NAME: ORIERE OSEZUA DENIS

COURSE YEAR: YEAR FOUR (400L)

SCHOOL: UNIVERSITY OF BENIN (UNIBEN)

FACULTY: FACULTY OF PHARMACY

TOPIC: THE STATE OF PHARMACY PRACTICE IN AFRICA: CHALLENGES AND THE

WAY FORWARD.

EMAIL: denisoriere@gmail.com
INTRODUCTION: Pharmacy practice in Africa involves the various healthcare and
educational/research practices dispensed by a pharmacist to people/patients seeking advise and
knowledge from the pharmacist. These can be in the form of advise on patients' medication, instructions
on how to use these medications, advise on side effects these drugs cause to the patients or even
adverse effects.

The pharmacists is usually the first-line healthcare provider to most people, being more close to the
community (hence community pharmacist) and mostly offering free medical advise to patients in the
community.

Other forms of advise a pharmacist can give can be to a general physician, when a pharmacist spots a
dangerous drug-drug interaction in a prescription, or when the pharmacist realizes another drug would
solve the problem of the patient better and with less side effects.

Educational and research knowledge from a pharmacist can come from institutions like an university, a
teaching hospital, both institutions that specialize in training future pharmacists. Students pharmacists
also learn alot about the field of pharmacy practice generally in community pharmacies, especially when
on training there along their study in school. For example, my lecturers, especially from the departments
of pharmaceutical chemistry and pharmacology would usually refer to things we students might've
learnt while on our industrial training (I.T), and most of the practical applications were from the things
we learnt while in the field in community pharmacies. Departments like pharmaceutics and
pharmaceutical technology were usually more sensible to one who had previously worked in a
production pharmacy.

Teaching hospitals also have scope for research, as a student or a pharmacist will be intimate with
patient cases, drugs and research materials. This also applies to universities, especially one that has a
teaching hospital attached. Professors will mostly head research groups in school, especially for project
students. But students can also have groups aimed at research, especially if it is to help understand
topics taught in class.

Seminars on research materials can also be held, to educate other like/interested professionals on new
discoveries in the general medical field.

Hardcore research facilities aimed at discovery and design may not be as common in Africa as in other
first world continents mostly due to funding and availability of first rate research equipments. This
brings us to discuss the state and challenges of pharmacy practice in Africa.

As a Nigerian pharmacy student, most of my experiences in this writing will be based on the Nigerian
pharmacy practice and then expanded to the general pharmacy practice in Africa.
- Hospital Pharmacy Practice.
Pharmacy practice in hospitals can be very engaging, especially when one works in large hospitals or
teaching hospitals. The pharmacist is always involved in a treatment plan that involves all patients
needing medications to treat one ailment or the other.

The pharmacist will act in-between the prescribing physician and the patient to check the compatibility
of a prescription, drug-drug interactions, patient compatibility and eventually dispense the medications.
This will require alot of the knowledge of the pharmacist, especially to detect dangerous drug
interactions or side/adverse effects.

When a pharmacist sees a dangerous drug-drug interaction, he is obliged to discuss with the doctor and
recommend better medications for the patient's treatment plan, and the doctor decides eventually what
would be best for the patient.

Situations may arise whereby a general physician rejects this recommendation from a pharmacist, and
still insists on what was initially written in the prescription. The pharmacist, due to his/her training, will
still refuse to fill the prescription. This can cause tension in an hospital setting, and in lots of cases,
usually involves superiors in the hospital to resolve such issues.

Due to the way things are in Nigeria for example, these superiors involved in solving the disputes are the
HODs of the various pharmacy and physician's departments. A CMD (Chief Medical Director) can still
overrule HODs, being higher in rank than them. And CMDs are usually physicians/surgeons. So there's
usually a general sense that the physician who had initially written a wrong prescription might be
favoured and the pharmacist who recommended corrections be scolded for being "arrogant".

A fair share of my lecturers have shared with us their experiences while on their internships with
residents in hospitals, where they reject a wrong prescription due to obvious reasons and tension
usually builds up in the hospital.

This has led many pharmacists, especially those who have very deep knowledge of pharmacologically, to
feel that hospital pharmacy limits their ability to practice the profession to the fullest, and that a
hospital pharmacist is likely to be "bullied" by physicians even when the physicians are wrong about a
prescription.

What solutions can be conferred in these cases? This will be discussed later in this essay.

- Community Pharmacy Practice.

Community pharmacies are where a pharmacist may feel the most freedom, due to the fact that it's
seen as their principal "abode". They may not be the only professionals working in a community
pharmacy, but they are the heads here. They have the final on matters in the community pharmacy.

Pharmacists in a community pharmacy setting usually have the freedom to recommend drugs to
patients almost without restrictions, mostly OTC drugs, supplements and in Nigeria and some African
countries antibiotics. Dressings can also be sold since nurses work in community pharmacies and can
attend to patients in need of services that need dressing.

Some pharmacists also have special licenses to administer some injections after special training. Drugs
pharmacists can't freely recommend include anti-hypertensives e.g. digoxin, anticancer medications e.g.
methotrexate, anxiolytics e.g. diazepam.

A pharmacist who spots a wrong prescription from a hospital is obliged to call the doctor to advise on a
better solution, especially if available at that pharmacy. If the physician doesn't change change the
prescription, the pharmacist can refer the patient back to the hospital.

Although, mostly due to impatience from the patients and the "way" of things here, the pharmacist may
change what he considers a wrong prescription to another medication. In some cases, a drug in the
prescription may not be available in that pharmacy and in a bid not to lose a potential customer, the
pharmacist informs the patient of this and changes the drug in the prescription to one available in the
pharmacy that is pharmacologically similar to the prescribed drug and has the same biological effect. In
the case of a community pharmacy, a pharmacist has almost unlimited freedom, compared to what a
hospital pharmacist might have.

Other forms of a wrong prescription that a pharmacist might correct if the physician doesn't include the
dose of a medication. A pharmacist may observe that the dose given to a particular patient is either
overdosed (e.g. for a child) or downright outrageous (e.g. a massive overdose of digoxin or
dexamethasone).

One reason that may make a patient buy drugs from a community pharmacy instead of the hospital
pharmacy where the prescription was issued is that community pharmacies may have the drugs cheaper
compared to the hospital pharmacy. This especially arises if the patient doesn't have health insurances
to cover for costs of drugs. The most common health insurance policies in Nigeria for example usually
favours children under eighteen years (NHIS - National Health Insurance Scheme). Federal schools in the
country also insure the treatment and medication of patients who register for the health insurance. In
most federal universities in Nigeria, you can't graduate and get your certificate without clearing your
health insurance with the school.
- Research/Education
Research and education in pharmacy practice are areas that keep improving in Africa generally, but still
hindered mostly by funds and adequate research facilities.

Numerous drugs have been discovered in Africa, especially from herbal sources. But because the African
market is mostly about making profits from sales, these researches have had to be published outside of
the continent in countries abroad that have the research facilities to turn research to finished products.
These has led to a massive brain drain from the continent, as research oriented pharmacists will prefer
to work where they know their talents will be more appreciated.

In the education field, especially federal universities, the equipment and facilities are so outdated that
lecturers, in their dismay, can't help but mock the fact that equipments used to teach them when they
were still students are what they're using to teach now. The equipments are covered in rusts,
maintaining them for teaching purposes or research becomes a hassle as the equipments struggle to
work attimes.

In cases where abroad these facilities would be automated e.g. a microscope connected to a big screen,
we still struggle with very old microscope that have shady lenses and lighting, or tableting machines that
look like they were used during the world war.

Ofcourse these don't help in teaching. Most students here only know how the theoretical aspects of
what's needed to be known. I'm sure African students will have more theoretical knowledge of
pharmacy in the research side than most other students in the world.

However, when it comes to practicals, how to use very technical machines and equipments, we really do
fall short. We have to rely on diagrams and platforms like YouTube to see how these things work.
Imagine if most of our learning was just theory with very little practical.

But atleast in my school this particular problem has been softened, as the school takes practicals with
utmost seriousness.

- Industry/Production Practice.
Industrial pharmacy in Africa that specialises in production and marketing are quite abundant.
Companies like Emzor, Jawa, May and Baker, Juhel specialize in making OTC drugs and antibiotics. These
companies are sufficiently equipped and make quite the profit.

Emzor for example is one of the biggest pharmaceutical companies in Africa, founded by Stella Okoli in
1984. It is one of the most easily recognizable brands in Nigeria, and also one of the most trusted.
There may be problems of substandard drugs produced by some companies in Nigeria for example. And
this issue also arises from the fact that the production industry also imports drugs from abroad, and they
may not be well regulated to detect defects in these medications.

They're then sold on the cheap in pharmacies.

- Administration Practice.
The chief regulatory body for drugs in Nigeria is the NAFDAC (National Agency for Food And Drug
Administration And Control). They regulate all drugs in Nigeria for example.

Other regulatory agencies in Africa include;

African Medicines Regulatory Harmonization (AMRH)

African Vaccine Regulatory Forum (AVAREF)

African Medicines Agency (AMA)

National Drug Law Enforcement Agency (NDLEA) - For Nigeria

National Medicines Regulatory Authorities (NMRAs)

These bodies aim at ensuring drugs meet the required standard in preparation according to the
pharmacoepias used in their preparation and record adverse effects associated with the drugs.

Any brand caught playing foul will have their drugs withdrawn from the market and the company will
face legal issues.

Issues can arise when constituted authorities accept bribes to push substandard drugs into the market,
especially if a manufacturer tries to cut losses on drugs that may have expired. These problems can be
seen from drugs imported into the country, and this poses massive problems in healthcare.

- Other challenges a pharmacist may face in practice include microbial resistance. Pharmacists try their
best to encourage patients to complete their dose of antibiotics in order for resistance to the bacteria
not to build. But we still see patients who tell the pharmacist that they just can't

adhere strictly to their prescribed/recommended medications, despite these warnings. This can
frustrate a pharmacist. There are times when treating a patient becomes very difficult as no antibiotic
works for their condition, and their sensitivity test also fails to show an adequately potent antibiotic as
well.

Drug adherence of patients generally is also a deep concern. Anti-hypertensive patients who usually
have to take their medications for extended periods will usually come down with severe headaches and
chest pains when their symptoms fail to subside and their blood pressure fails to calm down. We see
alot of cases where this was due to the fact that these patients didn't adhere to their medications
correctly.

After discussing all these problems, we should then discuss possible solutions that can help with
pharmacy practice in Africa.

THE WAY FORWARD - POSSIBLE SOLUTIONS.

- Hospital Pharmacy Practice.

We have discussed possible conflicts that physicians and pharmacists may have. What can be the way
forward?

From my point of view, strong jurisdictions should be made that favour the pharmacist and the
physician. A physician should be made aware that the pharmacist knows his/stuff, and trust their
decisions when a prescription is sent back with a recommendation. They should be make properly aware
that a pharmacist is much more than a "prescription reader". A pharmacist gives life to medicines. He
knows about each and every drugs in the shelf of the pharmacy, their side effects, adverse effects,
possible interactions with other drugs and how they will behave in the body. A pharmacist has as much
knowledge of anatomy and physiology as a physician has of pharmacology, or even more.

The pharmacists too should make sure they know their stuff very well. They shouldn't be half baked
individuals who can be ordered around because they don't know what to do and just sign all
prescriptions that come their way, because if a patient reacts badly to a drug, the pharmacist takes the
fall of it was a situation the pharmacist should have sported.

Heads of departments too should have proper resolution skills, and everyone must be made aware of
the fact that every professional is important in a treatment plan, the nurses, physicians/surgeons,
pharmacists, biologists/lab technicians and so on. No one must be made to feel superior to the other
and one must learn to stand their ground.

- Community Pharmacy Practice.

Community pharmacy practice comes with freedom and this freedom might be the problem, just a little
bit. A pharmacist shouldn't be giving out anxiolytics/benzodiazepines freely or treating patients suffering
from serious diseases like hypertension alone. It is a team effort that requires multiple professionals
from the hospital setting. In some countries, antibiotics have to be prescribed before they're dispensed.
This is done as a way to reduce microbial resistance.

Task forces are usually deployed in Nigeria for example to examine poisons books of community
pharmacies to check for discrepancies in filled prescriptions. A pharmacist working in a pharmacy
without a poisons book will have his/her license suspended or revoked.

Licenses are renewed yearly based in the field the pharmacist chooses to work in. This opportunity can
be used to test the pharmacist and re-orientate them on regulations they have to strictly adhere to so as
to avoid foul play.

- Research/ Education Practice.

This area simply needs the adequate funding and tools needed to take education and research to the
next level. I believe if schools were fully equipped, studying would be so much more fun than it is now,
and students wouldn't get that feeling of stressfulness while studying. Pharmacy itself is a bulky course
to study. Theoretical aspects that can be learned just through practicals and easier for students to
remember should be encouraged.

Proper grants should also be granted to individuals for research purposes from government agencies
and NGOs. This will reduce brain drain out of the country and encourage the production companies in
the country to produce what was indigenously discovered.

- Industry/ Production Practice.

Stronger regulations and punishments are needed to curb the importation and production of
substandard drugs. Corruption in these agencies too should be purged out and the safety of citizens
should be chief priority.

Task forces can be used to check that industries meet the required minimum of facilities and
equipments, and that their drugs are upto standard.

Expired drugs should be properly disposed of or recycled if still useful to the industry. Infact, industries
that specialize in utilizing such products can be setup and proper jobs can be made available to reduce
foul play.
- Administration Practice.
One problem with administration is politics. Favours may be granted to certain administrative offices
based on the political power of the individual in that office. This then impedes on how other pharmacy
practice perform as their administration is poor.

Finding the right balance between politics and practice will be helpful in passing out correct judgements
and ridding corruption.

Administrative forces can also work with task forces and law agencies to enforce proper policies in
pharmacy practice.

Strong punishments should also be made for defaulters in order to stare them away from foul play.

- Other challenges a pharmacist may face can be solved when a pharmacist doesn't decide to work solo.
In consulting with other healthcare providers, beautiful solutions can be made for the patients.

Creation of files that track a patient's treatment plan will help in making better treatment plans and
avoiding dangerous drug-drug interactions in the patient.

Keeping in contact with patient to ensure they take their medications as required solves the problem of
adherence and microbial resistance. Ofcourse this has to be done gently so the patient isn't
overwhelmed. The patient should be encouraged that they can do it and achieve good health again,
especially the hypertensive patients. All these in the long run makes for a better and healthier
community.

CONCLUSION.
Surely, there are numerous ways forward to improve pharmacy practice in Africa generally. There might
even be more problems to be solved. Time and development are the two major factors that will
determine how much pharmacy practice in Africa progress. If the administration works well, and there's
adequate funding for various pharmaceutical institutions, and people are made more aware of the
worth of a pharmacist, and what they can do, pharmacy practice in Africa will improve greatly and the
community will be more healthy.

So to end this essay, I say we keep improving in whatever way we can, to make pharmacy an enjoyable
practice in Africa.