EAST LONDON, South Africa — Nine-month-old Alime and his grandmother Cynthia sit at a table piled with pill bottles, cardboard cartons, and syringes. There are 19 items in all.
The squiggly Alime, who traveled that morning on his grandmother’s back to the hospital, happily munches on a cookie while the pharmacist counsels his grandmother on when he should take each of his medicines and how much to give him. It’s hard to believe such a tiny boy needs so many pills to survive.
Alime has been HIV-positive since birth. His treatment seems to be working. His weight has doubled, and as he smiles and gurgles quietly in Cynthia’s arms, he looks like a healthy toddler. He rarely takes his eyes off his grandmother, and he reaches out to touch her face as she talks.
Alime’s mother died of AIDS when he was just five months old, Cynthia says, her voice catching and grief pooling in her eyes. Now it’s up to her to care for her grandson.
So each month, they come here to Frere Public Hospital in East London. The trek takes most of the day, but Cynthia says she doesn’t have to wait long to see the pharmacist, and she always returns home with the medicine Alime needs.
She doesn’t know it, but one of the reasons for this is a tool called RxSolution. Though invisible to patients, it has transformed their experience at Frere and many other South African public hospitals, which treat the neediest and most vulnerable and were long-neglected during the country’s 46 years of apartheid. Developed by MSH with funding from USAID and the Eastern Cape Department of Health, RxSolution helps pharmacists easily monitor inventory, track patients, and aggregate data for planning and purchasing. It relieves pharmacists of time-consuming paperwork and allows them to spend more time with their patients.
Sammy Meintjes, lead pharmacist at Frere, still marvels that record-keeping tasks that used to take weeks can be accomplished in less than five minutes. He sees a direct connection between that and the quality of care patients receive.
“The more time you spend on a prescription, the less time you have to spend with the patient,” he says. “I think the system has really taken us to another level … we are moving in the right direction.”
Rolled out in 2004, RxSolution has been endorsed by the National Department of Health as the preferred monitoring system. It is used in more than 400 facilities across South Africa, including hospitals, community health centers, and primary health care clinics. Fifty-one percent of South Africa’s public hospital pharmacies have installed it, and almost 800 pharmacy staff members have been trained in its use.
On July 14, 2016, MSH reached an important landmark: officially handing over RxSolution to the government to be employed and sustained nationwide. Hospitals in five other nations—Haiti, Namibia, Rwanda, Swaziland, and Uganda—have also adopted the tool.
And the timing is propitious. Public hospitals are now in the spotlight, as they will form the backbone of the pending National Health Insurance plan that aims to provide access to quality health care to all South Africans.
The disparate conditions between public and private health systems in South Africa are a stubborn vestige of apartheid, when the government focused almost exclusively on economic and health advances for whites.
“The private sector was servicing the privileged white communities whilst the previously disadvantaged communities were still being serviced from the public sector … and that largely remains the case even today,” says Gavin Steel, chief director of sector-wide procurement at the National Department of Health. “[The public hospital system] was largely a chaotic environment that we inherited from the apartheid regime.”
The gap between the rich and poor in South Africa is among the largest in the world, according to a 2014 New England Journal of Medicine review. In health care, inequalities are especially stark.
While much progress has been made, serious health threats plague the country—many of them associated with poverty. South Africa’s unemployment rate is one of the highest in the world and rising, reaching almost 27 percent in early 2016. Tuberculosis is at epidemic proportions, and non-communicable diseases—diabetes, cancer, chronic respiratory conditions, heart disease—are beginning to gain a worrisome foothold. Violence and injury take a steady, high toll. And 6.8 million South Africans are living with HIV — a number higher than any other country in the world.
Pharmacists on the Front Lines
Pharmacist Meintjes is on the front lines. South Africa’s 400 public sector hospitals serve 84 percent of the population, most of whom are poor, with just one-tenth of the resources available to the private sector.
About 800 prescriptions are handled every day in Meintjes’ 34-ward hospital. Getting the right medicine to patients when they need it is the bedrock of his profession and his driving personal mission. And RxSolution helps him to do that, he says.
“Before RxSolution, we dispensed manually. The challenges we had were huge,” Meintjes says, recalling the time-consuming tasks of deciphering handwritten prescriptions, writing out labels, and making sure label and prescription information matched. It was a tedious, high-stakes job, which made it hard to retain staff.
“If the label is not clear, the patient can take the wrong dose … and it could have serious consequences,” he says.
RxSolution was piloted at Frere Hospital in 2002, and it has now become one of the engines of continual improvement in patient care and medicine safety. Pharmacy staff can use the system to track medicines from their delivery to the hospital stock room, to their arrival at the pharmacy, to dispensing to a patient. The electronic system also allows pharmacists to track patient histories and monitor their varied prescriptions and dosages. All of this adds up to safer regimens, which means patients are more likely to stay on their medicine and feel better.
“Ultimately no sound decision can be [made] without relevant and accurate information, so I think that’s the most important role of RxSolution,” says Stephanie Berrada, deputy country project director at MSH. It allows hospitals to track pharmaceutical expenditures, budgets, and inventory.
The system’s efficiency shows in Frere’s outpatient pharmacy, which hums with steady activity. More than 20 people sit in the waiting room and a half dozen pharmacists call patients to the dispensing windows. Behind them, shelves are full of medicines and supplies. Staff bustle around the central work counter, using RxSolution-enabled computers and printers to track, label, and package the prescriptions.
What used to be a three-hour wait for patients is now 45 minutes.
Reckoning with a Killer
In just one year, between 1999 and 2000, more Africans died of AIDS than in all of the wars on the continent, according to the then-UN Secretary General Kofi Annan, who likened the epidemic to World War III. Twenty-three million sub-Saharan Africans had the disease at the turn of the century, and South Africa was affected more than any other nation. Twenty percent of the country’s population was infected and about a quarter of a million people died of AIDS in 1999, according to UN statistics.
By 2003, the South African government agreed to make ARVs available in public hospitals, supported by funds from the President’s Emergency Plan for AIDS Relief (PEPFAR).
The Global Fund to Fight AIDS, Tuberculosis and Malaria, which had been formed in 2002, was ready to make similar commitments but would only do so if it was assured that its investment would be protected by a strong medicine monitoring system.
At the request of USAID, MSH set out to create such a system. MSH had been working to strengthen South Africa’s public health sector since 1997. One of its first innovations was RxStore, a tool developed in 2001 with local software developers. With RxStore, pharmacists began to get a handle on stock levels and could discard their paper-based systems.
In 2000, Steel, of the National Department of Health, was working as a pharmacist at Frere Public Hospital, where Sammy Meintjes now works. The pharmacy was routinely running out of medicines, and the issue made local headlines. Steel wanted a better system, so he reached out to MSH. Together they started building the tool that would eventually ensure that Alime’s medicines were ready when his grandmother came to pick them up.
They drew upon MSH’s first-of-its-kind bulk-purchasing system developed in the Caribbean in the late 1980s and the successes of RxStore in 2001. Within six months, they had the prototype for RxSolution.
Steel, by then an MSH employee, and his colleagues at Frere Hospital put the system to use, and paired it with other systems strengthening activities—improved pharmacist training and supervision, record-keeping, and data collection. In just two months, the hospital was no longer in the newspaper, and stockouts became rare.
“What [MSH has] simply done is gone into a country, look at the tools that they are using, what are the challenges … then we say to them, ‘maybe we should look at doing it this way,’ and we develop the new tool together,” says Bada Pharasi, MSH’s country representative for South Africa.
By 2004 the expanded RxSolution was ready, improved over the years with the input from the pharmacists who were using it. The tool would support the unprecedented infusion of medicine to treat HIV.
Heidi van Rooyen, a pharmacist at Rustenberg’s Job Shimankana Tabane (JST) Hospital, has used RxSolution since 2005. She credits MSH’s staff, many of whom are trained pharmacists, with easing the pressure of caring for more than 5,000 patients.
“They have helped us help ourselves,” van Rooyen says. “If [MSH staff] weren’t pharmacists, they wouldn’t really understand what we need.”
A 2013 report confirmed her impressions: facilities that were using RxSolution were outperforming those that were not. So the government asked that RxSolution be introduced in all of the country’s public hospitals.
“RxSolution is most probably the heartbeat of our supply chain,” says Steel.
It ensures that patients get the medicine they need when they need it, helps hospitals track expenditures, and provides more equitable access to healthcare for all of its citizens.
To ensure uninterrupted flow of medicines, the South African government has taken the next step and asked MSH to develop a nationwide electronic surveillance system that will provide decision makers with up-to-the-minute information on inventory across all facilities, enabling immediate troubleshooting and solutions to problems with supply. By the end of 2016, data from 103 hospitals will be interconnected via a shared electronic dashboard.
National Health Insurance
Universal health coverage is the dream of South Africa’s health sector. Achieving it for the nation’s 54 million people would be an epic accomplishment, and tools such as RxSolution will play a leading role.
Supporters are laying the groundwork and taking the first essential step: improving the public hospitals and positioning them to offer services at the level of private facilities. While much progress has been made since the days of apartheid, there is plenty of work to be done. Inspections in 2014-2015 by the Office of Health Standards and Compliance showed that 67 percent of public health care facilities were non-compliant or critically non-compliant with the expected norms and standards.
By the end of 2015, the white paper on a National Health Insurance plan, a precursor to legislation, was released after years in the works. With its 14-year timeline, the plan is ambitious, calling for health coverage for all, quality services for people irrespective of their socioeconomic status, pooled funds and purchasing, and increased support for public sector facilities.
Acknowledging that the plan will call for “massive reorganization,” the government evokes the principles that created the country’s democratic political system in the early 1990s. Accomplishing national health insurance, the white paper says, “is a reflection of the kind of society we wish to live in: one based on the values of justice, fairness, and social solidarity.”
“Under [national health insurance] there is going to be one health system, so this artificial divide between the private and public sector will no longer prevail,” says Steel.
And that’s one of the reasons he does this work.
“One of the reasons why I personally got involved in the development of RxSolution was to improve equity,” he says, “and make sure that whether you present in Cape Town, or the Eastern Cape in East London, or Idutywa, or Butterworth, you get the same package of care.”
On her way out of the pharmacy, Cynthia glances over her shoulder with a smile. The white plastic bag full of medicine swings from her arm. Alime has already started to nod off.