What it’s like: Being a pharmacist in South Africa in 2020
Pharmacists do much more than stand behind a counter dispensing medicine. These professionals have a key role to play in the health care system and the overall well-being of people.
“First and foremost, we are the custodians of medicine and we are responsible for providing quality pharmaceutical care,” says Geraldine Turner, pharmacy manager at Knysna Hospital in the Western Cape – a public hospital.
Their role is vital given estimates of the World Health Organization (WHO) that “half of all medicines are prescribed, dispensed or sold inappropriately”. The overuse, incorrect use and abuse of medicines can be a serious health hazard.
“We make sure that medicines are ordered correctly according to the Essential Medicine List, stored correctly to ensure optimal efficacy and available to treat patients,” Turner says. It is their job, she says, to make sure patients leave the pharmacy knowing exactly how to use their medicine correctly.
“It is our job to counsel patients. We make sure that the instructions are clearly indicated on the medicine, that the patient understands the instructions and we also advise on what side-effects to look out for. Part of what we do is keep prescription records of patients so when a patient comes with a prescription, we look at their prescription history and make sure that the new prescription won’t interfere with the medication they are already taking, for example, we check for drug-drug interactions. We also check for drug-disease interactions or other contra-indications like breastfeeding,” Turner says.
“We are the gatekeepers of medicine,” says Turner, emphasising their role in preventing resistance to antibiotics and explaining that antibiotic resistance is growing due to the medicines being used inappropriately.
“If we don’t contribute towards rational prescribing, in a few years, our choice of effective antibiotics will be severely limited. As gatekeepers we try to ensure that antibiotics are given only when appropriate, at the correct dose for the correct time period.”
Explaining the career paths for pharmacists, Dr Sham Moodley, a community pharmacist from Durban and the chairperson of the Independent Community Pharmacy Association (ICPA), says a pharmacist is someone registered with the South African Pharmacy Council after obtaining a degree in pharmacy (BPharm-4 years at University), completing a year of internship under the guidance of a tutor and then completing a year of community service.
“A pharmacist can choose to work in different settings with this qualification including hospital pharmacy (works within a hospital setting especially with patients that come to that hospital), community pharmacy, private institutional pharmacy, in regulatory environments like the national or provincial department of health, the South African Health Products Regulatory Authority (SAHPRA), Pharmacy Council – at policy level.
A community pharmacist is someone who works within the community setting. This can include retail pharmacies and supermarket chains. A pharmacy assistant does a part-time certificate course over either a one-year (Basic) or two-year (Post Basic) period with a training provider. They work in the dispensary under supervision and as assistants to the pharmacist. Together, they form a team to ensure a smooth operation within a pharmacy, says Moodley, explaining that through community pharmacy the public has access to medication and advice from the pharmacists that work there.
Moodley says the role of pharmacists are not only to provide for the patient’s medicine-related needs and “being accountable for meeting these needs”. Pharmacists will also advise patients on the correct use of medicine and determine patient compliance with the therapy.
Pharmacists in numbers
According to the South African Pharmacy Council, the patient-to-pharmacist ratio in the country is 3 389 persons per pharmacist. That is about 30 pharmacists per 100 000 people.
Current data from the Council shows that Gauteng has the highest number of pharmacists, sitting at 6 040. This includes 5 478 pharmacists, five specialist pharmacists (specialising in either pharmacokinetics or nuclear pharmacy), 234 interns and 157 community service pharmacists.
In the Western Cape there are 2 919 pharmacists which includes two specialist pharmacists, 2 680 pharmacists, 92 community service pharmacists and 145 interns. There are other provinces with very low numbers. The Northern Cape only has 288 pharmacists which include 17 community service pharmacist, 249 pharmacists, 21 interns and one specialist pharmacist. In the Free State there are 590 with no specialist pharmacists, 541 pharmacists, 26 community service pharmacists and 23 interns.
According to Moodley, there are not enough pharmacists in the country based on the WHO’s recommended pharmacist to population ratio and “a portion registered on our register are non-practising due to age or migration”.med
He says the numbers must increase substantially to meet the WHO recommendation and stresses that the country must create sufficient jobs. “While there may be pharmacists qualifying, there are not enough jobs being created resulting in unemployed pharmacists,” he says.
Challenges faced by pharmacists
Moodley says that pharmacists face many challenges and adds that ownership laws have removed the profession from the hands of professionals and placed it in corporate hands.
“Unfair business practice models make it really difficult for small pharmacies to compete,” says Moodley. “There are two major issues of unfair business practices. First, the concept of designated service providers. This allows medical schemes to select their providers, determine what they will pay and at what level. With designated service providers patients are restricted for choice as they are levied a penalty co-payment of 30% – an unfair business practice. We can’t compete at this level like this, as patients will go where there is no co-payment.”
He says this means corporations aimed at providing returns for shareholders rather than true healthcare, get an advantage.
“While a small pharmacy is dependent on income from pharmaceutical services, the corporate model is dependent on sale of other front-shop goods, and success is measured on the profitability of the basket that leaves the store. This open ownership model has done severe damage to existing independent community pharmacies and stifled the growth in peri-urban and rural communities which is a prerequisite for the success of universal healthcare coverage,” says Moodley. “Further, splitting the patients’ medical history may result in possibly unknown medicine interactions that could be fatal to patients.”
Moodley also flags a dispensing fee as problematic. “The price of medicines are regulated in South Africa and all patients should pay the same price across the country.” According to Moodley the dispensing fee is also regulated, but with the discounting of this fee there is no transparency.
“Government has not achieved its intended target. It is an unequal playing field with big companies having deals from more space and they end up getting discounts from landlords and manufacturers that subsidise their pricing, but for a pharmacist in Soweto who primarily focuses on helping the community, it becomes difficult,” he says.
“It has now become an issue of competition. We shouldn’t be competing; this is a service not a business. Young pharmacists can’t open pharmacies in outlying areas where they are needed because of the competition from corporates. They won’t survive,” Moodley says.
According to Moodley, the government has been reluctant to deal directly with the pharmacy sector. “There are no employment opportunities for pharmacists in government sector pharmacy. Many are run by under-qualified staff.” He says issues of poor pay for university staff also result in a lack of interest in lecturing at pharmacy schools. “There is no job creation and no opportunity for young (especially black) pharmacists to practise their profession so skills shortages need to be addressed.” he says.
Challenges faced by pharmacists can affect patients, Moodley warns. “Patient rights and patient care are compromised as South Africans do not enjoy the full benefit of full pharmaceutical care.” He also argues that unemployment in pharmacy and crisis management, rather than a comprehensive plan for pharmaceutical services, remains a challenge.
Spotlight put these concerns and additional questions to the national department of health for comment, but the department did not respond by the time of publication.
However, earlier this year Dr Anban Pillay, then acting director general for the department of health, acknowledged the role of pharmacists, especially in a time of COVID-19. In a statement Pillay said: “Pharmacists are key healthcare providers working on the frontline in the fight against COVID-19. They are often the first point of contact with the healthcare system for patients and are part of multidisciplinary teams to identify and manage the disease in patients. Pharmacists fulfil integral roles in the healthcare system within the many spheres in which they practice.”
It is about people
Lamees Wallace is the permanent roving pharmacist for the Southern and Western Substructure in the Cape metro region. This means she works at different clinics and hospitals that fall under the sub-structure.
Wallace says she loves helping patients understand their condition and how they can adjust their lifestyle to manage it. “I stress the importance of taking medication regularly to facilitate compliance that ultimately leads to a healthier lifestyle. I love being able to explain this to my patients and making the information easy to understand and to overcome language barriers,” she says.
Wallace says that pharmacy is about people, and she has a passion for people and that influences how she approaches her work.
“There are people from all walks of life, people coming from domestic abuse, drug addiction, teenage pregnancy, gangsterism and unemployment. There are people with their own socio-economic challenges, and they often come in with their guard up. This can really test your patience. They may come in aggressively or being defensive but if you address them with respect, hear their ‘side’ and be willing to listen, it’s easy to not only understand where they are coming from but also to relate. You cannot help but feel an immense form of genuine compassion and empathy towards patients. Sometimes they just need to vent and I often find that once I listen and not push back, they drop their defence mechanism just a bit and let you into their world for a split second. This is when I take the opportunity to allow them to let me help and listen.”
Turner says it is always great to see patients’ conditions improve. “We all work hard and make sure that mistakes don’t slip in. Obviously, we are all humans, we make mistakes. Anything can happen. Maybe we give someone the wrong dosage, or two medicines sound the same and we give one instead of the other. [But] we have a lot of double-checking measures in place to make sure that this doesn’t happen,” she says.
And the scribble of doctors on prescription notes that is notoriously difficult to read?
Turner says deciphering health practitioners’ penmanship “comes with experience” and they get used to the doctors’ handwriting. “At times when you just can’t make out what the doctor wrote, then you pick up the phone and ask. This is easy for us at the hospital pharmacy because we have a relationship with the doctors,” she says.
Turner says although there are many challenges, for her the biggest one is medicine supply.
“This is a struggle not only in the country but all over the world. There is not sufficient medicine. Companies can’t produce fast enough. As pharmacists, we ensure that there is stock. If a certain medicine is not there, you phone other nearby hospitals to check if they have. You can’t tell a patient to go because there is no stock. As a pharmacist, you have to make a plan,” she says.