The Patient at level 3 has changed. Has our care changed with them?

 

Are we sufficiently aware of the kind of patient walking into a Level 3 health facility in Kenya today? Increasingly, that patient is living with a chronic disease. Noncommunicable diseases (NCDs) now account for approximately 43 per cent of deaths in Kenya and nearly half of hospital admissions. In March this year, the Ministry of Health estimated that approximately 3.1 million Kenyans are living with chronic kidney disease, with hypertension and diabetes among the major drivers.

These figures should fundamentally change how we think about primary healthcare and particularly about medicines. Across Kenya, many Level 3 facilities run medical outpatient clinics (MOPCs) where patients living with hypertension, diabetes and other chronic illnesses return regularly. A patient may have their blood pressure or blood glucose checked, see a clinician, receive a prescription, collect medicines and go home.

But in a country carrying this burden of chronic disease, collecting another month's medicines cannot be our definition of successful care. The important question is not only whether medicines reached the patient's hands. It is whether those medicines are achieving what we intended in that patient.

That is where pharmaceutical care begins.

A patient with hypertension and diabetes should have someone looking across their entire medicine journey. Are the medicines controlling the disease? Is the patient actually taking them? Have doses been missed because of side effects, cost or misunderstanding? Are there interactions or unnecessary duplication? Is the dose still appropriate as renal function changes? Is apparent treatment failure actually an adherence problem? Does therapy require optimisation or referral?

A prescription tells us what was prescribed. It does not tell us what happened after the patient went home. And what happens after the patient goes home is increasingly where our health outcomes will be won or lost.

When a patient returns month after month with persistently uncontrolled blood pressure or glucose, simply handing over another month's supply without interrogating why treatment is failing risks turning access to medicines into an administrative exercise rather than a health outcome. The medicine has to be followed all the way to the outcome.

That is what pharmacists are highly trained to do; pharmacotherapy, pharmacology, pharmacokinetics, adverse effects, interactions, medicines optimisation and monitoring the safe and effective use of medicines. The pharmacist's contribution is therefore not simply ensuring that the correct medicine leaves the pharmacy. It is managing the patient's medicines by establishing whether they remain appropriate, effective and safe; identifying medicine-related problems; supporting adherence; monitoring outcomes; intervening where appropriate; and referring back to the clinical team where further intervention is required.

Consider our growing kidney-disease burden. If approximately 3.1 million Kenyans are already living with chronic kidney disease, our response cannot begin at dialysis. Primary healthcare gives us opportunities much earlier: better NCD control, improved adherence, identification of medicines that may further compromise renal function, appropriate adjustment as renal function changes, recognition of interactions and timely escalation when treatment is no longer achieving its objective.

The cheapest renal failure to manage is the renal failure we help prevent.

Kenya's evolving Primary Healthcare architecture presents an important opportunity to do exactly that. Community Health Promoters (CHPs) are increasingly identifying risk, supporting screening and connecting households to the formal health system. But that referral should not end when the patient reaches a facility and receives medicines.

A functioning Primary Care Network should create a continuum: the CHP identifies risk and refers; the patient is assessed and treatment initiated; at the Level 3 facility, the pharmacist manages the medicines component of care, checking appropriateness, adherence, safety and response, identifying medicine-related problems and escalating concerns within the multidisciplinary team. Follow-up then continues closer to the patient's home.

That is a Primary Care Network functioning as a network with accountability. Importantly, the pharmacist's contribution is not necessarily another medicine. Sometimes the most important intervention is discovering that the patient has not understood the medicines already prescribed. It may be identifying duplication, recognising an adverse effect, improving adherence, recommending optimisation to the clinical team or recognising that urgent referral is needed.

The objective is not more medicines. It is better management of medicines.

The same expertise matters in maternal healthcare, where medicines must be considered in the context of pregnancy and the safety of both mother and child. It matters in antimicrobial stewardship, where responsible antibiotic use must happen wherever antibiotics are prescribed and dispensed. It matters in the management of dangerous drugs and controlled substances, where custody, documentation, appropriate use and accountability demand strong professional oversight. And it matters in pharmacovigilance, medication errors and medication reconciliation.

There should be no negotiation on the relevance of pharmacists at Level 3 but we should definitely understand: What should a patient experience differently because a pharmacist is there? The patient should understand their medicines. Medicine-related problems should be identified before they cause harm. Adherence problems should be detected rather than mistaken for treatment failure. Therapy should be monitored for effectiveness and safety. Interactions and unnecessary duplication should be identified. Where the pharmacist can resolve a medicine-related problem, it should be resolved; where further clinical intervention is required, the patient should be referred appropriately.

And these interventions should be documented, followed up and held accountable.

Kenya's Good Pharmacy Practice Standards recognise this changing healthcare environment. They seek to address irrational medicines use, preventable medication errors and adverse events, weak integration of pharmacy into primary healthcare and under-utilisation of pharmacists' clinical and public-health expertise.

Having pharmacist oversight at Level 3 does not mean other pharmaceutical teams cease to work there. What changes as the complexity of care increases is that the level of professional responsibility and medicines expertise required around the patient requires a pharmacist.

Healthcare facilities must, of course, remain financially sustainable, but there is a principle we cannot lose: The business model cannot determine the clinical standard. The clinical needs of the patient must determine the standard.

Quality healthcare is not negotiable. If meeting an appropriate clinical standard presents implementation challenges, government, counties, regulators, providers and professional bodies should work together to solve them. We should not lower the standard until it becomes convenient.

Medicines are among the most powerful interventions in healthcare. They prevent strokes, control infections, protect pregnancies, manage diabetes, relieve suffering and extend life. But inadequately managed medicines can also fail, interact, cause harm and contribute to avoidable hospitalisation.

Perhaps patients should therefore begin asking more of us.

Not simply, “Did I receive my medicines? “

But: “Who is managing my medicines? Are they working for me? Are they still safe for me? Is someone looking at all my medicines together? Who will notice a problem before it becomes a complication? And who is finally accountable?”

Those are reasonable expectations and that is what pharmacists are trained to do and are legally accountable for.

Kenya cannot build a primary healthcare system that successfully identifies people with hypertension, diabetes and other chronic diseases, refers them into care and supplies medicines, only to fail at the crucial next step of ensuring that those medicines actually achieve better health outcomes. The debate about Level 3 is therefore much bigger than where a pharmacist should work. It is about what kind of healthcare Kenyans should receive closer to home at the grassroots.

If we are serious about Primary Care Networks, pharmaceutical care must connect to the CHP referral pathway. NCDs, we must move beyond supplying chronic medicines to managing them. To prevent renal failure, strokes, antimicrobial resistance, maternal complications and avoidable hospitalisation, medicines expertise must sit where those risks can be identified early. And if we are serious about the constitutional promise of the highest attainable standard of health, quality cannot become negotiable when it becomes inconvenient.

The patient walking into a Level 3 facility has changed. What they should expect from us must change too. The data tells us we no longer have the luxury of maintaining the status quo.

Dr Wairimu N. Mbogo is a Pharmacist and the President of the Pharmaceutical Society of Kenya