South Africa’s Healthcare system, like many developing nations is in a transitional phase. There is a huge burden of both communicable and non-communicable conditions leading to ill-health, disabilities and premature deaths. Clearly, most of these are preventable through health promotion interventions (NDOH, 2010). In response, the National Health Insurance mandate and the growing emphasis on primary healthcare (PHC) re-engineering, has strengthened the emphasis of many healthcare professionals towards equitable and quality healthcare service delivery, among them pharmaceutical services. This mandate leaves a window of opportunity to be explored for the integration of pharmaceutical care at rural public primary healthcare clinics. The following areas were identified as seeking the public pharmacist intervention within the PHC context, these include:
The Central Chronic Medicine Dispensing and Distribution (CCMDD) program afforded by a National pharmacy service provider, which is decanting the majority of stable chronic patients to be remotely dispensed by the service provider pharmacist, questioning and imposing stricter management and quality of chronic patients care offered
Medicine Supply Management (MSM) responsibility at the clinics, which has been extended to the Pharmacist Assistant and strengthened in monitoring and evaluation by the ideal clinic concept to ensure availability of medication.
The World Health Organisation, (2014) call for professional collaboration in managing non-communicable diseases also presents opportunities and imperatives for such exploration
The lack of Antibiotic stewardship resulting in alarming resistance patterns
The concomitant use of conventional medication with herbal medication
Lack of pain management in chronic terminally-ill patients
Increasing numbers of non adherence of ARV patients, who are virally unsuppressed, whom require a switch to secondary treatment
Concern over the paediatric ARV patients managed at PHC level with lack of dose alterations with weight band changes
Increasing number of adverse drug reactions with ARV treatment management reported for PHC managed patients
Undetected Cryptococcal meningitis despite the availability of the algorithm
ABC analysis report for PHC clinics, showing high cost drivers, thereby impacting on scarce pharmaceutical budget and most importantly questioning EDL adherence and rational prescribing
The need for healthcare reform strategies alluded to, implicitly positions the focus of the proposed intervention of the pharmacist within the PHC context. Hence, the rationale of the intervention encapsulates filling a void in firstly the pharmaceutical care at the clinics and secondly the new expanded roles and responsibilities of the public pharmacist by way of a compelling philosophical paradigm of ‘Ubuntu’ and ‘Care’ to improve on patient care outcomes. The proposed QIP intervention
The PCDT pharmacist, having advanced clinical knowledge and having practically trained within the public PHC context, finds themselves fortified to work in collaboration with the authorized nurse prescribers and the occasional visiting doctors within the PHC clinics. Before commencement of a Quality improvement strategy the challenge model and fish bone- root cause analysis was conducted as indicated below. An outline of the intervention is provided. The ABC analysis forms the basis for such a needed intervention. The majority of the high cost driver pharmaceuticals and those of increased usage impact negatively on the scarce Primary Health Care Clinic and Hospital budgets. Rational usages of pharmaceuticals will in event contain this budget and hence, ensure EDL adherence and most importantly afford quality and optimal patient care. However, for this to ensue, monitoring and evaluation is paramount to its delivery.
The detailed methodology adopted is provided below as follows:-
Activities Person/s responsible Date of start & completion of each activity Resources
Request quarterly ABC reports from PPSD through the DPM
Analyse the ABC reports quarterly per PHC clinic
Identify the high cost drivers to centre training around
Schedule training with OM’s of clinics
Schedule transport support visits to PHC clinics
Share feedback from the multiple choice & feedback questionnaires Mrs N Pillay
April 2018- ongoing ABC analysis report
Multiple Choice question
Availability of authorized
Transport for support PHC visits
GJ Crookes Hospital is proud to announce and has the privilege of three qualified PCDT pharmacists. From a sub- district PHC support model perspective I’ve, engaged and proposed a quality improvement strategy, whereby guidance on the analysis of the ABC report per clinic was shared with the PCDT pharmacists. This report was furnished by you, the District Pharmacy Manager and obtained from PPSD. We then micro- analysed the A items presented. A Medicine usage Review (MUR) was then conducted, which was thereafter aligned to the Adult Primary Care manual to foster an understanding of the EDL and STG adherence and compliance per clinic per pharmaceutical item. During this exercise, antibiotics were also highlighted. The stakeholders listed below will play a vital role in achieving the desired outcomes.
The focus adopted was to involve the nurse prescribers in this intervention of training to arouse ownership and commitment to the learning process.
Training sessions were then scheduled with the authorized nurse prescribers, mainly professional nurses (PN) per clinic. The individual clinic analysis was shared and the rational use of the identified pharmaceuticals then highlighted with reference to the APC manual.
This proposed intervention has been piloted at Umzinto clinic, one of the busiest, challenging and demanding of all the PHC clinics. The results are shared below.
Each item on the report was investigated per Clinic and the first questionnaire was designed based on this information. The questions were based on the medication being over-prescribed and the applicable condition or diagnosis. Ten questions were formulated in a Multiple Choice Question format (see attached sample).
The first pilot training was held at Umzinto Clinic on the 20 April 2018. There were eight PN’s in attendance. The average mark obtained in the questionnaire was 39%. Thereafter training was held at Scottburgh Clinic on the 16 May 2018. There were three PN’s in attendance. The average mark obtained in the questionnaire was 57%. It was therefore apparent that this training intervention is required.
A feedback questionnaire (see attached sample) was designed for the PN’s to rate the PCDT training on a scale of 1 (being excellent) to 4 (being poor) and also to note any comments and recommendations that the PN’s would have from their side towards the training.
All the feedback questionnaires were returned with excellent scores in all three categories;
Did you find the content of the presentation applicable to your daily work?
Did you feel you benefited from the presentation?
Would you like to attend further PCDT training?
The 3 comments/suggestions were as follows:
“Training is good for us because it keeps us updated”
“Very interesting and important workshop”
“We need to have this kind of presentation once in two months”
Subsequent trainings will involve antibiotics and other pharmaceuticals that they, the sisters deem challenging in their prescribing.
Hence the training was viewed by the PN’s as beneficial to them and they were optimistic to further trainings. They welcomed the mentorship offered by the PCDT pharmacists.
The questionnaire, along with direct feedback from the PN’s, provided a guideline on which conditions the trainings should be prioritized. For example, if all three questions on Asthma received an average score of less than 30%, then Asthma should be given priority (high usage of Budesonide and Salbutamol inhaler on ABC analysis), whereas the average score for Diabetes was 65%.
During the upcoming trainings, a presentation on the relevant condition will be given, followed by a questionnaire to assess the impact of the training, as well as a feedback questionnaire to further guide the training.
The challenges encountered was that it is difficult to train all the PN’s in a clinic due to shift duties, unavailability of the PN’s (either on sick leave, annual leave or scheduled training), staff shortages and the clinics being too busy. Time constraints, inadequate facilities for training and lack of equipment (projectors, laptops) are definitely difficulties.
It is clear that the PN’s are welcoming this training and feel as if they are being supported by the pharmacy personnel. Strong professional relationships are being built. With continued training, it is envisaged that there will be more rational prescribing and thus the overuse of medication should decrease. The ABC analysis is usually done annually but will be requested quarterly to monitor any changes.
The PCDT pharmacist can add value to the clinical governance of the PHC re-engineering strategy. With this PHC clinical support intervention, came respect, acknowledgment and appreciation for the pharmacist knowledge and expertise by healthcare professionals, among them the ones closely working in collaboration, the authorized nurse prescribers and the medical visiting doctors. This has also empowered other pharmacists in the GJC team to adopt the clinical realm to instituting pharmaceutical care, both in wards and in the OPD pharmacy. Similarly, ward pharmacy has strengthened, with clinical ward rounds, prescription audits with intervention and antibiotic stewardship. Being a training institution with an A grading from the SAPC, GJC has raised the bar affording a comprehensive training to the Pharmacist interns and many learners annually. Therefore, there is room for expanding the pharmacist’s role towards a more clinical path. Ongoing sustainability of this intervention is paramount with regular monitoring and evaluation of the progress and impact made. This will be documented and shared.
In conclusion, this case study can be similarly rolled out to other sub-districts and can pave the way for the new cadre of professional- the Primary Care Drug Therapy (PCDT) pharmacist or a Pharmacist who is confident, who is mentored, guided and empowered by policy and structured processes and procedures to deliver clinical governance within the rural public Primary health care clinics.
The results and recommendations thereof can inform relevant stakeholders in South Africa such as policy makers of both National Department of Health and higher Education, towards NHI and future pharmacist training and development with regards to inter-professional collaboration and pharmaceutical care in patient-centred care and outcomes.