On the Rural Road Again

By: Dr. Maria Paiva, BSP, PharmD, BCPS

I completed a rural health research internship at the Center for Rural Health, Mel & Enid Zuckerman College of Public Health as part of my post-graduate PharmD degree in April 2013 as a visiting scholar.  Upon completion of my studies, I planned on practicing in an urban setting in Canada.  Instead, I am On the Rural Road Again.  I have been volunteering as a clinical pharmacist in rural Ghana since August 2013 & would like to share some of my experiences.    

Similar to North Americans, rural Ghanaians face healthcare challenges, including access to quality care & health insurance. 

  • 16 km: average distance to a healthcare facility with physician; main modes of transportation are foot, bicycle, & taxi.
  • The World Health Organization’s (WHO)  “Model List of Essential Medicines,” not synonymous with accessible; multiple life-saving medications are not available.
  • Poverty, illiteracy, & poor sanitation are common, especially in rural communities; approximately 80% of cases covered by the public National Health Insurance Scheme (NHIS) are sanitation-related.

The WHO reports in developing countries, ratios of pharmacists & pharmacies are low enough to impede the provision of pharmaceutical care.

  • Standards of practice that define pharmacist roles from pharmacy technician are not enforced, often resulting in limited patient assessment, education, & monitoring.
  • Prescription & non-prescription medications can be purchased from Licensed Chemical Sellers (LCS) as these shops are more accessible than healthcare facilities, however, practices are unregulated & sellers seldom have medical training. 

Maria Paiva

I work in a 135-bed hospital in a rural municipality in the Ashanti region that provides basic services: minor surgeries, routine laboratory investigations, & X-rays.

  • Complex cases are transferred to the closest tertiary hospital, approximately 55km or two-hour drive; commute is lengthy due to poor road conditions & heavy traffic.
  • Dispensary is set up similar to community pharmacies in North America & pharmacy staff provide services to inpatients & outpatients.
  • Clinical service(s): a pharmacist- run Anti-retroviral Therapy (ART) clinic for HIV/AIDS patients.
  • Hospital has running water, surrounding communities do not, electricity is unreliable, & Internet can be purchased via pay-as-you go modems.

I split my time between the dispensary, ART clinic, public health programs, & teaching & research activities. 

  • Dispensary: I answer drug information questions & participate in dispensing activities. There is a wide range of staff experience, which has led to inconsistencies in the quality of care patients receive.  To help, we are creating a manual that includes how to review a prescription for appropriateness, provide basic patient counselling, & check for patient understanding.
  • ART clinic: This is a government-funded program that has improved access to quality care & made drug-therapy affordable for most Ghanaians.  We see newly diagnosed patients and provide ongoing counselling, education, drug-therapy adjustments, & medication refills.  We are forced to change ART frequently due to drug shortages.  This is combination with low literacy levels has led to challenges with patients remembering their current ART regimen & being able to verbalize this.  To help, we made an ART medication identification manual with descriptions & samples of the all the anti-retrovirals we stock & created a medication timetable with directions in both English & Twi (local language).  
  • Public Health Programs: The health district launched an immunization campaign & pharmacists are on-call for consults regarding needle sticks.  If an incident occurs, we drive to the site, test the patient for HIV, provide counselling to the nurse, refer the patient for follow-up & initiate Post-exposure Prophylaxis (PEP) if indicated.  I also taught hand hygiene at a primary school.  There were no prior presentations & my online search did not produce any culturally appropriate resources, so I created my own posters & games with foolscap & crayons.
  • Teaching & Research: The team I work with are eager to learn.  I have done presentations & in-services ranging from pharmacy practice in Canada, the basics of strategic planning, to diabetes management.  Research projects include investigating if the implementation of the NHIS has impacted antibiotic usage & a second project focusing on different ways to improve medication safety. 

Maria Paiva with Local Children

My experiences have been humbling & gratifying thus far.  I will be in Ghana until Christmas and there is so much more we hope to accomplish. The practitioners & communities that have & continue to advocate for change & provide patient care in the current landscape should be commended.  Though most of the discussion resides around the limitations of Ghanaian healthcare & pharmacy practice, it is important to remember that they are making strides to improve and what they do have is more than other developing nations.    

 About the Author

Maria Paiva, BSP, BCPS

Maria Paiva, BSP, BCPS, PharmD was a visiting scholar at the Arizona Center for Rural Health.  Her clinical area of interest is oncology and in the future hopes to be involved in health policy and education.  



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