4 August 2022

I spent the day in the office at the Makerere University School of Pharmacy writing the case scenarios and scripts for filming the pharmaceutical care training videos. It was wonderful to have Winnie by my side to answer all of my questions. I want to make sure these are realistic scenes the pharmacy students will encounter in their pharmacies in Uganda. I needed to think about the way a Ugandan patient would respond to questioning versus how an American patient would answer. Even the way we describe symptoms could be different. For example, would a Ugandan patient know the word mucous? I think most patients would know the term mucous, if I were to ask an American patient if mucous came up when they coughed. So is this the same in Uganda? Winnie thought the English speakers would understand but she described the Lugandan word or phrase for this as “bringing up secretions”. Another interesting cultural difference is that the pharmacist will dispense over the counter products like acetaminophen (Tylenol) in pre-packaged strips and they will give the patient only as much as they can afford. What I mean is that there may be a package of 10 strips of 10 tablets each in the original package but the pharmacist will take out 1 strip and put it into a paper packet so it is sold without the original packaging, however the blister pack does have the drug name and dose, usually. The only thing they typically write on the outside of the paper packet is the drug name and how many times the patient should take it a day. By the way, they use the British name for acetaminophen which is paracetamol or brand name Panadol. They do not use the amber (brown) vials we Americans do when we dispense prescription medications. We take the proper amount from a stock bottle of loose pills and package them into an amber vial and then print a complete label and affix it to the vial. The label has the drug name, using the generic name, if it isn’t a branded product, the dose, the full directions spelled out so a patient can understand (take 1 tablet by mouth twice each day), the number dispensed, the drug expiration date, and the number of refills authorized by the prescriber. It also contains the patient name, prescriber name, and the name and address of the pharmacy. If it is an antibiotic, the prescription will state the number of days the patient should take the medicine and this is typed on the label. Very rarely will an American patient refuse to purchase the whole amount prescribed. This is in part because health insurance usually covers a lot of the cost. However, in Uganda, patients frequently will tell the pharmacist how many they can afford and only take that amount of the drug product. Even if the medication is for the chronic treatment of high blood pressure and the patient should be taking it every single day for the rest of their lives, patients will commonly only be able to pay for three or five tablets at a time. They say they will come back and get more but frequently that is not the case and many days may lapse before the patient comes and gets more of the medication. Once we go to the pharmacy to film, I will take photos of the medication packaging and post them for you.

Another interesting fact is that in Uganda, a pharmacy can be open and medications can be sold even if the pharmacist isn’t there. Every pharmacy must have a supervising pharmacist but sometimes, the pharmacist only goes to the pharmacy once or twice a month to place drug orders and check on things. Also, even though there is a class of drugs that are supposed to only be sold if prescribed by a physician, there is no regulatory body with the human resources to hold pharmacies accountable for this practice so most of the time when these drugs are dispensed, it is NOT on a prescription. Rather either the pharmacy staff recommends the patient take this medicine because of the symptoms they complained of or the patient just comes in and asks for it and the pharmacy staff sells it to them. I’m speaking of medication such as blood pressure medications, diabetes medications, medications for sleep medications and especially antibiotics and anti-malarials. I’ve been told that one of the most common drugs patients will ask for are medications for erectile dysfunction and those are also dispensed without a prescription.

My faculty colleagues at Makerere University and I are trying to improve patient care by training the pharmacy students to have the communication and decision-making skills to effectively interact with the patients so that medications are only dispensed when appropriate. We also want them to recognize when a patient should be referred to a higher level of care, such as to a clinic or hospital, and avoid selling drugs just to make a profit as this can adversely impact patients and result in harm. These videos will show the students both good and bad examples of how to gather information from the patient, make a correct assessment of the situation, and recommend appropriate therapy or referral. They will be accompanied by classroom activities that help the students learn and practice the correct skills.