WHICH BETWEEN OUR FRAGILE HEALTHCARE SYSTEM OR CANCER SHOULD WE DECLARE A NATIONAL DISASTER AND OTHER IMPORTANT QUESTIONS

I'll start around my home i.e. medication utilization and work outward, so kindly flow with me.

Medicines are the widely used medical intervention, in most cases over 80% of all patients who visit a health facility leave with a medication. The same case applies for Chemotherapy (Chemo).

Other medical interventions for Cancer: Surgery, Radiation Therapy, Chemotherapy, Immunotherapy to Treat Cancer, Targeted Therapy, Hormone Therapy, Stem Cell Transplant, Precision Medicine etc

Whereas, there is low chance of curing cancers in stage 3 and above, the real or perceived manner in which chemotherapy patients worsen in health is alarming in both professionals and public circles.

Yet in Kenya, focus in cancer management through medication (just like in other health conditions: Non Communicable Diseases, Cancer, Reproductive Health, HIV, Communicable Diseases) has been on selecting, procuring, storage and reconstituting chemo.

There is no focus on having full teams, individualizing medication, documentation & research on impact in use especially since, most cancer medication are toxic and lack substantive local usage data & critical dose management to achieve success including the simple fact that different patents react and handle medication differently.

We know that chemotherapy drugs are hazardous (just like all medications for other medical conditions).

Some of their adverse effects include: kidney toxicity, liver toxicity, bone marrow suppression, immune system suppression, scarring of lung tissue, bladder inflammation, nervous system toxicity, hear toxicity, carcinogenic effects (can cause other cancers later in life) , teratogenicity (can affect unborn or yet to be conceived children) etc. These are life threatening adverse effects which cannot be ignored. We need to rule out the effect of these drugs on health of the patient.

"Aren't all medicines registered in Kenya safe?" I can hear you asking.

Safety of medicines is a complex matter. Medicines are declared safe after extensive research & clinical trials, mostly done in western populations, usually involving 100 to 200 patients in strict adherence and monitoring, follow up & care. No one knows, how the over 1 billion ‘Wanjiku’s’, ‘Wanjala’s’, ‘Momanyi’s’ or ‘Kazungu’s’ from millions of 'villages' across Africa will react when they take it with say Mursik, Mukhombero or any other local ‘peculiarities’ of even how we react to medicines here. The assumption is that they would go the way of the 100 or 200 we spoke of earlier. That is why we have to ensure we have full healtcahre teams on the ground, with systems that have them embedded in community to ensure individualised therapy is done especially for chronically ill patients, then we’ll start sharing knowledge that would help our patients benefit better from these toxic yet beneficial medicines. 

Therefore the question of why majority of cancer patients deteriorate in health after starting chemo is a complex one.

Focus should also be on individualized care i.e. a complete healthcare team with a medication action &review plan that anticipates and manages the adverse effects according to the drugs and drug regimens, patient follow up, reporting of side effects, and documentation of the same for knowledge transfer and sharing.

Beautiful unimplemented policies

We really need to put our heads together as health professionals, the government, and public on the way forward. Yesterday, I am sure you may have seen the Senator Sylvia Kasanga lament that there is a beautiful document on how this country (both at national & county level) can fight cancer i.e. National Cancer Control Strategy 2017 – 2022. Then she posed the question, "Is it just going to remain a beautiful document; we are good at drawing up documents but where is the implementation?"

If you missed the debate:

INTEGRATED HEALTHCARE

It must go without saying then that before we go breaking the healthcare system into even more silos like we did with HIV, even as calls come in for us to strengthen Cancer management in Kenya, can we do a holistic approach so that we fix healthcare once and for all.

Instead of dumping energy & resources in the most noisiest silo, which currently happens to be cancer, could this be an opportunity to fix our fragile healthcare system.

Though a missed opportunity, HIV/AIDS management provides us with the best model on how to fix healthcare.

I had the privileged to serve Kenyans within the then Mombasa & Samburu District public healthcare systems between 2006 to 2009 (I hear with devolution of healthcare after 2010, I may never have had that opportunity. I may have had to go to a 'cosmopolitan' or my home county of Kisii to get that privilege to serve as a District or Hospital Pharmacist as I did back then).

Back to the point, working in a HIV/AIDS Comprehensive Counselling Center was a great joy, we were adequately guided, resourced, our interventions meant something as we did knowledge sharing to make things better for our patients. I'd dare even say that: the air in a CCC as they used to be called even felt fresher, the patients happier, they glowed, some even had better intended outcomes than for other NCD, accidents, communicable diseases etc.

Therefore, as calls for disease specific interventions heighten e.g. NCDs, Cancer, Reproductive Health, HIV, CDs etc, we should work on integrating all these and scaling what we ave learnt from the HIV/AIDS programme.

For example if cash is available there for cancer HMIS, can we be coordinated to make it a UHC HMIS & have all UHC quality of care indexes therein i.e. No wasted opportunity and our generation will be found faithful in stewarding the little dwindling resources we have.

The same can be said for Referral, HRH, Financing, HPTs, Training, Public Private Partnerships etc.

In our view we need to strengthen the following areas we have seen modeled so well by the HIV/AIDS programme in Kenya:

1. Declare our fragile healthcare system a national disaster
2. Identification, Patient data portability, Referral & Research systems (level 1 to 6) (awareness of cancer prevention & curative services available at Level 1 to 6 e.g. where to get screening, oncology specialists (Physicians, Pharmacist, Nurses), palliative care etc & most importantly systems that identify the patient with portable health records to especially capture data on local effects of the cancer medication so that we have a local pharmacovigilance data as most clinical trials done outside Africa and in small groups of candidates)
3. Human Resources for Health (HSC, Patient to provider ratio, competence, specialities integrated, training, deployment & coordination)
4. Availability of affordable & quality medicines, health products and technologies & qualified personnel
5. Customer Service (awareness that there needs to be full healthcare teams on the ground to have patient focused and accountable care; for example we have cancer patients who from diagnosis and onto chemo yet have never met a medication utilisation expert (Pharmacist) to take responsibility for and be accountable to patients and healthcare teams by ensuring/confirming/crosschecking that:

               a. medication is indicated

               b. is effective

               c. is safe

               d. the patient can adhere to terms (afford, schedule etc)

On behalf of the full healthcare team, this Pharmacist also diligently does individualised profiles on how each patient handles the medicines vis other medication and their disease state, assess the severity of ADRs and makes advice to the team for best treatment outcome

To make situation worse, all these services and data, currently all go unutilised because we lack Nation and County Pharmaceutical Services Coordination Framework (County offers services with minimal or no policy, evaluation & monitoring support from Ministry of Health, right now we do not a pharmaceutical services Directorate in MoH to take responsibility on this.)

THE 4 MAJOR STEPS THE PHARMACIST AS PART OF COMPLETE HEALTHCARE TEAM TAKES TO ENSURE PATIENTS GET INDIVIDUALISED HIGHEST PHARMACEUTICAL OR (CHEMOTHERAPY) CARE:

Adoption of what Medication Therapy Management entails by TruPharma Care.

a.      Receive medication related queries from patients, pharmaceutical technologists, physicians or other pharmacists & healthcare team members

b.     Assessment and diagnosis of drug therapy related problems

                                                        i.           Comprehensive medical and medication history obtained

                                                      ii.           Each of patients medications (prescription, non-prescription, alternative, traditional, vitamins, or nutritional supplements) is individually assessed to determine that it is the most appropriate for patient, most effective for the medical condition, safest, available, most affordable and that the patient is willing and able to take them as intended

                                                     iii.           Identify if any Medication Therapy Problem are present and collaboratively, with the primary physician (clinician), determine if there is need for further investigation

c.      Development & initiation of a care plan

                                                                    i.           Formulate a comprehensive personalised medication management plan to resolve any medication therapy problems and achieve desired outcomes

                                                                  ii.           Establish personalised measurable parameter and time frames for monitoring effectiveness and safety of any medication

                                                                 iii.           Provide a Medication Action Plan (MAP) for each medical condition that is intended to improve the safety and effectiveness of the medication

                                                                iv.           Provide Personal Medication Record (PMR) for personal or other health professionals reference

d.     Follow up evaluation and medication monitoring

Response to medication varies according to individual patients and specific drugs based on the genetic make-up, health status, co-administered medications among other factors.

Therefore follow up ad monitoring closely for effectiveness and safety of the patient’s medication therapy is key.

In this process the pharmacist, will individualise medication regimens to ensure that they are both safe and effective. They also take responsibility for the same.

IDENTIFYING YOUR PHARMACIST

THE OATH YOUR PHARMACIST TAKES

CONCLUSION:

Indeed in Kenya Cancer is a monster with over 40,000 new cases and nearly 30,000 death a year.

All these nice things things, for cancer management alone require tonnes of money. Molecular biology level type of research, HRH to sit in hospital tumor boards & patient management teams.

Before we go breaking the fragile healthcare system into more silos, throw money inside there like we did with HIV, can we do a holistic approach so that with the same resources we fix healthcare once and for all. MoH can coordinate all this. They know, what all of us are doing on the ground. Maybe that's where we should start, a coalition of the willing to fix healthcare in Kenya once and for all.

The patient is one: The patient does not belong to the Cancer, Lifestyle/Non Communicable disease, Infectious Diseases silo. The patient belongs to the entire healthcare system.

HIV management as far it is a success story, which we now need to learn from and scale across all healthcare areas: management etc

If we need to declare anything a national disaster, it is our fragile healthcare system.