Reframing the Focus of International Health Experiences

Sonak Pastakia, PharmD, MPH, BCPS; Rakhi Karwa, PharmD, BCPS; and Mercy Maina, BPharm
Published Online: Friday, November 15, 2013
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A unique pharmacy school program changes the paradigm in Kenya.

Over the past decade, there has been a pronounced increase in the demand for international experiences as part of the curricula for health care providers. This has led to a marked effort by universities to rapidly globalize their curricula. The trend is most readily observable in the increase in opportunities for medical students and residents. In 1978, only 5.9% of graduating medical students had participated in an international clinical education experience as part of their medical education. This is in sharp contrast to the 22.3% of graduating American medical students who completed an international health experience by 2004 (Online Figure 1).1

Further evidence for this trend comes from the increased integration of global health coursework into the medical school curriculum. In 1991, only 22% of US schools of medicine provided students with elective coursework in global health. Presently, organizations such as the Foundation for Advancement of International Medical Education and Research (FAIMER) report that almost every medical school in the United States offers some type of global education opportunity for students.2 With the steady increase in opportunities for medical students, allied health professionals must follow this trend to meet the increasing student demands and, more importantly, provide patients in resource-constrained settings with the optimal level of interdisciplinary care and patient safety.3

Ethical Issues

While this escalating interest in international exposure likely suggests an increased appreciation for the importance of cultural awareness in delivering effective health care and reflects the ever-growing global influence in North America, practitioners leading the efforts to expand access to international experiences must consider the goal and purpose of these activities with respect to the host setting. Without careful consideration of the intent of such activities, it is very easy for the interest of individuals from developed settings to supersede those within the resource-constrained setting. For example, medical missions may create short-term clinics aiming to provide both acute and chronic disease management. These kinds of activities often disrupt local infrastructure by offering free, unsustainable care, rather than having patients rely on local health care infrastructure.

Consider the following patient example: A patient presents to the clinic with elevated blood pressure. As the clinician, you diagnose them with hypertension and provide them with a month’s supply of medication, readily available in the resource-rich world, which was donated to your medical mission. Without proper follow-up and continued access to these medications after the departure of the visiting providers, it is impossible to treat this patient safely and effectively. Unfortunately, the public health care system in developing countries is underequipped to sustainably address the large burden of chronic diseases. This dynamic often leaves patients in a difficult situation where they often only have intermittent access to chronic disease care, and introduces considerable stress as they have to independently deal with the burden of trying to manage a diagnosis that the local health care system is ill-equipped to handle.

Although these visiting clinicians and trainees have good intentions for patient care, they often risk destabilizing the inpatient and outpatient practice by potentially creating mistrust in local clinicians and adding to the lack of follow-up that is sometimes found in these settings.4 To counter this trend, clinicians should try to integrate themselves into the local health care infrastructure and spend the time understanding the unique dynamics of care in these settings. Through this approach, visiting clinicians can start to improve the care they desire to provide patients by working with the local health care infrastructure and providers, rather than creating unsustainable parallel avenues of care.5

International health experiences can be a valuable method for developed-world practitioners to obtain practical disease state knowledge not otherwise available in their setting (ie, tropical diseases). Due to their lack of prior experience, it is essential that trainees be supervised by clinicians who have an understanding of the particular culture and health care setting. Unfortunately, there is a serious shortage of health care clinicians in the developing world (Online Figure 2). Therefore, utilizing the limited number of local health care providers to supervise visiting students or orient visiting clinicians without providing adequate coverage for their normal duties compromises patient care.6 Programs that focus on encouraging a bilateral exchange and an integrated approach with the local health care infrastructure and culture are able to achieve the shared goals of both settings by increasing cultural awareness for the visiting students while also improving care for patients.7

Figure 2. Geographical representation of the share of the world’s pharmacy workforce (pharmacists, technicians, assistants).9



The Purdue Kenya Program

Since 2003, Purdue University College of Pharmacy (PUCOP) has been working in direct partnership with the United States Agency for International Development (USAID)–Academic Model Providing Access to Healthcare (AMPATH) (www.ampathkenya.org) to design and implement comprehensive pharmaceutical care solutions for the unique challenges faced by patients in western Kenya.

In order to achieve the mission and values of the Purdue Kenya Program (PKP) (Table 1), 2 full-time faculty members are permanently based in Eldoret, Kenya, with the goal of working alongside Kenyan health care providers to address the barriers that prevent the dissemination of high-quality care in resource-constrained settings in addition to providing mentorship for learners.

In the initial phases of the PKP, one of the main focuses of the partnership was providing international experiential training for PUCOP students. However, limiting education to these visiting trainees only provided temporary care for patients. This realization resulted in a change in the dynamic of the program, causing it to grow from an organization solely focused on the education of North Americans to one that was invested in simultaneously developing the future generation of local pharmacy leaders to usher in a much-needed paradigm shift in the practice of pharmacy.

With a sustained presence in Kenya through the past 7 years, the PKP has been able to see the consequences of the limited health care provider workforce available to deliver care. Data from 2005 suggest that there is a ratio of 4 registered pharmacists per 100,000 population in Kenya compared with 80 registered pharmacists per 100,000 population in the United States in 2007.8,9 The scarcity of health care providers to address the needs of patients in resource-constrained settings is often cited as one of the primary barriers to access care.

While many collaborating institutions address these limitations by focusing on increasing the numbers of pharmacists through educational opportunities locally and abroad,10 PUCOP has taken a slightly different approach by focusing on educational and research initiatives designed to improve the quality of the currently available pharmacists. PKP has strived for success in this domain by developing experiential training and mentorship programs for students, residents, and staff pharmacists to help bridge the gap between the didactic education received in a classroom setting and the implementation of patient-centered programs in practice.

As of July 2013, the PKP has provided experiential rotations for 50 University of Nairobi School of Pharmacy interns (6-month rotation blocks), 265 PUCOP month-long rotation blocks, and focused mentorship for 6 licensed Kenyan pharmacists, 5 Kenyan clinical pharmacy residents, and 4 North American clinical pharmacy residents. In all facets of the program, North American and Kenyan students, residents, and staff work together, benefiting from the education, experience, and ideas of their colleagues to create a true bilateral exchange experience. Furthermore, the PKP has created opportunities for almost all of the Kenyan pharmacy staff to travel to North America to engage in observatory visits designed to improve understanding of each other’s culture and practice settings.

Through these activities, PKP has been able to permanently change the landscape for pharmacy practice in western Kenya by implementing novel models for pharmacy distribution of HIV and non-HIV medications, provision of anticoagulation care, counterfeit detection, pharmacovigilance, drug information, medication safety, reproductive health services, chemotherapy, care for tuberculosis, and inpatient clinical pharmacy practice.11-17 The progress achieved at this site is largely due to the positive collaboration between North American pharmacy faculty and local health care providers. Because of the investment that has been made in local infrastructure and human resources, the program offers a richer experience for visiting trainees and, most importantly, better health care services for the patients in this setting.

Conclusion

Collaborative partnerships can lead to mutually beneficial partnerships if constructed with a greater focus on equity between the developed and developing setting. The needs of both should be considered rather than engaging in a self-serving type of presence that is primarily focused on addressing the interests of the resource-rich settings.


Sonak Pastakia, PharmD, MPH, BCPS, is associate professor of pharmacy practice at Purdue University College of Pharmacy and visiting lecturer at Moi University School of Medicine in Kenya.

Rakhi Karwa, PharmD, BCPS, is assistant clinical professor of pharmacy practice at Purdue University College of Pharmacy and visiting lecturer at Moi University School of Medicine in Kenya.

Mercy Maina, BPharm, is a pharmacist at Moi Teaching and Referral Hospital in Kenya.


References:
 
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  2. FAIMER Institute. www.faimer.org/education/institute/index.html. Accessed April 28, 2007. 
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  7. Gupta R, Farmer P. International electives; maximizing the opportunity to learn and contribute. Medscape Gen Med. 2005;7(2):78.
  8. International Federation of Pharmacy. Global pharmacy workforce and migration report. www.fip.org/files/fip/HR/FIP%20Global%20Pharmacy%20and%20Migration%20report%2007042006.PDF. Updated July 2006. Accessed oJune 26, 2013.
  9. Health at a glance 2009: OECD Indicators. www.oecd-ilibrary.org/sites/health_glance-2009-en/03/13/g3-12-01.html?contentType=&itemId=/content/serial/19991312. Accessed June 26, 2013.
  10. Anderson C, Bates I, Beck D, et al. The WHO UNESCO FIP Pharmacy Education Taskforce. Hum Resour Health. 2009;7:45.
  11. Liu E, Pastakia S, Schellhase EM, et al. The development of care focused adherence-tracking dispensing database for HIV care in a resource-constrained setting. J Pharmaceutical Health Services Res. 2013 4:63-67.
  12. Pastakia SD, Ali SM, Kamano JH, et al. Screening for diabetes and hypertension in a rural low income setting in western Kenya utilizing home-based and community-based strategies. Global Health. 2013;16;9:21.
  13. Manji I, Pastakia SD, DO AN, et al. Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost. 2011;9(11):2215-2220.
  14. Ouma MN, Chemwolo BT, Pastakia S, Christoffersen-Deb A, Washington S. Pilot study of single-use obstetric emergency medical kits to reduce maternal mortality. Int J Gynaecol Obstet. 2012;119(1):49-52.
  15. Strother RM, Rao KV, Gregory KM, et al. The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya. J Oncol Pharm Pract. 2012;18(4):406-416.
  16. Pastakia SD, Schellhase EM, Jakait B. Collaborative partnership for clinical pharmacy services in Kenya. Am J Health Syst Pharm. 2009;66(15):1386-1390.
  17. Pastakia SD, Vincent WR 3rd, Manji I, Kamau E, Schellhase EM. Clinical pharmacy consultations provided by American and Kenyan pharmacy students during an acute care advanced pharmacy practice experience. Am J Pharm Educ. 2011;11;75(3):42.
 
 


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