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Improving Pharmaceutical Service in the Primary Healthcare Sector Through the Training of Pharmacist Assistants

Improvement Report
Lizette Monteith, Erika Kapp, Ashraf Grimwood

Topics: Adherence to treatment, Adverse events, Antiretroviral therapy/ART/ARV, At-risk populations, Employee Engagement, Family planning, FP-HIV integration, HIV counseling and testing, HIV infection prevention/universal precautions, HIV prevention/positive prevention, HIV-TB, HIV/AIDS basic care and support, Infection control and prevention, Isoniazid preventive therapy, Monitoring and evaluation, Motivation/incentives, Pediatric HIV/AIDS, Performance evaluation, Performance management, Post-exposure prophylaxis, Program design, Program evaluation, Program management, Recognition/remuneration, Recruitment, Retention in care, Retention of health workers/reducing attrition, Scaling up, Stigma, Supervision, Sustainability, Task shifting, TB-HIV, Training, Waste management

Region and Country: South Africa

Organization: Kheth'Impilo
The Report

South Africa (SA) has 5.63 million people living with HIV/AIDS (PLWHA), 0.4 – 0.59million estimated TB cases reported per annum (according to the SA National Strategic plan 2012)1 and 800 HIV related deaths per day. In order to scale up the roll out of Antiretroviral (ARV) services, President Zuma announced on 1 December 2009 called for action so that “all health institutions in the country are ready to receive and assist (HIV+) patients and not just a few accredited ARV centres2.

The long overdue shift from hospital based ARV services to PHC based provision of ART has put tremendous strain on already thinly stretched pharmacy services and has highlighted the severe skills shortages within the sector. The South African Pharmacy Council (April 2010) has 12 813 pharmacists and 9 071 pharmacist assistants recorded on the SAPC register. Approximately 29% of the pharmacists practice in the public sector (which serves an estimated 84% of the South African population). South Africa currently has one pharmacist per 3849 population which is considerably below the WHO’s recommended 1 per 2300 population (South African Pharmacy Council, 2011)3The shortage of pharmacists necessitates increased reliance on pharmacist assistants for the delivery of pharmaceutical care to patients. 
Due to shortages of qualified post basic pharmacist assistants, this cadre of staff is mostly based at high level care facilities and is therefore not available to deliver services at PHC level where their input is crucially needed. Many public facilities currently depend on untrained or partially trained pharmacy support personnel to provide care to patients as system inadequacies have prevented successful training of many of these pharmacy workers.
The South African Gini co-efficient is ranked at one of the highest in the world (CIA world factbook)4 and the unemployment rate in SA is as high as 60% in some of the rural areas supported by Kheth’Impilo (KI).  South Africa has 0.7% of the world’s population but supports 17% of the world’s PLWHA.   

KI, in order to improve the quality of Pharmaceutical services, developed a model of care where Post Basic Pharmacist Assistants (PBPA) are employed and up-skilled. Once up-skilled, this Indirectly Supervised Pharmacist Assistants (ISPA) provide and strengthen pharmaceutical service at PHC level under the indirect supervision of a Designated Supervisory Pharmacist (DSP).

An USAID sponsorship was granted to me in 2009 to do a certificate in Advanced Health Management through FPD/Yale. As part of the studies I did a situational analysis and project to address the shortage of pharmacy support personnel in the Western Cape Metro district.
A small scale learnership project was started with SETA and PEPFAR funding. As part of the project, 5 unemployed candidates were selected and enrolled with the South African Pharmacy council as learner basic pharmacist assistants.
The project proved to be highly successful in filling a critical gap and the decision was therefore made to pursue opportunities to expand the program     
In 2010 Kheth’Impilo applied for additional funding from the Elton John AIDS foundation (EJAF) and SA Social Investment Exchange (SASIX) to expand this project to all provinces supported by KI.

The ISPA model of pharmaceutical care demonstrates robust patient outcomes with regard to Patients Remaining in Care, Viral Load Suppression and Lost to Follow up when compared to pharmacy supported services at baseline in the PHCs (for more information see Improved Access to ART;Post Basic Pharmacist Assistants)

The success rate of the initial learnership project was 100% as all 5 learners now have a national qualification as qualified basic pharmacist assistants. All five are enrolled as learner post basic pharmacist assistants in order to complete their second year of training. Once the second year is completed they will be able to be appointed in ISPA positions in the PHC to strengthen pharmacy service. They will also be in an enormously better position to provide for their families and strengthen the SA economy. One of the learners – Nicholas Ngalo – is a single father who was previously unemployed and lives with his mom and daughter in Khayelitsha – a peri-urban area outside Cape Town with an unemployment rate of 50% (City of Cape Town) 5. Because of this opportunity Nicholas is now able to provide a better education and future for his daughter (see uploaded video clip - KhethImpilo001) 
The funding proposals for both EJAF and SASIX were successful and with this, supplementary funding was secured to train 200 pharmacist assistants per year for two consecutive years. Currently we have 247 candidates (most of whom were previously unemployed) enrolled in the Learnership project. These learner pharmacist assistants are placed in 96 facilities throughout the Western Cape, Kwazulu Natal, Eastern Cape and Mpumalanga.

Tutors often lack time and capacity to adequately support learners with training – learners benefit from additional support as provided in weekly workshops in the Kheth’Impilo program.  

Training programs require good administration and, structured systems particularly during the registration process. Close monitoring of learner workshop attendance and progress ensures that training issues are picked up timeously and can be addressed with learners and their supervisors. 
Adequate pre-entry screening and selection ensure that only learners who have the capacity to complete the qualification are enrolled.
As an external independent organisation we have realised that we are well placed to drive the learnership project.
Processes we put in place are thorough  communication with all the role players (South African Pharmacy Council, Department of Health, service providers and the facility managers). We ensured that everyone is on board before the implementation of the project. We have created a strict entry selection process and once enrolled we provide regular support to the learners in the form of weekly contact sessions. 

For the project to succeed we recommend appropriate screening, the selection of a high quality accredited service provider, appropriate training material and constant monitoring and evaluation of the project.

1.     National Strategic Plan on HIV, STIs and TB, 2012 – 2016.
2.     Zuma, J. World Aids Day Speech. 1 December 2009.
3.     South African Pharmacy Council. (2011). Council Introduces Pharmacy HR plan for South Africa. Pharmaciae Volume 19 nr 2 , 8-9.
4.     CIA World Factbook.
5.     City of Cape Town Census 2001 – Khayelitsha.


To watch a short video about this work, please click the link below.

Kheth'Impilo: Improving Pharmaceutical Services in the Primary Healthcare Sector through Training of Pharmacist Assistants from Improving Health Care on Vimeo.