told by my Namibian travel companions that it's common that someone will be running an hour late for work, run into a friend, and still make 15 minutes to chat with them (unless they just recently got the job, and still need to be "mostly" on-time). To ignore a friend or colleague in order to get somewhere else would actually be the disrespectful thing to do, since there is such a large cultural value placed on the importance of good manners in interaction and maintaining relationships. 

The biggest impact polychronic time has had for this project is on the planning stage, and it has actually made things easier on me in the long-run. While in the US I would probably need to contact a head pharmacist (or their secretary) about a month in advance to get in a 30 minute meeting with them, here it's perfectly fine to call a day or two in advance and they'll fit you in (and in fact it's better to do so closer to your anticipated arrival, so that fewer things can come up between then and that time which may change their availability). This practice of flexibility and accommodation has been wonderful, especially during the times where we needed to reschedule. In particular, there was one time during an all-day drive where our GPS told us "turn left" when we were staring at a sand dune, and on selecting an alternate (existing) route, subsequently lead us down an informal road where our car got stuck in the stand and brush. Thankfully, both the person we were headed to meet that day and the person we'd planned to meet the next day on our way back were both able to reschedule, so we were still able to see one of them before end-of-business after we'd managed to escape the sand.

The other benefit of being on polychronic time is that nobody expects you at any particular time, so you aren't so worried about rushing from one place to the next that you can't pull over for a minute or two when you see something cool!

I was excited to cross the equator for the first time on the way to Namibia, and I figured I should get a picture at the next-largest invisible line I came across. I suppose now I need to visit the Antarctic circle for the sake of completion :)

Until Next Time!

In the next post I'll discuss my overall takeaways from this experience, talk about some of the experiences at individual sites and themes in these observations, and do a wrap-up on the cultural parts of Namibia I'll miss most once I return to the US! Until then:

The sunsets are great, but the sunrises are even prettier. This was taken in Erindi, a private game reserve/safari park which is a 3-hour drive Northwest of Windhoek. I absolutely love how the common types of trees in Namibia look against the sky!