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.

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!

Hospital Pharmacy Practice in Namibia

Hello, and Welcome to my Blog! 

My name is Mason Benjamin, and I am a doctor of pharmacy student at the University of Michigan College of Pharmacy. I began the program imagining my career as an in-patient clinical pharmacist in a hospital, but practical exposure early in my first year led me to discover a new passion for improving medication access systems. Realizing that this path would necessitate my branching out into areas that were still largely unfamiliar to me, I began taking classes at the Stephen M. Ross School of Business to complement my pharmacy education with a private sector framework. Courses in healthcare innovation, finance, commercialization of biomedicine, and entrepreneurship exposed me to case studies from around the world and I loved every minute of it. I realized then that an international career would bring me the ability to improve far more patients' lives, as well as greater personal fulfillment. I feel incredibly fortunate to have found an opportunity to begin this career transformation at the William Davidson Institute, where I am currently a 2018 Global Impact Fellow! In this blog, I will be discussing my 2018 summer internship in Namibia. In each post I will aim to describe what I'm doing in my project, share some of my favorite parts of Namibian culture, and talk about some of the more memorable experiences.

The Project, the Team, & the Location

My project is focused on pharmacy workforce development and hospital pharmacy practice. In this multi-organizational project, I will be collaborating with the William Davidson Institute (WDI), The International Pharmaceutical Federation-Hospital Pharmacy Section (FIP-HPS), and the University of Namibia (UNAM). Over the course of my project, I have been traveling all across Namibia to visit hospital pharmacies in different regions. Accompanying me on these site visits are two intern pharmacists, Moses and Olivia ('Liv), who recently graduated from UNAM's pharmacy program. I have been inspired by their drive and passion about their profession. I'm lucky to be traveling with them, talking about the future of pharmacy, and learning from them about Namibia. I'm beyond thankful for their help navigating the roads, introducing me to the culture, and for translating as needed during site visits. They're two of the best friends and colleagues I could have asked to meet!

Here I am with my project team in Namibia at the 4th Annual MURIA Conference, hosted by UNAM's School of Pharmacy. From left to right: Moses Thikukutu, Olivia Fikameni, Mason Benjamin, and Dan Kibuule. Moses and Oliva are the UNAM interns accompanying me on site visits around the country, and Dan is my project mentor here in Namibia. 

During my second week in Windhoek, I had the chance to attend the 4th annual Medication Utilization Review In Africa (MURIA) Conference with Moses, 'Liv, and one of my project mentors, Dan, pictured above. I'm thankful my time in Namibia lined up so well with this conference, because I had the chance to learn an incredible amount about pharmacy practice in Namibia (and indeed across Africa) before my site visits had even begun. I was aware of how different the healthcare system in the United States might be from anywhere else in the world, but always felt that researching other systems online had its limits. I much prefer to learn right from the source and in person, so I was grateful for the opportunity to ask questions to practicing pharmacists from over a dozen different African countries about how things worked in their setting. This, combined with three and a half days of presentations, workshops, and practice-sharing forums, was a fantastic way to develop understanding of some of my project's topics of interest. I also had the chance to present a poster on technologies used to improve medication use at this conference, which I felt was quite the honor! I will certainly look for opportunities to attend more conferences like this one in the future that present a platform to learn from other professionals and share stories, best practices, and discuss recent research.

UNAM's Health Sciences Campus, where I go to work when I am not

traveling, and where MURIA was hosted. I'm always in awe of how 

beautiful the architecture here is, and wish we had facilities as nice 

as these back home.

Here I am in front of my poster at MURIA, titled 

"Methods for Improving the Medication Use 

Process," for which I also gave a short podium

presentation. I felt honored to receive a time slot

at an international conference!

The Importance of Customs, as a Visitor

Olivia, Moses, and I at our first northern site visit in Rundu with

the chief pharmacist outside the hospital.

Reflecting on the preparatory work I did before traveling to Namibia, I'm the most thankful for the time I spent learning about Namibian history and present-day culture. This was probably more necessary even than my understanding of pharmacy practice or business was. There were customs I needed to understand to be well-received at these sites to avoid offending the people there, including the etiquette surrounding introductions, the proper way to shake hands, and especially the Namibian perception of schedules and time. For instance, the people I have met here have very relaxed, warm, and friendly attitudes, so long as you don't try and rush things. Pleasantries and affiliations are extremely important, and not to be taken for granted. Developing this understanding was especially important given my role as someone who was representing multiple affiliations including WDI, FIP-HPS, and UNAM for this project, as well as the University of Michigan in a broader sense. It was also very helpful on these site visits to be accompanied by Namibians, especially two who were affiliated with UNAM. Thankfully, we received a warm welcome everywhere we went.

Traveling Around Namibia

My first view of Namibia, upon waking from some much-needed

sleep in-flight. I always love the first glimpse of a new place, 

and this time it was especially exciting since I knew I'd be going

around to each of the places I was seeing from the plane.

Because traveling all around the country was a large part of my project, I thought in this first post that I should share a bit about the different areas in Namibia and my journey here so far. 

At the start of this trip, I had never before been so excited to board a plane. After a red-eye bus ride, 3 connecting flights, and 48 hours of continuous travel, I had also never been so excited to land! It wasn't as tiresome as it sounds though. I had the chance to get a Chicago Dog in the O'Hare airport after my flight to Chicago from Detroit, and also several hours to walk around Amsterdam during my layover there. That was a nice chance to stretch my legs and wake up a bit. I also got to visit the tulip museum, cheese museum, and walked around the network of canals. While the journey was long, I was glad that I arrived safely and that everything went according to plan with my connections.

Mountains south of Windhoek on the way to Mariental. I'm

originally from the foothills of the Rocky Mountains in Colorado,

and used to seeing a carpet of evergreen trees on those hills. It

was fascinating seeing a familiar sight with a new twist! 

Thankfully, my travels in Namibia wouldn't end when I arrived in Windhoek, due to the nature of my project. Namibia is home to several fascinating geographical regions, which I have been fortunate enough to see over the course of this summer. While it is named after the Namib desert and receives the least annual rainfall of any Sub-Saharan African country, Namibia is also home to beaches, jungle, and some of the most sought-out Safari parks in the world filled with unique grasslands, savannah, and an incredible diversity of flora and fauna. Namibia actually has a small population of 2.5 million for such a big country, and many areas are not inhabited. This resulted in some very long drives, and we were advised to fill our tank every time we saw a petrol station. They also don't stop filling when the pump shuts off. Instead, they'll shake your car a bit to settle the petrol, and over-fill it all the way to the brim since they know you may need more than a full tank to make it to the next town.

   

The coast in Swakopmund, where the desert meets the ocean, and the sand dunes

between Swakopmund and Walvis Bay. It was incredible on the drive between the

two being able to look one direction out the car out to the ocean, and then turn my
head the other way to see a vast desert and towering dunes.

One of Namibia's special claims to fame is being "the land where the desert meets the ocean." The vast landscape of desert sand sinks into the Atlantic Ocean along the west coast of Namibia, and this is quite the sight to behold! I would love to return some day when I had the time to enjoy the area and explore a bit, but our travel schedule only had us there one evening.

The long hours in the car gave me a good opportunity to study the variations in this landscape in detail, and spending time in over 20 cities for my site visits gave me an up-close look at some very diverse sections of Namibia. 

Basically all of Namibia is covered in palm

trees, as they grow well in hot, low-

moisture conditions. Many areas looked 

almost tropical because of all these trees!

This shot was taken leaving Oshakati.

In Rundu, looking out over the river

that forms Namibia's natural border

with Angola to the north. We had to

pull over for some stubborn goats, so I

had the chance to take a couple photos.

While I have traveled internationally a few times before, each time I would visit only one or two major cities. This project has given me a unique chance to truly get to know an entire country, and I can confidently say that I've never seen anything quite like Namibia. You also never knew when you were going to see animals crossing the road. That was exciting in two ways; first, you had to make sure you avoided a crash (especially in the north where there are commonly cattle, donkeys, and goats hanging out on the pavement), but second, you might see something really cool. We were extremely lucky to see this elephant!

One of my favorite moments of the summer was seeing this "little" guy cross the road. On the side of the highway, I had quite a list of animal sightings, including: ostriches, baboons, oryx, termite mounds taller than houses, springbach, flamingos, sheep, cattle, goats, warthogs, giraffes, wild horses, hippos, and crocodiles. 

Tagua Nuts: A Piece of the Culture

Carved tagua nuts purchased from a

craft market in Windhoek, early after

my arrival to Namibia. Namibians will

usually carve "The Big Five" into these

nuts, including lions, leopards, rhinos,

elephants, and buffalo. It was also not

uncommon to see zebra and oryx.

As an artist, one of my favorite things about Namibia is the tradition of carving animals into tagua nuts, sometimes called "ivory nuts" based on how closely the nut's color and texture resemble ivory. These nuts come from palm trees in the northern part of the country, and you will find craftsmen selling them all over the place. Commonly they leave a blank rectangle, which they use to personalize the piece by carving a name or desired message. After buying a handful for family and friends back home, I became fascinated by how beautiful they were, and decided that during my stay I would learn how to carve them. 

This is a tagua nut, which had an outer, furry husk that had been removed. 

Carving away the bark-like covering that remains reveals a slick, alabaster-

colored nut. It was a bit tricky to get the hang of it, but after twenty minutes

or so it becomes second nature. These things are sturdy, and nearly as hard

as stone. Apparently elephants will eat them, but human teeth would break!

My offer to purchase fresh, un-carved nuts from a local artist named Alfons started quite the conversation. He was curious why I wanted to buy the unfinished ones, and it turned out that in 30 years he had never had any visitor express interest in learning how to carve the nuts themselves! We chatted for 45 minutes about carving techniques, the preparation steps beforehand, the source of the nuts, how he began his career, and also what materials I would need. Because I hadn't seen any animals yet, I decided to carve the landscape I snapped a picture of on the way from the airport. 

I thought that since these nuts come

from palm trees, and since I had seen

so many of them, it was only right that
I include one of the makalani palms.

As instructed by Alfons, I included an

elephant I had seen in this carving. It

was both in-line with tradition, and
authentic to a memory that I'd made.

When I returned the next week to buy more, he was happy that I'd given it a go, and generous enough to give me five more nuts, along with the leather, beads, and wire to finish them for free in exchange for the promise that I return to show him what I carve. He had no doubt I would see animals during my travels, and so tasked me with inscribing the ones I saw. Nut carving ended up being one of my favorite hobbies during the weekends, and has resulted in some souvenirs that will last a lifetime! I decided I would try to commemorate this internship by carving the outline of Namibia, the names of the organizations I worked with, a makalani palm tree (where the nuts come from), and of course the elephant I saw crossing the road.

It was tricky to get in one shot, but I also carved the silhouette of Namibia, the year, and the initials for WDI, UNAM, and FIP into this nut to commemorate the purpose of my visit for this internship.

Until Next Time!

Thanks for reading this far! Hopefully now you've gained an understanding of the nature of the work I'm doing this summer, and can picture what I'm referring to when I talk about the country. In the next post, I'll share an update on the activities I'm involved in and highlight additional parts of Namibian culture!

Namibia has remarkably beautiful sunsets, and I thought it was only appropriate to end this first post with a shot of one :)