Integration of pharmaceutical care in rural public health : a case study in Ugu and Umzinyathi districts in KwaZulu-Natal

Abstract

South Africa’s Healthcare system being in transitional phase presented opportunity for pharmaceutical service development within the public sector, however, strong leadership with visionary advocacy and stewardship is indispensable. The National Health Insurance (NHI) mandate and the growing emphasis on primary healthcare (PHC) re-engineering, further strengthens the prominence of many healthcare professionals and processes towards equitable and quality healthcare service delivery, among them pharmaceutical services. This research sought to identify the gap in the provision of pharmaceutical care services within the rural public context. There are several reasons why an investigation into the role of the pharmacist in PHC facilities is warranted. Firstly, several pharmaceutical processes within the public sector have and are contributing to a void in the pharmacist primary role and responsibility, thereby promoting their expansion into PHC, which at present is limited. Secondly, the growing incidence of communicable and non-communicable diseases (NCDs) by the lack of clinical governance questions the quality of patient-centred care and outcomes. Thirdly, the absence of antibiotic and anti-retroviral clinical stewardship and the World Health Organization calling for professional collaboration in managing NCDs highlights the need for pharmaceutical care (PhC) intergration. Therefore, the study focus aimed to guide the development of a collaborative pharmaceutical care model, within the rural domain, by applying a mixed methodology to describe the roles and responsibilities of the Primary Care Drug Therapy (PCDT) pharmacist; identifying enabling and disenabling factors to consider in developing a collaborative health care team through the perceptions of key informants, authorized nurse prescribers, visiting doctors and pharmacists working at the public primary healthcare clinics, and by conducting the South African Pharmacy Council (SAPC) legislative assessment of the ‘ideal’ clinics. The basis of the argument encompassed philosophical perspectives, legislation, role and collaborative advantage theory including moral theory of Ubuntu and care ethics related to rules and regulations of pharmaceutical care practice. The study harnessed healthy discussions among public healthcare professionals. The outcome supported unanimously a need to integrate pharmaceutical care and that a Pharmacist can add a meaningful role to the delivery of optimal patient care. A role of collaborative practice was preferred, citing conclusively themes of role clarity, resources & location and drug supply management by 100% of the respondents. An interprofessional team of doctor, authorized nurse prescriber and pharmacist at facility level to ensure a public health, primary care, clinical patient outcome focus was favoured by 97% of the respondents. Continued training of nursing staff and pharmacists was advocated by 94% and 62% of respondents respectively. Further themes of patient safety (82%) and quality of care (76%) were highlighted. The Kruskal Wallis test (p<0.05), illustrated statistically significant differences for doctors and authorized nurse prescribers in four medication related processes, diagnosis & prescribing; administration/documentation; education & training and medication review, with nurses moreover monitoring patient safety. Pharmacists instead placed more emphasis on monitoring compliance, educating patients about chronic medication, providing drug information to prescribers and identifying prescribing errors than over prescribing rights. The barriers identified were transport unavailability for outreach services, language deficiencies, scarce resource equipment and the shortage of doctors and authorized nurse prescribers.The pharmacist advocacy in these under-resourced rural communities that was demonstrated beneficial is one that drives pharmacovigilance in adverse drug reporting, antibiotic stewardship, clinical governance with continuous prescription audits followed by structured training for PHC authorized nurse prescribers, patient engagement and interaction to ensure optimal patient outcomes and safety. The factors to be considered for such an intergration rely on facility infrastructure, co-location, SAPC legislative compliance standards among them, role clarity building on relationship and trust, leadership, principles of Ubuntu and care, a culture of accountability and responsibility, implementation time, and local context. Encounterted limitations of time, distance and challenging terrain confined the research study to two rural districts wherein selective sampling further narrowed the clinics to ideal status. Future action research of a larger sample across more rural health districts and primary healthcare clinics is hence recommended to validate and expand the findings of the study which commits to apprise significant role players in Sub-Saharan Africa that may wish to pursue similar practice within a rural context, in the hope of changing “Africa’s health care landscape”.