Pharmacies background information



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PHARMACIES


BACKGROUND INFORMATION

Kenya is the largest manufacturer of pharmaceutical products in the Common Market for Eastern and Southern Africa (COMESA), supplying 50% of the region’s market through 45 manufacturing industries. Training of pharmaceutical personnel began in 1926 at what is currently the Kenya Medical Training College (KMTC). The college started training compounders, then dispensers and later pharmacy assist­ants. In 1968, the government started a three-year diploma in pharmaceutical technology at KMTC. Over the last five years, the regulatory authority, the Pharmacy and Poisons Board (PPB), has accredited 17 more institutions to offer diplomas. Since 1974, the School of Pharmacy of the University of Nairobi has been the only institution training pharmacists in Kenya but in 2009, Kenyatta University (public university) and Mount Kenya University (private university) were accredited to offer degree in pharmacy. Their first graduates will be registered in 2014.

There has been an increase in the number of pharmacists from 1,866 in 2002 to 2,775 in 2008, while pharmaceutical technologists have increased from 1,399 in 2002 to 2,324 in 2009, an increase of 48% and 66%, respectively. It is estimated that for a country to meet its health-related Millennium Development Goals (MDGs), the pharmacy workforce needs to grow by 28% annually between 2010 and 2015, with the increase in institutions offering pharmacy degrees and diplomas; Kenya might be on the way to meeting this goal.

Requirements needed for someone to qualify as a pharmacist are as follows:



  • Qualify from a College/University that offers a minimum of four-year pharmacy degree course and is recognized by that Country's Pharmacy Regulatory authority (Pharmacy and Poisons Board).
  • Holds a bachelor Degree in pharmacy (BSc. Pharmacy) or diploma with a curriculum acceptable to the Pharmacy and Poisons Board.


  • Has command of English language and basic Kiswahili language.

  • Registered by the Pharmacy Regulatory Authority in the country offering the Degree Course

The only difference between a pharmacist and a pharmaceutical technologist (pharm. tech) is that a pharm. tech holds a diploma in pharmacy instead of a degree; otherwise the rest of the requirements are similar to that of the pharmacist.

Requirements that need to be fulfilled in order to set up a pharmacy are as follows:



  • There should be a registered pharmacist or enrolled pharmaceutical technologist with at least six years experience

  • Permanent building which has the following sections

    • Over the counter section

    • Dispensary section – This is where only prescription drugs are kept

    • Store – This is where the drugs are stored when they first come from the supplier

    • Washroom – This includes the toilet and running water

  • Two approved licenses, premise license for the building and practice license for the qualified personnel

METHODOLOGY

The data was collected from different sites using the following methods:



  1. Administering questionnaires.

  2. Interviews.

  3. Observations

Below are the sites we visited:

St. Mary’s Mission Hospital, Lang’ata

This is one of the catholic based hospitals located around the country. It is a non-profit facility that was established to provide for the lower-income communities with affordable competent health care. It has however overgrown that and currently also serves the middle class from all over Nairobi and even beyond the city. The hospital is run by a staff consisting of sisters , nurses and doctors .Sisters work as nurses and doctors . These members are usually employed by the mission. The hospital receives most of its donations from frontiers most of which are former medical staff i.e. Sisters and Surgeons.


Child and Family Wellness Clinic

This is a small clinic located in Raila villages in Kibera. Started in 2001, it offers consultation, first aid and pharmaceutical and outpatient services to kibera community. It’s one of 76 clinics within the country that is run by Sustainable Health Care Foundation (NGO). CFW serves averagely 15-30 patients daily. It’s operated by two trained nurses.



Revival Home Based Clinic

Revival Home Based Clinic is a small clinic located in Raila village in Kibera and run by the Revival for World Crusade Church. Started in 2009, it offers outpatient and preventive services in terms of immunization and awareness; the only inpatient service it offers is maternity. Its staff consists of a clinical officer as the head, 4 nurses and 4 subordinate staff. It serves an average of 15 patients per day.



Chemi Chemi ya Uzima Clinic

The translation of the name in English means “Fountain of Life”. It is an affiliate of Nairobi Baptist Church that provides basic quality medical services to the residents of Makina village in Kibera.


Tabitha Medical Clinic

This is a community based clinic started by the late Tabitha Atieno Festo, a widowed registered nurse from Kibera, in 2001. It is located in Soweto West one of the villages in Kibera and serves the residents of Soweto and Gatwekera villages. In 2009, it was reopened as a 3-story, 13-room, fully automated facility that utilizes solar panels and a rainwater catchment system. It offers primary healthcare services in partnership with the U.S Centers for Disease Control (CDC). It also provides training for volunteers in the community to become home based care providers. It serves an average of 200-300 patients daily. Patients have to be registered as members with the clinic in order to receive the free medical treatment. This is to enable follow up of the patients.


Bahati Health Center

This is government run clinic operating at the dispensary level. It offers outpatient and maternity services. There is one pharmacy that also caters for two other government clinics (Jerusalem and Bahati Clinic) that are nearby.



Eastleigh Health Center

This also a government run clinic operating at the dispensary level. It is located in Eastleigh where the majority of the residents originated from Somali. Most of them are considered to have come to the country as refugees from Somali and settled in this region. It offers outpatient and maternity services.



Pharmacy and Poisons Board

The Pharmacy and Poisons Board is the body that regulates the practice of pharmacy and manufacture and trade in drugs and poisons. Its aim is to make sure that medicine is quality, safe and efficient. It is under the Ministry of Medical Services but still functions as an autonomous body.



FINDINGS

PHARMACIES

Question One: What are the essential drugs in the area?

Site

Response to question

St Mary’s hospital

Mostly drugs for tropical diseases e.g. malaria, for infections, anti-malarial, antibiotics and antiprotozoals. Hypertension and Diabetes drugs are also becoming more common among the middle class.

CFW

Pain killers, Paracetamol, Stomachache drugs e.g. Antacids and Actals.

Revival Home Based Clinic


Anti-malarial drugs and painkillers.

Tabitha Clinic

Anesthetics, cough syrups, antibacterial, ARVs, Oral Rehydration Salts (ORS).

Chemi Chemi ya uzima

Anesthetics, cough syrups, antibacterial, ARVs, ORS(for diarrhea)

Bahati health center

Antibiotics, antimalaria, anesthetics

Eastleigh health center




Common diseases affecting the low income communities are:

  • Malaria due to lack of drainage system therefore the stagnant water provides the perfect environment to harbor mosquitoes

  • Diarrhea due to use of contaminated tap water, poor hygiene, no waste management system, food vendors operating on or near sewerage drainage trenches or on open road sides.

  • Upper track infections due to congestion. The average home size in Kibera is 3 meters by 3 meters with an average of 5 people per house.

  • Injuries, cuts, bruise and wounds – this is due to too much alcohol intake, short roofs especially walking at night.

  • Skin diseases (dermatological) – are mainly fungal related and are caused by sharing of clothes, children playing together, public bathrooms, not using antibacterial soaps.

Question Two: Where do you get your medical supplies from?

Site


Response to question

St Mary’s hospital

Mission for Essential Drugs and Supplies (MEDS) and UZURI exporters .

CFW

Sustainable Health Care Foundation which we are under does the ordering and we get the supplies from them.

Revival Home Based Clinic

Mission for Essential Drugs and Supplies (MEDS)

Tabitha

MEDS

Chemi Chemi ya uzima

KEMSA (Kenya Medical Supplies Agency)

Bahati health center

KEMSA – ( received as per the dispensary level of supply dictated by the government)

Eastleigh health center

KEMSA – ( received as per the dispensary level) but we also receive supplies from UNHCR-GTZ-BMZ program (a collaboration of UNHCR and the German Federal Ministry for Economic Cooperation and Development)

Question Three: How do you keep track of your medical stock?

Site

Response to question

St Mary’s hospital

Done both manually and automatic(hybrid)

CFW

Done manually, drugs used are recorded in a book at the end of each day.


Revival Home Based Clinic

It’s mostly done manually.

Tabitha

Use an automated health system; it keeps patients details and tracks their behavior, tracks drugs expiry dates and re-order levels

Chemi Chemi ya uzima

Use a manual book keeping system to record and track stocks.

Bahati health center

Manual recording using stock cards.

Eastleigh health center

Manual recording using stock cards. That’s what most government facilities do.

Question Four: What procedure is followed when ordering new stock?

Site

Response to question

St Mary’s hospital

Done monthly. Emergency ordering done any time.

CFW

Use stock cards to monitor stock level. When it reaches a certain level, we inform the Sustainable Health Care foundation to supply new stock.

Revival Home Based Clinic

There is a reorder level which when reached prompts us to place an order. It takes 4-5 days for us to get the new stock. The stock we operate on that is below the reorder level is known as the safety stock.

Tabitha


The system alerts us on reaching the reorder level and the normal business purchase ordering is followed.

Chemi Chemi ya uzima



Bahati health center

Since we are supplied by KEMSA we order drugs of a slightly higher quantity, for us to avoid shortages during the quarter.

Eastleigh health center



Question Five: How often do you restock the facility?

Site

Response to question

St Mary’s hospital langa’ta

Order is done monthly

CFW

Order is done monthly

Revival Home Based Clinic

Done quarterly i.e. after 3 months.

Tabitha

Order monthly and the order takes two weeks

Chemi Chemi ya uzima

Our purchases have long term expiry dates i.e. mostly over two years remaining on purchase.

Bahati health center

Government supplies the drugs quarterly

Eastleigh health center


The government supplies the drugs quarterly and UNHCR – GTZ – BMZ supplies monthly

Question Six: How do you keep track expiry dates of medicines in the store?

Site

Response to question

St Mary’s hospital

There is a system that keeps track of expiry dates of drugs.

CFW

Expiry date of drugs is noted and recorded during stock taking.

Revival Home Based Clinic

A book is kept of all the drugs and the expiry dates and dates are monitored manually.

Tabitha

Handled by the automated health system. When a drug is about to expire, the system alerts us.

Chemi Chemi ya uzima

It’s a manual system.

Bahati health center

Using stock control drugs card.

Eastleigh health center

Using control cards

Question Seven: How do you deal with cases of disease outbreaks/epidemics?

Site

Response to question

St Mary’s hospital

In case of an outbreak e.g. the recent swine flu outbreak, patients are usually referred to Kenya Medical Research Institute (KEMRI) for testing. Emergency drug ordering is usually done to curb drug stock out which might arise as a result of the outbreak.


CFW

For cases that the clinic cannot handle, patients are usually referred to government hospitals.

Revival Home Based Clinic

Samples from patients are taken to KEMRI for testing and for severe cases; patients are referred to Kenyatta National Hospital.

Tabitha

You can re-order drugs in case of any emergency (outbreak) from MEDS. Inform the community about the outbreak, Supply the community with containers for storing drinking water and water treatment drugs.

Chemi Chemi ya uzima

Inform the district Health Management team in Kenyatta National Hospital. Send the collected samples to KEMRI (Kenya Medical Research Institute) – we take the samples there or call them to come and collect the samples.

Bahati health center

Report the case immediately to the government for example there was a case of a cholera outbreak whereby we had to close the maternity; we were supplied with water treatment drugs and ORS to give to the community.

Eastleigh health center

We have to report the case immediately and the government will direct us on what to do next.

Question Eight: What type of questions do patients often ask?


Site

Response to question

St Mary’s hospital

They usually ask drug related questions and about the cost of the drugs. Patients make up medical follow ups regularly when given appointments.

CFW

Patients do not ask many questions, they only tell their problems to the nurse who then gives them medicines.

Revival Home Based Clinic

Drug related questions and drug usage. Most patients self treat themselves.

Tabitha

Most of them have all the information they need. We make it a point of educating them

Chemi Chemi ya uzima

The cost of the drug and whether you can waiver the fee a little. Prescriptions from other health facilities are allowed if it can be verified that the facility and the prescription are legitimate.

Bahati health center

Some come with prescriptions from elsewhere but we don’t allow prescription from other facilities. So patients have to follow the whole process of treatment from consultation

Eastleigh health center



Question Nine: What do you recommend to patients in case the drug prescribed is unavailable?

Site


Response to question

St Mary’s hospital

Patients usually referred to another hospital with the drug prescription.

CFW

Sometimes we refer the patients to other clinics or specific pharmacies which have the drugs. If there is a substitute for the same drug, we’ll give them the substitute

Revival Home Based Clinic

The patients are usually referred to any other pharmacy which has the drugs prescribed.

Tabitha

Drugs prescribed by the doctor are sent to the pharmacy department. If the drug is not there the transaction won’t commit and the doctor may be prompted to prescribe another drug or refer them to other pharmacies

Chemi Chemi ya uzima

We direct the patient on where exactly to buy the drug (e.g. Uchumi Hyper Chemist). We advice the patient to pass by after getting the drug to verify that he got the specified drug. (this is to try and help fight against drug resistance)

Bahati health center

We tell them to go and get it elsewhere.

Eastleigh health center

They just have to go find it elsewhere themselves since there’s nothing else we can do

Question Ten: How many other pharmacies are there in the area?

Site

Response to question


St Mary’s hospital

There are many pharmacies that are run by untrained personnel and the quality of the drugs they sell is not well known as they receive their drugs from different suppliers.

CFW

Many pharmacies exist in Kibera. Most of them are run by untrained personnel. There are also many herbal doctors.

Revival Home Based Clinic

Kibera has many pharmacies.

Tabitha

There are so many but most of them are not genuine

Chemi Chemi ya uzima

There are so many chemists, after every few meters.

Bahati health center

There are so many of them

Eastleigh health center

I can’t say for sure but they are many

Question Eleven: Which drugs are subsidized or offered free by the government?

Site

Response to question

St Mary’s hospital langa’ta

Drugs like ARVs, Anti-Malarial, TB drugs, Cancer patients’ drugs are usually given out for free to patients needing them. These drugs are usually donated by Non-Governmental Organizations (NGOs).

CFW

Measles drugs, Diptheria, tetanus and TB drugs.


Revival Home Based Clinic

Coatem, Contraceptives, Vaccines.

Tabitha

ARV and TB drugs

Chemi Chemi ya uzima

Coetem, ARV, vaccines, TB drugs

Bahati health center

All drugs are offered free since we are a government facility

Eastleigh health center

All drugs are free

Question Twelve: What challenges do you face in your line of work?

Site

Response to question

St Mary’s hospital

People living in the slum are low income earners, so the problem of cost is inevitable. Patients usually are given drugs on loans. They cannot afford even to pay for the low cost charged on drugs.

CFW

Cost problem, many people do not have money to afford the drugs. Sometimes we treat people we know and trust on credit but you cannot treat everybody on credit.

Revival Home Based Clinic

  • Cost

  • Dissatisfaction because we can only reach a small area

  • Information received wrongly

Tabitha

  • Sharing of drugs


  • Self medication whereby people mix drugs leading to drug overdose

  • Accessibility especially when it rains

  • some herbalist and religions(cults) confuse people

  • people moving in and out of the area so it’s hard to track their progress

  • Environment leading to a sequential course of diseases i.e. cough → flu → pneumonia. One can also come with pneumonia, is given drugs but still continues getting exposed to the cold

Chemi Chemi ya uzima

Unwillingness by people to spend on medication. Most people don’t finish their doses claiming it’s not effective or they feel better after half dose. Self medication and use of here say. Quack operated chemists, insecurity – thugs and rape. Attitude – we are poor and we need to be helped.

Bahati health center

Only one pharmacist hence too much work, under supply of drugs we need, over supply of what we don’t use often

Eastleigh health center

  • There’s the language barrier since most of the residents are from Somali and neither know English nor Kiswahili.

  • Accessibility especially when it rains. All the roads leading to the health center are completely flooded therefore making it difficult to reach us.

Julius, Pharmacist, Tabitha Clinic

There are cases where a member comes with the symptoms of the neighbor who is not registered. After doing all the tests, you find that there’s nothing wrong with them yet they claim to be sick. In such a case all we do is give them a placebo, e.g. vitamins and they go thinking that they have gotten the medication.




Fredrick Ochienge, Pharmacist, Tabitha Clinic

I once prescribed a drug to a patient telling them to take the medicine after meals. They then tell me to first give them food so that they can then take the medicine.




Question Fourteen: Give suggestions on how to improve health care access in urban low income communities

Site

Response to question

St Mary’s hospital langa’ta

There should be measures put in place keep affordable and quality drugs. There should be quality generators to eliminate counterfeit drugs in the pharmacies.

CFW

Government should build more toilets, improve sanitation, and supply clean drinking water.

Revival Home Based Clinic

Government should close down all quack operated clinics and pharmacies.

Tabitha

  • Improve infrastructure and sanitation

  • health education

  • Create employment opportunities for the community.

  • Have several facilities issuing the same services (free), mobile clinics, ambulance services,

  • improve hygiene, water system and sanitation

  • micro-finance to improve the living standards

Chemi Chemi ya uzima

Do away with quack chemists

Bahati health center


KEMSA to supply us with enough drugs that we need.

Eastleigh health center

The roads should be repaired

PHARMACY AND POISONS BOARD

Question

Answer

How many pharmacies are there in low income communities living in urban areas?

We can’t say for sure how many pharmacies there are specifically in low income areas. But we have information about how many pharmacies there are in overall in regions e.g. Nairobi

What measures are you taking to counter supply of counterfeit drugs?

Most of the counterfeit drugs come from outside the country so we have designated point of entries of drugs to the country, these are; Jomo Kenyatta International Airport, Malaba, Namanga, Busia, Eldoret and Mombasa Port. Drugs entering or leaving the country must have been issued with a permit that verifies their authenticity. We also carry out post market surveillance whereby we pretend to be customers and go to various pharmacies, buy drugs and test them in our lab. If they are found out to be counterfeit, we’ll take the appropriate measures.

What measures are you taking to control cases of unqualified personnel operating as pharmacists?

We have inspectors who go around accompanied by police to crack down on pharmacies that are not registered. The person found in the premises is arrested and charged. We have also enforced a rule to distributors that they should not sell to unregistered pharmacies.


What measures are you taking to educate the public on how to identify genuine pharmacists?

We are using the media to offer civic education to the public. For example telling people to look out for the two licenses (premise and practice) which should be hang in every pharmacy. A while back the pharmaceutical Society of Kenya had adopted the green cross whereby all the registered pharmacies were marked with a green cross so it was easier for the public to identify them but for some reason the initiative failed.

What are you doing to improve access to medication in urban low income communities?

We are registering as many quality generic medicines as possible which is sold at a lower cost that is affordable to the low income communities

With most people turning to herbal medicine, are you doing anything to encourage or discourage this?

There is no way of confirming who are genuine since some claim that they have the knowledge passed on from their forefathers. We can’t deny this since before conventional medicine we used to rely on herbal medicine and it used to work. But there is a law that states that anyone claiming of anything being of medicinal value must first be registered with us after we have verified it is true. As per now, the law only caters for conventional medicine but there we have set up a committee of experts to look into herbal medicine. This is headed by registered herbalists, Dr. Githae and Professor Mwangi and includes stakeholders such as pharmacognotists, National Museums of Kenya and traditional healers. The aim is to include testing and registration of herbal medicine

What are the challenges you face?

Insufficient human capacity in terms of inspectors needed to crack down on manufacture and importation of substandard and counterfeit medicines, supply of medicines to unregistered people and operation of establishments by unqualified people.

Insufficient resources in terms of the finances needed to carry out the inspections and to pay and accommodate the inspectors when they are on duty. For example, to carry out a post market surveillance for only day requires about 8 million shillings.



Dr. W.K Gachoki, Assistant Chief Pharmacist, Pharmacy and Poisons Board:

There is a case where a person claimed to be using a computer to heal people. I think it was just a simple computer program. A sick person would come and would have wires attached to him and the wires were connected to a computer. The patient would then be asked to say his symptoms which were fed into the computer. When all the symptoms had been entered, there would be lights, also connected to the computer, going on and off. The man then proclaimed to the patient that they had been cured. To most people this was like a miracle and they blindly gave money with the prospect of being healed. We therefore had to come in and take action so we arrested the man since he claimed that the computer had medicinal value.




OTHER FINDINGS

  1. Reasons as to why there are many illegal dispensing chemists in low income areas:

    • High county council annual fees while the returns are low.

    • The standards set by the Poisons and Regulatory boards are difficult to achieve here i.e. space, water, power, permanent structure, sanitation.

    • Free drugs offered by NGOs thus diminishing the possible returns, hence it’s not attractive for qualified private pharmacists to invest in this area. Also insecurity.

  1. Reasons why people prefer the dispensing chemists to pharmacies:

  • Time – people feel that they waste a lot of time while queuing in the clinics and health centers.

  • Feel dissatisfied in clinics but the chemists seems to listen to them more and offer them a wide variety of drug to choose which to buy.

  • Allow self medication of patients (in terms of which drug and dosage)
  1. Drugs from most of the private chemists are:


  • Poorly stored – the chemist may be made from iron sheets or mud; the drugs on the shelves are exposed to direct environmental weather changes; the high temperatures of the day and the low temperatures of the night, high humidity changes and wind. This affects the quality of the drugs, since most require ‘cool and dry storage conditions

  • Contaminated – the drugs are dispensed on bare hands (which may be dirty) since the sleeve cost a shilling or two which means extra cost to the patient and the chemist. For suspension drugs patients bring their own bottles to collect the drug. The source and cleanliness of the bottles is questionable i.e. are recycled

  • Expiry of drugs not regularly checked hence sometimes issue expired drugs. It’s mostly the patients’ duty to check whether the drug is expired if he does well and good if he doesn’t, too bad he ends up using the drug.

  • Giving under dose or overdose of drugs – When a patient doesn’t have the money for the whole dose, he/she will be given the medicine which the chemist assumes corresponds to the money the patient has, this therefore leads to the patient taking less than is required which could lead to the patient developing drug resistance.

  1. Misdiagnosis for example at Chemi Chemi ya Uzima Clinic we were told a story of a pregnant woman who went to a chemist bleeding and was given an unknown injection which led to her having a miscarriage.

  2. Patients normally come when they are really sick trying spiritual, herbals and the chemist intervention before going to a health facility. We try to interact with them on a very personal level socially in order for them to disclose if and when they used those drugs from private chemists.
  3. Most people mix religion (cults), herbs and conventional medicines simultaneously or alternating them in the treatment of one disease. This leads to undesirable side effects and overdosing. Mostly people come to the hospital as the last option.


  4. The prescription of herbal medicines is questionable since it’s difficult to determine the right dosage for a particular disease i.e. a patient may be given 5Litres of some concoction and told to take 2 glasses three times a day for a week. This may be an overdose or under dose since the medicinal contents in the concoction is a mystery, if it’s not a misdiagnosis by the herbalist.

  5. The advertisements of the herbalists sound too good and are therefore attracting most of the residents for example “A Chinese herbalist offering contraceptives from China with a lasting effect of one year.” The people see this as a good offer since the medicine has been brought from China and need only to be taken once a year as compared to the conventional medicine which has to be taken every single day.

CHALLENGES FACED

  1. Accessibility – Getting to some of the areas was difficult. For example getting to Eastleigh was a problem since we went while it was raining. We found the roads flooded a little and the rain was not even a lot. We could only imagine how the roads are during the long rains.

  2. Uncooperative respondents especially the ones operating pharmacies illegally since they thought that we were inspectors coming to arrest them

SUMMARY

Both the public and private health facilities are understaffed and have shortages in terms of pharmacies and laboratory departments. This is due to govern­ment economic constraints as well as policies which were advocated by the International Monetary Fund (IMF) to freeze public sector employment. Kenya has about eight pharmacists for every 100,000 people which is even an increase from 1998 when the ratio was much less than that.

Most of the facilities still use manual methods in all their transactions. This is due to the fact that it’s the method most of them are used to therefore they find it normal. This can also be attributed to the fact that most of them do not have any knowledge of technology. If they can be given an easier automated way of doing their transaction and taught how to use them, they would really come to appreciate it.

KEMSA (Kenya Medical Supplies Agency) supplies only to the government facilities depending on the level of the facility. The lowest level is the dispensary followed by the Sub-district, further up is the district hospitals and finally the national hospital which is Kenyatta National Hospital. The other NGO or mission based hospital are supplied by MEDS (Mission for Essential Drugs and Supplies)


REFERENCES


  • International Pharmaceutical Federation (FIP). 2009: Global pharmacy workforce and migration report. (www.fip.org/hr)

  • Soren Ambrose, Preserving disorder: IMF policies and Kenya's health care crisis, Issue 257(http://pambazuka.org/en/category/features/34800)



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