Final internship
Masters Pharmacy
Health Access Network, Accra, Ghana
ADHPL Pharmacy, Kumasi, Ghana
St. Patrick’s Hospital, Maase Offinso, Ghana
Seventh Day Adventist Hospital, Sunyani, Ghana
Name of student: Freek van Gorp
Student number: 0440701
Period:
07-06-2010 – 23-07-2010 (includes 1 week of holidays)
Supervisors:
Charles Allotey (Health Access Network, Accra, Ghana)
Paul Lamberts (Bathmen, the Netherlands)
Table of contents
Introduction
3
Week 1 and week 5-6: Health Access Network, Accra
4
Week 2: St. Patrick’s hospital, Maase Offinso
7
Week 3: Seventh Day Adventist (SDA) Hospital – Sunyani
12
Week 3-4: Archdiocesan Health Pharmacy Ltd (ADHPL), Kumasi
16
Evaluation
23
Analysis of strengths and weaknesses
24
Appendices
26
Appendix 1: letter of motivation (in Dutch)
Appendix 2: Terms of Reference (ToC)
Appendix 3: example of trainers’ manual
Appendix 4: evaluation form
2
Introduction
Ghana! After reading an article in the UPPER magazine from a student who went to Ghana for
his final internship, I was sure: I had to go there too! Soon I came into contact with Paul
Lamberts, a pharmacist living in Bathmen who has a lot of connections in Ghana. After our first
meeting, I was even more sure of my choice. I was highly motivated to go to Ghana. See
appendix 1 for my letter of motivation.
However, I couldn’t go to Accra without a proper preparation. So before leaving for Ghana, I
was invited by Mr. Lamberts to come to Bathmen for a thorough preparation session. During
these days Mr. Lamberts and his wife told me all about the healthcare system in Ghana and the
major issues related to them. I got to read through a big pile of books and articles about
mission hospitals, the National Health Insurance Scheme (NHIS), the Health Access Network
(HAN), and some more national and international projects aimed at improving the Ghanaian
healthcare system.
Furthermore, Mr. Lamberts discussed my program in Ghana with me. I was going to work in
Ghana for a total of six weeks. I would spend the first week in Accra to get familiar with the
Health Access Network, drug supply to mission hospitals and the country in general.
Afterwards, I would head for Kumasi to work at a production site for a period of two weeks.
From there, I would also go to mission hospitals in Offinso and Sunyani for a total of seven days.
Finally, back in Accra, I would work for HAN for another two weeks.
To make sure I would reach my targets and learn as much from my stay in Ghana as possible,
Mr. Lamberts wrote me some Terms of Reference as a guideline. These can be found in
appendix 2.
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Week 1 and week 5-6: Health Access Network, Accra
The Health Access Network (HAN) is a non-governmental organisation (NGO), consisting of a
group of health professionals that strives to make essential medicine available to all people in
Ghana. It has been established in 2005. It tries to bring relevant health care workers and health
care related workers together to form a network that has the following aims:
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Provide procurement and distribution services for affordable essential medicines of
good quality;
Conduct research and advocate for more public awareness of important health issues in
general, with focus on affordable essential medicines;
Train health workers to provide the best possible health care service.
HAN tries to achieve these goals by working according to their core values: HAN is a network,
committed to professionalism and access to essential medicines, and HAN strives to be
transparent, accountable and reliable.
HAN is financially supported by the Debman foundation from the Netherlands. This foundation
offers donations and loans (free of interest) to projects that aim to improve health care in
Ghana. The projects have to be concrete, and they should strive to be self-supportable. For
HAN, this means that the focus is now on providing essential medicines throughout the country
with the best possible cost-effectiveness.
Procurement and distribution services
At the moment, twenty hospitals throughout the country are accessing the essential drugs
programme. HAN can supply these hospitals with a total of 17 imported drugs, consisting of
medicines for malaria, antibiotics, antihypertensives and others. However, because of the big
demand for essential drugs HAN wishes to increase its number of imported drugs to 50 by the
end of 2010.
In order to achieve this goal, the number of staff has recently been increased. One of their most
important tasks right now is to find out what other drugs could potentially be added to the
assortment. Therefore, data have been collected from the mission hospitals that are supplied
by HAN. These data include the prices that hospitals currently pay for their medicines, the price
they sell them for and information from questionnaires considering the availability and
affordability of drugs.
Contact with the key players of the mission hospitals (administrator, accountant and
pharmacist) is crucial for HAN. Therefore, agents will be sent to the hospitals to investigate
their needs and form a contact person for HAN.
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A major problem for HAN is the delayed payments from the hospitals for the drugs they
receive. Sometimes this delay is caused by ignorance, but in most cases hospitals simply do not
possess any money to pay HAN with. This is in its turn caused by the delayed reimbursement to
the hospitals by the National Health Insurance Scheme (NHIS). This scheme has been around for
a few years now, but it takes 3 to 6 months for the NHIS to pay the hospitals for the drugs they
provide to the patients. As a consequence, the cash flow for the hospital stops, and the hospital
is unable to pay HAN.
Right now, HAN is considering how to react on delayed payments from the hospitals. Until now,
there has not been a lot of pressure on the hospitals because HAN is aware of their difficult
situation. However, due to inflation (which is about 10% per year in Ghana) money devaluates
rather quickly, so the delayed payments actually harm the financial status of HAN. Because HAN
strives to be financially independent, they have to come up with a way to get the payments
coming in quicker. In my view, it is crucial that HAN makes it attractive for the hospitals to pay
quickly. Discounts could be a good way of encouraging hospital decision makers to pay their
bills as soon as possible.
Research and advocacy for public awareness
The public in Ghana is generally not as aware about current health issues as the public in the
Netherlands. There is little knowledge about hygiene, diseases and medication. HAN tries to fill
up this gap. One of their activities is conducting research in the availability and prices of
essential medication. Hereafter, the results are published (in newspapers, radio and tv spots) so
that awareness about them increases among the public and policy makers. At the moment,
HAN is working on a report about the influence of manufacturing, distributing, wholesale and
other costs on the total costs of medication. This report aims to make the government more
aware that retail prices are much higher than the manufacturing prices and what factors
contribute most to this effect.
The Medicine Transparency Alliance (MeTA) is a global initiative that aims to improve the
availability and affordability of quality essential medicines. MeTA tries to achieve this goal by
creating more transparency and accountability in the medicines supply chain. HAN is the
coordinating organization for the Ghana MeTA group. Through the influence of HAN, MeTA has
achieved the following in Ghana:
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Creating a network amongst civil society organizations across all regions in Ghana
Creating more awareness amongst network members about access to medicines and
transparency issues
Development of 4 educational posters on relevant medicines issues in Ghana
(responsibility as a patient, correct use of the NHIS, awareness of counterfeit medicine,
taking the full course of medicine) in English and local languages
5
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Organizing public fora about medicine awareness
Training and development program
HAN has a supportive role in the training programs for health professionals to improve the
quality of service they provide. These programs are organized in collaboration with the World
Health Organization (WHO) and mission health services. HAN has worked with these
organizations to develop the educational material and start up the programmes. The main role
of HAN in this process has been to network with the diverse members to come up with a
training programme of good quality together. However, HAN does not supply any trainers to
give these lessons, but rather provides them with the material to do so.
Training sessions have been organized for pharmacists, doctors, nurses and administrators and
dealt with subjects as drug management for pharmacy staff, drug and therapeutics committee
training and supervision and monitoring. So far, the facilitation of training sessions has been
free of cost. In the future, these activities should generate more income for HAN.
At the moment, a course for medicine counter assistants (MCAs) is running. I have assisted in
designing a better layout for the training modules for the trainees of this course. Furthermore, I
have worked on the development of teachers manuals. These consist of the same text as the
trainees modules but also contain (in a different font) remarks, discussion topics and questions
for the students. An example of this is attached in appendix 3. On the last day of my internship,
I was allowed to go teaching. That day, the course was about HIV, so I prepared by looking into
HIV and AIDS, recent figures on HIV in Ghana and problems that surround (awareness of) HIV in
Ghana. I found out that even amongst the trainees there are a lot of misunderstandings about
HIV. For example, most trainees thought that one can get HIV from hugging or kissing a person
with HIV, which is not the case. I really enjoyed teaching this group of people and I think I did a
fine job.
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Week 2: St. Patrick’s hospital, Maase Offinso
During the second week of my internship in Ghana, I had the chance to see the daily practice of
the pharmacy of a mission hospital, located in a small town near Kumasi. Following my terms of
reference (appendix 2), I worked with the staff of the pharmacy in their daily activities.
Furthermore, I went a bit deeper into a few things, mentioned below.
The first thing that striked me when I entered the pharmacy was the big crowd that was waiting
until their prescription was ready. In the Netherlands, people start complaining when they have
to wait for 10 minutes, but there must be times when people wait way longer here. However,
the staff of the pharmacy worked pretty hard, so that was definitely not the cause of the long
waiting times. The pharmacy serves both patients in the hospital itself and patients who went
to see a doctor in the hospital but do not have to stay. The last group is by far the biggest.
Prescriptions for inpatients and patients in the emergency department always have priority
when they are handed in.
Hospital Output
St. Patrick’s Hospital is a non-profit mission health institution established in 1951. In 2009, the
hospital had a total of 254 employees. Among them are nurses, medical officers, administrative
and support staff and paramedical staff. The hospital can provide laboratory research, ultra
sonography, dental care, ophthalmology, surgery including urology, pharmaceutical care,
special clinics in diabetes mellitus, HIV and tuberculosis, x-rays, physiotherapy and other
services. The hospital has a total of 140 beds for inpatients. In 2009, the following numbers of
patients received treatment in this hospital:
Table 1: output of St Patrick’s hospital in 2009
Children’s ward
723
Female’s ward
unknown
Male’s ward
451
Maternity unit
2776
Theatre
589
X-ray unit
1130
Dental clinic
333
Eye clinic
16481
Procurement of Drugs and Medical Supplies under the NHIS
Since a few years, the Ghanaian government has started the National Health Insurance Scheme
(NHIS). The NHIS published a list of medicines that from that moment on were free of costs for
patients that are insured (this contains >90% of the patients). The list is not as extensive as it is
7
in the Netherlands: it only contains the most relevant medication. Some medications that are
very common in the Netherlands, like naproxen and tramadol, are not on the list and should
thus be paid for by the patients. On the medicines list, every product is coupled to a price. This
is the price that the government will pay the pharmacies each time that product is dispensed,
so pharmacies will have to make sure they buy their products either for the same price or
cheaper in order to make profit. The list only contains generic products as these are cheaper,
but pharmacies sometimes can make arrangements with producers to buy brand medicines for
a lower price.
A major problem in Ghana is the delayed payment of funding by the NHIS to the pharmacies.
The NHIS should provide the pharmacies with 40% of the costs right after declaration, and pay
the rest of the money as soon as all the declarations are checked and substantiated. However,
it usually takes 3 to 6 months until any money comes through. This can cause the pharmacies to
get into financial trouble, and in the worst case they will not be able to buy any additional
stock. The pharmacy of St. Patrick’s hospital also has to deal with this problem. Fortunately, a
lot of the suppliers know about the status of the NHIS in Ghana, and don’t expect the pharmacy
to pay very early. The few suppliers that do require payments to be made right away, are paid
as soon as possible. This also goes for some small local producers that really need the payments
to keep their business going. All other bills are being paid as soon as is possible, so this usually
takes as long as it takes the NHIS to pay the pharmacies. This way of dealing with things does
now not create a lot of problems in this hospital.
Availability, affordability and counterfeit drugs
In a country like Ghana, it can cost a lot of effort to keep all medicine available and affordable.
Furthermore, counterfeit drugs always pose a treat. A big deal of the affordability issues is now
covered by the NHIS. Pharmacies will simply have to find a supplier who provides them with
medicine for a lower price than the NHIS covers for. In St. Patrick’s hospital, doctors have made
a drug bulletin together with the pharmacy, which contains all drugs that can be described by
doctors. Most of these drugs are normally well available for the pharmacy. There are a few
exceptions: nystatin, activated charcoal and anti tetanus serum are difficult to find. Otherwise, I
feel this hospital meets its targets in terms of affordable and available medication.
Counterfeit medicine is a major problem in Ghana. Because some drugs are sometimes
unavailable or too expensive to buy, cheaper counterfeit medicine could be a serious health
risk. For this hospital, counterfeit is hard to detect. There is no quality analysis of the drugs,
apart from the pharmacist’s professional view on the appearance and labeling. Otherwise, the
hospital relies on the quality control system that the Food & Drug Administration of the
government executes. When a new drug is introduced in Ghana, it will first be tested by the
F&D. If it passes the test, the drug can be imported into Ghana (or keep being produced inside
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Ghana). From that moment on, the F&D organizes post-marketing surveillance to check
whether the contents of the medication are still the same. If not, they will recall all the
medicine and the hospital will not use that product anymore.
Rational Use of Drugs: Diabetes
One of my assignments was to check whether the way diabetes mellitus is treated in this
hospital matches with Ghana’s Standard Treatment Guidelines. In order to do so, I discussed
with the pharmacist (member of the Drugs and Therapeutic Committee) what prescriptions for
antidiabetic drugs she sees most, and I spoke to one of the doctors to find out how he treats
patients with diabetes mellitus.
The pharmacist pointed out that the Standard Treatment Guidelines (STGs) have been written
in 2004 and can thus be considered quite outdated on some points. An update should be on its
way. For diabetes mellitus type 2, the STGs advise to first prescribe metformin to all obese
patients and a sulphonylurea to all other patients. In the pharmacy, most patients seem to get a
combination of metformin with a sulphonylurea. There seems to be a shift going on from the
long-acting sulphonylurea glibenclamide to the short-acting glimepiride. The pharmacist feels
that, although the STGs advice to start with one oral antidiabetic, most patients get a
combination of two products from the start.
However, my talk to the doctor gave me a different view on the situation. He said that all
patients start with a single drug. The choice between metformin or a sulphonylurea is not a
very strict one, the STGs only say what is usually prescribed. As a consequence, there are
differences between the choices the doctors make as their first line treatment for diabetes type
2.
I find it very strange that the STGs do not gave a clear first choice for the first line treatment of
diabetes type 2. I think metformin should be the first choice for all diabetic patients, like in The
Netherlands, because it has a lower risk on hypoglycemia than the sulphonylureas.
Furthermore, I think the STG should prefer the short-acting sulphonylureas to the long-acting
sulphonylureas for the same reason. For as far as the STGs go, the hospital seems to follow the
guidelines in terms of oral medication for diabetes mellitus type 2 quite well.
Nutrition is of major importance in the treatment of diabetes. Even though the hospital staff is
well aware of that, I feel more attention is being paid to the medication. This is a result of the
following:
-
In the pharmacy, there is usually not enough time to give a lot of information about
diets.
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-
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Patients get a talk about the importance of nutrition and lifestyle before they go to their
doctor’s appointment. However, this talk is given to many patients at the same time and
is therefore not designed for an individual patient.
The doctor only sees the patient for about two minutes, so there is little time to give
information on nutrition.
A consult with a dietician is covered by health insurance. However, patients have to
travel a large distance to get there, and transport costs are not covered. Furthermore,
waiting hours for the dietician are very long and can take up to a full day.
Patients are often used to eating the same food every day, which may often not
contribute to their health as it contains a lot of fats and carbohydrates.
Recommendations to improve pharmaceutical service in the hospital pharmacy
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-
-
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Prepacking is a very good way to save time for dispensing, so keep doing so. Keep
looking for increasing the amount of prepacked medication, for example, ciprofloxacin.
The table with prepacked medication can be a bit messy. This increases the chance that
the wrong tablets are dispensed. It would be good to alphabetically order prepacked
medication in a cupboard.
Labeling the appropriate place to store every product decreases the chance that
products are placed at a random place. This makes the stock more organized and
decreases the chance that a wrong product will be picked. The same goes for all
medication stored in the general store.
Try to find out how much of every medicine should be pre-packed to be sure there is
enough in stock for one day. Every morning, the amount of prepacked medicine could
be counted and filled up if necessary.
Train the staff of the pharmacy in such a way that they use the time in the mornings to
get things organized for the busy afternoon. This includes prepacking, bringing syrups to
the dispensing area, cleaning up trash, etc.
For hygienic reasons, it would be good if toilets were provided with toilet paper.
It would be good to purchase a (second-hand) scale to make the prepacking process go
faster. The scale should have a feature that sets a certain weight to a number of tablets,
so that the scale can count the tablets. (I offered to try if I can find a cheap supplier of
these in The Netherlands).
Counting plates should be cleaned after use to make sure no residues of other medicine
will be contaminating the product.
Use the waiting area to hang up some educational posters. Possible topics could be,
among others, good hygienic practice, prevention of malaria, awareness about HIV,
awareness of patient responsibilities when taking medication, counterfeit medicine and
daily practice in the pharmacy (to create understanding for long waiting time). (I offered
to make contact with Health Access Network to see whether they have posters
available.)
Strive towards a computer with software that is able to keep records of all the
dispensing. Even though this may be a long-term goal, it will greatly improve the quality
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of pharmaceutical services. Furthermore, prescribing habits and periodical consumption
of certain drugs (painkillers, sleeping pills, antihypertensives) can be calculated.
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Week 3: Seventh Day Adventist (SDA) Hospital – Sunyani
In 2005 the SDA hospital was founded as a result of overcrowding of the two existing public
hospitals in Sunyani, the capital city of the Brong Ahafo region in Ghana. The hospital was
founded with funds from the regional church and was set up as a non-profit mission hospital.
During the first five years of its existence, the hospital has grown a lot. The staff grew from 12
to 46 workers, there were more patients and new buildings were added to the hospital site.
Right now, the hospital offers OPD, in-patient service, pharmaceutical care, eye care, major
surgeries, gynecology and antenatal care, emergency care, public health&family planning and
diagnostic services (ECG, ultrasound and basic laboratory).
The hospital is dealing with some major issues and help is asked from the Netherlands to deal
with these. My task here was to give a description of the hospital, the problems they are facing,
the plans there are to improve the quality of health care and what external support could be
useful.
In 2009, the hospital provided health care to a total of 28333 patients. During the year, the
number of patients was growing from 4049 in the first 3 months to 9296 in the last few months.
This illustrates the rapid growth of the hospital and also forms the basis of the major problems
that exist here. In 2009, no surgery was performed. This started in 2010; so far, 15 surgeries
have been performed, and their number is growing rapidly. The hospital has a total of 17 beds
for inpatients and there is one theatre available for surgery. The organogram of the SDA
hospital is as follows:
Faculty in-charge (hospital administrator)
-Clinical care services
-Medical
-Nursing
-Pharmaceutical
-Laboratory
-Medical Records
-Finance and administration
-Finance
-General administration
-Stores and Supplies
-Paramedicals
-Chaplaincy Service
-Public Health Service
-Preventive
-Promotive
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The pharmacy of the hospital is sited in a very small room (about 3x3 m). Additionally, there is a
storage room, which is about the same size. The hospital has one pharmacist under contract.
Furthermore, there are two pharmacy assistants and two pharmaceutical technicians to assist
him. Medicines are brought in from about 12 different companies. There is no own production,
but there are plans to get this process started. The pharmacist is thinking about starting an own
production of cough syrup, infant cough syrup and magnesium trisilicate mixture. From the
main store room, most products are in some amount brought to the pharmacy itself. However,
this amount is limited by the space available. The products that are described the most are also
present within hand reach of the dispenser.
Plans to improve services
The hospital strives to keep up its good name for taking time to treat the individual patient and
provide him with quality service. However, current facilities are by no means sufficient to reach
that target. Therefore, there are plans to build a new hospital building, for which the
foundation has already been made. This building would facilitate the hospital with about 160
beds for inpatients (including surgical wards), three theatres for surgery, two beds for
emergency patients, X-ray analysis techniques, a better equipped laboratory and a larger room
for the pharmacy.
For the pharmacy, as stated above, there are plans to create an own production line for certain
products. The pharmacist would like to start producing cough syrup, trisicilate mixtures, ferric
ammonium mixtures and other oral mixtures. Experience from earlier working places from the
pharmacist has shown that these productions are always better in terms of cost-effectiveness
then products that have to be bought from other companies. However, the pharmacist does
not have any data for this hospital to support this. The pharmacist is also unhappy about the
quality of the mixtures and thinks the SDA hospital would be able to produce medication of
better quality. In order to achieve this, staff must be trained so that they have the required
skills to produce medicines of good quality. They all have working experience for production of
medication. Another wish for the pharmacy is to purchase a software system to get a better
view of the logistics and a printer.
Another major improvement would be the purchase of a vehicle for the hospital. There is no
ambulance available to pick patients up from their homes in case they are too sick to come
themselves. Furthermore, all patients that are referred to another hospital have to arrange
their own transport. Transportation would also be useful for the staff, for example to pick up
orders of pharmaceutical products.
Major problems
General
When I viewed the current situation and spoke to the hospital administrator and staff, I found
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out that the most urgent problem is the lack of space to create more beds for inpatients. As a
consequence, patients are often situated on mattresses on the floor, which is a very unwanted
situation. The hospital is even in danger of losing its hospital status and getting back to a clinical
status, which would decrease the income per patient drastically. There is no room available for
more beds, so creating a new building is necessary to achieve progression. The lack of means of
transport, as mentioned above, is another issue that really needs to be addressed.
Furthermore, the hospital only owns a small generator, which is insufficient to provide the
whole building with power in case of one of the many power cuts. A more reliable supply of
power is therefore welcome.
Surgery
It is expected that the one theatre that is available will soon not be enough to perform all the
required operations. Therefore, more theatres are needed. However, even the one theatre that
is available is not provided with the necessary equipment. The anesthetist equipment is
borrowed from another hospital and may at any moment be demanded back. The same goes
for the surgical bed. The light of the theatre is also a big problem: it is too small to provide the
surgeon with a good view over the patient. Furthermore, it is also difficult to provide the
surgeon with good surgical equipment. There is no autoclave, so that staff now tries to sterilize
products with a gas stove (or sterile products are brought in from elsewhere).
Pharmacy
The pharmacy mainly lacks space to place all the required medication. Another issue is that
there is no refrigerator available (and if there was one, there would be no room to place it), so
that the refrigerator of the laboratory has to be used. Another main issue is that
reimbursement from the NHIS for the medication delivered to the patients is usually paid after
about six months. As a consequence, the hospital sometimes lacks the funding to afford all
medication. If that is the case, patients are referred to another hospital to get the required
medication.
Ward
The main problem of the ward is as simple as it is serious: there are way too little beds to place
all patients. Before any new beds (including pillows and sheets) can be used, the new buildings
have to be completed. There is hope that the first 10 beds will be available within one month.
The rest of the building will take a lot of time to be completed. If the hospital can retain its
hospital status for the government, hopefully money can be saved in order to continue this
process. For the last year, no building activities have taken place due to a lack of funds. This was
partly causes by the financial crisis the world was going through.
Other problems that the ward faces are the fact that there are no hospital beds of which the
position of the patient can be adjusted. These beds are wanted desperately. Other problems
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are the availability of only one trolley to carry patients and the lack of good thermometers (they
tend to break down quickly), digital apparatus for blood pressure and blood glucose and a
screen.
Maternity ward
Most of the women are not comfortable to deliver in this hospital due to the fact that a lot of
equipment is lacking. Among the most urgent needs are a delivery bed which can be turned, a
section machine, an electronic vacuum aspirator, incubators, heaters, phototherapy machines,
billimeters and a vacuum extractor. Other equipment, like a blood oxygen meter, a machine to
monitor the heart and a blood glucose meter are also lacking.
External support
Considering the above, external support is very welcome for this hospital. I feel that the main
thing here is that some priorities have to be made: it will not be possible to solve every single
problem that is mentioned. When I discussed this with the hospital administrator, he indicated
that for him the main priority would be to find an ambulance to transport patients. Maybe it is
possible to find a donator of a second hand vehicle from elsewhere. Next, the hospital urgently
needs funds to complete the construction work in order to create more beds for inpatients.
When this is completed, any kind of help in terms of surgical equipment, beds, sheets,
mattresses, pillows, trolleys and drugs is very much needed. However, it is not useful to buy
beds and belongings now, because there is no room available to place them.
According to the hospital administrator, there is enough educated staff available to fill up any
possible vacancies. All staff working at the hospital is well trained, and there is no need for
trained specialist from abroad. When funds are available, the hospital would like to attract a
gynecologist (as there are only 5 of them in the whole region), a surgeon (so that less patients
have to be referred to other hospitals) and nurses.
For the pharmacy, the argument that own productions would be cheaper then when products
are bought from elsewhere seems reasonable. However, there is currently no equipment
available to start the process. The pharmacist thinks a container, homogenizer, measuring
equipment and filling equipment would be necessary for producing mixtures. Help from
elsewhere could be useful for this. However, I think the hospital pharmacy would first have to
write down a plan what mixtures are going to be produced, what material would exactly be
needed, what the costs would be, how the quality of the production can be guaranteed and
how much money this production can generate for the hospital.
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Week 3-4: Archdiocesan Health Pharmacy Ltd (ADHPL), Kumasi
I spent a total of nine working days at the production site of the ADHPL in Kumasi. The ADPHL
produces several eye, ear and nose drops, oral mixtures, lotions and injections for mission
hospitals in the region. My work here consisted of taking part in daily production activities,
reviewing production records, make suggestions to design new protocols for eye drops (and
updating old ones) and discussing present and future plans with the pharmacist.
Production
The production activities can roughly be divided in three categories: non-sterile production,
sterile production and packaging/labeling. The largest group of non-sterile products is the
group of the oral mixtures. Cough syrup and magnesium trisilicate mixture are two of the
fastest moving products of this company and are therefore often produced. The main group of
sterile products is the eye drops.
Compared to Dutch standards, the quality of the activities at the ADHPL is on a lower level than
in most Dutch production facilities. However, it would be unfair only to compare the ADHPL to
European standards. I feel that the quality of products is as good as you can expect them to be
in Ghana. The ADHPL always uses protocols, which is very important for improving quality of
preparations. Moreover, the staff is able to follow protocols and fill them out during
production, and protocols are subject to reviews.
However, there were some things that I feel would require more attention in order to create
effective and safe medicines.
Recommendations:
Stop making use of chloroform as a preservative. Oral ingestion of chloroform is
hepatotoxic and nephrotoxic and can result in cardiac problems. Furthermore, the staff of the
pharmacy is exposed to a health risk as chloroform can penetrate after skin contact. For further
discussions on preservatives: see ‘designing/upgrading protocols’ hereunder.
When a suspension (such as the magnesium trisilicate mixture) is bottled, it would be
good to stir after every 25 bottles. Due to sedimentation of solid particles there will be
differences in concentration between the first and the last bottles. Regular stirring results in a
more homogenous mixture, and thus in a product of better quality.
Make sure the working space is clean after production of one product before starting
production of another one. This will decrease the chance of cross-contamination of medicines.
The same goes for the material that is used to weigh raw materials (spoon, silver vessel, scale).
For all products, it would be good to mention the purpose of use and the dosage on the
container, so that the patient can easily see where the product is used for and what dose to
take.
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Eye drops are often difficult for patients to administer. Therefore, it would be a good
idea to add an instruction to the leaflet of eye drops that visually explains how the eye drops
should be administered.
Unfortunately, during my stay here I have not been able to witness the production of
ointments and injections. Therefore, I can not give any recommendations about them.
Production Records
To give the pharmacist a better view of the fast and slow moving products, I reviewed the
production figures of the last few years and made histograms out of them.
70000
60000
50000
40000
30000
20000
10000
0
Figure 1: histogram of fastest moving products in 2009
30.00
25.00
20.00
15.00
10.00
5.00
-
Figure 2: histogram of slowest moving products (average per year in period 2007-2010)
17
Furthermore, there were a few products that had a clear trend: their production was either
increasing or decreasing rapidly. The following graphs are the most important ones. The figures
of 2010 are predictions based on the production of the first four months of 2010.
Methylcelulose 1% eye drops
Gentamicin 0.3% eye drops
8000
20000
6000
15000
4000
10000
2000
5000
0
0
2007
2008
2009
2007
2010
(pred)
Zinc Sulphate 0.25% eye drops
10000
8000
6000
4000
2000
0
2008
2009
2010
(pred)
Total Ointments
30000
20000
10000
0
2007
2008
2009
2010
(pred)
2007
2008
2009
2010
(pred)
Figure 3-6: production of certain products in period 2007-2010
Recommendations:
The oral mixtures are still the group that account for the most important group for this
company, both in terms of size of production and in their value. Next come the group of the eye
drops. Because of their importance for the company, I feel these products should receive
special attention: their protocols have to be correct and the production should be done in a
way that guarantees a product of good quality. Furthermore, if any new product would be
considered, it would most probably be either an oral mixture or an eye drop, as the demand for
these products seems to be the highest and the company is the most experienced in production
of these groups.
It could be worthwhile to see for the slowest moving products whether they are still cost
effective. Can the raw materials always be used, or are they often thrown away because they
pass their expiry date? Is there any special reason to keep these products in the assortment? It
seems that the production of ointments is decreasing. If the company is trying to specialize into
a certain kind of productions, I think the ointments would be the first to be stopped. However,
18
this view is only based on production figures. Other factors may also have an impact on the
decision what preparations are going to be produced.
The following table is a list of the cost prices, selling prices and profit margins for the products
that are produced the most in the ADHPL.
Table 2: cost prices, selling prices and profit margins
Top selling products
Mist. Mag. Trisilicate
Mist. Expect Sed
Gentamicin 0.3%
Mist. Senna-Co
Ephedrine N/D 1%
Ephedrine N/D 0.5%
Prednisolone 0.5%
Antoniq Blood Tonic (FAC)
Chloramphenicol eye 0.5%
Prednisolone 1%
Mist. Pot-Cit
Selling price
0.70
0.70
0.55
0.80
0.85
0.80
2.15
1.10
0.55
3.00
0.80
Cost price
0.337
0.245
0.385
0.335
0.359
0.327
0.568
0.413
0.301
0.838
0.578
Margin (%)
51.83
64.93
30.00
58.12
57.78
59.14
73.59
62.49
45.29
72.07
27.75
The margins of the products seem to be quite widespread between 25% and 75%. To me, it is
unclear what the origin of these differences is. According to the pharmacist, the margin should
be fixed to a percentage of 30-40%, independent on the product. However, I think some
products are more difficult to produce than others. For example, eye drops need to be
produced, bottled, sterilized, labeled and packed in boxes, while most oral mixtures only need
to be produced, bottled and labeled. In my view, it would be better to make an estimation of
how many hours it would cost for how many persons to produce a batch of each product.
Calculating from this number of hours, a margin could be designed that is appropriate for all
oral mixtures, all eye drops, etc.
Designing/upgrading protocols
One of my tasks here was to get some information to design a protocol for the production of
timolol and ciprofloxacin eye drops. As these eye preparations are frequently prescribed in eye
clinics, they would form a good addition to the existing productions.
Due to some problems with power cuts and internet connection issues, and the fact that there
is no standard FNA (Formulary of Dutch Pharmacist) protocol, I did not have enough time to
complete a whole new protocol for these formulations. Instead, I agreed with the pharmacist
that I would write down as much information that is important for these formulations as I could
find.
19
Ciprofloxacin eye drops
In the Netherlands there is one ciprofloxacin eye drop on the market, called Ciloxan. This
product contains 3,5 mg/ml ciprofloxacin HCl (corresponding to 3 mg/ml ciprofloxacin) which is
the usual recommended and prescribed dose in the Netherlands. Ciloxan further contains
benzalkonium chloride as a preservative and EDTA as a complex former. The other components,
apart from water, are acetic acid (pH), mannitol (adjustment of osmotic value) and hydrochloric
acid/sodium hydroxide (pH). Ciloxan can be used for 2 years after manufacturing and, due to
microbiological reasons, for 28 days after opening.
Ciprofloxacin can degrade when it is exposed to light. Therefore, light exposure should never be
any longer than 6 hours.
Timolol eye drops
Timoptol, the brand product of timolol eye drops, is available in two different doses in the
Netherlands (0,25% and 0,5%). The solution is buffered by sodium dihydrogen phosphate and
disodium phosphate. Furthermore, it contains sodium hydroxide for pH adjustment,
benzalkonium chloride as a preservative and water for injections. After manufacturing,
Timoptol can be used for 2 years, and it should be used within 28 days after opening.
Other generic products containing timolol have a comparable composition and are also
available in a 0,1% solution. Some of these products can be used until 3 or 4 years after
manufacturing.
Preservatives
The ADHPL uses chloroform as a preservative for most oral mixtures. However, chloroform is
hepatotoxic and nephrotoxic. Furthermore, it can result in cardiac problems. Because
chloroform can penetrate after skin contact, the staff of the pharmacy is exposed to the health
risks that chloroform poses. For these reasons, I urge the ADHPL to consider stopping the use of
chloroform as a preservative. There are other agents available as preservatives that are safer
than chloroform.
Methylparahydroxybenzoate (MHB) and propylhydroxybenzoate (PHB) belong to the group of
parabens. These agents can function as a preservative in the concentration range 0,1-0,2%.
Disadvantages of parabens are that they can cause an irritant sensation on the tongue, and that
they are only effective when the pH of the mixture is below 9.
Benzoic acid is an aromatic carboxylic acid and has preservative qualities in the concentration
range 0,1-0,2%. However, it is only effective when the pH is below 5. Furthermore, many
people are oversensitive for benzoic acid. Another widely used preservative is sorbic acid,
which is effective below a pH of 5.
20
Some fluid components of oral mixtures can also function as preservatives. Examples are
propylenglycol (15% or higher) and ethanol (alcohol; 15-20%). Problems with these substances
can be that some patients complain about the bad taste of these substances. Furthermore, they
can not be used in mixtures designed for children. Glycerol 85% is another liquid that can be
used as a preservative. It is effective at a concentration of 30%. An advantage of propylenglycol,
ethanol and glycerol is that they are effective at any pH.
In summary, there are many agents available that can serve as a substitute for chloroform. I
would advise the ADHPL to measure the pH of each of the mixtures where chloroform is used
now, and see what preservative could be effective for that mixture. I think MHB and PHB could
well be used in most mixtures (if the pH is below 9). If the pharmacy can find a supplier, these
agents would form better and safer preservatives than chloroform.
General management
History
The Archdiocesan Health Pharmacy Ltd (ADHPL) was founded in 1979 and started producing
intravenous infusions. However, in the late 80’s, interest in infusion in glass bottles, as
produced by the ADHPL, was waning, mainly because of the rise of HIV and hepatitis B.
Therefore, the company started producing mixtures, ointments, syrups, a few eye/ear/nose
drops and later filtered water for commercial use. This improved the financial situation of the
ADHPL. However, in 2006 the Food and Drugs Board (FDB) of Ghana demanded all filtered
water for commercial use to be produced in an automatic way. It was very difficult for the
ADHPL to get the required equipment, so the production of filtered water was stopped.
Therefore, attention was shifted to the oral mixtures and eye drops, and with some help from
The Netherlands the number of eye/ear/nose drops increased. Right now, the ADHPL is the
largest producer of certain eye drops (pilocarpine, prednisolone) in northern Ghana.
In the past, the company has only delivered their products to mission hospitals. The slogan of
the ADHPL was ‘evangelization through health delivery’. However, other customers were
coming, and it was difficult to deny them. That is why the board decided to start delivery to
other hospitals as well. This way, more people would see the role of Catholics in providing
health care, and there were more chances to spread the ideology of the ADHPL.
Present plans
When the pharmacist that is now leading the ADHPL came in in 2007, he had plans to revive the
production of IV infusions and filtered water. However, again this proved to be difficult. To find
a market, IV infusions would have to be produced in plastic containers, but a lot of new
equipment (autoclave, mixing pans, plastic material and all belongings) would have to be found.
The same was true for filtered water, so that this was only produced on a small scale for own
use and a few mission hospitals. Both plans are now temporarily put on hold.
21
Instead, the number of eye/ear/nose drops is still growing. The company is starting to become
a specialist in this field of work. Most eye drops available in Ghana are now produced.
Exceptions are timolol and ciprofloxacin eye drops, but there are plans to start production of
these products on a short term. The reason that the ADHPL is specializing on eye products is
that it is not easy to produce them. Oral mixtures are produced throughout the country in
different conditions, so it is hard to compete against all concurrence. Eye drops, however,
require specific knowledge and equipment, which is available at the ADHPL. Furthermore, there
is a good market for eye products as many people in Ghana have eye diseases.
Future plans
Very close to the ADHPL, a new hospital, specialized in cancer and eye diseases, has been built.
There is hope that this hospital can start early next year. The board of the hospital has asked
the ADHPL to produce most of the eye preparations for them, which would mean a massive
increase in production from the ADHPL. Therefore, the first target would be to be able to
produce most of the eye products requested by the hospital.
When this is finished, the company wants to increase their production of creams and
ointments. The north of Ghana is usually very wet in rain season and very dry in other times of
the year, which makes the people vulnerable to fungal infections in the rain season and dry skin
and cuts in the rest of the year. Therefore, there is a big market for ointments and creams. For
the last few years, one dermatologist has collected all his products from the ADHPL and is very
happy about the service and products delivered. The ADHPL hopes to be able to use this
dermatologist to increase their network in the field.
Currently, the company buys all the water it uses from another company, which costs a lot of
money. Right now, the ADHPL is collecting orders from companies to go drilling for spring
water, so that the company would have its own source of spring water. This would save money
because water does not have to be bought elsewhere, but it also opens the door to the sales of
commercial water. There is still a good market for water, so the pharmacist hopes to be able to
find equipment for automatic filling of bottles in order to meet the FDB demands.
In my opinion the plans of the ADHPL sound very reasonable and well-thought. The hospital
nearby could have a major impact on the financial situation of the company, so it is of major
importance to provide them with all products they need. Therefore, my advice would be to
keep increasing the quality of eye preparations, and not to start any new product lines
(creams/ointments, commercial water) before the supply to the hospital is satisfactory for all
parties involved.
22
Evaluation
At the end of my internship, I had an evaluation with Mr. Charles Allotey, the chairman of
Health Access Network. The corresponding evaluation form can be found in Appendix 4.
My supervisor was happy with the work I did here in Ghana. In his view, and I agree, my
experience in Ghana will be a very useful one for me in the future, and he is hoping that it
contributed to my view about health care in Africa and Ghana in particular. He is also hoping
that someday I will return to Africa to work here for a longer period.
Furthermore, he was happy that I had been able to make some useful contributions on the
teacher’s manual for the medication counter assistant training and on the paper about pricing
of medicines. He also called me focussed on my work and dependable.
My supervisors in Offinso, Kumasi and Accra all describe me as someone who is hard working
and can work in an independent manner. I really hope (and expect) that I will be able to work
this way when I get a full time job in the Netherlands or, who knows, elsewhere.
23
Conclusion: Analysis of strengths and weaknesses
This internship has been the last course of my masters of pharmacy studies. Therefore, after
this internship, I should be ready to work in daily practice of a community pharmacy, in a
hospital or elsewhere. Although there are some aspects I need to work on (as there will always
be), I feel that I possess the qualities required to be a good pharmacist. In the following, I will
analyze my strengths and the weaknesses I have to improve upon.
First of all, life in Ghana is very different from my life I’m used to in the Netherlands. Especially
in the first few weeks, I sometimes did not know what to expect or how to react in a certain
situation. Being in a completely different culture for 2 months is an exceptional experience
from which I gained a lot. An experience like this teaches you how to be flexible and
understanding. Many things in Ghana (food, public transport, work activities) go in a different
way than in the Netherlands, so you simply have to adjust to the situation. This has increased
my flexibility and also taught me to do my best to try and understand why people live the way
they do. I think these are very valuable characteristics for every pharmacist (and every human
being). Furthermore, I think I will be able to handle stressful situations more easily after my
time here in Ghana.
Another strength of me that I already knew was that I can work in an independent and selfsupporting way on my projects. During my stay in Ghana, independence was definitely one of
the key qualities that were required to bring my internship to a good end. When you make a
plan in Ghana, you can be sure that things always work out a bit different in the end. In that
case, you have to come up with your own new plan and start working on it yourself. I think that
my stay here has greatly improved my ability to work on my own.
In Offinso, I have worked in the pharmacy of the local hospital. My task was to see what
activities where going on, what the main problems were and how they could improve the
quality of the services. Furthermore, I was investigating the financial situation as a result of
delayed reimbursement by the NHIS, the output of the hospital and rational use of drugs for
diabetes. The way things are going in the pharmacy is very different from the way they go in the
Netherlands. One of the things that struck me was the long waiting time for the patients to get
their drugs. It was a very new and rewarding experience for me to go through every step in the
logistic process and see what things could be improved.
In Sunyani, my main task was to do an assessment of the most urgent needs of the hospital.
This sort of work I had never done before, so the whole experience was new for me. I realized
quickly that there were so many needs in the hospital that there was little chance they could all
be fulfilled by external support. Therefore, I decided to discuss with the staff of the hospital
(and see for myself) what the most urgent needs were so that they could be prioritized.
24
At the ADHPL in Kumasi, I was also asked to look into production, protocols and present and
future plans and make recommendations for future activities and improvement of the quality of
the medicines produced. Comparable to the work in Sunyani and Offinso, this also taught me a
lot about screening for weaknesses in the working process and look for improvements.
When I will start a job in the Netherlands, I should also take a look around at my new workplace
and see what things I would like to change or improve. Therefore, my experiences in Offinso,
Kumasi and Sunyani may well be very useful to me when I start a new job. In a similar way as
I’ve done here, I can then look for the processes that I think require improvement.
My stay at Health Access Network in Accra mainly gave me a good view on the total health care
system in Ghana. Because HAN has a lot of different stakeholders, they meet people from all
kinds of health organizations. It was very interesting to see what work, of which you are
normally not aware, is being done in order to try to improve access to essential medicine in the
whole of Ghana. Also, I had my first experience of teaching, which I really enjoyed. Teaching is
still one of the professions that I am considering for the future, and I feel that, thanks to my
enthusiasm, I would be quite a good teacher.
My main weakness will be my lack of experience when it comes to leading an organization. As a
pharmacist, in most cases you are expected to be the head of an organization, make decisions
and tell people what to do. As I’ve never done this before, I think it will take some time for me
to get used to this and find my own way of doing so. However, I am sure that after a while I will
find my own style and lead the pharmacy successfully.
In summary, my time in Ghana has not only been very enjoyable, but also useful and rewarding.
I learned a lot of new skills, and my self-confidence increased. I am sure that, partly thanks to
this internship, I will be able to be a good pharmacist in the future.
25
Appendix 1: letter of motivation (in Dutch)
Al sinds een paar jaar zit ik erover te denken om mijn keuzestage in een land in Afrika uit te
gaan voeren. Na een reis naar India 3 jaar geleden zit het reisvirus in mijn bloed, en wil ik heel
graag meer van de wereld zien. Daarnaast denk ik dat een keuzestage in Ghana mij op een
aantal vlakken heel goed kan ontwikkelen. Ik denk hierbij aan de volgende punten:
-
-
-
Ik ben uberhaupt ontzettend benieuwd naar de farmaceutische dienstverlening in
Ghana. Het lijk me erg interessant eens te zien op wat voor niveau deze ligt en tegen
welke problemen men dagelijks aanloopt en hoe men daarmee omgaat. Ik heb nog
geen helder beeld van mijn toekomstige beroep, maar werk in heb buitenland
behoort daarbij absoluut tot de mogelijkheden. In dat licht zou ik graag eens zien of
het werk en leven in Ghana me bevalt.
Ik denk dat het beroep van apotheker meer vaardigheden vereist dan je op de
universiteit kunt leren. Een periode in een land dat enorm verschilt van Nederland
leert je op bepaalde vlakken enorm veel. Zo verwacht ik nog zelfstandiger en
assertiever in mijn handelingen te worden. Daarnaast denk ik dat je in een land als
Ghana, waar soms hele basale voorzieningen niet aanwezig zouden kunnen zijn,
leert enorm flexibel te zijn en om te gaan met tegenslagen. Ik denk dat dit
kernkwaliteiten zijn voor elke apotheker.
Hoewel ik me besef dat mijn stageperiode kort is, hoop ik toch een heel kleine
positieve invloed te kunnen hebben in de plaats waar ik stage loop. Met de kennis
en vaardigheden die ik in Nederland heb opgedaan, wil ik proberen, hoe kleinschalig
ook, mensen vooruit te helpen.
Bovenstaande afwegingen hebben mij enorm gemotiveerd een stage in Afrika te gaan proberen
te regelen.
26
Appendix 2: Terms of Reference (ToC)
PHARMACY ATTACHMENT
= Freek van GORP =
Terms of Reference
1. Work through the Health Access Network (HAN), Accra for a period of 6 weeks between 7th
June and 16th July 2010.
Supervisor: Mr. Charles Allotey, pharmacist
2. Use the schedule given hereunder as a guideline, final arrangements by
Mr. Allotey.
3. Get introduction to the Ghanaian healthcare system on national level by Mr. Allotey.
4. Get introduction to pharmacy practice at the regional level at the Archdiocesan Health
Pharmacy Ltd (ADHPL). Supervisor: Mr. Sarfo Mensah, pharmacist.
5. Be involved with pharmaceutical services in a mission hospital, e.g. St. Patricks Hospital,
Maase Offinso. Posting by Mr. Sarfo Mensah.
6. Any other pharmaceutical subject (like teaching pharmaceutical staff, project for MeTA/
Medicine Transparency Alliance, etc.) handled by HAN, to the discretion of Mr. Allotey.
7. Present short written report (Recommendations) to Supervisor before leaving.
8. Complete Final Report within six weeks after return.
Don´t forget to include this T.O.R.
Points of Attention
Introduction at Accra/ Mr. Allotey
1. Be introduced to some players at national level in the field of health care like Korle Bu
Teaching Hospital, FDB, MOH and/or international level like Health Action International
(HAI) or MeTA (Medecines Transparency Alliance).
2. Get familiar with drug supply for mission hospitals: NHIS (National Health Insurance
Scheme) for funding, NHIA Drug List specifying reimbursement.
Ask Mr. Allotey: can the objective of Availability/ Affordability be met ?
Is counterfeit a real threat ?
3. Be introduced to HAN as an organisation, aimed at participation in a later stage.
A.D.H.P.L. Kumasi
1. Acquaint yourself with activities at the pharmacy and take part in daily activities,
including production and Quality Assurance.
2. General management: Discuss with Mr. Sarfo Mensah his plans with ADHPL.
Working for mission hospitals only, or external institutions as well ? Is the pharmacy
specialising in product lines ? If so: why is a specific choice made ?
3. Production/ eye drops
Assist in upgrading production protocols, or designing new ones.
27
St. Patrick’s Hospital, Maase Offinso
1. Acquaint yourself with activities at the hospital pharmacy and assist the pharmacist/
technician-in-charge whenever possible.
2. Give a short description of the output of the hospital, based on the latest Annual Report
3. Describe the procurement of Drugs and Medical Supplies under the NHIS. How does the hospital
cope with delayed payment by NHIS ?
4. Describe ways and means in which pharmaceutical services could be strengthened.
5. How is the hospital addressing the issues of Availability, Affordability and Counterfeit/Fake
drugs ?
6. Rational Use of Drugs: discuss with doctors or (preferably) with the Drugs and Therapeutic
Committee diagnosis & care of Diabetes at the hospital.
Compare with Ghana’s Standard Treatment Guidelines, and (if any) discuss the difference.
S.D.A. Hospital, Sunyani
1. Contact via Mr. Michael Boamah, Sales Manager (0243- 137 529; 0271-128 928) and Mr. Paul
Kyeremeh, SDA Hospital Administrator/Pastor (027-897 5604)
2. Be there for 2 days
3. Describe the health care, delivered in the year 2009 (O.P.D., in-patients, surgery, counseling;
annual report ?)
4. Describe the pharmaceutical services (staff, organogram, suppliers, distribution system, own
production)
5. What are the plans to improve on the services ?
6. What are the major problems ?
7. What type of external support could be useful ?
H.A.N. , Accra
1. Additional pharmaceutical topic, see TOR/ 6.
2. Suggestion: assist in the course for Medicine Counter Assistant, teaching or reviewing course
material.
Proposed Schedule
week start
1
Institution
Remark
7-jun-10 Accra intro
2
14-jun-10 ADHPL Kumasi
3
21-jun-10 ADHPL Kumasi
incl.Maase Offin Hosp.&
4
28-jun-10 ADHPL Kumasi
2 days SDA Sunyani
5
5-jul-10 HAN Accra
6
12-jul-10 HAN Accra
Last day: Fri 16th
28
Appendix 3: example of trainers’ manual
This is an example of the work I did on the trainers’ manual of the courses for pharmacy
employees that HAN organizes. My contributions are displayed in italics.
1.1 PHARMACY APPRECIATION
Under this heading, we will discuss what pharmacy is, the history of Pharmacy, some modern
concepts of Pharmacy and the role of the Pharmacy Assistant/ Medicine Counter Assistant in the
Pharmacy in particular the healthcare system as a whole.
Ask the trainees: what do they already know about pharmacies? What are in their view the daily
practices of pharmacy assistants?
Discovery
This will usually be as a result of research as in the case of the development aspirin or accident
as in the case of the discovery penicillin.
Tell the trainees some background: many pharmaceutical agents are discovered from a natural
source. As an example, aspirin comes from the bark of the willow. Other agents are derived
from substances that naturally occur in the human and animal body, like prednisone. Penicillin
is one of the many examples of drugs that were discovered by accident. Mr. Alexander Fleming
noticed a halo of inhibition of bacterial growth around a blue-green mould on a plate culture.
The mould later appeared to be Penicillium notatum, which produces a substance that was later
called penicillin.
1.1.1 Modern Concepts
The modern Pharmacist deals with complex pharmaceutical remedies far different from the
elixirs, spirits, and powders described in the Pharmacopoeia of London (1618) and the
Pharmacopoeia of Paris (1639). Most countries with a regulated health-care system prepare a
compendium, or formulary, of authorized drugs and formulae.
The modern Pharmacist is also involved in giving advice to the other members of the healthcare
team to ensure the efficacious use of drugs.
29
Create a discussion: can the trainees think of other duties for the pharmacist apart from
compounding medicines? How can the pharmacist and the physician help each other in their
work?
Restriction of the use of “pharmacist”
1.
A person who is not a pharmacist shall not describe himself or hold himself out to be a
pharmacist by the use of the terms ‘pharmacist’, ‘chemist’, ’dispenser of drugs’,
‘druggist’, ‘compounder of drugs’ or any other similar term.
2.
No person shall open or any premises to the public under the description of ‘pharmacy’,
’dispensary’, ’chemist’, ‘drug store’, or any other similar description unless a registered
pharmacist is on the premises to supervise the dispensing of drugs or medication.
Ask the trainees: why do you think it is important to restrict the use of the word pharmacist?
What would the risks be if those restrictions were not in place?
1.3 PHARMACY AS A HEALTHCARE SERVICE
1.3.1
Place of pharmacy in Healthcare structure
1.3.1.1

Hospital / Health centre
After consulting the doctor, the patient goes to the Pharmacy or dispensary with a
prescription from the doctor.

At the Pharmacy, the Pharmacist or Pharmacy Technician / Technologist will interpret
what the prescription says.

The Pharmacist or Pharmacy Technician / Technologist may dispense the medicines or
direct an assistant to dispense.

Dispensing is accompanied by appropriate counselling.
Why would counselling be important? What issues do you think should be addressed during
patient counselling?
30
Appendix 4: Evaluation form
31
32