30 31

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Figure 5.1.1. Overview of the assessment and strategic framework development process

5.1.2. Key Issues

Major pharmaceutical human resources issues in Afghanistan include:

Gaps in information and information flow

Prior to 2010, there was limited information available about the pharmaceutical human resources in Afghanistan with regards to density, distribution, roles, competency development needs, or projected human resources requirements. Information on pharmaceutical human resources was also not disaggregated by cadres. Information regarding pharmacist and pharmacy assistant graduates and vacancies did not systematically flow among training institutions, GDPA, and GDHR. The lack of a licensing renewal mechanism meant that information kept by GPDA on the number of pharmacists was out of date, and the directorate had no way of knowing which of pharmacists were in-country and actively working in the pharmaceutical sector. All of these factors made it difficult to maintain an up-to-date and accurate human resources information system to inform human resources for health (HRH) planning. There was also limited interaction, information flow, and coordination among MoPH, training institutions, employers, and development partners on pharmaceutical human resources issues. Although stakeholders recognized the importance of these issues, there was an absence of pharmaceutical human resources strategies and plans designed to address them.

Pharmaceutical human resources shortage and distribution imbalance

The last few decades have seen rapid growth in the number of private sector pharmacies in Afghanistan, particularly in urban areas, as a result of demand and weakened regulatory mechanisms. Over time, the number of private pharmacies has far exceeded the supply of pharmaceutical human resources in the labor market. Increasingly, other health workers and lay workers provide pharmaceutical services in both private and

public sectors. Of the 136 private pharmacy personnel participating in the assessment, only 11% were pharmacists and 21% were pharmacy assistants; the majority were other cadres including nurses, physician assistants, teachers, school students, and lay workers. Although pharmaceutical establishments outnumber the pharmaceutical workforce, only 57% of pharmacists who graduated between 2009 and 2010 worked in the pharmaceutical sector, and 20% were unemployed at the time of the graduate tracking survey in February 2012.

The survey also found maldistribution of pharmacists and pharmacy assistants, with the density varying from zero to more than three per 10,000 population in different provinces (Figure 5.1.2).

Figure 5.1.2. Density of pharmacists and pharmacy assistants per 10,000, by province (Provincial Health Authorities, 2011)

Aside from provincial distribution imbalances, the graduate tracking survey also found a lack of pharmaceutical human resources in rural areas of each province; rural areas in some provinces lacked pharmaceutical staff entirely (Figure 5.1.3).

Figure 5.1.3. Proportion of pharmacists and pharmacy assistants in rural

areas, by province (Provincial Health Authorities, 2011)

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Development of assessment tools and assessment team

PHASE 1 Assessment team development

PHASE 2 National & provincial HR

assessment

PHASE 3 Facility and individual HR

assessment

PHASE 4 HR startegic framework

Competency framework development

Assessment of competencies at facility and institucional level Stakeholders

consultation

Development of strategic frameworkQuantiļ¬cation

of national pharmaceutical human resources

Assessment of HR availability, requirements

and attrition

October 2010 - June 2011 December 2011 - February 2012 March - June 2012

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Percent of pharmacists and pharmacy assistants in rural areas by province

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In a February 2012 workshop, key stakeholders voiced their concern regarding the growth in the proportion of non pharmaceutical cadres and informal workers, stressing that it posed major risks to the public and reduced the number of available positions for pharmacy graduates. The assessment showed that physician assistants had a major role in the pro- vision of pharmaceutical services in health facilities the pro- portion of health facilities for which they were responsible for dispensing was comparable to that of pharmacy assistants. The assessment also identified key competency gaps. Of the surveyed individuals:

40% did not have any or only had very little knowledge of formularies and essential drug lists,

36% did not have or had very limited ability to arrange pharmaceutical products based on storage guidelines, and

24% indicated being able to fully evaluate the appropriate- ness of prescribed medicines.

Low salaries

The average pharmacist and pharmacy assistant earn similar salaries (around 5,500 to 7,500 Afghanis per month or US$115 to 155). With the increasing cost of living in Afghanistan, these salaries make it difficult for pharmaceutical human resources to earn a living.

5.1.3. Strategies used and lessons learned

This section describes the strategies applied through the pharmaceutical human resources assessment and strategic framework development processes and key lessons learned and summarises the strategic objectives in the human resources framework.

Needs-based approach

The needs in Afghanistan are unique, particularly given the conditions, history, and trends in the pharmaceutical sector. The core team first identified what information they would need in order to develop a strategic plan, and from this they identified a set of assessment objectives. They used these assessment objectives to guide processes to adapt existing WHO tools [3] or to develop required tools (e.g., graduate tracking tool, competency assessment tool).

The assessment thus set out to address specific information needs, generating data to inform the development of a strategic plan that addresses priority pharmaceutical human resources issues. Specific assessment objectives and their purposes at each level are summarized in Table 5.1.1.

Table 5.1.1. Purpose of assessments at each level

The integration of the assessment and strategic framework development processes into broader MoPH efforts was critical, as was ensuring alignment with existing strategic plans such as the Human Resources Management and Development strategic objectives and priority interventions described in the MoPH Strategic Plan 2011 2015.

Multi-stakeholder engagement

Pharmaceutical human resources is a relatively new focus area, and this assessment and strategic framework development process provided opportunities for key stakeholders to engage in discussions and share information and insights required to see different dimensions of complex and challenging issues. Before the first stakeholders forum in 2010, the core team conducted a stakeholder analysis to identify priority stakeholders to engage. Throughout the process, a broad range of stakeholders that influence pharmaceutical human resources planning, management, or development were kept informed and invited to contribute to the development of the strategic framework. Such engagement was also key to gaining the commitment of stakeholders throughout the process, including stakeholders outside of the MoPH and pharmaceutical sector who hold decision-making authority over strategies described in the strategic framework.

Evidence-based approach

Prior to 2010, there was a lack of information on pharmaceutical human resources and a lack of data that described priority issues. The pharmaceutical human resources assessment provided muchneeded information to inform human resources planning, management, and development. The assessment was carried out at the national, provincial, facility, and individual levels. The national and provincial level assessments were conducted in the first phase, and consisted of a review of existing policy documents and records. Facility-and individual-level assessments were conducted in four provinces (Kabul, Hirat, Nangahar, and Balkh) across 205 randomly selected facilities (Table 5.1.2). A total of 265 personnel providing pharmaceutical services filled out an

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Assessment levels

National

Provincial

Facility

Individual

Purpose

To identify total number of pharmaceutical personnel, data sources for information on pharmaceutical human resources, and current policies and strategies for pharmaceutical human resources.

To identify number of facilities providing pharmaceutical services and total pharmaceutical human resources and distribution, and to gather facility lists.

To determine employee demographics, cadres providing pharmaceutical services, and human resources policies in each facility.

To examine the work environment, supervisory support provided and received, support for training received, and competencies of cadres providing pharmaceutical services.