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Essential Medicines Supply Management: Developing a Competency Framework for Pacific Island Countries
January 16, 2012

photo of staff persons at a pharmacy

By Andrew Brown, Assistant Professor, University of Canberra

In the South Pacific region, problems in maintaining the supply of essential medicines, including reproductive health commodities, affect the health of approximately 10 million people. In these small island states with populations varying from a few thousand to several million, and spanning a diverse range of cultures, many maternal and child health-related deaths could be prevented if essential medicines were readily available.

Training in essential medicine supply management (EMSM) is often not present within institutions responsible for training nurses, pharmacists, and other health care personnel, and there is no formal pharmacy assistant training course in the region. Unless health care personnel responsible for the medicines supply management system are trained with the appropriate competencies to manage medicines supply systems, the Millennium Development Goals (MDGs) cannot be achieved in the Pacific.

As part of the Pharmacy Education Action Plan—an initiative of the World Health Organization (WHO); the United Nations Educational, Scientific and Cultural Organization (UNESCO); and the International Pharmaceutical Federation—the University of Canberra joined forces with the United Nations Population Fund (UNFPA), ministries of health, and heath care personnel in certain Pacific Island countries (PICs) to build a regional competency framework for PICs in a three-year project.

The Competency Framework

The project used existing national pharmacy competency frameworks from around the globe to develop an initial framework consisting of domains, competencies, and behavioural statements considered to be suitable for PICs. The approach included consideration for culture and local needs and participatory action research (PAR), which is based on reflection, data collection, and action to improve health and reduce health inequities by involving the people who, in turn, take actions to improve their own circumstances.

The framework was validated using workplace observation, face-to-face interviews, and focus groups from a cross section of cadres (doctors, pharmacists, pharmacy assistants/technicians, stores personnel, nurses and midwives) in Papua New Guinea, Solomon Islands, and Vanuatu. It was then realigned with the International Pharmacy Federation Pharmacy Education Taskforce (FIP-PET) Draft Global Pharmacy Competency Framework, and further feedback was collected from eleven countries through an internet-based survey.

The validation process confirmed that the competency framework was relatively consistent across the variety of PICs in the region. The same competencies were expected of pharmacy services with the exception of the compounding of pharmaceuticals, which was only expected in a limited number of countries. A significant finding was that cadres of staff varied by country as did the competencies expected by them. A clear distinction was made regarding the clinical functions of participating in ward rounds, adverse drug reaction reporting, and medication consultation with doctors regarding medication options in the event of a stockout. These functions were clearly seen as the role of the pharmacist.

As a result, the competency framework is NOT cadre-specific but represents a complete framework of competencies necessary for adequate pharmacy services, including medication supply. How this is applied in a particular country depends on specific country needs and circumstances as directed by the ministry of health in each country.

The competency framework contains four domains with competencies and plain language behaviour statements specific to the practice of pharmacy in PICs. They include—

  • Organization and Management Competencies - a systems focus (human and material resources)
  • Professional/Personal Competencies (a practice focus)
  • Pharmaceutical Public Health Competencies (a population focus)
  • Pharmaceutical Care Competencies (a patient focus)

EMSM is part of the domain of Organization and Management Competencies. All of the competencies in all four domains must be present in a country for effective EMSM. The list of organization and management competencies are listed at the end of this article.

As part of the project, the University of Canberra is developing new training methods to put the framework into practice. We intimately involve local health personnel in improving the competencies they require for medicines supply management at their level of practice. The strategy has as its starting point an understanding of culture and its impact on learning and teaching, followed by mapping of competency requirements of the main levels of heath care personnel involved in EMSM. Reproductive health commodities are used as tracer medicines in the essential medicines supply system in each country that we work in.

photo of staff persons at a warehouse

The questions driving this project include:

  • What culturally sensitive principles need to be considered when assessing the learning needs of South Pacific pharmaceutical health care personnel?
  • What information currently exists addressing competencies and training requirements for health care personnel in PICs involved in EMSM?
  • What are the competencies required by the various cadres of health care personnel in the area of EMSM?
  • What is the assessment of training materials currently used for any health care personnel in PICs involved in EMSM?
  • What effective pedagogical approaches can be developed that show the development of country- and cadre-specific competencies in the area of EMSM?
  • Can these new pedagogical approaches be applied to a variety of PICs?
  • Can these new pedagogical approaches be transferred to local institutions of learning for sustained use?

In PICs, the workforce responsible for maintaining this medicines supply system is pharmacy-based with significant input from nursing personnel. It includes three levels of health care personnel (see figure 1). So far, the University of Canberra has developed training courses for primary care facilities (levels 1) and district/provincial pharmacy personnel (level 2).

Figure 1. An overview of cadres involved in essential medicine supply management in PICs

Figure 1. An overview of cadres involved in essential medicine supply management in PICs
 

The Case of Vanuatu

In Vanuatu, a range of posts exist within the pharmacy department across the country, including pharmacist, pharmacy managers, pharmacy intern, assistant pharmacist, dispenser and store manager. The following definitions are used within Vanuatu for these cadres:

  • Pharmacist: Staff that have completed a traditional Bachelor of Pharmacy degree or equivalent
  • Pharmacy manager: The staff member in charge of a provincial pharmacy who does not have a pharmacy degree
  • Pharmacy intern: A staff member having completed a bachelor of pharmacy degree but undergoing twelve months local internship training
  • Assistant pharmacist: A staff member who has significant pharmacy experience but does not hold a pharmacy degree
  • Dispenser: A staff member with the main task of outpatient dispensing including associated pre-packing
  • Store man: A staff member with the main task of completing orders for dependant facilities and responsible for the movement and organization of pharmacy stock.

Although each of these posts exists within the Ministry of Health, a consistent application of cadres across provinces does not appear to exist except for the cadre of pharmacist and dispenser. It is clear that, regardless of the staff present and their training, the same set of EMSM activities are required to occur within the pharmacy system.

The responsibility of staff to complete various activities was dependent on which staff was available at a particular point in time. Factors such as holidays, attendance at offsite training or meetings, and touring of health facilities were the main activities resulting in staff being absent from the hospital pharmacy. Regardless of the staff available at the pharmacy department, the full set of activities were completed by the available pharmacy staff irrespective of their position. This inevitably means that the store man could be directly involved in dispensing to patients and providing orders for dependant facilities, activities not listed in their job description.

The mapping of a pharmacy competency framework for PICs has provided a tool that can be used to aid in the allocation of appropriate tasks to the available human resources for the management of pharmacy services, including EMSM. Such a framework also provides the basis to review and develop appropriate sustainable, needs-based education to enable specific health care personnel to meet the competencies they require to effectively manage medicines supply.

Within the context of our research in PICs, we are currently testing two different competency development approaches for specific cadres:

  • A country-specific, five-day skills-based workshop with workplace follow-up for nurses, primary health care personnel, and nurse aids, which make up the primary health care level (level 1).
  • A ten-month on-the-job certificate using a combination of distance and short intensive sessions with workplace follow-up for health care personnel in medicines supply at the provincial level (level 2).

The level 1 project has involved using an individual country needs-based approach to develop a practical training manual and a country-specific interactive workshop which uses the principles for effective training with a focus on medicines supply management competencies. To do this a pre-level 1 training screening tool is used in conjunction with stakeholder engagement by phone and e-mail to determine the current standard operating procedures and policies that affect medicines supply management in that country. This data is then used to develop a competency-based, workplace-oriented, practical training manual and an interactive five-day workshop with the involvement of local health care personnel.

Skills games, role play, group discussion, story telling, and site visits provide the basis of the workshop with limited use of computer projection and maximum involvement by local health care personnel. Selected competencies and participant self assessment is measured before and after the workshop. Three months after the workshop, the heath care personnel are visited by a local supervisor to note the translation of developed competencies into the local environment and discuss any workplace-related issues.

In the absence of training programs in the region for level 2 health care personnel, we are currently using the competency maps and principles for effective training to develop a comprehensive training approach for these cadres. A ten-month on-the-job certificate using a combination of distance and short intensive sessions with workplace follow up is envisaged and will be tested in four countries in 2011 . The development process is engaging Ministry of Health staff and local academic institutions where they exist to help develop the overall course structure and required training material. Mechanisms are being explored that use mobile phone and internet technologies to provide out of country support where this is required. Providing local supervision through the use of senior staff within the pharmacy and medical stores environment is seen as a priority in this training approach.

Conclusion

Mapping a validated Pharmacy Services Competency Framework for PICs is a step farther along the path to developing innovative, sustainable approaches to improving health care workers’ ability to make medicines available to clients.

When we developed the country-specific competency maps for the three levels of health care workers involved in medicines supply management in PICs, we clearly saw that the competency requirements of each cadre level differ; this needs to be taken into consideration when preparing training. Culture and local ways of learning also differ within regions and need to be considered. Our experience is that training activities that are based on these considerations and involve local health care personnel in their development are well received with a high degree of ownership.

We have used our competency framework and insights into cultural ways of learning to develop innovative ways to teach,which focus on practical work-based competency development. These approaches are showing quick competency development, with immediate application to the workplace, by a range of health care personnel in different countries. While this data still needs to be quantified, our preliminary observations show that a range of health care personnel are responding well to this approach with improved development of competencies in EMSM.

Within our project we found that engaging local practitioners, locally active international organizations, and academia is a constructive way to promote a needs and best practices approach to medical supplies education. Our future challenge is to work with these partners to demonstrate sustainable change and imbed these approaches into local and regional educational institutions.

Detailed EMSM Competencies from the Pharmacy Competency Framework for PICs

1) Organization and Management Competencies - a systems focus (human and material resources)

1.1 Procurement (Stock Ordering)

  • Demonstrate the use of the ordering systems for obtaining medicines and medical sundries for provincial pharmacies from the Central/National Medical Store
  • Describe the importance of patient and facility supply records to determine usage
  • Describe the factors that affect usage patterns of various medications and equipment and how this affects ordering (e.g. disease outbreaks), using national policies as a guide and to ensure consistent application.
  • Demonstrate the paperwork and calculations required to order medications
  • Demonstrate the ability to check off orders received
  • Demonstrate the ability to follow up on orders not received
  • Demonstrate the use of the ordering system used for overseas procurement, including a yearly activities schedule
  • Demonstrate the use and monitoring of processes for prequalification and tender contracting
  • Demonstrate a detailed knowledge of the national medicines supply information system (Electronic or manual)

1.2 Donations

  • Describe and follow the national donations policy referring to national pharmacists for advice
  • Demonstrate the ability to say no to donations that are not consistent with this policy

1.3 Storage

  • Demonstrate the ability to layout a medicines/pharmacy store including; the arrangement of medicines according to order form, labelling of medicines, use of stock cards/computerized system
  • Describe the importance of securing the pharmacy store and limiting access
  • Demonstrate appropriate use of, and ability to maintain the cold chain
  • Demonstrate the ability to apply stock rotation (e.g. FIFO or FEFO)
  • Demonstrate the ability to store medicines appropriately, including the considerations of temperature, access and cleanliness of the work area
  • Demonstrate warehousing skills suitable to organise the national supply of medicines and medical sundries

1.4 Distributing Medicines to Hospital Wards and Departments (imprest system)

Demonstrate ability to:

  • Establish imprest lists for wards in conjunction with relevant doctors and nurses
  • Demonstrate the use of an imprest system including the implementation of imprest schedules
  • Regularly review imprest quantities

1.5 Supplying Dependent Service Delivery Points (e.g. clinics and aid posts)

Demonstrate ability to:

  • Prepare and use order schedules
  • Order filling priorities in relation to delivery opportunities and urgency
  • Screen orders (Modify order quantities on the basis of available stock, impact on service delivery, distance of facility from hospital.)
  • Assemble, check and pack orders
  • Promote regular, rather than urgent order culture
  • Co-ordinate transport options
  • Supply NGO’s and other individuals who seek assistance for medication supplies.

1.6 Safe re/pre-packing of Pharmaceuticals

  • Demonstrate the ability to determine when re-packing or pre-packs are required
  • Demonstrate the ability to follow a safe system for repacking

1.7 Record Keeping

  • Describe the importance of record keeping as a tool to help look after patients
  • Demonstrate an understanding of the importance of record keeping as a tool used by government and NGO’s to monitor the health of the country
  • Demonstrate the use of the appropriate recording system. (e.g. stock cards, order forms, computer systems (e.g. M-Supply))
  • Demonstrate the appropriate use of computer stock control systems

1.8 Disposal

  • Describe the importance of disposing of expired medications and medical equipment according to national policy
  • Describe how to dispose of specific individual items of greatest risk e.g. oncology medicine
  • Demonstrate the process used to dispose of expired medicines and used medical sundries including syringes

1.9 Budget and Reimbursement

  • Describe the general monetary value of medicines and equipment
  • Demonstrate the ability to manage all resources with care
  • Demonstrate the ability to create and manage budgets as necessary for work (e.g. wages budget, touring budget, stationery budget, project budgets for using NGO funds)
  • Demonstrate an ability to produce national budgets for both purchases and organizational costs

1.10 Improvement of Service

  • Creates and uses check lists to regularly monitor the activities they are responsible for
  • Plans and conducts supervisory tours of dependent facilities

1.11 Human Resources Management

  • Demonstrate the ability to assist in training nurses and other health professionals in the areas of medicines ordering and storage procedures
  • Orientates new staff to the workplace explaining standard operating systems and procedures.
  • Demonstrate the ability to identify and deal with unproductive staff
  • Orientates new doctors to the formulary and the systems and procedures of the medicines supply system
  • Demonstrate the ability to prepare human resource plans to meet the future staffing needs of the organization
  • Demonstrate the ability to develop a system for staff recruitment, appraisals and monitoring
  • Demonstrate the ability to ensure members of staff have the necessary skills and understanding for safe practice in the event they need to fill a management role due to absence or illness
  • Demonstrate the ability to ensure members of staff have the necessary skills and understanding to use appropriate documentation in the event they need to fill a management role due to absence or illness

1.12 Disaster preparedness

  • Demonstrate an understanding of the process for dealing with disaster events
  • Demonstrate the ability to work with the national disaster planning team if required

>>Back to SCM Newsletter, Quarter 4, 2011 main page


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