How did you experience the journey in general?
I just totally fell for Rwanda…
First of all hot, very hot.
Apart from that I think, no I am sure, I have learned many things. After my secondary school I spent a couple of months in Malawi. As that being my only African experience I expected a slightly similar situation. Yes, I do realize that is quite narrow minded…
Things are just different in Rwanda. It already started at the airport in Kigali. Everything looked highly structured and clean. There was for example free wifi in the airport and every person got checked for temperature (Ebola). This first impression was confirmed during my whole stay. Rwanda: the Switzerland of Africa. I have lived in Switzerland and I think this really is true. Rules and regulations, they just love it. Where I got fined in Switzerland for riding someone on the back of my bike, I got a warning from a Rwandese police officer that I was standing in the grass along the pave yard (to shelter under a tree from the rain). Apparently not allowed. When a person with a magnum 2.1 warns you, you just take that seriously.
Furthermore, I have been highly impressed by the health care system. The way it is currently working, especially after having been told how the situation was 20 years ago. Of course, it is not functioning perfectly yet and there are still many challenges to overcome, but the foundation has been led. In neighbouring countries the system has not been developed as well as it is in Rwanda.
This trip has certainly broadened my view on the pharmaceutical care in general. You only realise what you have the moment you don’t have it anymore. This is applicable to many things. In the Netherlands we take everything for granted. We don’t realise what we have because it’s just there. Being in a country as Rwanda makes you realise that for many people things you assume to be normal are something they have to fight for every day. In respect to pharmaceutical care, in the Netherlands we assume that every medicine is available and moreover, covered by our insurance. And of course there is a social security and everyone has a basic healthcare insurance. Those are all not the case in Rwanda. Not every medicine is available. Moreover, even the essential medicines are not always available. Not every medicine is covered by the insurance. And, yes you can guess, not everyone is insured…
To be a bit more specific on the role of a pharmacist, in the Netherlands the pharmacist does not spend most of his time working in logistics, making sure all medication is available. In the Netherlands the pharmacist is – at least we aim to be- a health care professional whose role is to optimize pharmaceutical care for their patients. In Rwanda, there is just no time for medication surveillance. So again, what for us is considered normal is certainly not the case in other parts of the world. I do realise this sounds all very obvious. But still, I think we generally take things for granted and do not realise in what kind of heaven we live.
Lastly, I have met many nice people, which really added to my overall feeling about Rwanda. People were helpful. Sometimes because you were ‘musunge’ (white person) and therefore rich in their eyes. However, many times people were just friendly.
Can you give a global description of your daily activities during the three weeks?
In the first week I was placed within the two hospital pharmacies. Apart from getting to know the function of the pharmacists, I additionally focussed on getting a broad overview on how the pharmaceutical care is regulated within Rwanda. I got to know about the different insurance systems, the role of the hospital in relation to Health centres, the list of essential medicines of Rwanda, how hospitals are being supplied with medication and many more basic aspects.
I was impressed how well regulated the pharmaceutical care in Rwanda is. There are still many challenges to overcome, but the foundation has been led. Every single person has theoretically access to the essential medicines. This has been made possible by an insurance system in which a yearly amount of ± 3.5 EURO per person covers basic care given in public hospitals. A percentage of 10% of the given care has to be paid by the patient and the additional 90% will be paid by the insurance. The system is not yet functioning perfectly. Question marks can be placed whether 3.5 EURO is enough to cover all the expenses made. Thereby, health centres are for many people hard to reach. Still, the healthcare of Rwanda is far more developed than in their surrounding countries. Things seem to work here in Rwanda, generally speaking…
In both hospitals the pharmacists made time to answer my question and discuss my concerns. This basic knowledge was very useful and necessary for the follow up of the internship because it made it possible to put everything in the big picture.
In the second part of the internship I (with Wietske and Endraen) was situated for two days at the University of Butare and for three weeks at the wholesaler Kipharma. At Butare, we gave a lecture to students of the third grade of the Bachelor of Pharmacy. We choose pain management as the topic of the lecture as we had seen some cases in the hospital where the pain management was, softly expressed, suboptimal. For this reason we assumed that the knowledge about pain management could be lacking among students too. We discussed the pain ladder of the WHO with the students and related aspects, which were all fairly new to them. The lecture was a success followed by a lively discussion afterwards. This example is illustrative that the combination of the different fields within this internship was working beneficial.
The last three weeks I spent at a wholesale, named Kipharma. It was my first time at a wholesale, so many things were new to me. The first week I was given an introduction of the different departments. I was introduced in the work of the laboratory, the procurement process and the supply chain management. I spent 1.5 day in two pharmacies owned by Kipharma. After this week of introduction I discussed with de director in what projects I could participate. We decided that I work on two different projects. In the following two weeks I spend most time on those projects. I was very well supervised during these weeks which made it fun to work on those topics. Also in this place it was an advantage that I had already gained knowledge of the pharmaceutical care in the field. With that background it was easier to position the role, goals and challenges of Kipharma.
Can you elaborate more on the projects you worked on?
I worked for example on a project that was related to the (potential) import of generic medicines. Kipharma was approached for collaboration with an NGO. This NGO has several health posts around the country and was looking for a reliable wholesale for the supply of generic medication for these health posts. Kipharma is currently not focussing on cheap generic medication. One of the reasons is that the cheap generics that come from India and China do not always meet the quality standards. I was not aware of the fact that companies from India and China (and of course probably other countries) have two different production lines. One for Europe, where they produce high quality generic medicines and one production line for Africa, where they produce low quality generics. So, for the selection of a generic company, many attention needs to be paid to the quality. I have approached different generic companies whether they supply – or are interested in supplying – to Rwanda. I additionally made an analysis of the prices the NGO currently pays for their medication (which they import from different wholesales within the country) and prices given by other generic companies. The companies that have responded could not meet the prices the NGO is currently paying, so for now it was decided not to contract the NGO for the supply of generic medicines. The search for a company to cooperate with that produces high quality and low priced generics will continue.
What were your nicest experiences?
I really enjoyed the teaching at the University of Butare. Mainly because the students were very interested and eager to learn about the topic presented. They did not seem to know a lot about this specific subject, but their questions showed that they took it up very quickly and were able to put the content in the big picture. After the lecture we got in dialog with some of the students and found out how active they were in pharmacy related activities next to their study. They were highly motivated and energetic and all seemed to share the aim of improving the health care in Rwanda. This really gave me a lot of positive energy.
As already mentioned, I was impressed by their health care system. Although things did not function perfectly yet, the foundation has been led. It seems that the government in Rwanda aims very high in for example improving health care and reducing poverty. Although the goals itself are too hard to reach, many improvement are and will be made. They don’t use the strategy ‘increasing success by lowering the expectations’, but the other way around. There are of course pros and cons for both approaches. Setting (too) high goals works in Rwanda.
Another aspect that touched me was ‘umuganda’. Umuganda is the last Saturday of the month whereby everybody is asked to do community work in the morning, like sweeping the streets or building houses for poor people. This is followed by a community meeting were political questions are discussed. It brings people together. A day where you focus not on yourself but on the community. It touched me and made me realise that we lack community thinking in the Netherlands, people generally focus on themselves. Of course, it’s not that black and white, but generally speaking…
What were your less pleasant experiences?
Realising that the role of a hospital pharmacist is mainly logistics and the role of a public pharmacist is mainly dispensing. When I was in the hospital of Ruhango, the hospital pharmacists was almost only focussing on logistics. When we visited some patients in the hospital, their pharmacotherapy was far from optimal. There was for example a patient with late stage cancer under palliative care. She was in real pain. She just got a low dose of tramadol every day. I was the one that had to purpose to higher the dose of tramadol or preferably start straight away with a strong opioid. I think this was a really sad situation. What additionally frustrated me is that there was no tramadol available and that the pharmacist went to another hospital (1.5 hours away from this hospital) to get a box of tramadol. It seems to me that this is not an optimal time-management strategy. As there is already (too) much logistic work to do it is necessary to carefully allocate tasks, in my opinion.
One other thing I struggled with is that I don’t really like to be ‘the musunge’ (white person). People see you as a big white Oliphant with a lot of money. So sometimes you think you are have a nice conversation, but in the end there is just one thing the person wants. This was not the case all the time of course! I think I just don’t like it to be seen as different, I want to be one of the people I am living with.
If you could take this trip again, what would you have done differently?
I would have gotten more into detail beforehand with the pharmacists and director of Kipharma. By this we could have more specified what activities I could do at the different locations. A good preparation can highly benefit the work that can be done locally. For example, in the hospitals a preparation could have made the work locally way more beneficial. Both hospitals struggled with too much logistic work and too less time for clinical pharmacy. This resulted in a lack of pharmaceutical knowledge of the pharmacist and also the nurses. A program to train them could have been designed before going there and the time there could have been used to train the pharmacists and nurses.
Apart from more preparation in the pharmaceutical field I would have read more about the history of Rwanda. Its history explains a lot about the current Rwandese culture. It seems hard to really get deep into their culture. Everything looks almost perfectly structured. To get more in depth in their culture and customs I would highly recommend to read, read and read about it.
Merel Philippart – firstname.lastname@example.org – 0031634828830