This in not an official U.S. Department of State (DOS) blog and the views and information presented are my own and do not represent the Fulbright Program or the DOS.
Today I spent the day with Vicky Nyombi, one of the Ugandan Pharmacists who came to the USA to work with me last fall. We started the day early as she picked me up just after 7am to head to the China-Uganda Friendship Hospital in the Naguru part of Kampala (“Naguru” Hospital). This hospital is quite new having opened in 2012 and was build with funds from the Chinese. It is much smaller than the Mulago National Referral Hospital, but nonetheless, it is a referral hospital meant to help decongest the large numbers of people that Mulago serves. Naguru Hospital has a large outpatient facility along with a surgical theater*, labor and delivery and wards for OB-GYN, Adults, Pediatrics, and Surgical patients. One of the things that Vicky has started since returning from the USA where she gained more skills in the provision of Pharmaceutical Care and pharmacy administration is a Medicine and Therapeutics Committee. This is a group of physicians, pharmacists, nurses and other important stakeholders in the provision of patient care and the team serves the hospital by making sure that drugs and policies related to drug use are appropriate and meet the needs of the patients. This morning I helped Vicky look at her drug formulary, the list of drugs the hospital routinely stocks, to see if there were any drugs that could be deleted so that funds could be reallocated to provide other medicines or products. I was able to help her see that a specific combination IV antibiotic actually costs substantially more than if the single drugs were given separately. In the USA we often try to use combination drugs when possible to increase patient adherence and decrease the number of oral tablets they have to take but this was an intravenous med which the nurses administer. Also, the two drugs separately could be combined and infused in one solution the same as with the combination product. So in this situation, the combination product is probably not worth the extra expense. And often, in a resource-poor environment like Uganda, even oral medications have to be given in separate formulations because the cost of combination products is just not affordable. In the USA we often use long-acting preparations as well, again to improve patient adherence, but if these are substantially more costly in Africa, they are not able to be utilized. I’m sure the same adherence issues occur here as everywhere else so sometimes the best healthcare outcomes aren’t achieved due to lack of products the patients can easily take. Back to the formulary, I’m sure that as she systematically reviews it over time she will find more instances that could really help improve her budget. One of the difficult things is that Vicky, although a pharmacist, is now actually in charge of the entire stores* for the hospital. This includes both the drugs and healthcare supplies like gloves, masks, etc. She has to make her yearly budget cover all of the healthcare and drug supplies. In addition, something as basic as stationery* must also be bought with her budget. This latter item is something that we in the USA take for granted. It would be very unusual for us to be told that we can’t complete a project because the budget for stationery has run out for the year and if we want to print something, we will need to purchase it ourselves. So, one of the things Vicky is also implementing since coming back from the USA is a form to document her clinical interventions. Whenever she talks to a physician or clinical officer to make a recommendation about drug therapy or whenever she counsels a patient, she will write it down on this form. In this way, we can begin to gather objective data about what she is able to accomplish on behalf of patients with her new skills and hopefully this will lead to more support for future training for other pharmacists in Uganda. But, if the stationery supplies run out and she has no more money in the budget to purchase them, or needs that money to procure drugs, she is limited to either ceasing to document or using her own funds to purchase the paper. Patrick Opio at Mulago Hospital is also struggling with this basic challenge.
One of the purposes of my visit to Naguru today was to meet with the Hospital Director to discuss the possibility of having pharmacy students from Makerere University complete some of their clinical experiential training at his hospital. The curriculum I’m developing will have a “practice lab” component where students learn skills in a classroom setting and then practice them through role play as they identify and solve drug therapy problems that are in the patient case vignettes they are given. A faculty facilitator helps students to identify problems they missed and works with them on skills techniques like patient counseling. The other critical component is “experiential” where the students go to a healthcare facility and are supervised by pharmacy interns and pharmacists, which is called being “precepted” while they interact with real patients and healthcare providers to put their new skills to work helping patients. Mulago Hospital is the traditional site for gaining clinical experience for Makerere students as it is very large and a walkable distance from campus and it will remain the primary site, but it would be nice for students to have the opportunity to see another hospital setting and work with a pharmacist, Vicky, who has had experience in the USA using these skills herself. (At Mulago they will also be able to work with the other pharmacist who came to the USA, Patrick Opio.) Anyway, the Director was wholeheartedly enthusiastic about this opportunity and will welcome the students. The primary barrier will be transportation to Naguru Hospital, which he can’t provide and I am not sure the University will be able to provide this either. Once again, there is a non-medical barrier to implementation of a program that could help improve patient care. In the USA, most pharmacy students have their own cars and in some cities there is low cost public transportation. This is not true of Uganda. At this point, I’m not sure the transportation barrier will be able to be overcome but at least the Naguru Hospital site is a possibility and if we can’t implement this soon, perhaps in the future.
*Definitions: If you are from the USA and reading this blog there may be some terms that sound “funny”. The term surgical theater is a British term for the operating room. Back when surgical procedures were started, they were held in an ampitheater where all of the medical students and doctors would sit on raised seating around the table in the center so they could watch and learn. Today there is not normally “visitors viewing” for most surgical areas in the USA or elsewhere. The term medicine or medical stores is also probably unfamiliar to Americans. We would call our storage facility for drugs or medical supplies the “stock area” or a “storage facility” or “medical supplies closet” or simply “Central Supply” for the term for the area of the hospital that stores no medicines but stocks all the supplies like patient gowns, equipment, etc. The government of Uganda’s central drug storage facility from where they dispense to healthcare sites all over the country is called the National Medical Stores (NMS) and the central supply from which private facilities order their drugs and supplies is called the Joint Medical Stores (JMS). A similar facility in the USA would be called a “healthcare supplies wholesaler”, and an example is Cardinal Health. Now another term that is not unfamiliar to Americans but its use above is unfamiliar- stationery. In the USA this term is used in a very specific way to denote the paper you use to write letters or thank you notes. Stationery in the USA is often fancy and has designs on it. Paper that is used in printers is simply called paper. In Uganda this term refers in general to the paper supplies that are needed for printing, taking notes, etc. In the USA, the term we use for this is a larger catchall phrase- “Office supplies”- or simply paper products or paper goods.