Swaziland has limited human resources in the healthcare sector and an increasing workload due to the dual epidemics of HIV and TB. According to the Human Resources for Health Strategic Plan 2012-2017 (Oct 2012) from the Ministry of Health in Swaziland, there was a deficit of 22% of healthcare workers in 2011 resulting in 655 open positions for healthcare workers. In 2011, 21% of medical doctors and 22% of nurses’ positions were vacant. Expatriates accounted for 35% of the pharmacist/pharmacy technician positions in 2008 and that number increased to 67% in 2011. All of the expatriate pharmacists/pharmacy technicians are from Africa, mainly Zimbabwe, South Africa or Kenya. There are multiple factors contributing to this crisis which include trained healthcare workers leaving the country for better positions, and loss of workers to HIV/TB related illness or death (yearly loss of 3 to 4% of public health workers). Clearly plans to overcome this vicious cycle need to be implemented.
Task shifting in Swaziland is supported by MSF due to the limited pool of healthcare workers. Task shifting is done at 5 key points during the cycle of patient care: Nurses initiating Active Release Technique (ART) and 1st line TB treatment in the rural clinics, lay persons doing HIV testing & primary counselling in the clinics, lay persons as pharmacy assistants dispensing ARVs and TB drugs at some clinics, lay persons as phlebotomists at clinic mini-labs and expert clients (individuals living with HIV) working closely with patients to increase their understanding of their treatment with the goal of increasing adherence to treatment.
The role of Pharmacy Assistant (PA) is new in Swaziland and it is not yet officially recognized by the Ministry of Health (MoH). MSF has trained lay people to become PAs through internal trainings as well as by engaging faculty from the accredited South African Pharmacy Council. In 2012, the South African Nazarene University (SANU) in Manzini opened a two year Pharmacy Assistant certification program and MSF is sponsoring six employees, previously working as PAs, to get their degree. The SANU curriculum was developed by the MoH and MSH (Management Sciences for Health) and therefore graduates should be recognized by the MoH.
Currently we have six trained lay people working as Pharmacy Assistants (Swazi’s) at the clinics receiving supervision from three Pharmacy Technicians (all from Zimbabwe) who cover the region and provide most of the training. The focus of the training is the PA role in stock management (preparing orders to Central Medical Supply (CMS) and MSF, receiving orders, updating stock cards, inventorying stock, etc.) pre-packing medications, dose calculation for children (and educating parents / caregivers on how to administer medications), filling / dispensing from a prescription (abbreviations, checking for appropriate use, dosing, etc.), counseling patients on the medications (dosing, instructions, side effects, adherence, etc.) and filling pill boxes for patients. We continue to offer monthly training focused on aspects of their role in the pharmacy and associated MoH SOPs as well as disease state training.
Task shifting began in the clinics in early 2011 and while the national task shifting framework has been finalized for almost 2 years, it has not yet been adopted into the legal framework of the country. Task shifting is not fully accepted by the MoH and MSF continues to lead the charge for gaining support for this initiative through lobbying and advocacy.
There is an opportunity for growth and continued training of the PAs on the MSF team. While formal certification would be ideal, it is not possible and task shifting offers an opportunity to decrease pressure on an overwhelmed healthcare system. Over the next few months of my mission, my plan is to focus the training sessions on the medications related to HIV, TB, and the fundamentals of the job of a pharmacy assistant.