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!