Conclusion
DTC present a compelling opportunity towards achieving rational
medicines use at the hospital level in Sierra Leone. Nonetheless, lack
of funding, operational resources, are significant limitations.
Policymakers must note these drawbacks whilst expanding DTC programs to
other hospitals in Sierra Leone.
Introduction
Irrational medicines use is a systematic and global widespread problem.
The World Health Organization (WHO) estimated that more than half of all
medicines are improperly prescribed, dispensed, sold, or used1. The prevalence of irrational medicines usage is
comparatively higher in low and middle-income countries than in the
developed world, and this is partly due to lack of robust regulatory
infrastructure, high proportions of low skilled health workers,
underfunding of health systems, and sporadic infectious diseases with
fewer drugs options 2, 3. Medicines are an expensive
commodity that slices up a substantial proportion of every nation’s
healthcare budget. However, when not correctly used this may result in
unintended consequences.
Perhaps, the most significant impact of irrational medicines use is the
worsening of the global antimicrobial crisis. Patients infected with
resistance bacteria, for instance, have higher odds of worse clinical
outcomes, exerting a significant burden on health resources4. If trends in antimicrobial resistance continue
unabated, by 2050, an estimated 10 million lives will be lost to
untreated infection and at a global cost of $100 trillion5. To slow the antibiotic resistance epidemic, and
promote rational medicine usage, the WHO and partner organizations6, 7 have been providing technical support to member
states for the establishment of the Drug and Therapeutics Committee
(DTC) within healthcare systems.
DTC has a broad range of functions, including; providing drug
information services for medical staff, development, and monitoring of
drug use policies, selection of medicines for a local formulary, and
developing standard treatment guidelines (STGs). Furthermore, DTC
promotes best practice in medicines use, monitor, and manage medication
errors and adverse drug reactions (ADRs) 6. However,
country specific goals vary greatly. In a report from Australia and
South Africa, the main objectives of their DTC were to ensure the
optimal supply of medicines that are safe, efficacious, and
cost-effective 8, 9. In Nigeria, hospital formulary
review, surveillance of narcotics and antimicrobial use were among the
primary DTC functions 10.
The epidemic of irrational medicines use is equally a significant
problem in Sierra Leone and has been highlighted in previous findings.
In a study involving the analysis of prescriptions form the outpatients’
department (OPD), Cole et al. concluded that medicines were not
rationally prescribed for children under-five as per WHO prescribing
indicators 11. Similar findings from a study focusing
on antibiotic prescribing at a national level 12 and
antibiotics use for none bacterial infection, and prophylaxis13 have also been reported, which might explain the
high prevalence of multidrug resistance bacteria in Sierra Leone14, 15. The key reason for this trend, according to
the WHO and empirical evidence, is the shortage of skilled health
workers, fragility in the health system; 16, 17limited diagnostics capacity in most hospitals and inadequate regulatory
framework on the import and sales of pharmaceuticals13, 17.
In 2016, Management Science for Health (MSH) post-Ebola recovery
portfolio included catalyzing and promotion of appropriate medicines
usage in Sierra Leone through the establishment of a pilot hospital DTC.
The pilot program included four hospitals in Freetown, and three
hospitals in the three provincials headquarter towns of Bo, Kenema and
Makeni, with the prospect of adding more hospitals in the future.
Currently, DTC is established in seven government hospitals across
Sierra Leone. Some of the achievements include; efficient data gathering
on medicines use at the hospital level and improved pharmaceutical
management, thus advancing containment of antimicrobial resistance18, 19. However, the specific role and
responsibilities of DTC, including its membership, activities, success,
and challenges, have not been reported. Such information might be
essential in driving policy decisions towards the sustainability and
optimization of DTC nationwide.
In this study, we aimed at evaluating the current structure, functions,
activities, opportunities and challenges in the overall setup of DTC in
Sierra Leone. The results are intended for formulating policy towards
the improvement of DTC in Sierra Leone.
Methodology
Study setting and design
Sierra Leone has a total of 24 government hospitals distributed across
its four provincial regions. The Western region harbours the largest
cluster of eleven hospitals, including all the tertiary hospitals in
Sierra Leone. The northern province has six hospitals whilst the
southern and eastern province has four and three hospitals respectively20.
Of the seven hospitals included in the pilot DTC in Sierra Leone, four
are from the Western area. They include Ola During Children’s Hospital
(ODCH), a specialist paediatrics hospital’ Princess Christian Maternity
Hospital (PCMH), a specialist obstetric and gynecologic hospital21, Connaught hospital; a general specialist hospital,
and Lumley government hospital a secondary level hospital. The remaining
three hospitals are from the three other provincial regions. These
include Bo government hospital from the southern province, Makeni
government hospital from the north and Kenema government hospital in the
Eastern province
A mixed-method approach was adopted in this study, integrating both data
in the result to reduce the limitation associated with a single research
method 22. Two sequential phases were used in the data
collection process; a survey followed by a semi-structured individual
interview. In phase one, an online questionnaire was used to
cross-sectionally survey hospital pharmacists on the formation,
activities, outputs, and challenges of their hospital DTC. In the second
phase, a follow-up semi-structured individual interview was conducted to
probe further into the key issues that emerged from the survey.
Data collecting tools
The online questionnaire (https://forms.gle/oKHpgKtMFGDT5LJH7) was
developed using the WHO manual on DTC, 6, a guide to
implementing Drugs and Therapeutic Committee 23, and a
published systematic review involving 17 studies 24.
The first draft of the questionnaire was sent to two experts and a
pharmacist that previously worked in a hospital with a DTC for
validation, and their inputs informed the final draft used for data
collection. The questionnaire has 54 items and four sections with both
open and closed questions. The first section assessed respondent
sociodemographic characteristics; age, gender, educational level, years
working in the hospital, and hospital location. Section two assessed DTC
membership, the professional designation of the chairperson and
secretary, frequency of meetings, and the latest meeting date. Section
three evaluated the key indicators of DTC with three responses, ’yes,’
’no,’ and ’not sure.’ Four questions in section three were about the
number of meetings held in the past twelve months, the proportion of
members that regularly attend meetings, the number of ADR recorded, and
the policy decisions taken during that period. The last question within
the section rated the effectiveness of the DTC on a scale of 1 to 10.
The fourth section evaluated the challenges of DTC with ’yes,’ ’no’ and
’not sure’ responses and a follow-up question to give details
explanations if the response is ’yes.’
The semi-structured interview guide was developed based on the results
of the questionnaire survey. It included eight questions, ranging from
membership to DTC, training of members, DTC subcommittee functions, ADR
reporting, drug use policies, and challenges within local DTC. See
details in Appendix 4.
Sampling and data collection
The pilot DTC program was established in seven hospitals across the
country. We purposively recruited pharmacists who have been working in
those hospitals for both the questionnaire survey and the individual
interview. Pharmacists were targeted as they were vital ‘in the pilot
program and attended most of the DTC workshops conducted by MSH. They
are also the secretary of DTC and servers to coordinate DTC activities,
contribute to the formulation and Implementation of local drug use
policies.
In each of the seven hospitals, the pharmacist-in-charge or a pharmacist
who has been working at the hospital for the past 12 months leading to
April 1, 2020, was contacted via WhatsApp massaging
app a social media application that is getting popular in medical
education and communication 25, 26. The lead
investigators relayed detailed explanations of the research through text
messages, voice notes, WhatsApp call, or a combination of these methods.
A link to the online questionnaire (google form) was then sent to the
WhatsApp number of all selected pharmacists that consented to
participate in the study. A reminder message was sent to all
participants at the end of each week from April 1 to April 21, 2020, the
respective start and end date of the survey data collection.
Interviews were conducted using WhatsApp call feature or voice message
when necessary after the analysis of the survey data. Similarly,
participants were recruited using WhatsApp messenger, and a convenient
time for the online interview was scheduled. All interviews were
conducted in English between May 10 and June 2 2020, and the
conversations were recorded using a voice recorder.
All participants in this study were given a token of $10 as a
motivation for their time and to help cover mobile data charges they
would have incurred.
Ethical consideration
The Sierra Leone Ethics and Scientific Review Committee of the Ministry
of Health granted ethical clearance. All participants consented to take
part in the study, and due to the small sample size, pharmacists and
hospitals were anonymized in the results.
Data analysis
Survey data was exported to MS Excel for analysis. Categorical and
continuous variables were analyzed descriptively. Response to open
questions were coded according to the themes that emerged and
quantified.
Interviews were transcribed verbatim in MS word, in instances where
discrepancies arose, the individual interviewee was contacted on
WhatsApp for clarification. Following an inductive analytical approach,
the transcripts were thoroughly read by the two lead authors, the text
condensed into themes, and further categorized into general and
subthemes 27. Other members of the research team
reviewed the results from the two leading authors, and a consensus on
the themes was met, which inform the final result. Data management and
analysis were done using NVivo version 12.
Results
Characteristics of hospital and respondents
There are seven hospitals with established DTC (pilot program) in Sierra
Leone, the majority are in Freetown (n=4), and the rest are distributed
within the other three regions in Sierra Leone. Except for Kenema
government hospital, all other hospitals have at least two pharmacists.
All hospitals in which DTC is piloted had a participant that responded
to the questionnaire, was interviewed, or both. Summarized in Appendix 1
Six pharmacists, one each from the six different hospitals with DTC,
responded to the questionnaire. Most were male (n=5) and had been
working at their respective hospitals between 1-3 years (n=4). Three out
of five pharmacists interviewed were from Freetown. (Appendices-2 and 3)
Membership of DTC in Sierra Leone and their specific functions
In the formative stage of DTC, training workshops were organized for key
medical, pharmacy, and nursing staff of the seven hospitals selected in
the pilot program. Following the training of these healthcare staff,
local DTCs committees were set up in each of the seven healthcare
facilities.
Table-1 summarises the membership of DTC in the different hospitals.
Each has at least ten members except secondary hospital 1. DTC
membership composed of a representative from each of the departments in
the hospital, although priority was given to healthcare staff directly
involved in the medication use process, and key decision-makers such as
the hospital secretary and matron. Almost all hospitals have at least
two pharmacists, three doctors, a nurse, a microbiologist, a community
health officer (CHO), and a representative from the hospital
administration as members of their DTC.
In establishing membership within our hospital, our target was to
have a representative from each of the units at the hospital with a
target of getting at least ten members [Pharmacist Tertiary Hps 2].It [DTC membership] must involve all those that deal with
medicines and does clinical work within the hospital. Hence, prescriber,
dispenser, those who handle and administer or being involved in any
therapeutic functions which incorporate professionals like nutritionist
can be members. [Pharmacist Tertiary Hps 1]We have a representative from internal medicines and all the
sub-clinical units because they are prescribers. We also included the
hospital secretary and matron, because they are vital administrators who
influence the decision-making process in the hospital [Pharmacist
Regional Hps 1]
Main functions of DTC
Accordingly, the main functions of DTC are ensuring rational medicines
use at the hospital level, monitoring and reporting ADRs/ADEs,
antimicrobial stewardship, and providing drug information support to
medical staff. Four hospitals extended DTC functions to include
preventing drug shortages while only one of the regional hospitals
engaged in drug procurements processes. Table 2
In my hospital, the functions of DTC also include making drug
procurement recommendations, especially antibiotics. This is because we
know the disease patterns locally and can, therefore, recommend the most
effective antibiotics to procure [Pharmacist Regional Hps 1]
DTC indicator
As listed in table 3, virtually all hospitals local DTC have a stated
mission and an annual plan, which includes capacity building and
continuous professional education. Five of the hospitals’ DTC
acknowledges having a well-established standard guideline for DTC
operations. Subcommittees are present in all hospitals except one;
however, not all were effective according to the account of some of the
pharmacists interviewed.
We have two sub-committee ADR and antimicrobial stewardship
committee [Pharmacist Tertiary Hps 1]So far, there are sub-committee on antibiotics stewardships;
however, none of those committees is functional. [Pharmacist Tertiary
Hps 2]The ADR committee members are mainly tasked with the
responsibility of circulating ADR forms in collaborations with the
Pharmacy Board of Sierra Leone (PBSL) pharmacovigilance departments, who
also monitors ADRs. The antimicrobial stewardship committee ensures the
rational use of antimicrobial agents within the hospital. [Pharmacist
Tertiary Hps 1]
DTC meetings are usually held monthly (three hospitals) or quarterly (3
hospitals), and more than 50% (five hospitals) of DTC members do
attend. However, there are instances of low meeting turnout (one
hospital) due to members being busy with other functions. As one
participant puts it, low meeting turnout tends to give the impression
that DTC is not critical in ensuring the rational use of medicines, and
in improving patient health outcomes.
The chairperson of DTC seems very busy with other tasks in the
hospital. He is absent for most meetings. Even though that does not stop
the meetings from going on, it gives the impression that DTC is not a
priority at our hospital. [Pharmacist Tertiary Hps 2]
DTC effectiveness measured on a 1-10 scale, in which 1 and 10 represent
least and most effective respectively. The result (in table 3) shows
that effectiveness ranges from not effective (1/10) reported in one
hospital to very effective (8/10). Three out of six hospital DTCs’
reported being averagely effective (5/10 -.6/10).
Drug use policies introduced by some hospital DTC
Table 4 summaries some medicines use policies introduced by hospital
DTC. Drugs such as Paracetamol tablets, Nystatin syrups, and
antimalarials were observed from routine drug use evaluations to be
irrationally prescribed, dispensed and administered to patients
Paracetamol was observed to be given as an incentive to encourage
antenatal clinic attendance. Nystatin syrup was sometimes given to
neonate with white patches in their mouth and amoxicillin to patients
with signs of upper respiratory infection, without laboratory evaluation
or specialist clinician recommendations. Also, antimalarials were
prescribed for patients with fever irrespective of cause without
laboratory evaluation for definitive diagnosis. This led to the
introduction of local policies to reduce such practices.
The use of antimalaria, testing should be done before initiating
antimalaria medication and antibiotics must be prescribed rationally
[Pharmacist Tertiary Hps 3]
Non-standard prescription writing, which has tendencies to cause
medication errors was also a common practice; local policies were
introduced to prevent or reduce such occurrence.
The policy [on prescriptions] informs prescribers about the
standard writing format of all prescriptions; this prevents
non-professional from writing prescriptions as it used to be in the
past…. the policy dictates all prescriptions must come from
professionals with the legal framework to prescribe. [Pharmacist
Tertiary Hps 1]Prescribers, which includes doctors, and CHOs, they have to adhere
to the set standards when writing prescription failure to do so will
render a prescription invalid. The policy also guides on the number of
drugs that should be on a prescription at the outpatients’ departments.
Also, when prescribing for children, their weight should be written on
the prescription’s leaflets. This is important in that if the prescriber
did not calculate the actual dosage of the patients, the pharmacist
would rectify that at the dispensary. The introduction of these policies
saw a reduction of possible errors, ADRs, and there was a substantial
reduction in wastage of drugs [Pharmacist Tertiary Hps 1]The introduction of such policies has tremendously changed the
situation of irrational drug use, especially for antibiotics. We use to
having some prescribers prescribing three to four antibiotics on one
prescription but not now [Pharmacist Tertiary Hps 3]
Challenges in functioning and maintaining DTC
Table 5 summaries the respondents’ challenges in maintaining DTC
functions. All survey respondents, highlighted funding (n=6) as their
main challenge in maintaining DTC functions. Other challenges are
implementing DTC decision (n=4), and unmotivated DTC members (n=4).
Concerning funding, at any time we present our annual budget for
running DTC to the MoH, it never gets approved, so that has been a
serious challenge [Pharmacist Regional Hps 1]No logistical support at the moment or financial support, also
people [from MoH] do not come around to check and provide support,
that is demotivating [Pharmacist Regional Hps-2]Hospitals do not want to capture DTC in their annual budget
planning; some [Hospital management] will tell you, probably they
make the budget plan, but the funding allocations did not come on time,
so these constraints are common. Holistically, the main problem is
resources allocation; if they are made available, then members will be
motivated [Pharmacist Tertiary Hps-1]
Lack of technical competence (n=3) in the functions of DTC and interest
(n=3) were also reported as challenges summarized in table-5.
Another challenge is that
members need technical training to enhance their competence in the
activities of DTC [Pharmacist Regional Hps-1]
Strategies towards improving DTC suggested by pharmacists
The three major subthemes that emerged from interviewing pharmacists on
strategies to improve DTC in their hospital and nationally, includes,
resources availability, monitoring and evaluation of DTC activities, and
capacity building for DTC members
Pharmacists suggested that the allocation of DTC specific resources,
which include but not limited to financial resources, will promote the
optimal functioning of DTCs functions in Sierra Leone.
let the MoH capacitate the Directorate of Drug and Medical Supply
by providing them with all the resources and necessary equipment’s
needed to achieve that goal (optimal DTC functionality)
[PhmTertiaryHps-1]The hospital management need to include in their annual budget
funding for DTC activities because for now we have funding from the MoH
and donor partners, but what if they stop, automatically the DTC will
stop functioning [Pharmacist Tertiary Hps-3]Funding is not only limited to financial resources by all
necessary inputs like computers, stationery, printers, and even internet
connectivity should be provided [Pharmacist Regional Hps-1]
Also, effective monitoring and evaluations of DTC functions and
activities were suggested as another measure to improving DTC
functioning in Sierra Leone.
The focal person at MoH should follow-up on hospital-specific
progress routinely, which would serve as a motivation for us to be
serious about DTC. This is important because in our hospital there are
lots of other committees in which we are also engaged in [Pharmacist
Tertiary Hps-2]Periodic checks on the progress of DTC by MoH officials will also
serve as motivation. For example, we once had a representative from WHO
and the National Chief pharmacists attending our DTC meeting. Their
presence that servers as a motivation for many, and it also affirms the
importance of DTC to individuals who might not want to take it
seriously. [Pharmacist Tertiary Hps 1]Lastly, pharmacists recommended that, as part of the capacity building
strategy, the current drafted DTC operational manual should be rectified
and implemented. They also suggested that DTC members should have access
to various educational materials such as newsletters, research articles
in order to build capacity, which would improve their output in the DTC.Also, the DTC operational manual should be effected because the
one drafted had not been rectified for use. [Pharmacist Tertiary
Hps-1]Educational materials like newsletters or recent developments in
DTC are also necessary for capacity building. Information sharing about
DTC functions and activities withing Sierra Leone and internationally
will serve as motivation [Pharmacist Regional Hps 1]
Discussion
This study presented a detailed and comprehensive overview of the DTC
program that was piloted in Sierra Leone, and included details of
structure and membership, key indicators and activities, challenges, and
improvement measures. The findings are integral towards developing and
understanding the framework of activities and challenges facing such
programs and ways to consolidate them while expanding DTC nationally. It
also provides a reference point and baseline data for healthcare
professionals and policymakers involved in rational medicines
user-related activities in Sierra Leone and other countries within the
sub-region.
Membership
Unlike in other settings 28-30, as this was a pilot
program ,DTC membership in Sierra Leone is mainly homogeneous and
identical across all the hospitals studied. It is dominated by medical
staff 31, including doctors, pharmacists, nurses,
laboratory technicians, and CHO, but also included administrative
personnel. The representation of medical staff is similar to DTC in
Brazil 28, Nigeria 10, and in
Danmark30, but it is not as complex as in Spain32 and Jordan 29. According to the
WHO 6, the interprofessional mix is essential for the
successful and effective functioning of the DTC and the implementation
of key policies. Furthermore, it provides an opportunity for the
interaction of multidisciplinary medical personnel and hospital
administrative staff, this allows for a multidimensional perspective
towards medicines use discussion and policies 33, 34.
The role and responsibilities of members in the DTC are critical towards
its success. In this current study, the hospital medical superintendent,
and pharmacist-in-charge are respectively the chairperson and secretary
as recommended by the WHO 6. Similar DTC setups have
been reported in hospitals in Nigeria 10. This
structural make-up is very common, but instances have also been reported
in which a pharmacist acts as chairperson, and in some settings,
pharmacists are excluded as DTC members depending on the scope, aims and
objectives of the DTC and availability of pharmacists29, 31, 35.
Functions of DTC
The scope and framework of DTC’s primary functionality are dynamic and
differs significantly according to settings and, in some cases, the
hospital type. In his review, Mikael Hoffmann gives a vivid account of
the change in scope of DTC over time in different countries, from
logistics solutions to cost-effective analysis and a focus on patients’
safety 36. The WHO manual also detailed DTC functions6, 7; however, it advises on adapting DTC aims and
objectives as per local needs. In Sierra Leone, DTC functions are
centered around rational medicine use and audit on patient’s safety at
the hospital level. Only one hospital extended the scope of its function
to include drug procurements. These findings are similar to a study from
South Africa 37, Jordan 29, but
differ from DTC in Nigeria 10, and the USA31 in which their main aim is drug formulary
development and management. Two main factors may explain the limitation
in the function of DTC in Sierra Leone. Firstly, this was a piloted
program that is focused mainly to promoting rational medicine use at the
hospital level; therefore, a complex mix of aims will be ambiguous and
farfetched in a donor-driven healthcare system like Sierra Leone.
Secondly, highly skilled healthcare professionals are few in Sierra
Leone 38, and those available are mostly demotivated39; hence a narrow scope is essential for success.
Key DTC indicators in Sierra Leone
DTC’s success is, in part, dependent on effective planning, the
establishment of feasible terms of reference and guidelines, which
should include continuous training and readily available educational
resources 6. The majority of hospitals reported
establishing these parameters; nonetheless, few are still on the process
of doing so, and an account of their effectiveness cannot be verified.
Subcommittees
It is common practice for DTC to be fragmented into subcommittees tasked
with specific specialized roles and responsibilities in line with its
primary overall aim 6, 9, 23. These subcommittees may
vary considerably across jurisdictions and hospitals based on the
general scope of the DTC 29, 30, 32, 40. Although some
of the sub-committees are believed to be inefficient, nonfunctional, and
inactive, in Sierra Leone, there are only two reported subcommittees in
all hospitals, antimicrobial stewardship, and ADR subcommittee. The
existence of these two subcommittees might be directly linked to WHO and
PBSL’s longstanding collaboration with hospitals 41.
This is found to be similar to other DTC elsewhere 9but different from what is obtains in Nigeria. DTCs in Nigeria, are
known to have subcommittees on infection control, operational guideline,
and quality assurance of medicines in addition to antimicrobial
stewardship, and ADR10.
DTC meetings
The frequency of meetings reported in this study is similar to that
reported in a South African study in which most meetings are held once a
month and a few quarterly 9. Nevertheless, it differs
from findings in Nigeria 10. Therefore, it may be
sufficient to argue that the frequency of meetings varies considerably
from country to country and from hospital to hospital. DTC meetings have
been reportedly held bimonthly, monthly, quarterly, when necessary, or
no meetings in some setting depending on the scope and mandate of DTC24, 32, 42-44. Notwithstanding these variations, a
successful meeting required a clear agenda and the attendance of key
members like the chairperson and secretary of DTC 45.
In doing so, it signals the importance of the meeting to other members,
ensures the seriousness of proceedings, proper record keeping through
active minutes taking, which inform better decision making31.
Drug use policies, their implication, and unforeseen
challenges
The introduction of local drug use policies (Table 4) by members of the
DTC may be regarded as a great leap, and perhaps so-far the most
tangible measure towards rational medicines use at the hospital level.
Such policies might be useful and achieve its purpose if they were
formulated based on data from routine drug use evaluation, if there is
no conflict of interest among members, and lastly if there is a
consensus among all members in policy formulation, process24. An unbiased data-driven approach and inclusivity
of the inputs of all members enhance adherence to the policy in that key
heads of departments within the hospital are spear-heading the process;
hence their subordinates will likely comply. A significant but commonly
neglected practice is the documentation and monitoring of the impact of
the new policy introduced 37. The WHO and United
Nations agencies, in collaboration with MSH and USAID6, 7, 23, have published manuals that provide stepwise
instruction towards introducing and managing new drug use policies in a
DTC.
Opportunities and challenges of DTC in Sierra Leone
DTC presents a subtle yet rare opportunity in ensuring rational
medicines use at the hospital level in Sierra Leone. Generalized
rational medicines use strategies or interventions introduced by
governments are not always effective as intended in that each hospital
has its specific root cause unique to them. DTC, therefore, is
advantaged with assessing irrational medicines use problems specific to
a hospital and formulating targeted policies towards their problems.
There might be higher chances for success in policies introduced due to
multidisciplinary inclusivity of local healthcare providers and heads of
hospital units who are also members of DTC and can influence their peers
and subordinates.
Amid the opportunities presented, the results highlight significant
challenges within almost all DTC in Sierra Leone, which must be overcome
for effectiveness to be realized. Among the challenges reported, the
non-availability of resources is classified as the most important and
needs immediate intervention. Resources limitations represented a
foreseeing challenge as do most interventions in the healthcare system
in Sierra Leone, due to its reliance on donor funding3. Resources in this context are not limited to
funding but encompass equipment, office space, educational materials,
and human resource.
Going forward towards effective DTC in Sierra Leone
The future of DTC is difficult to predict; nonetheless, there are
tangible yet subjective suggestions from both the literature and by
pharmacists on ways to improving DTC in Sierra Leone. For instance,
despite differences in setting and complexity, Mandy C et al.made a critical analysis of DTC management strategies to maximize
output. They proposed that the attendance to meetings, sensitivity to
timeline for policies and interventions, an appeal process that
criticises all decision processes, and lastly, the implementation of
decisions should be holistic and involve all members for optimal output
of DTC 44. Additionally, providing the resources
needed for DTC operations, capacity building among members of DTC,
governance, monitoring, and evaluation are suggestions put forward by
pharmacists in Sierra Leone
Going forward, DTC functions may evolve to include medicines selections
and procurements, and as such protocol on the selection of new
medications to be added to a local formulary and how a conflict of
interest issues are handled will dictate it fit for purpose and success46, 47.