2025 Vision for Pharmacy - Speculation 3

The third of six Speculations by eminent pharmacists to assist you with your submission for a chance to win a prize on a vision for pharmacy in 2025. See the end of this article for details.

Looking forward to 2025 in Africa and the Global South

By Andy Gray, Senior Lecturer, Centre for the AIDS Programme of Research in South Africa (CAPRISA)

Africa is all too often portrayed simply as the "Dark Continent" – a place echoing with Conradian horrors, never changing, hopeless. The reality is far more complex. While parts of the continent are still wracked by conflict, some countries have recorded several cycles of peaceful, democratic elections; while some areas are devastated by natural catastrophes and environmental degradation, others are showing the benefits of careful stewardship of both the natural and man-made environments; while poverty remains widespread and inequities abound, some of the world’s fastest growing economies are located in Africa. In trying to predict which factors may impact on the profession of Pharmacy, both in Africa and Global South, over the next 15 years, it may be worthwhile identifying the constants first – the factors that are unlikely to change. In Health, these would include:

• a high burden of disease, including both communicable and non-communicable diseases, as well as a high burden due to injuries (accidental and otherwise);
• a relative lack of financial resources, resulting in lower human resource provision as well as a relative lack of infrastructure and health-related commodities (including medicines) compared with developed countries;
• a relative lack of skills, including both skilled health professionals and health managers;
• a greater reliance on donor funding, as well as on out-of-pocket payment for healthcare services.

However, no region of the world and no country, whether developed or developing, will remain entirely constant over 15 years and more. The following trends are expected to impact on the profession of Pharmacy in Africa over this period. In many ways, they are expected to be similar to trends affecting the Global South – the developing and transitional countries. Globalisation per se leaves no country unaffected, and choices made in powerful countries and organisations (not least in the donor countries) will also impact on healthcare in developing countries.

Healthcare financing in developing countries has traditionally relied on user fees, paid at the point of care. In many cases, this has involved patients or carers paying for medicines at the point of care, whether at a government hospital or clinic, at a private community pharmacy, or at an unregulated drug seller. There is a growing trend towards pre-payment systems, such as National Health Insurance schemes, as well as a realisation that user fees have a negative impact on access. As greater emphasis is paid to chronic, non-communicable diseases (which are of growing importance in Africa), so greater emphasis will also have to be paid to ensuring access to sustainable funding for such care. The efficiency (or inefficiency) of such systems can have a dramatic impact on healthcare providers from whom services are purchased, including pharmacists. Slow or erratic payments can reduce confidence in the system, and corruption can lead to the diversion of much-needed funds.

As greater reliance is placed on insurance systems in African countries, so the selection of medicines to be reimbursed will become more important. Although many African countries have long experience with creating and maintaining Essential Medicines Lists, these have largely guided government and donor-funded procurement. Extending such systems to cover the private sector remains a challenge, but one that must be met if insurance is to be sustainable. Pharmacists will not only have to learn how to work within such constraints, but also contribute their particular expertise to the rational selection of medicines.

Greater involvement by insurance structures also implies a greater emphasis on quality assurance of the providers of healthcare services, including pharmacists. Insurance systems in Africa will have to take tough decisions about the role to be played by non-pharmacist sellers of medicines, especially in settings where access to registered pharmacies is inadequate. Greater regulatory oversight of pharmacy practice and greater emphasis on and enforcement of explicit Good Pharmacy Practice guidelines hold both challenges and opportunities for pharmacists in both the public and private sectors. In order to meet these standards, better use will have to be made of scarce human resources (notably of pharmacists), with expanded roles for mid-level (technician) cadres.

While access to donor funds has improved in many settings, there has been a clear preference for vertical programmes that focus on a single disease (HIV/AIDS, tuberculosis and malaria, for example). There is, however, a growing realisation that more funds and efforts need to be directed at systems strengthening. Pharmacists have often remained outside of these debates, and have accepted an artificial divide between state-provided, notfor- profit (including faith-based) and for-profit systems. If healthcare systems in Africa and the Global South are to be improved, made sustainable, and strengthened in every way, pharmacists will need to ensure that their voices are heard and their contributions valued and incorporated.

Stating that the status quo is not an option sounds trite, but remains true. Pharmacy in Africa and the Global South cannot expect "more of the same". Instead, they can expect continued pressure from high disease burdens, more emphasis on non-communicable diseases and mental health, while still dealing with high communicable disease burdens, but also profound shifts in healthcare financing. Meeting those challenges requires meaningful engagement, commitment to equity and quality, affordability and rational medicines use.

CPA is encouraging its member organisations and its members to make a submission on what they feel will emerge to have an impact on health care directly or indirectly relating to pharmacy by 2025. A prize will be awarded to the member organisation or member sending in the best submission.

The Presidents Message from Commonwealth Pharmacy Day can be read online.

Full details can be downloaded here: 2025 Vision for Pharmacy (PDF)