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Humanitarian aid in Casamance

As part of a diploma in pharmacy and humanitarian aid, Emmanuelle Lambert embarked on a mission to improve management and long-term availability of medicines to rural, underprivileged populations in Casamance, Senegal, with another pharmacist and two pharmacy students

by Emmanuelle Lambert

As part of a diploma in pharmacy and humanitarian aid, Emmanuelle Lambert embarked on a mission to improve management and long-term availability of medicines to rural, underprivileged populations in Casamance, Senegal, with another pharmacist and two pharmacy students

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Casamance, an area south of Gambia, is recognised as the most beautiful region in Senegal. The Casamance River winds its way through the region in a maze of creeks and lagoons. Small islands, areas of palm grove, forest, mangrove swamp and abundant estuary vegetation accompany its picturesque course.

However, Casamance suffers from isolation, being separated from the rest of Senegal by Gambia, an English speaking country.

(Gambian territory follows the Gambia River more than 300km inland. The shape and position of Gambia epitomises the absurdity of the national boundaries carved by the European colonial powers at the end of the 20th century.)

This led to its people feeling neglected by the Senagalese government and a claim for independence, leading to a rebellion in 1982. The conflict involved violent confrontations with Senegalese forces and decades of killings until 2005. As a result, Casamance was profoundly traumatised.

Today, reconstruction continues, despite other difficulties including rainfall deficit, fall of international groundnut prices and increase of food prices.

Predominantly a farming region, Casamance relies on rice and groundnut cultivation, tourism and livestock. The Diola are the dominant ethnic group.

Health system

The Senegalese health system can be described as a three-tiered pyramid. The top tier includes the ministry of health and related offices, the second tier consists of 14 medical regions, each of which is led by a public health doctor, and a third tier corresponds to the peripheral health districts.

One of the village health posts in Ouonck rural community

One of the village health posts in Ouonck rural community

Each health district has at least one health centre and a network of dispensaries established in towns or relatively large villages. Each dispensary is led by a nurse who also supervises all the village health posts (VHPs) in its ward.

Usually, each VHP has one village health worker who is given a training session before he or she starts providing services. Village health workers are volunteers and do not receive any wage for their service.

VHPs also have a midwife (but these do not have formal qualifications) and a managing committee.

Rural areas are clearly underprivileged with regards to health care. Despite the fact that only 40 per cent of the population is based in cities, 70 per cent of doctors and 80 per cent of pharmacists and dentists are based in Dakar, the capital of Senegal, and those who are not in the capital usually work in other main cities.

Traditional medicine is popular — the provision of patient care can be complex and often involves healers as well as modern medicine.

Essential drugs

In 1987, the Bamako Initiative was launched by African health ministers. This aimed to improve the access to essential drugs and care, and to overcome the lack of Government funds for health by involving populations in primary care services.

In practice, it means that the population pays a reasonable amount for medicines and medical consultations. These funds can then be used to buy new essential drugs so that medicines are continuously available.

A national list of essential drugs (based on the World Health Organization list) was established. Essential drugs satisfy priority health needs (the main causes of death in Senegal are described in Panel below).

They are chosen according to their efficacy and relative lack of toxicity as well as their cost/efficacy ratio. The list is reviewed every two years and differs depending on the level of care.

For example, the list is restricted for the VHPs, at the bottom of the pyramid.

Main causes of death in Senegal

Respiratory infections

Respiratory infections account for 16 per cent of deaths and are particularly critical in children. Co-trimoxazole is now available in village health posts (VHPs) for the treatment of non life-threatening pneumonia in children from two months to five years of age. Other cases are referred to the nearest dispensary and dealt with by a nurse.

Malaria

Thirteen per cent of deaths in Senegal are caused by malaria. The country is classified as “very high risk” with chloroquine resistance being widespread. Acute uncomplicated malaria is treated with artemisinin-based combination therapy (ACT).

The most used ACT is artesunate and amodiaquine, which should be kept in VHPs. Village health workers refer complicated cases and pregnant women to the dispensary so they can be treated with parenteral quinine.

Pregnant women should receive two doses of sulfadoxine-pyrimethamine (intermittent preventive treatment) to minimise the risk of developing malaria during pregnancy.

Perinatal conditions

Perinatal conditions (eg, infections, birth asphyxia and premature births) account for 9 per cent of deaths.

Diarrhoeal diseases

Diarrhoeal diseases are responsible for 7 per cent of deaths, with children again being the most vulnerable. Oral rehydration solution should be stocked by VHPs but health workers can also explain to mothers how to prepare a home-made rehydration solution.

Other

The other main causes of death are: tuberculosis (5 per cent), cerebrovascular disease (4 per cent), ischaemic cardiopathy (4 per cent), AIDS (3 per cent; Senegal has one of the lowest prevalence of HIV in Africa [0.9 per cent] but this varies between regions) and whooping cough (2 per cent).

Ouonck Rural Community project

I started my three-month project at the beginning of January 2008 in Ouonck Rural Community (ORC) in the region of Ziguinchor. The community extends over 16km and consists of 24 villages comprising approximately 12,000 inhabitants. There are two dispensaries and 10 VHPs although only six were functional during my stay.

The people of the ORC face the difficulties described above (eg, shortage of doctors, rainfall deficit, etc) as well as lack of drinking and running water, absence of electricity and lack of transport — all of which impact on health and access to treatment.

Our mission was divided into three main parts. The first was to assess the VHPs, the second was to design and implement training for the village health workers and the third to provide essential drugs.

Post-training assessment of a village health worker

The assessment of VHPs was carried out using paperwork created by the previous PAH team and covered staff, structure, equipment, drugs availability, pharmacy, medicine management, population involvement and VHP committee.

The aim was to identify the needs and forward ground information to the health authorities (ie, regional and district doctors).

We designed the training for village health workers by drawing on national references and the work of Africare, a US non-governmental organisation that is active in the region. There were six modules:

  • Module 1: Organisation — tidying the pharmacy (this training involved theory as well as practice!)
  • Module 2: Medication knowledge, including indication, posology, side effects, etc. (VHPs are allowed to keep only a restricted number of drugs, among which are paracetamol, ACT, co-trimoxazole and oral rehydration solution)
  • Module 3: Dispensing and pricing
  • Module 4: Stock management (this dealt with how to complete correctly the medication or consultation register, stock chart and order book)
  • Module 5: Stock management — expression of needs (when, what and how much to order)
  • Module 6: Hygiene and equipment decontamination

Every training session was provided on site to each village health worker. The idea was to link theoretical knowledge with practical action. This enabled us to identify everyday issues that might prevent the health worker from applying what he or she had learnt.

For each module, we designed pre- and post-training tests to identify gaps in knowledge and provide motivation (the marks always improved after the training). We also defined outcomes indicators and charts to evaluate outcomes and improvement.

An assessment two to three weeks after training was also performed. This could be repeated every year. The process, although painstaking, was necessary to ensure the sustainability of our work (and to lead us to question it if no improvement was achieved).

Sustainability is one of the biggest issues involved in any kind of humanitarian or development action — things often work well while project members are there, but what about when they leave?

Our training resulted in improvements in knowledge and practical application, and each village health worker gave us positive feed-back. It was a true pleasure to work with them; they were so keen to learn and improve their practice. It was amazing that they were all volunteers.

Our work was also appreciated by the region’s chief doctor. The aim is now to obtain validation for the modules so they can be used for other rural communities in the future.

At the end of the training PAH donated medicines to each VHP and dispensary. This was continued by my colleagues after I returned to the UK. The medicines were bought in Senegal at the regional supplying pharmacy. They were all essential drugs belonging to the national list.

During my stay I was faced with the problem of medicines returned to pharmacies in developed countries and sent to Africa. Even though people act with the best of intentions, this is was not the right way to help developing countries.

Looking at the carton boxes stored in one dispensary was illuminating: half the stock was expired and a quarter was not on the national list or unsuitable for the dispensary and population needs. In fact, the WHO now prohibits the collection of medicines returned to pharmacies.

Although it may seem sensible to send our unused medicines to the developing world, thereby reducing waste, there are a number of reasons against this practice:

  • The drugs sent often do not belong to the national list of essential drugs of the country
  • The drugs sent are often unsuitable for population needs
  • The drugs sent may not be appropriate for the health structure, which is unsafe and leads to waste because the drugs will not be used (eg, morphine and warfarin are unsuitable in dispensaries because the nurse is not trained to use such medicines)
  • By the time it arrives, the stock sent has often expired
  • Supply can be insufficient for a full course (eg, one strip of antibiotics)
  • Leaflets may be missing or in a foreign language
  • The practice is not sustainable and creates dependence on these supplies
  • Supplies are inconstant and random (so, for example, a proton pump inhibitor can be started but is then stopped abruptly when the stock runs out)
  • The practice can finance medicines mafias
  • Unsuitable drugs will have to be destroyed in the developing country with a financial, safety and environmental impact

If people still want to send unused medicines to developing countries they should at least first check the national list of the country and choose appropriate drugs for the targeted health structure. These should be new packs and not dispensed drugs returned to pharmacies.

Alongside our mission, we carried out other activities, such as organising an HIV consciousness raising day in Ouonck with the collaboration of a local organisation. We also helped a young woman who had obvious signs of an HIV-positive status to access diagnosis and hospital care, where she quickly improved.

Volunteering as a pharmacist in Senegal has been the most beautiful and rewarding experience in my life so far. Despite all the difficulties we faced and my anxiety before discovering this new world, I have wonderful memories of this time. Senegal can be proud of its teranga (hospitality).


ACKNOWLEDGEMENTS Thanks to David Campbell, chief pharmacist and clinical director for medicines management, and Graeme Richardson, deputy chief pharmacist and head of clinical pharmacy, both at Northumbria Healthcare NHS Foundation Trust, for enabling me to take a career break; Jean-Louis Machuron, Jean-Jacques Bléas, and Jean-Loup Rey, for organising the Pharmacie et Aide Humanitaire (PAH) diploma; Dominique Rouffy, PAH, for her support during the project; and Richard Copeland, lead clinical pharmacist for clinical governance at Northumbria Healthcare NHS Foundation Trust, for help with editing.

Pharmacie et Aide Humanitaire

The aim of the association Pharmacie et Aide Humanitaire (PAH) is to promote humanitarian actions in medical and pharmaceutical areas and to carry out emergency, development, expertise and audit missions in developing countries. It organises the PAH diploma at the Caen School of Pharmacy (Faculté des Sciences Pharmaceutiques de Caen, Boulevard Becquerel, 14032 Caen Cedex; tel +33 2 315660080).

The diploma consists of two parts. An initial one month training course provides knowledge related to humanitarian issues and a review of several tropical diseases. During this course, each student is given a three to six month voluntary project in a developing country.

Completion of the diploma is mainly based on a written report on return of the mission as well as an oral presentation.

Citation: The Pharmaceutical Journal URI: 10043816

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