Lessons from the field: implementing pharmacy services in the Tanzanian hospital setting

Abstract

In hospital practice, pharmacists are healthcare professionals trained to store, handle, prepare and dispense medications that are used inside the hospital. There are benefits if pharmacists provide extended services to patients in hospitals. These include improved health outcomes, increased patient satisfaction and economic benefits.1 Hospital pharmacy services (HPS) differ by country and even within countries. They can include activities related to the selection, administration and monitoring of medicines through counselling, communication with other healthcare professionals, medication reviews, reconciliation and clinical decision-making.1 Although HPS have been implemented in different settings worldwide, there is limited literature on HPS in sub-Saharan Africa. It is difficult to extrapolate international literature to this setting due to the lack of services, trained staff and medication availability and its unique population.2 Tanzania could be one of the first examples of extended HPS being implemented more widely in this setting. Here, we outline what HPS should look like in Tanzania, how they can best be implemented and where implementation should occur first based on multistakeholder perspectives, as well as the lessons we have learned from this. Tanzania consists of 184 districts with district hospitals. These districts combine into 31 regions with regional hospitals. Overarching these are six National Super Specialised Hospitals. Hospitals are 40% state-owned, 40% owned by faith-based organisations and the rest privately owned.2 In 2020, clinical pharmacy services were named as one of the core functions of pharmacists by the National Pharmacy Council and the Ministry of Health. Nevertheless, HPS beyond dispensing are currently not widely implemented throughout Tanzania and significant differences exist between hospitals. This includes differences in the role of medication coming from drug sellers (duka la dawa) and the extent to which hospital pharmacists are involved in such medications. Five universities offer a pharmacy curriculum, although the content of their programs is not strictly aligned. Moreover, HPS have low priority in the pharmacy curriculum, if they are present at all. One medical university has included aspects of hospital pharmacy in its curriculum in bachelor’s and master’s degrees of pharmacy since 2008. However, there has been limited enthusiasm for these programs. Several barriers to implementing HPS have been identified,3 including lack of time, money, resources such as gloves and syringes, skills, staff and confidence among pharmacists and hospital care structures that disfavour pharmacy units in the hospital. In 2021, the Muhimbili University of Health and Allied Sciences in Dar es Salaam and the Christian Social Services Commission implemented a project to improve the provision of HPS in Tanzania. Action medeor e.V. sponsored this project and built on an earlier project that increased the number of trained pharmacy assistants and pharmacy technicians in Tanzania. A 2-week curriculum to train pharmacists to provide HPS was developed and >100 pharmacists from 5 different areas of Tanzania and 26 public regional, zonal and national hospitals were successfully trained to provide HPS in selected hospitals, leading to changes at the micro (individual pharmacists, patients and healthcare staff), meso, (pharmacy departments and hospital wards) and macro (national) levels. This training has been described earlier.4 At this stage, after initial training of pharmacists, it was necessary to explore how to upscale HPS further and how implementation successes could be monitored. More than 100 pharmacists, medical doctors and university teachers from 17 hospitals and 5 universities provided their views on HPS through visits from a local team of researchers. Additionally, hospital directors, the president of the National Pharmacy Society and the Registrar of the Pharmacy Council of the Ministry of Health were interviewed to provide their views. Tanzanian healthcare stakeholders acknowledge a broad range of tasks and responsibilities for hospital pharmacists, substantiating that pharmacists can and should play a prominent role in hospital care. Most of these tasks and responsibilities are similar to those that have been reviewed in other settings around the world with different income levels. Nevertheless, the input of stakeholders in adapting this international literature to the Tanzanian context was essential. Changes to the tasks and responsibilities of hospital pharmacists in Tanzania that should be implemented based on this study include: Participating in ward rounds and consulting with other healthcare professionals Providing education to patients and pharmacists in training Being involved in clinical decision-making and policymaking Undertaking research activities Ensuring the availability and rational use of medicines Monitoring therapeutic response and resolving medication-related problems Formulation of medications Documenting and reporting adverse drug events Being involved in antibiotic stewardship activities The positive attitude of different stakeholders seems promising towards implementation. However, the extensive and various tasks that pharmacists may perform can make implementation diverse and therefore more challenging. Moreover, despite much agreement between the stakeholders, different perspectives remain on specific aspects of HPS. In particular, those tasks where the responsibilities of doctors and pharmacists could overlap need additional attention during the implementation of HPS. All stakeholders agree that extensive training is needed before pharmacists can perform all tasks relevant to HPS. Education can occur at universities or during training activities of practising pharmacists. Topics that need to be taught are communication, specialised pharmacotherapy and treatment safety, teaching, developing treatment guidelines and conducting research. Moreover, documenting pharmacy practice, including the activities and responsibilities mentioned earlier, should become standard practice and should be taught from the start of implementation of any hospital pharmacy training. Implementation of HPS in Tanzania is a significant and long-term undertaking. These lessons learned relate closely to factors influencing the successful implementation of hospital pharmacy (Table 1). Variations in hospital resources (e.g. staff, digital systems, medications, funding) produce differences in hospital pharmacy practice. Increasing HPS in Tanzania faces challenges due to disparities in funding and resources between public and private hospitals. Well-funded private hospitals can implement best practices while public hospitals struggle with inadequate funding, limited resources and understaffing. Considering the disparities between well-funded private hospitals and resource-limited public hospitals is crucial when implementing HPS. Tailoring HPS strategies to address these differences is essential to ensure equitable access to quality care. For private hospitals, the focus could be on leveraging existing resources for innovation and continuous improvement. For public hospitals, the emphasis should be on building capacity through targeted investments in staff training and infrastructure. A phased, context-specific approach would allow for gradual but sustainable HPS implementation across diverse settings. Lessons learned from the project concerning factors influencing the successful implementation of HPS. Lessons learned from the project concerning factors influencing the successful implementation of HPS. Pharmacy services should be introduced gradually, one department at a time. Selection of the activities that are implemented first should align with pharmacist expertise, physician willingness and hospital priorities. Exact implementation may therefore differ by hospital. To successfully implement HPS, the barriers mentioned earlier need to be overcome. Lack of time, staff, money and resources are interrelated. The number of hospital pharmacists needs to increase. Moreover, for intensified multidisciplinary collaboration, shortages of nurses and doctors should also be resolved. The Ministry of Health is the most important funder of hospitals, and their objective to strengthen HPS should be accompanied by appropriate funding. Funding from outside, e.g. from international non-governmental organizations, could kickstart the development of HPS. Given the potential cost savings1 of HPS, such one-time investments could lead to long-lasting improvements. Structurally integrating pharmacy units into hospital leadership may ensure that pharmacists get better access to hospital resources and can result in more consistent access to essential medications. Additional staff is only valuable if they are sufficiently trained for their duties. Pharmacy education should be strengthened through short-term professional development and long-term curricular improvements. For practising pharmacists, there is a need for competency-based courses that can be undertaken alongside clinical responsibilities. These should include multidisciplinary case discussions, clearly defined learning objectives and formal assessments to ensure competence in hospital pharmacy practice. Curricular changes should include improving entry qualifications, integrating hospital pharmacy competencies into core coursework and formally recognising specialisations within postgraduate programmes. National harmonisation of pharmacy education is essential to ensure consistency and quality across institutions. Strengthening collaboration between universities, the Ministry of Health and professional associations will be critical for aligning academic programmes with national healthcare needs. The exact method of implementation is outside the scope of this article, but suggestions have been reported by others.5 Performance indicators are critical for assessing implementation outcomes and building interdisciplinary support. The participants of this study specifically recommend quality indicators for adverse drug event reporting, resolution of medication-related problems, participation in ward rounds, patient education at discharge and during the hospital stay and medication reconciliation at admission and discharge. Which quality indicators are useful and feasible to implement will differ based on hospital characteristics and resources. Tanzania shows potential to integrate HPS due to stakeholder support. Yet significant challenges remain, including resource constraints and the need for educational reform. A phased, context-specific approach, guided and checked through the abovementioned quality indicators is essential for sustainable HPS implementation. ML, JM, SK, BAM and KT conceived the study and designed the study protocol. JM, SK, CB, GB and BAM collected local data. ML and KT analysed and interpreted the data. ML drafted the manuscript. JM, SK, CB, GB, BAM and KT critically revised the manuscript for intellectual content. All authors read and approved the final version of the paper. ML is the guarantor of the paper. This work was supported by action medeor e.V., a German non-profit organisation that considers itself ‘the world's emergency pharmacy’ and protects the health of people in crisis situations, especially in low-income countries. None declared. Ethical approval for the current study was obtained from the Muhimbili University of Health and Allied Sciences Ethical Review Board as part of an overarching project (MUHAS-REC-05-2022-1132). The questionnaire data underlying this article will be shared upon reasonable request to the corresponding author. The interview data underlying this article cannot be made publicly available to protect the privacy of the individuals who participated in the study; these data will be shared upon reasonable request.