Principles of Medicine in Africa

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Book Review: Mabey’s Principles of Medicine in Africa

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Lynd, Larry D. Pyrexia of unknown origin in clinical practice.

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All data collection tasks were conducted by the first author, a qualitative researcher with a background in public health. We focused on the intervention as it had been implemented, i. Where possible, interviews were recorded; alternatively, notes were taken.

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Three participants refused to be recorded as a matter of preference. Once no new information was generated from the interviews saturation , no further interviews were conducted. Preliminary results were discussed with respondents in order to allow for member checking, an important validation technique in qualitative research [ 17 ]. The process was participatory: we presented at pre-scheduled provincial stakeholder meetings in two cases and organized a separate meeting one case. This process allowed participants to engage with and contribute to our interpretation of results.

Ethics approval was granted by the Senate Research Committee at the University of the Western Cape and provincial government approval to conduct research in facilities was granted by the WCDoH. All participants were taken through the informed-consent procedure prior to interviewing and were also informed of their right to withdraw at any time without any consequences in accordance with the requirements of the Helsinki Declaration of The recorded interviews were transcribed verbatim. A hybrid approach of inductive and deductive coding and theme development was applied [ 18 ] to the analysis.

This approach was appropriate because it is data-driven and uses pre-determined codes while also allowing for the addition of newer codes. Broad pre-determined codes were drawn from the components of the initial program theory covering CDU processes such as patient selection and management of non-collections. At the same time, emergent codes were identified during the analysis. The first author coded the data using Atlas. TI version 7 software.

Reports were made for each facility, and a comparison looking at responses to similar questions by respondents from different facilities was done to ascertain how the initial program theory could be refined. Key informants held overwhelmingly positive perceptions about the CDU and reported that the establishment of the CDU was a useful strategy to address prevailing barriers to accessing medicines. The majority indicated that the CDU was a part of their operational routine upon which they were dependent and without which the health system would be weakened.

Automation of the dispensing process was perceived by some informants as useful to improve the dispensing rate and relieve pharmacists of mundane dispensing tasks, as reported by two pharmacists:. So, you can do the calculations. Even prescriptions are a huge workload, even if we were able to pay salaries … and now we have an influx problem [with patients].

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It also reduces the pressure on the pharmacist. So I think it has helped the pharmacists to reduce their workload and I hope that it makes us better pharmacists at the end of the day, able to focus more on the patient more than just focusing on getting that big pile of folders down. All four facilities included in this study were reported to still have high patient volumes, with patient waiting times for medicine collection still reaching up to five hours at the largest facility. This meant that CDU beneficiaries had separate queues from other patients at designated times in the facility or PMP were distributed from a separate building on the facility premises or in the community.

One pharmacist stated that their facility was able to distribute in excess of parcels within two hours. Whether the designated times for distribution were convenient for all patients remains unanswered. Other benefits appreciated by healthcare practitioners included the flexibility of the dispensing system to accommodate special requests from facilities to dispense medicines for multiple months for mobile populations.

This benefit was achieved in small increments from an initially rigid system to one with improved functionality. Information on medicines expenditure for example was already used consistently for planning and monitoring. Finally, the CDU program also encountered multiple challenges pertaining to contracting of suppliers and the operating context. The former, although outside the direct control of the intervention influenced its implementation significantly as highlighted below. The CDU service is a contracted service, whereby the appointed service provider is given a five-year term.

During interviews, many respondents mentioned how the first tender change-over disrupted the service greatly, while also presenting lessons for the future. Delays were greatest during the supplier change-over periods where stock-outs rates rose from between to items at a time. When a PMP was dispatched to the facility without all the prescribed items, the local pharmacist would either dispense a suitable generic medicine if readily available in the pharmacy or an alternative under the authorization of a prescriber.

This supplementary dispensing for patients registered with the CDU was not well received by healthcare practitioners as it created additional workload for pharmacy personnel. With regard to infrastructure, limited storage space was a major determinant of how pharmacy personnel managed PMP at the facility. Referring to early days of implementation, one respondent said:.

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The fridge items were also a huge problem because facilities had these little fridges for their own purposes. If you deliver a prescription which contains fridge items, you have to put the whole PMP into the fridge so the fridge becomes full. Limited storage space was further exacerbated by missed appointments by patients.

Over the years, the WCDoH facilitated installation of additional shelving in facilities. Also, improved shelving and storage, and clear labelling of parcels by the service provider led to improved retrievability of PMP. Previously, facilities had no system in place to organize the PMP, therefore, boxes containing PMP piled up and it took a long time for pharmacy personnel to locate PMP for distribution.

They indicated that the patient load in urban facilities is much higher, hence the infrastructure demands are also high. As a result, minimal infrastructure and process adjustments were required when the CDU was introduced. Pressure from provincial management emerged as a factor that worked against facility preparedness for the intervention. Also, the number of enrolled CDU patients at each facility was used as an indicator of good performance, which in part contributed to selection of patients whose suitability might be questionable.

Another issue, particularly in the early years of implementation, was inadequate orientation of health practitioners to the intervention. An informant who was closely involved in the early years of implementation indicated that in the beginning, much attention was given to ensuring that the dispensing processes, the product and implementation protocols were in place but facility preparation was neglected:.

I always say: in the first six months, when the CDU was implemented , it did so much more harm to the reputation of the CDU than it did good. Facility preparation improved over time and standard operating procedures were revised owing to the lessons learnt from implementation in urban facilities.