Pharmaceutical policies and access to medicines: a hospital-pharmacy perspective from Ghana

Abstract

Access to quality medicines is a universal human right which featured prominently on the agenda of the World Health Organisation (WHO) over the past decades. Hospital pharmacists play a pivotal role in ensuring that treatment outcomes are optimal. This thesis studied pharmaceutical policies and access to medicines from the perspective of the hospital pharmacist in Ghana. The first theme of this thesis involved the role of hospital pharmacists in improving access to medicines. Here the importance of patient information leaflets (PIL) was discussed; those who read the PIL were more informed about the benefits and risks of their medicines. The patient’s perception of the pharmacists as a member of the health care team was investigated. We noted differential levels of counselling services provided at different pharmacy units and recommended an improvement in this practice. We then studied paediatric medicines and identified that although Ghana has adopted the WHO Children’s medicines list as a working document, some of the medicines are not readily available and are prepared extemporaneously at limited centres in the country leading to problems with acquisition. We also identified the practice of off-label prescribing and suggested the stepping up of surveillance on such products to protect the public from unnecessary harm. The second theme was on adherence to antiretroviral treatment (ART). Data from a historical cohort of a HIV/AIDS treatment unit showed that pragmatic treatment policies based on empirical evidence guided practice; stavudine was substituted with safer alternatives like tenofovir or zidovudine. A subsequent study to ascertain the relationship between adherence and treatment change revealed that overall 88.9% of patients who continued first line treatment compared to 79.9% of patients switching therapy had adherence levels greater than 95%, thus concluding that non-adherence to was associated with treatment change including change to more expensive medicines. In a follow-up study we therefore focused on risk factors associated with non-adherence to ART. WHO stage of disease, low CD4 cell count and presence of symptoms at baseline were the risk factors identified, which could help target adherence counselling. Finally, facilitators of and barriers to ART adherence among adolescents were studied using a qualitative study. Assistance from health care workers and forgetfulness emerged as the most important facilitator and barrier, respectively. The final theme was on the role of hospital pharmacists in safety surveillance during immunization programs. Two prospective studies were conducted, one on adverse events following immunization (AEFI) against 2009 H1N1 influenza and one on signal generation using data from the Food and Drugs Authority in Ghana collected during active surveillance from six immunizations. These studies showed that vaccine safety surveillance can be effectively carried out, also in a low resource setting, if given the right support. This thesis emphasizes the role of the hospital pharmacist in Ghana in access to medicines and pharmaceutical policies. It highlights the importance of medicines information, service provision and delivery of essential medicines to paediatric patients, adherence to antiretroviral therapy, and the monitoring of adverse events following immunization including the detection of signals.