Erin and I started working at the Katutura Health Clinic (KHC) on Tuesday, May 29th. We work from 8AM (on Wednesdays and Fridays) or 9AM (on Mondays, Tuesdays and Thursdays) to 4PM, five days a week.
We work early on Wednesdays and Fridays because those are the outreach clinic days.
On Wednesdays we travel about 30 minutes to a clinic in a very underprivileged area called Otjomuise. People live in tin and aluminum houses and there are very few places with water service. There are a few public toilets and some public taps, but not enough to be considered acceptable, let alone sanitary.
Friday’s outreach locations alternate between two locations, the furthest of which is Dordabis. I haven’t been to Dordabis yet, but I’ve been to the other clinic once. There I met a man who travels two hours on a cart pulled by donkeys to get to the clinic for his medicines every month. He looked kind of intimidating at first but he had some of the most beautiful eyes I’ve ever seen. He just lit up when I tried to talk to him in Oshiwambo. I don’t mean that to sound corny, but I think it reflects how there are so many hardships here, but then, almost unexpectedly, you get to see this beauty and the friendliness in the nature of Namibian people. It’s really amazing. The short conversation we carried still stands out to me.
On Monday, May 28th, before we started our placement at KHC, we had an orientation session that was led by the Dean of Nursing and Public Health at UNAM (University of Namibia). Between that and the first hand experience we’ve gained over the past month, I think that we’ve acquired a decent amount of understanding of healthcare in Namibia.
There are a few insights that I feel qualified enough to lend, but I am strictly speaking from my limited experience, within the context of KHC and the experiences of my fellow volunteers.
Here are some of the biggest differences I’ve seen between pharmacy in Canada and pharmacy in Namibia:
1. Health Passports
Remember the E-health scandal? Well Namibia has a health record. It’s definitely not state-of-the-art but it’s a lot less expensive than the consulting firms McGuinty hired!
All Namibians have health passports. It’s a paper booklet that patients take to every health-related centre that they go to. Their patient history and notes are all recorded in this booklet that the patients keep and carry around. They are fairly small paper booklets, and once one has run out of fresh pages, the patient is issued a new one to attach to the old one (with staples, tape, stickers, etc.). A lot of these booklets come in to the pharmacy in tatters or with questionable stains on them, but for the most part they are very legible and pretty easy to use.
Other challenge with these booklets are when patients lose them or don’t bring in the older parts of their health passport. Overall though, I am honestly surprised at how few patients present with these problems!
At KHC all of the follow up blood, doctor, counselor, and pharmacy dates are hand written at the end or within the patient notes. Erin and I have seen patients that have missed their follow-up appointments simply because they cannot locate the date within the notes. In response to this Erin and I have developed an idea for a stamp system. Erin had made a template for a stamp that has a symbol representing the service (a bottle of pills for pharmacy, a stethoscope for doctor’s appointments, etc.) and a box beside it. The healthcare provider would stamp the passport and write the follow-up date in the box to make the dates stand out for the patient.
Another project we will run is an evaluation of patient wait times. There was a survey and subsequent changes made at KHC to improve patient wait times at some point in the past, but there have been no follow-up evaluations of said changes. Erin and I will survey the changes in wait times and do an initial evaluation of our date stamp project.
2. FREE HIV Care
In some ways HIV patients are getting better health care in Namibia than those that are not HIV positive. That is a very bold statement to make, and a controversial one at that. So I’ll take this time to reiterate that I am speaking from a very limited context, although I stand by what I’m typing here.
All HIV-related services are FREE in Namibia. All testing, doctor appointments, MEDICINES (this is especially different from Canada where HIV medications can lead to catastrophic drug costs among HIV positive Canadians), are completely free.
The free medicines were initially provided by the Global Fund and PEPFAR, but recently they withdrew their financial and/or medication donations (more information to come). Now the government of Namibia provides the funding for all ARV (antiretroviral) medicines.
They even provide free condoms (both male and female condoms).
One really funny experience I had at the beginning of my placement started when we first toured the KHC facilities. There’s our ARV clinic (meaning it’s an AIDS clinic with a very limited scope of medications), and a sister clinic in the building next door that has a full pharmacy. When we were visiting the other pharmacy I saw all of these orange boxes that were labeled “Smile!” and there was a picture of a smile on it. I pointed them out to Erin and was like: “Wow! Check it out – they must be as in to teeth whitening as we are back home! It’s weird that those are in the pharmacy though…” and then we shrugged it off and continued with the tour.
(I’ll get a picture of the boxes asap)
Turns out that those boxes are full of free condoms!! So not quite the smile I originally thought they were referring to!!
Smile condoms are free for everyone. Each individual box comes with three “dotted” condoms (which means studded). Pretty fancy for free condoms if you ask me, but I maybe that’s where they get their name from? I don’t know! Either way, it’s made counseling patients to use condoms a lot easier!
Speaking of recommending condoms!
As I mentioned, I’ve been learning some Oshiwambo. That’s the most common language among dark skinned people, and has been immensely beneficial to my counseling at KHC. I recently learned how to say (what I thought was) “Use condoms every time”. Every time I speak Oshiwambo the first response I get is either a look of shock and surprise or laughter. So when patients were laughing while picking up their smiles, I figured it was because I was speaking Oshiwambo unexpectedly. It wasn’t until my boss, the Zambian pharmacist, Ms. Kunda said “who taught Amber these condom words?” that I realized something might be wrong. In fact I had been telling patients to “use condoms EVERY DAY”, all day! No wonder they were taking so many boxes of smiles!!
3. Pharmacy VS. Counseling
The last thing I’ll touch on here is a bit more of a negative. In Canada we’re taught to have a dialogue with patients. We are expected to verify that the medication prescribed is the best medicine for the patient and then tell patients what they can expect from said medicine, how best to take it, what the potential side effects are, and how best to manage them. In Namibia, pharmacy is still very much a dispensing process. Patient education is left to counselors and is done in another room with little record of what was discussed.
At first I really hated this because dispensing, while it is very important, is a task that is being shifted more to registered pharmacy technicians in Canada. It is less in my scope of education and practice as a future pharmacist in Canada. Interestingly, pharmacy assistants (PAs – similar to pharmacy technicians) can dispense independently here. In fact there are full days when the pharmacist is away. This is actually kind of scary. PAs and pharmacists don’t have to sign or keep a record of their dispensing. Everything is documented in the heath passport, but accountability is rather low. Furthermore, there are no double checks. One single person will handle the full dispensing process. I say this is scary because these are circumstances that can easily lead to errors! Erin and I are trying to brainstorm ways to enforce double checks, but the workflow seems so entrenched and there are so many patients that need to be seen, that it’s difficult to think up a solution/have a conversation about implementing procedural changes at the clinic.
As for the counseling vs. dispensing in pharmacy practice, I have overcome this challenge by being stubborn and counseling anyway. I think that, for the most part, patients are able to understand my English or Oshiwambo. I hope that they take what I say seriously because I am a very different source of information, compared to what they are used to. Erin and I are the only white people in the pharmacy, and so we’ve become a bit of an attraction to some patients. We’ve also made a big effort to reinforce that patients are welcome to ask questions. Healthcare at KHC is still very paternalistic compared to practice in Canada, and hopefully Erin and I will help give patients the confidence they need to start dialogues with their regular health care providers.