Pharmacy Community Service

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Health

25 October 1999
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Meeting report

HEALTH PORTFOLIO COMMITTEE

HEALTH PORTFOLIO COMMITTEE
26 October 1999
PHARMACY AMENDMENT BILL: DISCUSSION

SUMMARY
The South African Pharmacy Council and the South African Pharmaceutical Students' Federation made presentations on the Pharmacy Amendment Bill.

The South African Pharmacy Council is very positive about community service for pharmacists. 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 South African Pharmaceutical Students' Federation is of the opinion that community service can benefit pharmacy and the public, but they want consultation to be completed before the Bill is passed.
This year's final year students believe that it is too late now for the Department of Health to start consultation as the end of their studies are in a few weeks and by then they can be seen as interns and not final years anymore. The SAPSF feels that the consultation process will then be extremely difficult for the students will be spread throughout the country.

MINUTES
The South African Pharmacy Council
The President of the Council, Prof. Peter Eagles, presented the submission.

South African Pharmaceutical Students' Federation
Mr Johan Moolman, President of the Federation, presented their submission.

Questions by committee members
Dr S Gous (NNP): How many posts will be available in the provinces, and how will the provinces pay for it? How important is supervision of pharmacists?
Dr Jassat (ANC): How much remuneration will these students receive? Is there any scope for them to develop their managerial skills, and if not, does this development of managerial skills form part of their study cirriculum? To what extent has the commission looked at the community service for doctors, and to what extent will the Council be involved in the process?
Dr S Cwele (ANC): What is the extent of the financial implications as stated in the Bill?

Prof P Eagles: The idea of pharmacy community service was started by the SAPC in January 1998. We were proactive in looking at what this entailed, and what benefit it would give to the profession as a whole. The council agrees with the principle of this Bill and wants to be part of the logistics of this process, to ensure that the Council's pharmacists are given the best that is available.
We look at where the posts are available in the provinces. The SAPC does not receive funding from the government, but get its money from pharmacists through membership fees. The SAPC will assist in supervising community service pharmacy. The internship period of one year has a structure to it. During this period, we will try to expose them to as many different sectors as possible. In the private sector, these interns are worth approximately R3000-R5000 per month. The curriculum at university includes Communication and some form of Accounting. We will however incorporate managerial development as a component but this more likely in the private sector than in the public sector in the rural areas. We would like to see a system where pharmacists are reimbursed for their professional services, and not for selling drugs.

We do not want to make the same mistakes as the medical doctor internships. We are learning from their experience by working and consulting with various medical councils.

The system of monitoring supervision should involve the private sector and universities. The stakeholders' meeting should address the logistics of it. The posts will become available in various areas, according to the need of pharmacists. This has financial implications for the SAPC, and we have committed a certain amount to put this programme in place.

Mr Ellis (DP): Section 14A(2) states:
'The Minister may, after consultation with the council, make regulations regarding the performance of the pharmaceutical community service'
but should it not read: in consultation with?"

Mr J Moolman said that the SAPSF is not against community service, but wants consultation to be completed before the Bill is passed.

Ms Njobe (ANC): What is the membership breakdown of SAPSF, and have you consulted with doctors who are doing community service. What role do students see themselves playing in the transformation process?
Dr Mbulawa (ANC): When did students first hear about the plan for community service. What have pharmacists contributed to this country, and do you think it is fair not to have a change in the country? Have you consulted the Acts governing employment conditions, as to how it would apply to yourselves?
Dr S Gous (NNP): Are you still classified as students when doing community service. Will community service outside SA's borders be allowed?
Dr R Rabinowitz (IFP) commented that DST television is not an important commodity so why was it included in SAPSF's list of demands? She believed that students should first complete their community service before they are registered, otherwise they might just skip the country.

Mr J Moolman, in response to these questions raised the following points:
- Our membership consists of approximately 3000 people. We have consulted with other medical student's councils, and always keep in contact with them. Students are not negative towards the idea of community service.
- The first time we heard about this was at a conference three years ago. We then consulted with the Department of Health to receive more information regarding this. We have looked at the Act regarding employment conditions.
- Students have sympathy for the concerns of the rural areas, but also want their basic remuneration.
- After completion of community service, students are not registered pharmacists, but are only registerable pharmacists.
- We want to serve this country and not outside countries.
- An average salary for community service should be R70 000 per annum.
- Not all students would leave the country. Forcing students to stay will create negativity.
- Students would like supervision for at least 3-4 months of their community service.
-We would like DSTsatellite television to stay informed with the world, and the advancement of modern technology. There are some areas that are isolated, and it would be difficult to keep in contact with changing trends in the profession.

Dr Cwele (ANC): This Bill only puts forward the principle, which gives us more time to deal with the logistics, therefore we should move faster.
Mr Ellis (DP): We have a problem to pass the Bill in principle, without all the consultation having taken place.
Mr J Moolman: Students want to know where they will be placed, as well as the conditions of their employment. Students who have completed the one-year compulsory army training want to be exempted from this Bill.
Mr Ellis (DP): This department has the responsibility to consult with the various groups.

Due to time constraints, the hearing was concluded.

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.

COMMUNITY SERVICE FOR PHARMACISTS

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.

The Plan

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.

Issues

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 number of pharmacists that would be involved

The nature of the current internships

The sector distribution of pharmacist interns

The distribution of pharmacy resources in SA

The distribution of pharmacy human resources between the public and private sectors of pharmacy

The Stance of SAPC on Community Service for 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:
    4. 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.

    5. 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

CONCLUSION:

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 1st 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:

Community service"

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?

* Can we do community service in private clinics or hospitals that serves underserviced areas?

* Will there be concessions made by banks to repay student loans?

* What happens if a lady falls pregnant and need to take maternity leave during community service, will her community service time be extended?

* What professional support will be provided?

* Where will we be placed to do the community service?

* If the internship is done in the industry, how will community service be done?

* Will we work in public sector clinics or only public sector hospitals?

* Will marital status of individuals be considered favourably for placement?

* Will there be assured accommodation, DSTV and Internet access to community service pharmacists?

* How will we be paid and will we be taxed on accommodation and other privileges, leaving us with basically nothing to live with after tax.

* How will the government afford approximately 450 students each year?

* Why give another year of your life to this country if you already did national service?

* Fourth year students would like to know why they are only know being informed, August 1999, during their last year of study?

* What is the registration status as pharmacists before and after community service in 2001?

* What happens to contracts already signed with the private sector that gave us financial support on condition we work for the various financial supporters on completion of our studies and training?

* What happens to contracts made with public sector to work in rural hospital areas after completing their internship in an urban hospital?

* Will we be orientated after doing our internship in the private sector?

* How will students doing an academic internship be affected especially if they intend to further their education to for instance a Ph.D.?

* Will we be sure of a safe environment, taken into consideration that most of us are female students?

* If we have to stay far away from where we work will our traveling expenses be covered?

* Being away from our loved ones will we get a telephone allowance to keep in contact?

* Exactly what will our working hours be?

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.

What does the latest statistics say?

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:

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

This shows clearly that final year students are more opposed

to the idea. This can be due to the fact that they were informed so late in their studies. Consultation will only start on 6 December 1999 which means that the final years are on the doorstep of their internship and already have completed their studies under the current law as it is, four years theory and one year practical. All of a sudden another year has been added on to this. This was not part of the agreement when they started to study Pharmacy.

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.

This clearly shows the dilemma students find themselves in should community service be forced onto us too fast.

It normally takes about two years for someone to come to terms with a mind paradigm shift. To press on people and force them to get used to the idea can only cause damage to the process with a snowball effect.

2. What do students want in order to perform community service?

a. Salaries

* Security of salaries

* Salaries according to scaling

* ± R 70 000.00 with the influence of inflation taken into consideration.

* Study loans and the interest should be looked at. The proposal is that the government should take over the interest for the time the people are doing the community service year.

* Salaries should be confirmed and binded by contract

* No salary - no work!!!

* Accommodation and other privileges should be tax-free.

* What is meant by the minimum for any public sector servant?

* Students should be able to locum according to locum tariffs in their free time, which is surely our own.

* Transport expenses should be covered if long distances must be travelled.

3. Where?

* Students should be informed early enough meaning

not later than May 2000 where they will perform community service.

* Meals and accommodation should be provided

* In rural areas access to Internet and DSTV is essential.

4. Dependants

* What about single parents?

* Special merit should be given to married couples with a legal marital certificate, these couples should not be separated.

* If a lady should fall pregnant during her term of community service she should fall under the normal laws concerning maternity leave.

5. Contracts

* Holiday and sick leave must be accounted for.

* Extra privileges like pension, medical aid, life insurance and AIDS insurance must be accounted for.

* Where contracts is already signed, special merits should be given by the government. The government should take responsibility where contracts are broken and students are left workless.

* After hours and special request to locum with normal locum fees must be agreed to.

* Working hours defined clearly as well as over time payment.

* Students must be placed according to own preference of placement and must obtain the right of mutual transfer.

6. Work description

A detailed work description must be set up before the consultation are completed including the following aspects:

* a prototype contract between the government and the pharmacist must be set up and revised through consultation

* salaries and other privileges

* Where services will be performed

* Lay out of services that must be performed by the pharmacist

Proposal:

For the interns of 2000 the option of a shortened community service should be taken into consideration.

7. Security

* Security is an absolute requirement and guarantees must be given in writing.

* Anti-AIDS insurance is also an absolute requirement.

* AZT must be available in the working environment at all times, should the possibility occur that a student become infected by accident through needles or direct contact with blood or other body fluids during their work.

8. Industry and academic interns

* How will it be implemented in the industry and academic environment?

* Students in the industrial sector must be accommodated to do community service in this sector of pharmacy.

9. Other

* Students finishing their internships before the end of December 2000 and registered before 1 January 2001 must be excluded from community service. The law can not work backwards in time.

* Motor loans and telephonic expenses must be taken into consideration.

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.

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