The high cost of having too few pharmacists

It’s acknowledged in key policy documents, well known at the coalface and much ventilated in the media: South Africa’s public health-care system has too few health-care workers, especially medical doctors, certain specialists, and theatre nurses. Less recognised however is the shortage of public sector pharmacists. Spotlight lifts the lid on this until now largely hidden problem — and its impact.

There are too few public sector pharmacy posts across South Africa to deliver a comprehensive service, with no clear staffing norms and an uneven distribution of pharmacists, especially in rural districts. This contributes in part to medicine stockouts and the emergence of deadly hospital-acquired drug-resistant infections.

This is according to Andy Gray, a senior lecturer in the division of pharmacology at the University of KwaZulu-Natal’s school of health sciences and co-head of the World Health Organisation Collaborating Centre for Pharmaceutical Policy & Evidence-based Practice. His views are echoed by at least two other key local stakeholder organisations.

Flagging the alarming rise in resistance to antimicrobials — an urgent global public health threat — driven by the misuse of antibiotics in hospitals and ambulatory care, Gray tells Spotlight that there are not enough pharmacists to intervene if they see inappropriate use of medicines.

“This just continues without any effort to fix it. Inadequately trained and understaffed prescribers are working under immense stress, so they are prone to use the wrong medicines at the wrong time with the wrong doses,” he says. “There are also very few microbiologists and certainly not enough pharmacists at the bedside. They’re not doing what’s necessary to ensure the proper use of medicines — for example, better control over antimicrobials.”

The excessive dependence on antibiotics has resulted in the emergence of antibiotic-resistant bacteria, commonly known as superbugs. This is called bacterial resistance or antibiotic resistance. Some bacteria are now resistant to even the most powerful antibiotics available.

South Africa has been ranked 67th out of 204 countries for deaths — adjusted by age per 100,000 people — linked to antimicrobial resistance. It has been estimated that 9,500 deaths in the country in 2019 were directly caused by antimicrobial resistance, while 39,000 deaths were possibly related to resistant infections.

The national department of health warned in a background document that rising antimicrobial resistance and the slowdown of new antibiotics could make it impossible to treat common infections effectively. This could also lead to an increase in the cost of health care because of the need for more expensive second- or third-line antimicrobial agents, as well as a reduced quality of life.

Low numbers

Gray says that while not matching the paucity of public sector doctors and nurses, pharmacists stand at 24% of the staffing levels calculated as necessary to deliver a comprehensive service.

“We need just over 50 pharmacists per 100,000 uninsured population as a target, but we’re sitting at about 12,” he says.

Gray says the South African Pharmacy Council (SAPC) has no data on the total number of pharmacists actually working in the country, or the number working in particular settings. A SAPC spokesperson says they have only provincial statistics, but can’t track pharmacist movements.

Gray notes: “You can’t use their database to find out how many pharmacists are working where. The Health Systems Trust South African Health Review Indicator chapter has figures of public sector pharmacists per province and per 100,000 uninsured population.”

As at February 2024, there were 16,856 pharmacists registered in South Africa (working and not working), excluding the 971 community service pharmacists.

The 5,958 pharmacists employed in the public sector represent the full complement of funded posts, but that is well below the number needed — and varies dramatically between provinces. While almost all funded posts are filled, Gray says the number of posts is lower than needed to deliver a comprehensive, quality service.

Taken across South Africa’s population of about 62-million, there are about 28 registered pharmacists (working or not working), per 100,000 people (insured and uninsured). According to data from 2016, the mean global ratio stands at 73 per 100,000.

“We’re better than many other African countries, but that’s cold comfort,” says Gray.

Increases spread unevenly

There are some positives. The number of pharmacists in the public sector has grown since 2009, rising from five to 12 per 100,000 uninsured people by 2023. However, the ratio varies markedly by district — for example: from 15 in the best-served Western Cape district to a mere three in the most poorly served Northern Cape district.

Gray says the more rural districts suffer the most when it comes to understaffing of pharmacists and this contributes to medicine stockouts. While the causes of medicine stockouts are complex, one of the major contributors is the refusal of suppliers to deliver any more stock until accounts are paid.

Understaffing of pharmacists often results in nurses managing patients without any pharmaceutical oversight, Refiloe Mogale, executive director of the Pharmaceutical Society of South Africa, tells Spotlight. She associates such task-shifting with medicine misuse and inappropriate prescribing, noting that while it’s a vital strategy in budget-tight environments, medication errors are on the rise. This, she argues, could be solved by ensuring that appropriate pharmaceutical personnel are placed to support primary health-care facilities — such as pharmacist assistants.

“A primary care drug therapy [PCDT] trained pharmacist can diagnose, treat and dispense medications. So, this is not as much about task-shifting as about the pharmacist providing comprehensive care. These PCDT pharmacists can do family planning, screening for diabetes and hypertension, and other clinical tasks that take the burden off doctors. We need more of them,” she says.

‘No clear staffing norm’

Addressing the human resources quandary, Gray says the core problem has always been that pharmacist posts per hospital or clinic were not evenly distributed. “There’s been no clear staffing norm. The old ‘homeland’ hospitals are likely to be underresourced with pharmacists and pharmacists’ assistants. Posts are poorly distributed and by global standards we’re nowhere near where we should be,” he says.

The department of health’s most senior pharmacy official, Khadija Jamaloodien, agrees that pharmacy posts should be distributed better. But she says work protocols dictate that state pharmacists must visit each clinic in their district at least once a month. She says there are 3,000 primary health-care facilities in the country and 6,000 (albeit maldistributed) public sector pharmacists.

Nhlanhla Mafarafara, president of the South African Association of Hospital & Institutional Pharmacists, tells Spotlight that too many of the almost 6,000 pharmacists in the public sector are doing stock management, dispensing, administration and management work in hospitals and pharmaceutical depots. He says the numbers do not necessarily reflect pharmacists in clinical or patient-facing areas.

Gray notes: “The reality is that pharmacists are restricted to trying to get drug stock in and out.” 

However, the lack of pharmacists and pharmacist assistants at clinics and hospitals means timely and/or knowledgeable ordering often results in shortages of essential medicines, something all experts interviewed for this article agree on.

Mafarafara says that by defining what services a pharmacist should render and what’s needed to enable a quality service, more realistic staffing numbers could be reached. Pharmacies are central points in all hospitals, with closure for even an hour crippling a hospital. Thus, adequate staffing is critical to ensure uninterrupted access to good-quality pharmaceutical care.

South Africa, Mafarafara adds, is far behind many other countries in the effective use of pharmacists’ clinical expertise in leading evidence-based care in hospitals. “I’d even go so far as to say doctors should be stopped from dispensing in favour of pharmacists to improve quality of patient care,” he says.

‘If you don’t have a pharmacist, nothing gets done properly’

Jamaloodien says the cost of having too few pharmacists is more far-reaching than just antimicrobial resistance. “You can have stockouts because there’s nobody to manage the supply chain. In my experience, if you don’t have a pharmacist, nothing gets done properly,” she says.

Her solutions? Compliance with the “comprehensive and robust” evidence-based standard treatment guidelines, access to an updated and well-maintained app that gives everybody access to the latest information and medicine changes, and more attendance by all health-care professionals of webinars held after every medicines committee meeting, plus clinicians regularly reading drug update bulletins to keep up with new medicines.

* This article was published by Spotlight — health journalism in the public interest. Sign up for the Spotlight newsletter.