The MSF missions in South Kivu are currently increasing their focus on primary care and health education. Not only is earlier intervention better for patient care, but it should also reduce demands on hospital care.
The Kimbi project based in Lulimba supports healthcare workers and educators in communities; in malaria points; basic health points where patients are treated for the three main illnesses of malaria, respiratory infections and diarrhoea; and health centres, which treat, or refer, all illnesses.
The three health centres supported by the Kimbi project are almost mini hospitals, with observation beds, maternity beds and pharmacies. On this visit to Kimbi, one of my tasks was to visit the health pharmacies to assess the premises, levels of service, stock management; to make recommendations to the project medical staff and to develop appropriate staff training.
Misisi health centre © Barbara Pawulska
I started with Misisi; it is a gold mining town in the hills, and is somewhat wild west. The road to it winds past a river, with people waist deep in the water, looking for gold. The banks are dug into what are presumably individual stakes - I wonder what will happen as the rains set in and the river level rises.
The road is awful, and when you get to the outskirts of Misisi is gets worse - it is like driving down a river bed, with deep gorges and potholes. Both sides are lined with restaurants and bars, often brightly painted, and there are many traders - piles of clothes, mattresses, kitchenware, suitcases and backpacks - even a stall of hiking boots. Motorbike taxis wait around - a fair proportion parceled in bubble wrap, presumably to protect them from the ravages of the terrible roads.
The MSF supported health centre in Misisi is the busiest of the three – it serves a growing, often transient population. It is open 24 hours a day, seven days a week.
I visited with Emmanuel, who is the MSF national staff pharmacy supervisor in the hospital. He is a nurse by training, but with an excellent understanding of pharmacy – both from a supply systems and a clinical point of view. People like Emmanuel provide the stability and continuity in MSF projects. International staff like me come and go, but Emmanuel is permanent. His skills are currently being developed so he is able to support the staff in health centre pharmacies as well as in the hospital.
MSF pharmacies have three main activities: dispensing medication to patients, administering the first dose with explanations and information so patients know how to take them, and pharmacy stock management.
Emmanuel (left) and Fidel in the Lubondja pharmacy © Barbara Pawulska
Every last tablet that leaves a pharmacy has to be accounted for; at the end of each day, quantities used of every item in the pharmacy are totaled, daily totals added up each week, weekly totals added up each month. A complete inventory is carried out every month which is used to prepare a monthly order. All this is done using pen and paper. It is a painstaking process, involving a considerable amount of time, but it is necessary to manage medicines supply and ensure the project does not run out of medical supplies.
The first dose service, with its patient explanations, is a crucial part of medicines use – if the patient does not take the medicines as they should, then all of the effort and resource put into the supply chain from Amsterdam to DRC is wasted. At Misisi, we found that the third person in the pharmacy, whose job it is to deliver the first dose and advice, was regularly given other duties in the centre, so a priority will be to ensure staffing is organized to avoid this.
We also visited the health centre in Lubondja, a picturesque village in the hills. It is a quiet health centre, and only one person is needed to carry out all the pharmacy duties. We sat in the pharmacy, watching the patients come in and receive their medicines, first doses and explanations. Other than a few suggestions for minor improvements, and some support in managing the medications for planned additional services, this pharmacy needed little input from us, Fidel was managing it well.
Our last health centre visit was to Lulimba, which is the village where the project and the supported hospital are based. Like Lubondja, the pharmacy is run by one person. However, this is a much busier health centre, and one person is not able to carry out all of the pharmacy duties; at least one other person in the pharmacy is essential – this was flagged as a priority with the project medical staff. The health centre building is also more basic than the other two health centres – the main issue for the pharmacy is that there is no ceiling, only a roof of corrugated metal, which offers no protection from the heat of the sun. The construction of a ceiling was requested from the project's technical logistician.
In between these visits, Emmanuel and I ran a training session on stock management for pharmacy staff – both in health centres and the hospital, repeated on two consecutive days so that the pharmacies would keep running. I prepared material and exercises – starting with the supply cycle – how medicines get from Amsterdam to the patients – then the use of stock cards, inventories and the monthly orders to the MSF medical depot in Lulimba. How the Congolese love to talk and they expect everything to be paraphrased several times! I tend to be brief in English, and have little hope of being able to do endless repetition in French, so Emmanuel’s help was extremely valuable; he did a lot of the talking, and is a natural teacher. We started and finished each session with a test – getting them to enter information on stock cards correctly, and they all showed a marked improvement afterwards. So we must have done something right.