Getting to the Last Mile: Pharmaceutical Services and Care Delivery
Access to quality pharmaceutical services is limited in Malawi. Although most Malawians can easily access clinical and diagnostic services, expanding access to qualified pharmacy personnel is a challenge. The public pharmaceutical sector in Malawi is failing as there is a huge shortage of qualified professionals at all levels of the health care system.
I believe healthcare services should be provided by qualified people in a safe environment with adequate supplies. Because of the shortage of qualified pharmacy personnel, Malawi has resorted to task shifting in the provision and management of pharmaceutical services, particularly at the primary level of the Malawian health system. Pharmacy personnel are known as “the last gate” to patient care since they are often the last members of the health team to interact with patients as they dispense medicines. Unfortunately “the last gate” is mostly inadequately trained Health Surveillance Assistants (HSAs) who are classified as non-technical support personnel in the Ministry of Health at most health centres.
While task shifting has worked in some cases, such as in the performing of rapid malaria tests and mass drug administration campaigns like deworming, in many instances the quality of pharmaceutical care that patients receive is compromised. Current trends in the Malawian health system mirror those in many countries in that most patients are seen at the primary or community level, fewer at the secondary or district level, and very few at the tertiary central level. This implies that a majority of Malawians do not have access to quality pharmaceutical services, since most health centres do not have trained pharmacy personnel who are able to ensure correct drug dispensing and dosing.
I believe desired patient outcomes can only be achieved if patients are able to access quality services at each stage of the patient treatment cycle. While much of the low life expectancy in Malawi is attributed to malaria, HIV/AIDS, respiratory infections, poor sanitation and unsafe drinking water, I feel that substandard health services are also a major contributing factor.
Here are photos that illustrate the difference between management of a dispensary area in a rural health center by a trained pharmacy personnel versus a task shifted personnel:
What is causing these health inequities?
I often ask myself “What is a human right?” and “What is access to health?” and these questions lead me to wonder if Malawians are accessing quality pharmaceutical services. According to the World Health Organization, access to health is defined as “the right to the highest attainable standard of health” which requires a set of social criteria that is conducive to the health of all people. This includes the availability of health services, safe working conditions, adequate housing and nutritious foods. Healthcare access has many dimensions including availability, affordability, and acceptability.
The Malawi government provides free healthcare to all Malawians at the point of delivery. According to a World Bank 2016 country overview report, 85% of Malawians live in rural areas, which means that a majority of Malawians access health care at the rural health centers. Rural masses depend on public health facilities and mission hospitals, and yet the majority of qualified health workers are assigned to secondary and tertiary levels of care.
Health equity can only be achieved if people have access to quality services that increase the quality of life, and for Malawi that means addressing the shortage of qualified personnel at all levels. Everyone deserves health care that is of quality standards. Denying the majority of Malawians access to this basic need is an infringement of their human rights.
I have had the opportunity to appreciate the role of qualified health personnel in attaining health equity throughout my time as a Global Health Corps fellow with VillageReach. As long as a majority of the population is receiving poor service due to a shortage of qualified personnel, health equity will be only a dream. Health equity can only be achieved if people have access to quality services that increase the quality of life, and for Malawi that means addressing the shortage of qualified personnel at all levels. Everyone deserves health care that is of quality standards. Denying the majority of Malawians access to this basic need is an infringement of their human rights.
The structure of a health system is one of the social determinants of health and as such it can either reduce or worsen health inequities. One disheartening example of a health inequity experienced by a majority of Malawians is the consistent shortage of drugs at health facilities. On a number of field trips that we conducted, when the essential medicines were out of stock at the health centre, patients were asked to go and buy them from grocery stores. Paracetamol, a commonly prescribed painkiller in Malawi, costs around K40 (less than 25 US cents) to purchase in a local grocery store. A majority of the patients would mumble or complain about how expensive it is to purchase these drugs with their own money. For some drugs that cannot be bought from grocery stores, people are forced to travel long distances to access the nearest drug stores to buy them.
Lower respiratory tract infections are one of the leading causes of mortality in Malawi and they are treated using antibiotics. When antibiotics are out of stock in rural health centres, people have to go to the cities to access them from private pharmacies as most districts in Malawi do not have private pharmacies. A complete dose of Amoxycillin, which is a common antibiotic prescribed for respiratory tract infections, costs around K1000 (approx. $1.50), which is not affordable for many Malawians. Even for those who are able to afford the medicine, transport costs are a huge deterring factor. Unfortunately, few people are willing to open private pharmacies in rural areas as there is a huge risk of losses since many medicines are expensive and require proper infrastructure for storage.
We are getting there
In my work with VillageReach, a U.S.-based non-profit organization, I have been able to be part of identifying challenges and innovating lasting solutions to critical problems affecting the “last mile” of health care. VillageReach identified the lack of pharmacy personnel who are crucial to the supply chain management of medicines, and then invested in the training of pharmacy personnel to allow them to work effectively in rural health centers in Malawi.
Since 2012, VillageReach has been working in collaboration with the Malawi College of Health Sciences (MCHS), the Ministry of Health (MOH), and other partners to implement the Pharmacy Assistant Training Program. The Pharmacy Assistant Training Program is a two-year training course where students complete both classroom-based learning and practicum placements each year. Students spend approximately 20 weeks per year on campus, and 20 weeks per year working at a practicum placement site. Throughout this fellowship I have had opportunities to travel to remote parts of Malawi to supervise students who are placed in the rural health centers during their practicums. These trips have made me ask myself the above questions each and every day as I had experienced what was really happening on the ground.
The Malawi Ministry of Health (MOH) has 650 health centres and only 8% of these have a trained pharmacy personnel. In the last three years, VillageReach has trained 135 Pharmacy Assistants (PA) to work in rural health centres. So far MOH has employed 37% of these PA graduates. The MOH has acknowledged that this is a priority area and through donor funding will continue to invest in the training of PA’s. The MOH has created a permanent post for the PA’s in the MOH, and pledged its commitment to employing graduates of the PA program.
The WHO recognizes medicines as priorities in the attainment and enjoyment of health as a fundamental human right. If medicines are a priority, we need qualified people handling and managing them at all levels of care. There are a lot of areas within the Malawi health sector that need attention, but training of pharmacy personnel to manage medicines should be a priority.
Lusubiro Mwamsamali is a young pharmacist who is passionate about Health Policies, Pharmacoeconomics, Human Resources for Health and Access to Quality Medicines for all.
