- Somaliland is in the eastern Horn of Africa, to the north west of Somalia. Although not officially recognised in international law, it operates as a democratic self-governing state within Somalia and as such has greater political stability. The country has a population of 3.5 million; with the capital city, Hargeisa, home for 1.3 million. King’s College Hospital, London, established a link with Somaliland in 2000 with the help of the Tropical Health and Education Trust (THET), and in 2004 secured Comic Relief funding to develop a pharmacy system in Hargeisa Group Hospital (HGH), the main state hospital of the capital city.
The pharmacy project was to set in place a revolving drug fund (RDF), designed to address the limited range of drugs available in Somaliland, to ensure a sustainable supply of high quality medicines and to improve medicines control procedures and quality assurance. For an RDF, an initial investment, in this case Comic Relief money, is used to purchase essential drugs from a reputable source. These are then supplied to patients on the request of a doctor at locally affordable prices. The money accrued through these sales is used to purchase further medicines supplies, and hence the drug fund “revolves” to ensure sustainability.
Over the past eight years, London-based pharmacists, with the support of THET, have been involved in every stage of the development of the RDF from assisting with the drug ordering process, helping establish the pharmacy store and dispensary, designing and implementing a stock control system, developing a pricing structure and exemptions process and working alongside and training local staff in Somaliland.
I have been involved with the project from its inception, and first travelled to Hargeisa in 2005 to assist in unpacking the first medicines supplies received for the RDF from the International Dispensary Agency (IDA) based in the Netherlands (364 boxes of drugs and medical equipment). A colleague and I set up the newly built pharmacy store and trained the local staff of the store and dispensary in basic paper-based stock control procedures, as well as working with the regional health board to develop the pricing structure — a complex process as prices had to be calculated from purchase in euros via US dollars to a selling price in Somaliland shillings.
A year later I returned to find the pharmacy functioning effectively, with the stock control systems in place and dedicated pharmacy staff.The HGH pharmacy had five members of staff; it was open 24 hours a day, seven days a week, and provided medicines for a 200-bed hospital and dispensed 150 outpatient prescriptions per day. Within the first year the RDF banked $46,000, which was used to purchase further supplies of drugs.
Key challenges in these early days were to encourage the clinicians to make full use of the wide range of drugs now available within the pharmacy, to implement and maintain processes for stock, to deal with (often inappropriate) donations of drugs from other sources and to facilitate ordering of ongoing drug supplies in response to local need. The financial management of the RDF was a major concern because administrative processes in the hospital were not readily transparent.
While the day-to-day, paper-based stock control systems functioned well, it was difficult to match the movement of stock against the money paid into the system. And the RDF “leaked” money to the main hospital and via the exemption scheme, which provided free medicines for those who were unable to pay.
Since the set up, there have been times of turmoil within the hospital —the medical director has been replaced a number of times, the regional health board was disbanded, hospital staff were not being paid their wages — and as a result some of the systems we set in place faltered, with stock control systems failing and demotivated pharmacy staff. Additionally the pirating problems in the seas around Somaliland meant we were unable to ship out medicines on a regular basis.
Over the past two years, following the appointment of a local pharmacy business manager, new dispensary staff and with encouragement from regular pharmacist trips from the UK and on-site support from THET, the pharmacy project has been revived and the RDF programme is again functioning well. Improved systems of administration have allowed better tracking of RDF outgoings and income; and the reinstatement of the regional health board has improved hospital oversight.
I returned to Somaliland in February this year because the Comic Relief funding for the project is coming to an end. A stocktake revealed much improved stock control within the dispensary, with less than 1 per cent expired stock on the shelves. This was the result of a recently implemented rolling stock check programme, with each member of staff taking responsibility for checking specified drugs lines. It was disappointing to see that the medicines purchased through the RDF were sparse — much of the stock had been purchased though the local market system to maintain supplies.
With improvements in security along the Gulf of Aden, we are now able to ship supplies again, and a large order is due for delivery in May to replenish the pharmacy stores. The financial position of the RDF is now more robust, with an income of 92 million Somaliland shillings (approximately £15,000) in January 2012 alone.
This visit saw the launch of the first edition of the HGH Formulary, which will support local clinicians in the appropriate use of medicines within the RDF.
We still struggle with some issues, one of which is the the appropriate use and monitoring of refrigerators. For example, on this trip we found eight bottles of Kalitra in a freezer within the pharmacy stores. Lack of on-site pharmacist supervision is also exemplified by the large volume of ketamine found on the open dispensary shelves but stored in “water for injections” boxes. Supplies of Capoten and Capozide were mixed together, naloxone was locked in the newly installed CD cupboard with the supply of opiates and there were 1,200 short-dated clotrimazole pessaries. Only by visiting can these issues be identified and addressed with the pharmacy staff.
Back in the UK, the work to support our colleagues in Somaliland continues. The pharmacy team hopes to provide online tutorials for medical students and interns based around the drugs available locally, as part of a wider King’s-led programme of training and education. In time, we hope that the pharmacy department will also have internet access to facilitate web-based learning and improve communication between UK and Somaliland teams. As the Comic Relief funding comes to an end, we hope that the partnership will continue to flourish, as part of the broader King’s-THET-Somaliland Partnership programme.
*Reflective account of a trip to Somaliland
Somaliland is a nation trying to break free of its war-torn past and emerge as an independent republic, with a democratically elected government, a functioning healthcare service and a thriving private business sector. Working as part of the UK pharmacy team setting up a revolving drugs fund (RDF) in Somaliland has been exhilarating, challenging, frustrating, exhausting and rewarding in equal measure.
The flight from London to Hargeisa is long and fragmented, and as the aeroplane touches down on the dusty runway you really begin to understand the challenges the trip will bring. The hot air takes your breath away. The airport is bustling and excited, and scattered around are remnants of combat planes, leftovers of a less peaceful time. In the centre of Hargeisa there is a monument of an old Soviet plane and a dove, a symbol of a more hopeful future.
Poverty is widespread, and there is a sizable refugee camp on the outskirts of the city, but each year there are more new businesses, and there is a sense of vitality and enthusiasm that is palpable.
This is a city struggling to cast off its past, and working in Hargeisa Group Hospital, and being involved in the RDF makes me feel part of a new beginning for Hargeisa and Somaliland.
Sinead O’Halloran, associate chief pharmacist, clinical services, South London Healthcare Trust
This report was written by Helen Williams, consultant pharmacist for cardiovascular disease, South London, and pharmacy group lead for the King’s-THET-Somaliland Partnership, on behalf of Obafemi Shokoya, Sharon Horder, Yassmin Mohamed, Rosalind Bryne, Sinead O’Halloran, Tase Oputu, Olubanke Olufinjana, Victoria Collins, Siobhan Gee, Asha Essa, Helen Turner and Sam Stephenson.