THEME ISSUE Cultural Sensitivity and Global Pharmacy Engagement In
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American Journal of Pharmaceutical Education 2019; 83 (4) Article 7222. THEME ISSUE Cultural Sensitivity and Global Pharmacy Engagement in Africa Imbi Drame, PharmD,a Sharon Connor, PharmD,b Lisa Hong, PharmD,c Israel Bimpe, BPharm,d Jeronimo Augusto, MHSA,a Johnny Yoko-Uzomah, PharmD,a Salome Weaver, PharmD,a Ferealem Assefa, PharmD,e Jonathan Portney, MPh,f Scott Gardner, MD,f Jarrett Johnson, PharmD,a Toyin Tofade, MS, PharmD a a Howard University, Washington, District of Columbia b University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania c Loma Linda University School of Pharmacy, Loma Linda, California d Zipline International Inc., Kigali, Rwanda e Carilion Roanoke Memorial Hospital, Roanoke, Virginia f Waterloo Hospital, Waterloo, Sierra Leone Submitted June 25, 2018; accepted October 18, 2018; published May 2019. Global engagement between schools and colleges of pharmacy in the United States and Africa is increasing. For a balanced and fruitful engagement, sensitivity towards the cultural and clinical needs of the people and professionals of the African region is critical. In this paper, we have divided the discussion into Southern, East, Central, and West Africa. General information about Africa, with unique aspects for individual subregions and countries, will be introduced. Stereotypes and miscon- ceptions about the region and the people will also be discussed, along with recommendations for culturally sensitive engagement for pharmacy and other health care practitioners when hosting mem- bers from, or visiting this region. The paper is a resource for schools and colleges of pharmacy who are currently engaged or considering future outreach opportunities in Africa. Keywords: Africa, global pharmacy education, World Health Organization, pharmacist, pharmacy technician INTRODUCTION colonization and conquest.1 However, postcolonial Afri- While it is the second largest continent in the world, can societies continue to uncover strong evidence of flour- by guest on September 30, 2021. © 2019 American Association of Colleges Pharmacy Africa is still largely viewed as a single country with a ishing politico-cultural and economic centers that predate monolithic culture.1 Foreigners often believe that people colonization.1 Africa today has many cultures rooted in a from Africa are all similar.1 Although cultural practices in history of African dynasties and belief systems that con- African countries have similarities, they vary significantly tinue to promote and preserve humane living and health. from country to country and within each country. Western Early concepts of health, of course, stemmed from beliefs media coverage of Africa has played a large role in depict- that placed “spiritual health” above physical health.1 http://www.ajpe.org ing a region and people associated with famine, poverty, Though heavy reliance on foreign aid remains an 2,3 disease, war, and political corruption. This coverage has enormous issue, many African nations have worked dil- fueled a narrative among outsiders that Africa is not a igently to leverage aid resources from global organiza- place for investment and partnership, but rather a place tions such as the World Health Organization (WHO) and 3 worthy only of aid. Although the aforementioned prob- nongovernmental organizations (NGOs) to spur the Downloaded from lems exist variably depending on the country, and most of growth of sustainable, tailored, self-reliant health care the countries face enormous challenges in addressing systems that have improved health care in their coun- them, not every individual is in need and not every country tries.4 The Rwandan government, for example, has made is in a crisis. health care system investments over the past 10 years that Pervasive also is the notion that African civilization, have led to an 80% drop in Human Immunodeficiency including writing, literary traditions, nation-state gover- Virus (HIV) tuberculosis (TB), and malaria-related deaths nance, and trade economies began with European and Arab over two decades, and established a health insurance pro- Corresponding Author: Imbi Drame, College of Pharmacy gram that now covers 90% of its population at a cost of less Howard University, 2300 4th St., NW, Washington, DC than one eighth of the US economic output for health care 20059. Tel: 202-806-6875. E-mail: [email protected] coverage.5 604 American Journal of Pharmaceutical Education 2019; 83 (4) Article 7222. In light of the aforementioned growth, engagement of governmental organizations (NGOs)/faith-based, and tra- African nations by US schools and colleges of pharmacy ditional/spiritual healers.12-14 The public health sector is has expanded steadily over the past few years. Areas of made up of primary-level health clinics, which generally interest have varied widely and have included the develop- provide free services, secondary-level district hospitals to ment of advanced pharmacy practice experiences (APPEs), which patients are referred from primary clinics for more student medical missions, clinical research fellowships, advanced care, and tertiary academic hospitals for advance clinical practice residencies, and capacity-building projects diagnostics and treatment, as well as training of health care based upon partnerships between US institutions and those professionals.14 Private sectors operate similarly to private of African nations.6-8 These partnerships have been multi- clinics and hospitals in the United States. Individuals “sub- faceted and mutually beneficial, allowing pharmacy faculty scribe” for services rendered by private physicians and hos- members, students, and residents/fellows to exchange best pitals.14 South Africa is currently undergoing a protracted practices.9 In this paper, authors from several disciplines, implementation phase for a National Health Insurance pro- including pharmacy, medicine, and public health, have gram that will provide “universal health coverage” for its depicted the health care landscape in key nations on the citizens by connecting public and private sectors.15 The African continent. The purpose of this paper is to provide NGOs and faith-based institutions in Africa mainly focus insight into the overall health care infrastructure, the status on specific health issues in the region, such as maternal and of pharmacy practice, and the nature of pharmacy educa- child health, HIV and Acquired Immunodeficiency Syn- tion in these nations, while also providing important con- drome (AIDS), and tuberculosis (TB).14 In all regions, pub- siderations for pharmacists and pharmacy students lic institutions are accessed most frequently as sources of planning to travel to, practice in, or partner with academic, health services.12 AccordingtoaWHOsurvey,thereare health, and governmental entities of these nations. In doing some significant regional differences in use of the remain- so, schools and colleges of pharmacy in the United States ing sectors.12 In East and Southern Africa (17.5%), faith- who wish to engage the African region will have the nec- based health centers are used with much greater frequency essary information to proceed with both knowledge and than in West Africa (5%). In Central (18%) and West Africa sensitivity. (15%), patients may seek medicine from “informal drug sellers,” making these sellers another sector of the health METHODS care system. This practice is seen less frequently in East and Southern Africa.12 Traditional and spiritual healers are General methodology was discussed in the introduc- accessed by peri-urban and rural patients in all African re- tion paper for this special issue.10 Aseriesofonlineency- gions for health issues not addressed at health centers.12 clopedias were also searched.11 Other keywords or terms Informal drug sellers represent another non-institutional by guest on September 30, 2021. © 2019 American Association of Colleges Pharmacy used included: names of perspective countries, Africa, access point, mostly sought by urban dwellers in West Economic Community of West African States (ECO- Africa. 12 While many people in Africa agree that health WAS), Southern African Development Community systems are in place to help people, many site-specific prob- (SADC), Global Pharmacy Education, United Nations lems such as high demand, low workforce, high fees, and (UN), and World Bank. Countries within four regions of various inefficiencies present major challenges to receiving Africa, including Southern, East, Central, and West, as 12,13 http://www.ajpe.org quality care and appropriate services. defined by the United Nations, were selected based upon The “prescription of medicine” is a major service having an infrastructure that supported the dissemination sought by patients entering the health care system in of researchable information. Countries were also selected Africa.12 However, the shortage of pharmacists is perva- based upon availability and expertise of authors from the sive and persistent across African regions. According to a areas. The region of North Africa was excluded from this global workforce analysis, most African nations have less Downloaded from discussion, as it was covered in the section labeled the Arab than one pharmacist per 10,000 population.16 Contextu- World. Local authors and reviewers from Africa were also ally, the World Health Organization recommends at least solicited for their contribution to the manuscript. one health care worker per 439 individuals. For this rea- son, workforce ratios for the African region reported as RESULTS