Pharmacy Community Service

Appendix 1:
The South African Pharmacy Council (SAPC)

The South African Pharmacy Council is the statutory council of the country. Its vision clearly indicates its commitment to the pharmacy profession and the people of the country. The vision reads as follows: "The South African Pharmacy Council (SAPC) ensures that the pharmaceutical services are the best to meet the health needs of the people". The SAPC also has clear objects, as defined in the Pharmacy Amendment Act of 1997, which fits in perfectly with the vision of the new council, inaugurated in December 1998.

In January 1998 the Council pro-actively began its work on community service for pharmacists. It gathered comment from councillors and other stakeholders. This enabled the Council to be better prepared when for the first time it was informed later, in December 1998, by Deputy-Director General Pretorius of the government's intention to institute the first one year period of community service for first time registering pharmacists.

At that time the SAPC had also already conducted a survey (mid-late 1998) amongst a sample of students, pharmacy interns and tutors of these interns on community service for pharmacists. Some of these results are mentioned in the ensuing discussion.

At the meeting arranged between the Council, represented by the Registrar, Mr Jan DuToit, of SAPC and manager Ms Sue Putter, and the Chief-Director Prof. Rachel Gumbi to discuss the realities of community service (CS) for pharmacists the Registrar conveyed the offer of Council to help. The agreement of Council with the principle of CS for pharmacists and its willingness to assist with the development of the logistics were also conveyed to the department of health.

A broad plan was developed which included the holding of meetings and seminars, in the future, with stakeholders to fully identify and discuss the proposed community service. The first meeting was planned for October 1999, this was subsequently moved to 15 November 1999. The participants who would be invited to attend this meeting were representatives from the SAPC, the pharmacy students, the pharmacy academics and the Department of Health.

Some of the broader issues to be discussed in these meetings included the following ones, identified by some students, pharmacist interns and tutors of these interns and other pharmacists:

The principle, as mentioned, was fully supported by SAPC, who believed that its purpose and government's would be best served by the Council being brought on board as a full partner in the development of this programme. We still believe that many benefits will accrue to the country once this service is systematically and deliberately instituted. Currently approx. 400 pharmacy students in their final year will be the target group to perform CS, in 2001, should the legislation be enacted timeously.

The SAPC realises that the CSP system, like any new system, will experience challenges, but this is what the Council thrives on and will be more than willing to assist in their solution. Some of the relevant facts and the challenges, identified by Council through its research, will be referred to in the ensuing discussion.

1. Internships:
1. Currently 65% of internships are in the private sector. The content will have to be changed somewhat to accommodate the needs of and preparation of CSP's who will begin working the next year after their internships
2. Many more job opportunities will have to be created in the public sector for the CSP to function adequately
2. The ratio of male to female students is 51:49. This simply heightens the need to place more emphasis on the safety and security of these CSP's.
3. The distribution of pharmacists, in SA, is far from ideal:
1. These statistics include both the public and private sector situation: there are approx. 4100 pharmacists in GP; 1500 in KZN; 1600 in WC; 800 in EC. However, there are less than 400 in each of the other provinces. The total number of pharmacists in SA being 10 000. This means that 70% of all pharmacists are stationed in three provinces. This then translates into, with regard to the CSP, the fact that many CSP's might prefer to be employed in these provinces. This would promote a situation that would be contrary to the intention of this venture viz. To make pharmaceutical services accessible to all of the population in SA.
2. Appropriate distribution of the CSP's could have a positive result in that the CSP system could help form a sustained and better overall distribution of pharmacists and services in the country.
3. Distribution of pharmacists: population ratios:

In the WC the ration is 1:2500; in GP 1:1700 and in NP1:16000 - the average for the country is 1:3897. These figures cannot be taken at face value as about 75% of all pharmacists are employed in the private sector and that means that they are found mainly in the central business districts of the country.

4. In the sample surveyed by the SAPC, in 1997 and 1998:
1. Only 37% students interviewed preferred private sector pharmacy
2. With regard to the length of the community service: a majority, 71%, of the respondents (pharmacists, interns and students) indicated that the one year period was too long. However at the one end of the scale students from UWC and U North (both 65%) supported the length of the service period, while at the other end there was a university that showed only 2% support for the CSP
3. Overall in 1997 approximately 44% of students surveyed actually supported CSP while in 1998 only 40% did.
4. There was no racial breakdown available for the persons surveyed who were supporters of CSP system
4. The main issues, some were mentioned before, that needed to be addressed according to the survey, included:
1. Definition was needed of the role to be played by CSP's
2. Infrastructures had to defined and then supplied which would also help to promote continuity and even initiate post-CS employment
3. Suitable posts for CSP's would be needed
4. The present internship might need tweaking to get the most out of the CSP's during the following year, the CSP year, especially if one considers the fact that 65% usually are interns in the private sector. This might adversely affect the placements of these interns in CSP programme, especially in rural settings.
5. Safety and security and accommodation arrangements while working in the public settings were unclear
6. There should be appropriate remuneration and benefits such as TV and DSTV (according to the students) in the communities of practice especially for married pharmacists;
5. Other miscellaneous points and issues included:
1. Debt of students due to study loans, etc.
2. Sufficient leave, including maternity leave of absence, should be given
3. The possibility of the employment of CSP's by NGO's and other nonorthodox public settings where CS can be performed
4. Perhaps a shorter time, 6 to 9 months, the rest of the CS year could be spent in other settings, if available, e.g. in certain private settings, and university/academic environments
5. Undergraduate training should include exposure to the rural setting (in a block type programme)
6. Appropriate supervision of CSP's could be required in some cases
7. A problem would arise in the private sector where there would be very few, if any, new pharmacists available in the year 2001
6. Support of universities could be requested in an attempt to appropriately help the SAPC in its preparation of students for rural settings

In general SAPC is very positive about community service for pharmacists in the future health care system of the country. It fully supports the principle and is even willing to assist the government by offering some human resources, by perhaps footing some of the expenses itself and by fully involving itself in setting up the programme. The SAPC requests the government to make it a full partner which would be in line with its objects as outlined in the Pharmacy Amendment Act of 1997 and with its new vision namely that SAPC ensures that the pharmaceutical services are the best to meet the health needs of the population of the country". We wish the pharmacists and the people well in this the community service for pharmacists system.

Appendix 2:
South African Pharmaceutical Students' Federation (SAPSF)

About three to four years ago community service for pharmacy students was firstly mentioned. Immediately the South African Pharmacy Students Federation (SAPSF), the representative of all pharmacy students in South Africa, started to make a study of this subject. At the annual SAPSF conference in Durban 1997, the situation and the concept of community service was explained and debated, but no set dates where, when and how this would be implemented were available.

Soon after the doctors were introduced to the concept and the process of community service. The processes were carefully studied by SAPSF and many concerns were raised. The next step that was to study the doctors' community service, the community services for dentists and after the dentists the pharmacists. When this subject of discussion were still in the early stages, our Past President Mr Joao Carapinha made contact with Department of Health (DOH) as well as with the South African Pharmacy Council (SAPC) to get more details about this subject, unfortunately no details could be given, the only promise, and I quote "You will definitely be informed a long time before you have to do it and definitely not in your final year."

On March 3,1999 an article was placed in Beeld and Die Burger with the heading: "Tandartse an aptekers doen vir eers nie gemeenskapsdiens". The article was placed by Dr Ayanda Ntsaluba. This created a wrong perception amongst the students. A month after this article were published, roomers but no official documentation were circulated that community service for pharmacy students were to commence on the 1^st January 2001. Students honestly did not know what to believe, until July 1999 where the SAPSF annual conference were addressed by Pharmacy council and DOH. Students knew for the first time when community service was scheduled for. The first written report by DOH was received last week after several attempts.

Soon after this the amendment to the Pharmacy act, 1974, insertion of section 14A in Act 53 of 1974 was announced on 13 August 1999. I Quote:

14A. 1. Notwithstanding section 14, a person registering for the first time as a pharmacist in terms of the Act after the commencement of section 14 of the Pharmacy Amendment Act, 1997, must perform remunerated pharmaceutical community service of one year in terms of the regulations contemplated in subsection (2) and shall, on the completion of such service, be entitled to practice the profession of a pharmacist.

2. The Minister may, after consultation with the council, make regulations concerning the performance of the service contemplated in subsection (1), including but not limited to-

(i) the place or places at which it is to be performed

(ii) the conditions of employment.

Reaction of the students:

The SAPSF follow a democratic principle of consultation. Task groups were formed at each branch of SAPSF which monthly report back on the concerns of the students. A national survey was done as well, seeing that DOH and Pharmacy council was using statistics of 1996 to 1998, in other words people who will not be affected by the proposed community service. The SAPSF wanted to know how the people who will be directly affected by the community service felt.

The following concerns were raised:

* Can we do locum whilst doing community service?

This sounds fairly negative. When surveys were done by Pharmacy Council the question is not clearly asked whether the students are negative in principle towards community service or are they concerned about not being informed and not being taken into consideration regarding to their futures. A definite separation must be made between these points. An uninformed student is a dangerous student. On numerous occasions had the SAPSF made contact with Department of Health. SAPSF asked for a roadshow from DOH. This was done. All concerns were raised, but no answers were given. Only empty promises were made that we will be consulted and our concerns here mentioned, addressed.

I have asked for monthly reports from DOH at the beginning of August, unfortunately this was met by no response. Four different meetings were scheduled and constantly changed. The last meeting scheduled for 15 November 1999 was in the middle of our exams. DOH were informed about the unavailability of students for this day, when a week later SAPSF were informed that the meeting will continue regardless of the fact that the students will not be able to attend this meeting. Students were very unhappy with this and petitions were drawn up stating that students are not negative towards community service but would like to be consulted in the whole process and should they be excluded they would sharply react against this. After the report was given to DOH, an agreement was formed for a separate meeting with the students. One can only ask if we as students would have been consulted if we did not demand to be part of the process.

From there the standpoint of SAPSF. In principle we are not against community service, but we strongly believe that the consultation process should be followed through carefully and all needs and services finalized before community service can be started. We do not believe that a law should be passed through parliament before consultation have been finalized, completed and everything in place in order to do community service. If it is done the other way around, one could ask what the purpose of a meeting like today is for? Is it only a formality that has to be done? Will the government only follow their own agenda in order to get community service for students started?

If one look at the Bill as published in the government gazette of 13 August 1999, it is stated that, I quote "The minister may, after consultation with the council, make regulations concerning the performance of the service contemplated in subsection (1), including but not limited to-

(i) the place or places at which it is to be performed

(ii) the conditions of employment

The opinion of SAPSF is that from the viewpoint of a student the wording of this is very dangerous. The wording "after consultation" does not include agreement, which is essential in the process of negotiation and consultation. Therefore we propose that the wording be changed to "agreement and consultation with council". What the role of Pharmacy Council is, could also to be questioned as representative of the public as a government body? Students strongly believe that they should also be given the chance to give definite input on the making of these regulations, as we are the ones that will be affected by it and not the public.

The SAPSF strongly believe that the latest statistics shown by students whom this will definitely affect by this new law and not those who have already completed their studies, internships and the last of them registered by the end of 1999. The survey by SAPSF was done during September and October 1999.

The statistics show the following from fourth years to second year.

1. Willingness to do community service:

4^th 31% 3^rd 47% 2^nd 65% overall 47%

This shows clearly that final year students are more opposed

The SAPSF strongly feels that a student should be consulted from their first or second year or at the latest in their third year. Most fourth year students have already arranged work for 2000 and 2001. Some are binded by contracts including bursaries and loans, which can increase dramatically, should community service be implemented. The SAPSF also have written prove that some loans will be increased by R 10 000.00, which puts the students under tremendous pressure. R 10 000.00 is an enormous and unignorable amount of money. More details of the survey can be obtained from the SAPSF but for the purposes of today, showing the decrease in the positive attitude from the second to the fourth year students will suffice.

Proposal:

7. Security

If a student or intern should perform the work of a pharmacist he or she should be considered a qualified pharmacist and not only as a registerable pharmacist in a training process. The process of registration is also debatable. Community service should not be seen as cheap labour to fill the posts of senior pharmacists in the public sector in order to save on the costs of these pharmacists. Community service is not part of the training process and therefore the pharmacist can not be kept from registering and being a fully registered pharmacist.

The SAPSF is of the opinion that community service can benefit pharmacy and the public, if the right steps are followed and completed before implementation.