Health Exchange

How do you provide pharmacy services for over 100,000 HIV patients with very few resources? How do you treat newly emerging illnesses like diabetes and heart disease? In Kenya, the Indiana University School of Medicine (IUSM), the Purdue University School of Pharmacy and Pharmaceutical Sciences (PUSOPPS) and the Moi Teaching and Referral Hospital have taken fresh approaches to improving clinical pharmacy. By collaborating and working with national and international partners, they are providing unique pharmacy services to thousands of patients.

Imran Manji tells us more.

The Indiana University School of Medicine (IUSM) has been involved in a unique collaboration with the Moi University School of Medicine (MUSM) in Eldoret, Kenya, since 1989. The HIV and AIDS crisis led the IUSM to broaden its focus to build the infrastructure necessary to address the stark realities of the epidemic. Since December 2001, the United States Agency for International Development – Academic Model for Providing Access to Healthcare (USAID-AMPATH) partnership has enrolled over 100,000 patients at 23 clinics located throughout western Kenya, with the headquarters located at the Moi Teaching and Referral Hospital (MTRH), in Eldoret.

The core of this partnership is based on the exchange of ideas and work to improve the public health of Kenyans, by enhancing medical education and community-based research. The partnership works with the Kenyan Ministry of Health to provide focused care in conjunction with the district health centres. The partnership has collaborated with academic medical centres from all over the world to bring in the support and resources necessary to provide the comprehensive level of care necessary for people living with HIV in settings with limited resources.

HIV and AIDS and clinical pharmacy services

The Purdue University School of Pharmacy and Pharmaceutical Sciences (PUSOPPS) agreed to collaborate to provide pharmacy services for the thousands of people living with HIV cared for by the partnership. This collaboration has addressed many of the immediate pharmacy needs of providing antiretroviral therapy and medications for opportunistic infections throughout AMPATH’s sites in western Kenya.

In addition to ensuring the effective distribution of medication, a full-time onsite faculty member from PUSOPPS and two Kenyan clinical pharmacists serve as teachers for pharmacy clerkship students from PUSOPPS and pharmacy interns from the University of Nairobi. They instruct in the delivery of clinical pharmacy services in both inpatient and outpatient settings.

American and Kenyan students are paired up in a unique partnership to facilitate the provision of these services. The main focus of student activity is in the adult internal medicine wards at MTRH where they participate in daily ward rounds under the supervision of a clinical pharmacist and assist in all aspects of care. This includes providing drug information to physicians, nurses and patients; updating medication administration records; ensuring appropriate dosages of all medication; as well as monitoring drug therapy. The students also participate jointly in daily patient discussions, case conferences and journal clubs, with practitioners from other disciplines and other countries.

In addition, they have the opportunity to experience outpatient care during their rotation. This includes spending a day at one of the rural HIV clinics or at one of the specialised care clinics (oncology, psychiatry, cardiology, diabetes and anticoagulation). This collaborative model has given Kenyan students a unique perspective into differences in the American practice of pharmacy, and vice versa, and has created lifelong friendships.

Following the success of the HIV care programme, AMPATH is now shifting its focus to expand the benefits of the established healthcare infrastructure to address the primary care needs of the general population. In this endeavour, PUSOPPS is leading the way by providing clinical pharmacy services in the outpatient management of chronic diseases, specifically in diabetes care and anticoagulation monitoring.

Pharmacy for diabetes

The diabetes programme is a database driven approach for the care of patients with diabetes, a rapidly emerging disease in Kenya. In this programme, all patient encounters are documented on standardised forms that are then entered into a database. The database is then used to generate summary sheets which practitioners have access to during subsequent patient visits. This allows for easy follow up and improved glycemic control.

The programme has led to the implementation of the home glucose monitoring programme for patients with more complicated diabetes and poor control of blood sugar levels. In this programme, patients are provided with glucometers to measure their blood sugar levels at least twice a day from home. Then once a week, clinic staff members call the patients to obtain their readings and adjust their insulin doses based on specific protocols. This fine tuning of insulin doses allows for strict control of blood sugar levels. Once a patient’s blood sugar levels are well controlled, the glucometer is taken back and given to another patient who requires tight sugar control.

In this way, a large number of patients benefit from close monitoring over a long period of time. Future plans of the diabetes care programme include expanding the programme to the various AMPATH satellite clinics, as well as initiating door to door screening for diabetes throughout AMPATH’s catchment area of western Kenya.

Pharmacy for heart disease

With a high incidence of rheumatic heart disease and its complications in sub-Saharan Africa, there are a large number of patients requiring anticoagulation with the vitamin K antagonist warfarin, which has a high risk of causing bleeding if not monitored appropriately. This prompted PUSOPPS in conjunction with Kenyan pharmacists to set up an anticoagulation monitoring clinic. The clinic is staffed by the Purdue faculty, two clinical pharmacists, a physician, a pharmacy technologist and community volunteers. Patients are referred to the clinic from the outpatient cardiology clinic and from the adult medical, obstetrics and gynaecology wards by physicians or gynaecologists.

Warfarin is monitored by measuring bleeding time, also known as the international normalized ratio (INR). At every visit, the patient’s INR is tested and the warfarin dose is adjusted, based on specific protocols. Standardised encounter forms, similar to those used in the diabetes programme, are used. Patients are provided with ready-filled pillboxes containing warfarin at the appropriate dose, thereby simplifying the dosing as well as promoting adherence. The clinic currently follows close to 100 patients and is enrolling more on a daily basis. The staff intend to expand this clinic throughout the western Kenya catchment area as it is the only clinic of this kind in the region.

Both programmes are jointly run by the Purdue and Kenyan clinical pharmacists, thereby fostering a collaboration that encourages the exchange of ideas, while promoting sustainability and independence at the same time. Moreover, the organised structure of the programmes provides a platform for both training and research. In this way, students are able to rotate through these clinics and gain an insight into their working as well as the challenges faced on a daily basis.

Through the provision of clinical and community pharmacy services and care-focused research, the AMPATH/MTRH/IU-Kenya/Purdue collaboration is aspiring to optimise the level of care patients receive in this resource poor setting. At the same time, the collaboration aims to develop future leaders of pharmacy from both resource rich and resource poor settings. Every activity is geared towards fostering bilateral exchange, thereby building the infrastructure to help Kenyans address the health care needs of its citizens.

Imran Manji
Moi Teaching and Referral Hospital, Kenya

www.iukenya.org
http://ampath.pharmacy.purdue.edu/

Filed under: Access to medicine