FARMACIE MONDIAAL

Report Internship Rwanda

Merel PhilippartPeriod: 05/01/2015 until 08/02/2015

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Content

Project plan & goals Page 3

Short overview of activities Page 4

Activities & Analysis Page 5-13

Reflection Page 14

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Project plan & goals

During my time in Rwanda I, first of all, aim to get a broad overview on the pharmaceutical care within the country. Additionally, I hope to add value were possible by transferring knowledge gained during my education at the University of Utrecht. I aim, in this short notice of time, by analysing different aspects of the pharmaceutical care to be able to design project plans which I could hand over to students who could optimize them and where possible (and wanted) start with their implementation. I will be placed in different locations, namely two hospitals, a wholesaler (Kipharma) and at the University of Butare. I will have specific aims within these different places, which will be the following:

- Transfer of knowledge to pharmaceutical students of the university in Butare. I will do this by giving a lecture and additionally get in dialog with the students about the content of their study and their opinion on the quality of their education.

- Get to know what the function is of a hospital pharmacist in Rwanda. Where possible (and wanted) I will consult how to optimize processes related to the work field of the pharmacist.

- Get to know how medication surveillance is being practised in the public pharmacy. Where possible I will consult how to optimize medication surveillance.

- Get more insight of the different functions of a wholesaler and additionally be involved in different projects related to the supply of medication.

I have been places at three locations:

1) Hospital pharmacy (Ruhango and Kibogora) – 1.5 week2) University of Butare – 0.5 week3) Wholesaler (Kipharma) – 3 weeks

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Short overview of activities

In the first week I was placed within the two hospital pharmacies. Apart from getting to know the function of the pharmacists, I additionally focussed on getting a broad overview on how the pharmaceutical care in regulated within Rwanda. I got to know about the different insurance systems, the role of the hospital in relation to Health centres, the list of essential medicines of Rwanda, how hospitals are being supplied with medication and many more basic aspects.

I was impressed how well regulated the pharmaceutical care in Rwanda is. There are still many challenges to overcome, but the foundation has been set. Every single person has access to the essential medicines. This has been made possible by an insurance system in which a yearly amount of +/- 3.5 EURO per person covers basic care given in public hospitals. A percentage of 10% of the given care has to be paid by the patient and the additional 90% will be paid by the insurance. The system is not yet functioning perfectly as question marks can put whether 3.5 EUR is enough to cover all the expenses made. Still, the healthcare of Rwanda is far more developed than in their surrounding countries. Things seem to work here in Rwanda, generally spoken.

In both hospitals the pharmacists made time to answer my question and discuss my concerns. This basic knowledge was very useful and necessary for the follow up of my internship because it made it possible to put everything in the big picture.

In the second part of the internship I was situated for two days at the university of Butare and for three weeks at the wholesaler Kipharma. At Butare, I gave a lecture to students of the third grade of the Bachelor of Pharmacy. I choose pain management as the topic of the lecture as we had seen some cases in the hospital were the pain management was, softly expressed, suboptimal. For this reason we assumed that the knowledge about pain management could be lacking among students too. We discussed the pain ladder of the WHO with the students and related aspects, which were all fairly new to them. The lecture was a success followed by a lively discussion afterwards. This example is illustrative that the combination of the different fields within this internship were working beneficial.

The last three weeks I spend at a wholesaler, named Kipharma. It was my first time at a wholesaler, so many things were new to me. The first week I was given an introduction of the different departments. I was introduced in the work of the laboratory, the procurement process, the supply chain management and I spend 1.5 day in two pharmacies owned by Kipharma. After this week of introduction I discussed with de director in what projects I could participate. We decided for me to work on two different projects. In the following two weeks I spend most time on those projects. I was very well supervised during those weeks which made it fun to work on those topics. Also in this place it felt like an advantage that I had already gained knowledge of the pharmaceutical care in the field. With that background it was easier to position the role, goals and challenges of Kipharma.

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Activities & Analysis

I have divided this section in four parts: hospital pharmacy, the university of Butare, public pharmacy and the wholesaler Kipharma. Each section is introduced by the goal(s) I had within this section. Then I describe what I have learned and additionally the activities done related to achieve the predefined goals(s). I close each section with a recommendation on how different aspects/processes of the pharmaceutical care could be optimized in my view.

1. Get to know what the function is of a hospital pharmacist in Rwanda. And, where possible (and wanted), I will consult how to optimize processes related to the work field of the pharmacist.

In total, I have spent 1.5 week within two hospitals. During this period I gained knowledge about the tasks of the hospital pharmacist as well as about the (pharmaceutical) care in Rwanda in general.

Rwanda has 30 districts. Every district has one or more hospitals. One of the hospitals within a district is considered the ‘District Hospital’. Apart from hospitals, districts have several health centres. Within health centres there are only nurses working and only basic medication is available. All doctors, so also GPs, are based within hospitals. A patient generally visits first a health centre. When the given care is not sufficient for the patient or the medication is not available within the health centre, the patient twill go the visit a doctor at the hospital.

Most people in Rwanda are insured. This is made possible by the insurance system developed by the Rwandese government. It works as follows. Apart from private insurance companies there are two public insurers. One is called the RSSB, mainly developed for people working at public institutions. Employees pay a certain amount every month and the employer pays the same amount to the insurer as its employee. When visiting a hospital, a person with this insurance has to pay 15% of the total expenses. The other 85% will be paid by the insurance company. The second public insurance company is developed for the least wealthy people living Rwanda. Every person pays +/-3.50EUR on yearly basis. For this amount they can visit any health centre or public hospital. The have to pay 10% of the care receive, the other 90% is paid by the insurance company. Currently, some question marks are put whether such a small amount is enough to cover all the expenses. Within the government is has been decided to merge both systems. There will still be a separation between the amounts of money that has to be paid by different classes. One more financial point worth to mention is that for a number of diseases special programmes have been developed that cover the expenses of the medication for this diseases, including TB, Malaria and HIV.

The supply of the medication within the hospital is highly regulated by the government. A hospital is not allowed to buy or import their medication wherever they want. Hospitals are obliged to order their medication at public institutions called District Pharmacies (DP). Additionally, DP’s are obliged to order their medication at a public wholesaler, named MPPD. Only when MPPD is not able to deliver the ordered medication, the district

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pharmacy is allowed to import from other wholesalers. For every product that can’t be delivered by MPPD, a DP has to ask permission at the minister of Health to get permission to import it at a different wholesaler. Only when the DP is not able to deliver the medication to a hospital, than the hospital is allowed to import from other wholesaler. As you can see, many parties are involved in this process. This all could work in case the MPPD has most products in stock and is thereby able to deliver quickly. Unfortunately is this not the case. MPPD has only approximating 14% of the products available. The results of this are obvious. It can take ages to for a hospital to receive (only a part of) their order.

The role of the pharmacist within the hospital is mainly being a store manager, doing a lot of administrative work. The highly regulated supply chain results in a lot of logistic work for the pharmacist. Because most of the time only a part of the order is delivered, the medication that was not supplied needs to be ordered at other wholesalers. Most wholesalers in Rwanda do not have every medication in their stock, resulting in the fact that the pharmacist has to approach different wholesalers for the medication needed.

Another logistic challenge is the fact that all medication dispensed during a day needs to be inserted in a computer system to update the Ministry of Health on the consumption. The main issue here is that the system works online. The internet within the hospitals (if there is internet at all) is slow. Resulting in the fact that it takes ages to insert all dispensed medication. In both hospitals, the pharmacist was doing this, which took a significant part of the day. Apart from the logistic part the pharmacist were mainly dispensing medication to patients. There was just a small amount – if any—time left for patient care in the form of optimization of the farmacotherapeutics and medication surveillance.

In my opinion it is a pity that the hospital pharmacist lacks time for the core business of a pharmacist. Unfortunately is seems not possible to reduce the time that has to be spend in logistics. However, it is not necessarily the pharmacist that needs to insert the numbers in the system of the ministry of Health. Neither is it the pharmacist that has to leave to hospital for a couple of hours to get a box of tramadol of another hospital (happened in Ruhango). The pharmacist can win a lot of time by allocating tasks to others. They could, for example, train a nurse in inserting all the dispensed medication and send a driver to get the box of tramadol. The pharmacist in Kiborgora was very open fort his and planning to train one of his nurses in computer skills.

The pharmacist also mentioned that because of the lack of time he has for clinical pharmacotherapeutics. He would be very open for a student that could join him for a longer time to discuss different the medication of different patients within the hospital. By this he could gain knowledge in pharmacothepautics as well as spending time to train one of the nurses on the computer system. Both pharmacist had just little knowledge of contra-indications, interactions and side-effects. To help them gaining knowledge within this field I asked them

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to provide me a list of the 30 most subscribed medication within their hospital. I suggested to the next student to use this list to make an overview of the interactions, contra-indications and side-effects of these medicines.

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2. Get to know how medication surveillance is being practised in the public pharmacy. Where possible I will consult how to optimize medication surveillance.

Kipharma has two pharmacies, which are mainly being supplied by the wholesaler Kipharma. Both pharmacies, like every pharmacy that is not situated within a public hospital, is private. Citizens with the ‘mutuel’ insurance are not covered within private pharmacies. They are allowed to get their medication from private pharmacies, but need to pay the total amount. As the ‘mutuel’ insurance has been developed for the least wealthy, those people are not able to pay for their medication. So they are solely dependent on the medication being available within the public hospitals. Kipharma supplies its medication to persons with the RSSB insurance as well as private insurance. Meaning it serves the middle and upper middle class of the population.

Many brand names are found in the pharmacies. Even when the patent of the product has expired, the brand name is still being dispensed. I was surprised to see this as it seems to me that this results in an unnecessarily high costs of the health expenditure. As this used to be the case in the Netherlands, it has been decided by the government that only the cheapest generic (or a somehow comparable mechanism) will be covered by the insurance. Which has resulted in a major drop of the Health Care expenditure.

I discussed this with one of the pharmacist and he could give me a clear explanation why this is not (yet) the case in Rwanda. First of all, brand names are associated with quality. And, additionally, generics are associated with low quality. The reason behind this is that many generics come from India or China. The generic manufacturers of those places apparently have two different production lines. One for Europe, where they produce high quality generics that fit all criteria set by the European Health Authorities. And one production line for African countries, where low quality generics are produced. So, many generics in Africa are not comparable with those in Europe. The low quality generic medication results in the fact that generics have a bad name in general. Which is, in my opinion, a shame. This is at the same time the reason why brand product are associated with high quality and still being sold in significant amount even when their patents are expired.

As said, I have only spend one and a half day within the pharmacies. This was mainly related to the language barrier. I don’t speak Rwandese and my French is minimal. Because I had one specific point of interest, namely medication surveillance, this period of time was sufficient to get an idea how it works and how it could be improved. Kipharma had developed its own computer system. When a product is dispensed the stock will be automatically updated and a sign is given when the stock of a product falls under a certain amount. The system has been expanded to the procurement section. By this system the sales can be analysed and the procurement can be based on the analyses. The system is being used by different pharmacies within Rwanda. It is simple, straightforward that seems to work most of the time.

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When a patient gets it medication, his/her name and insurance company is inserted in the system. The prices of each insurance are automatically coupled. When dispensing the medicine the pharmacist or nurse gives some basic information like the dosage, the time the drugs need to be taken and to finish the cure in case of an antibiotic. For interactions they use ‘basic knowledge’ which differs between people. The system does not remember the medication that has been prescribed in the past to the patient. And therefore the system is for example also not able to identify potential interactions or double medication. The patient is thereby not questioned about his medication history.

My suggestion to the pharmacist was to therefore to implement medication history of patients within the system. (Later on automatically generated medication surveillance can be added). Both pharmacist thought it was a good idea, so I suggested this to the director. Who also could see the benefit of the implementation of medication history within the system. Another student going to Rwanda could possibly take this up as a project.

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3. Transfer of knowledge to pharmaceutical students of the university in Butare. I will do this by giving a lecture and additionally get in dialog with the students about the content of their study and their opinion on the quality of their education.

I have visited the University of Butare for two days. The first day we (Wietske, Endriaen en me) had an appointment with the head of the department. He explained about how students are trained in Rwanda to become a pharmacist. A bachelor in Rwanda has a duration of 5 years. After the bachelor you can call yourself a pharmacist. This is different from the education system in Europe, where a bachelors is three year and a master two or three years. Only when you finished your master successfully you can work as a pharmacist.

One other aspect that surprised me was that a significant part of the study was allocated to logistics, which is not at all the case in the Netherlands. But, as I experienced in the hospitals, logistic activities take most time of the pharmacist so it makes sense that students are being trained within this field.

Out of the conversation with the students came that the role of the pharmacist has not been fully recognised. Some changes are being made in the law now, but for a long time it was for example not obligatory for a pharmacy to have a pharmacist. Everyone could open a pharmacy. Luckily this has changed. But, still pharmacist are fighting to be fully recognised in the law. Some students were active within this field, having contacts within the ministry were they discuss the topic. Also doctors generally do not recognise the value of a pharmacist. It was remarkable to see that pharmacists struggle here in a similar way as they do in the Netherlands.

The students showed us the laboratory, which looked amazing. It was a spacious room with all kind of analysing machines. Unfortunately the laboratory was not used very much. This was mainly due to a lack of human recourses and too much students to teach all in once. Another reason was that it is hard to order materials and substances needed for different experiments. It is apparently a huge administrative burden when you order something. Again, highly regulated.

The second day we were given the opportunity to give a lecture for the students in the third year of the bachelor. In the hospital in Rwanda I experienced several times that the pain treatment was suboptimal. This is the reason I choose pain management as the topic of the lecture. I assumed that the knowledge about pain management could be lacking among students too. I discussed the pain ladder of the WHO and related aspects with the students, which was all fairly new to them. The lecture was a success with a good discussion afterwards. This example is illustrative that the combination of the different fields within this internship were working beneficial.

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I have too less experience to have an opinion about the quality of the pharmaceutical education in Rwanda. Although, I experienced that the knowledge about pain management was minimal, the students seem to have good knowledge about related topics. Their questions were sharp and showed a good analytical capacity. It is a fact though that the students do not gain many experience in the lab during their education. The students regretted that fact. Moreover, since they have this high tech laboratory with many interesting analytical machinery. The three reasons why they did not use the laboratory could, in my opinion, easily be overcome. First of all, the lack of human resources can be overcome training older students to become student assistants. The students never heard of this term and liked the idea. That there are too many students to teach in once can be solved to make smaller groups. This was initially not possible due to lack of human resources, but since that problem is challenged it is not a limitation anymore. The problem with the difficulties of ordering lab material can be minimized to design experiments where minimal materials are needed. I think this would be enough content to set up a project plan.

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4. Get more insight of the different functions of a wholesaler and additionally be involved in different projects related to the supply of medication.

I spend three weeks within the wholesaler for medicines and medical products. Kipharma is one of the biggest – if not the biggest wholesaler – of Rwanda. It used the be the only wholesaler in Rwanda, nowadays there are more pharmaceutical wholesalers within the country. There are approximately 15 other wholesalers, of which 6 big ones. It serves public as well as private institutions. Many private pharmacies within Kigali are supplied by Kipharma. As already mentioned, public institutions first need to buy their medication at public wholesalers. Only when these wholesalers are not able to supply, they can go to private wholesalers like Kipharma. Apart from the supply of different institutions, a significant part of their revenue comes from participation in tenders. The departments within Kipharma can be generally categorized in: lab, sales, marketing, procurement, logistics, general management, stock & tender. In the laboratory the focus lays on the production regular production (mainly dermatology products), magisterial preparations and repackaging. The laboratory is not GMP qualified. For the pharmacist informed me that for the future they are planning to expand the activities of the laboratory and would like to get it GMP qualified.

In the first week I got an introduction in all departments of the company in order to give me a broad overview on how the company is structured. The company is subdivided in different departments, namely lab, sales, marketing, procurement, logistics, general management, stock & tender. The person in charge within every department made plenty of time to inform about their activities and answer questions.

In the laboratory the focus lays on the production dermatology products and magisterial preparations. The laboratory was not GMP qualified. The pharmacist informed me that for the future they are planning to expand the activities of the laboratory and would like to get it GMP qualified. For me, this project was too big to be involved in in such a short amount of time.

In the weeks that followed I decided to focus most on the supply chain management. The supply chain management involves the following departments: sales, stock, procurement, tender and general management. I was highly interested in this department, namely because of all challenges of access to medicines in the developing world. And also because of what I experienced within the hospitals in Rwanda. As already mentioned, the supply of medicines in public hospital is a huge challenge due to strict regulations set by the government. Apart from this I found it really interesting to get more insight in how different departments work together in order to optimize the supply chain management.

Apart from some small side activities I have been involved in two projects. The first project was related to the potential import of generic medicines. Kipharma was approached for collaboration with an NGO. This Ngo has several health posts around the country and was looking for a reliable wholesaler for the supply of generic medication for these health posts. Kipharma is currently not focussing on cheap generic medication. One of the reason is that the cheap generics that come from India and China do not always meet the quality standards. I was not aware of the fact that companies from India and China (and of course probably other countries) have two different production lines. One for Europe, where they produce high quality generic medicines and one production line for Africa, where they produce low quality generics. So, for the selection of a generic company, many attention needs to be paid to the quality. I have approached different generic companies whether they supply – or are interested to supply – in Rwanda. I additionally made an analysis of the prices the NGO currently pays for their medication (which they import from different wholesalers within the country) and prices given by other generic companies. The companies that have responded could not met the prices the Ngo is currently paying, so for now we decided not to contract the NGO. The research in a high quality and low priced generic company to cooperate with will continue.

Another project I have been involved in was the import of different lab materials. One company, which is known to produce high quality materials, gave a price list of different lab materials which are of interest of Kipharma. My task was to compare these prices with the prices Kipharma currently pays for these materials. During the analyses I found out that there was an order placed (not conformed yet) for the same materials

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produced by another company. The materials within this company lay significantly lower. Some prices where 1/7 the of the market reference price. For this reason I put question marks by the quality of the materials. In consultation with G I approached the lab pharmacist to question him if he had received any samples of those product. He did. The pharmacist had received two different samples, namely white Vaseline and acetylsalicylzuur. Both samples had a low quality. The extreme low price in combination with the low quality made us decide to cancel the whole order. We decided to cancel that order.

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Reflection

Apart from that I think, no I am sure, I have learned many things. After my secondary school I spent a couple of months in Malawi. As that being my only African experience I expected a slightly similar situation. Yes, I do realize that is quite narrow minded..

Things are just different in Rwanda. It already started at the airport in Kigali. Everything looked highly structured and clean. There was for example free wifi in the airport and every person got checked for temperature (ebola). This first impression was being confirmed during my whole stay. Rwanda: the Switzerland of Africa. I have lived in Switzerland and I think this really is true. Rules and regulations, they just love it. Where I got fined in Switzerland for riding someone on the back of my bike, I got a warning from a Rwandese police officer I was standing in the grass along the pave yard (to shelter under a tree for the rain). Apparently not allowed. When a person with a magnum 2.1 warns you, you just take that seriously.

Furthermore, I have been highly impressed by the health care system. The way it is currently working, especially after having been told how the situation was 20 years ago. Of course, it is not functioning perfectly yet and there are still many challenges to overcome, but the foundation has been led. In neighbouring countries the system has not been developed as well as it is in Rwanda.

A have thereby certainly broaden my view on the pharmaceutical care in general. You only realise what you have the moment you don’t have it anymore. This is applicable to many things. In the Netherlands we take everything for granted. We don’t realise what we have because it’s just there. Being in a country as Rwanda it makes you realise that for many people things you assume to be normal are something they have to fight for every day. In respect to pharmaceutical care, in the Netherlands we assume that every medicine is available and moreover, covered by our insurance. And of course there is a social security and everyone has a basic healthcare insurance. Those are all not the case in Rwanda. Not every medicine is available. Moreover, even the essential medicines are not always available. Not every medicine is covered by the insurance. And, yes you can guess, not everyone is insured..To be a bit more specific on the role of a pharmacist, in the Netherlands the pharmacist is not most of his time working in logistics by making sure all medication is available. In the Netherlands the pharmacist is – at least we aim to be- a health care professional who’s role is to optimize pharmaceutical care for their patients. In Rwanda, there is just no time for medication surveillance. So again, what for us is considered normal, is certainly not case in other parts of the world. I do realise this sounds all very obvious. But still, I think we generally take things for granted and do not realise in what kind of heaven we live.

Lastly, I have met many nice people, which really added to my overall feeling about Rwanda. People were helpful. Sometimes because you were ‘musunge’ (white person) and therefore rich in their eyes. However, many times people were just friendly.

I really enjoyed the teaching at the university of Butare. Mainly because the students were very interested and eager to learn about the topic presented. They did not seem to know a lot about this specific subject, but their questions showed that they took it up very quickly and were able to put the content in the big picture. After the lecture we got in dialog with some of the students and found out how active they were in pharmacy related activities next to their study. They were highly motivated and energetic and all seemed to share the aim of improving the health care in Rwanda. This really gave me a lot of positive energy.As already mentioned, I was impressed by their health care system. Although things did not function perfectly yet, the foundation has been led. It seems that the government in Rwanda aims very high in for example improving health care and reducing poverty. Although the goals itself are too hard to reach, many improvement are and will be made. They don’t use the strategy ‘increasing success by lowering the expectations’, but the other way around. There are of course pros and cons for both approaches. Setting (too) high goals works in Rwanda.Another aspect that touched me was ‘umuganda’. Umuganda is the last Saturday of the month were everybody is asked to do community work in the morning, like sweeping the streets or building houses for poor people. This is followed by a community meeting were political questions are discussed. It brings people together. A day were you focus not on yourself but on the community. It touched me and made me realise

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that we lack community thinking in the Netherlands, people generally focus on themselves. Of course, it’s not that black and white, but generally spoken..

What I likes less was to realise that the role of a hospital pharmacist is mainly logistics and the role of a public pharmacist is mainly dispensing. When I was in the hospital of Ruhango, the hospital pharmacists was almost only focussing on logistics. When we visited some patients in the hospital, their pharmacotherapy was far from optimal. There was for example a patient with late stage cancer under palliative care. She was in real pain. She just got a low dose of tramadol every day. I was the one that had to propose to higher the dose of tramadol or preferably start straight away with a strong opioid. I think this was a really said situation. What additionally frustrated me is that there was no tramadol available and that the pharmacist went to another hospital (1.5 hours away from this hospital) to get a box of tramadol. It seems to me that this is not an optimal time-management strategy. As there is already (too) much logistic work to do it is worth to carefully allocate tasks, in my opinion.

One other thing I struggled with is that I don’t really like to be ‘the musunge’ (white person). People see you as a big white Oliphant with a lot of many. So sometimes you think you have a nice conversation, but in the end there is just one thing the person wants. This was of course not all the time the case! I think I just don’t like it to be seen as different, I want to be one of the people I am living with.

I would have gotten more into detail beforehand with the pharmacists and director of Kipharma. By this we could have more specified what activities I could do at the different locations. A good preparation can highly benefit the work that can be done locally. For example, in the hospitals a preparation could have made the work locally way more beneficial. Both hospitals struggled with too much logistic work and too less time for clinical pharmacy. This resulted in a lack of pharmaceutical knowledge of the pharmacist and also the nurses. A program to train them could have been designed before going there and the time there could have been used to train the pharmacists and nurses.

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