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.