PharmaPOC

Data from the Primary Health Care Performance Improvement (PHCPI) initiative show that diagnostic accuracy in Nigeria (36.4%) is one of the worst in Africa. This suggests that 2 out of 3 diagnoses are inaccurate and could potentially lead to poor clinical decision making and poor health outcomes including mortality. 

A plausible explanation for this diagnostic inaccuracy in Nigeria is the shortage of qualified healthcare personnel like physicians (~1 physician to 10,000 population) compounded by lack of adequate government health facilities. As a result, the majority of  primary care services (~80%) are delivered by non-physician providers including nurses and pharmacists in community settings.

Community pharmacies are the first point of call for most Nigerians seeking primary healthcare services. This is so because community pharmacies are readily accessible in most communities relative to health centers/clinics, and also more efficient. There are approximately 4000 private and well-functional community pharmacies and over 21,000 registered pharmacists in Nigeria.

Although pharmacies are readily accessible and pharmacists sufficiently trained to deliver primary care services, they are currently underutilized in the delivery of primary care services especially those related to diagnosis of disease conditions. Again, a plausible explanation for this is the lack of standardized clinical protocols for accurate diagnosis, treatment, and referral through point of care (POC) services by community-based pharmacists. 

Under the current realities of resource constraints in primary care settings in Nigeria and given the fact that they potentially perform an important role in counseling and health promotion, training of community pharmacists will fast track solutions to the following challenges:   

1. Inaccuracy of diagnosis: Inadequate knowledge, capacity and competence

2. Underutilization of community pharmacies as a channel for primary care delivery

3. Lack of standardized approaches for performing POC services in a pharmacy settings

Our solution consists of 1) a comprehensive, evidence-based Point-of-Care (POC) training, and 2) a collaborative learning portal for community pharmacists who constitute the frontline of primary care delivery in Nigeria. Pharmacy-based POC services are deemed ethical and legal under the relevant existing laws in Nigeria.

Our solution seeks to leverage community pharmacies and pharmacists as a channel for improving access to and quality of primary care services, specifically POC services.

It utilizes already existing and user-friendly technology to enhance the knowledge and capacity of pharmacists to provide high-quality services with the goal of improving patient outcomes that are sensitive to health services provided in non-traditional primary care settings in Nigeria.

PharmaPOC has 3 main components:

1. Training and Assessment Tools

2. POC Diagnostic Protocols

3. Online Learning Lab  

Training and Assessment Tools: Our training curriculum provides comprehensive modules that include introduction to POC testing, implementation of POC testing, sample POC testing and POC testing demos that can be conducted in a community pharmacy to inform clinical decision-making. This component also contains pre/post assessments to evaluate the effectiveness of the modules in developing capacity for POC training. It is built on google classroom, a user-friendly and easily accessible cloud-based platform that is already commonly used in Nigeria. The primary objective of the training and assessment is to improve knowledge, capacity and competence required to provide appropriate, high-quality primary care in community pharmacies.

POC Diagnostic Protocols: The POC protocols provide easy-to-use guides that address three key areas which are:

1. Diagnosis of minor ailments using point of care test results and symptoms

2. Referral of potentially serious conditions to secondary and tertiary health facilities

3. Treatment of minor ailments such as uncomplicated malaria, sore throat, diarrhea, etc.

Online Learning Lab: The Learning lab is hosted on Telegram as the digital platform where pharmacists receive updates on how to improve quality POC services. They will also be able to ask questions, share information and exchange ideas about POC based on their day-to-day experiences. Telegram will also be the platform for hosting webinars from time to time.

Our solution serves community pharmacies and pharmacists and by extension the patients that they serve in their communities, as follows: 

1. Improve knowledge, capacity and competency required to increase accuracy of diagnosis. This will make last mile delivery of accurate diagnosis possible.

2. Create new sources of data on primary care in community settings, i.e., data on POC services provided at individual patient level which, in combination with other existing data sources including from the WHO and the World Bank. These data will contribute to generating data-driven analysis and interpretation for planning a better primary care delivery system in Nigeria. 

3. Empower pharmacists as frontline primary care personnel with point of care testing with evidence-based protocols for accurate diagnosis and appropriate treatment as well as with kits of basic POC medical supplies needed for actually providing these services in community- and pharmacy-based settings that are a predominant source of essential primary care services. 

4. Improve quality of care through personnel training on protocols and use of current clinical evidence.

5. Reduce complications during childbirth, maternal and infant mortality, under-5 mortality, reduce disability and loss of life, and improve health-related quality of life of individuals and public health in general.

6. Improve medication safety, prevent harm from inappropriate use of antibiotics and other drugs.

7. Reduce preventable harm to the health of individuals, reduce preventable hospital admissions, reduce the burden of disease as well as avoidable financial costs to individuals and families, and to the public in general. Overall, these positive changes in health and wellness will contribute to Healthy People/SDG goals; help realize the promise of human capital for a country that has the highest majority young population in the African continent, by improving the health of the nation and reducing avoidable costs that could have been incurred in hospital admissions, premature deaths and lost productivity resulting from higher disease burden and complications of illness. 
   

Akindele and Temitope Opeyemi both founded and run Instapharm, a chain of community pharmacy practice full-time and are already champions of the pharmacy as a Point of Care testing site (PharmaPOC). Since 2015, Akindele and Temitope have combined financial and professional resources to bootstrap and gain traction to date. They already practice pharmacy as a point-of-care with protocols, processes and documented cases all of which lend credence to the fact they are uniquely positioned to deliver PharmaPOC solutions.

In addition to a first degree in Pharmacy, Akindele and Temitope both have a master's degree in Public Health/Health Promotion, a multidisciplinary field that has broadened their scope beyond clinical considerations in healthcare to also encompass social and economic determinants of health. Akindele also has formal training in Consumer Protection based on his professional background with the Advertising Practitioners Council of Nigeria (APCON). 

Because of their extensive field experience, they  have a firsthand knowledge of issues affecting performance and outcomes in the sector. All our current business locations are directly opposite government-owned primary health centers. This has given us the opportunity to gather data through unconventional means.

Wale Olaleye is a pharmacist trained in Nigeria and health systems  consultant with multidisciplinary training in areas that are core to this project (Health Policy, Global Health). He posses an MBA with a focus on Health Systems Management with business and consulting expertise and proven experience starting up and scaling business in Nigeria.

Shyamal Sharma is trained in the multidisciplinary field of health services research in the United States. She is a public health and health policy professional with an extensive career in both public and private sectors in the US and in developing countries. 

She is well-suited given her robust expertise in identifying and developing evidence-based measures for improving primary care performance for both routine health maintenance and population health management for a vast array of physiological and mental/behavioral health conditions; her track record of convening high-profile public-private partnerships for innovative solutions to clinically relevant data sources that are meaningful to measuring and improving primary care, as well as care transitions and care integration in other care settings, for segments of vulnerable populations with diverse health care needs; and her facility with both common-sense, low-cost solutions for collecting core data in low and middle-income countries on the one hand, and her visionary approaches to leveraging emerging technologies for novel digital applications for managing care for specific high-needs populations and especially those with chronic conditions.

She is the founder and principal investigator of The Relational Society Project grounded in an innovational, multi-level complex adaptive systems framework for addressing grand societal challenges that include disparities in population health outcomes emanating from systemic issues that currently threaten our environment and overall health and well-being of our global communities. 

The components of PharmaPOC are currently being piloted and progressively being improved upon. We believe that this approach of leveraging community pharmacies/pharmacists and frontline primary care delivery agents is an efficient and effective way to improve primary care outcomes and early feedback from our pilots are evidence to this. We believe that this grant will afford us the opportunty to improve and move our product further along the product lifecycle. Given the entities involved (SOLVE, Gates), funding from this Challenge will offer PharmaPOC a prime opportunity for wide scale impact.

PharmaPOC utilizes a  multidisciplinary, public health approach that combines clinical science and social science theories for behavior change (a concept not covered in the traditional pharmacy school curriculum). For example, our solution utilizes the Social Ecological Model (SEM) and more specifically the Opportunity-Ability-Motivation (OAM) Framework common to SEM and comparable social science theories to help community pharmacists understand how various factors (personal, institutional, societal and public policy) influence the adoption/implementation of POC in their practices as well as patient care seeking behavior. Apart from the innovative OAM conceptual framework, in practical terms our solution: 

• PharmPOC training complements ways of improving services  by most pharmacies rather than replace -making it easier for adoption.

• Not very technical - easy-to-use by non professionals??

• Utilizes existing user-friendly technology 

• Leverages existing channels (community pharmacies) to improve the quality of primary care delivery

• Generates data that are crucial to measuring and improving the quality of primary care services in community settings

Our Impact goals over the next 5 years include to:

1. Improve the knowledge and skills of Pharmacists as providers of primary care (specifically POCT) (40% change in Year 1, 80% change Year 5)

2. Improve the quality and safety of care received by patients

3. Improve data collection and use for decision-making

How:

• Pilot with community pharmacies - (over 1000 in yr 1 and 5000 by yr 5). This is already in progress with great feedback.

• Scale reach from one state (Ibadan) to 36 states in Nigeria by leveraging our google cloud and our learning lab powered by telegram

• Partner with the National Primary Heath Care Development Agency (NPHCDA) with a goal to embed PharmaPOC into their programming.

• Incorporate public policy advocacy and change

We propose to measure progress toward impact goals as follows:

1. Improve the knowledge and skills of providers (% change in Year 1 COMPARED TO BASELINE AS MEASURED BY PRE-ASSESSMENT SURVEY (11 item survey designed by Akin,) 40% progress  in Year 1; at least 80% progress by Year 5 

2. Improve the quality and safety of care received by patients: 40% progress in Year 1; at least 80% progress by Year 5; Patient safety of care at least 30% progress in Year 1; close to 90% progress by Year 5

3. Improve data collection and use for decision-making:   At least 20% in Year 1; close to 50% by Year 5; use data for decision-making at least 60% of the 20% who are projected to do data collection in Year 1; close to 95% of the 50% who are projected to do data collection by Year 5

At the center of our intervention is behavior change through comprehensive training and building a learning community of peers (pharmacists) at the frontline of primary care. 

Our theory of change is grounded in the Opportunity-Ability-Motivation (OAM) Framework. The OAM Framework is derived from a small but growing field of study of the continuum of behavioral theories and their application in the context of international development programs in low- and middle-income countries (LMICs) (Evans et al, 2022). While these theories are primarily used in the application and evaluation of implementation practice of health behavior change for attaining a public health goal such as smoking cessation, we argue that the three components of the OAM Framework can be similarly effective in changing practitioner behavior too. 

It is recognized that socio-ecological theories or models are often too multidimensional and complex to systematically put into practice in resource-constrained LMICs such as Nigeria. For this reason, Evans et al suggest that essential variables like OAM can be used in place of more complex theories as these three variables are more practical to implement and measure, and also the foundational concepts common to leading theories. 

The OAM Framework is a good fit for our solution since all three variables – i.e., Opportunity, Ability, and Motivation – are present and actionable for behavior change under our solution (PharmaPOC) as summarized below:

Community pharmacists have the opportunity to provide high quality point-of-care (POC) services to their clients if they choose to do so above and beyond simply dispensing medicines to their clients. 

Our solution consists of a comprehensive suite of POC training modules. This will enhance the ability of the trainees to provide appropriate point-of-care services to each client, on a case-by-case basis as needed, in an accurate and timely manner. 

Based on our ongoing interactions with fellow pharmacists, we are aware that a significant proportion of community pharmacists, nearly 80% especially those in the younger generation, express high levels of interest, enthusiasm, and self-motivation to learn and improve the POC services they currently provide…. We posit that our solution, i.e. POC training and peer learning network, will elevate their motivation further. We plan to offer recognition awards for improvement in POC performance and data collection, free subscription to the PharmaPOC Toolkit  etc. to further incentivize them. Together, these will boost their motivation for behavior change.

We propose to link the behavior change, using data from our pre/post-PharmaPOC training assessment, on what effect this change has on each of our impact goals in quantifiable terms. We will also link self-reported, qualitative data from participating pharmacists how PharmaPOC training has impacted each of our goals. 

PharmaPOC leverages existing technology to deliver our solution to the end use. 

1. Google Cloud Technology - Our training and assessment modules as well as diagnostic protocols are built/hosted on google classrooms, google docs and google forms. 

2. Telegram (SMS/Conferencing application) - Our learning lab is built on telegram which offers a very simple and user-friendly approach to building communities and collaboration.

We leverage these technologies for two reasons:

1. They are already well-used technologies within our context

2. They are cheap, accessible, user-friendly and easy to use.

Primary health care data will be collected through the various components of PharmaPOC;

1. Through our training and assessment component, we will gather data on learning progress and knowledge levels of providers.

2. Our learning labs offer an opportunity to assess and capture data regarding the skill and competence levels of providers.

Our team is comprised of a diverse group of individuals with multidisciplinary background and exposure to multiple health systems across the world. The team is currently made up of 2 males and 2 females and we have adopted a shared leadership model where each and every one of us takes leadership of specific areas of the project. We hope to expand our team as we scale and are committed to engendering diversity, equity and inclusion into every aspect of the work that we do including diversity of thought, diversity of individuals and experiences. 

Our solution makes appropriate and affordable primary care services accessible to among the most vulnerable populations who do not have a reliable source of timely care for their most urgent healthcare needs. This solution is available to all regardless of social identity and status.

Future updates of PharmaPOC will incorporate various local languages as a way to increase access and reduce barriers to adoption

Key Resources: We currently run a lean operation and have bootstrapped since inception. Our goal was to establish a proof of concept on order to build a valid business case for our solution. 

Key Activities: Building the capacity of Pharmacies and Pharmacists to leverage their organization as a channel for providing high quality primary care services. We offer self-taught modules on point of care testing as well as competence testing to assess learning progress. Additionally, we offer standardized diagnostic protocols to support consultation and clinical decision-making. Finally, we provide a learning lab - an online community of pharmacists engaged in POC training to learn from each other and collaborate. It also offers us the opportunity to create partnerships that can be leveraged to improve the performance of primary care delivery.

Type of Intervention: A service (training toolkit and protocol) and an experience (learning lab)

Segement: The main beneficiaries of our services are community pharmacists, their pharmacies and the communities they serve

Value Proposition: Our solution increases the knowledge, capacity and competence of community pharmacists and pharmacies to offer high quality care, the ability to enhance their value within their communities and in the healthcare value chain, and the ability to earn more revenues and grow their businesses.

Social Impact: Improved access to, and improved quality and efficiency of diagnosis in the community.

Partners and Key Stakeholders: Our primary partners are community pharmacists and pharmacies in our local area for the first year and across the country over the next 5 years. We hope to partner with the National Primary Health Care Development Agency (NPHCDA) of Nigeria over the next couple of months, to increase our reach and impact. We also plan to partner with manufacturers and pharmaceutical companies to secure discounts and rebates on medical supplies test kits distributed to members of PharmaPOC community as an incentive.

Channels: We are currently reaching our users through our free monthly webinars (primarily). We are also leveraging our relationship with the Pharmacist council of Nigeria, Pharmaceutical Society of Nigeria, as well as the Association for community Pharmacists of Nigeria, to reach our clients. We are also utilizing social media and referrals as outreach channels.

Customers: Community Pharmacies/Pharmacists, NPHCDA, Pharmaceutical Companies and Suppliers

Cost Structure: Current expenditures include time cost of research, recording modules,  creating content, and the cost of internet usage. Our operation is currently very lean and scale up cost will involve mostly personnel cost for managing the digital platform and administrative work.

Surplus: Profits will be spent improving the quality of our content (recording, print, designs) and scaling. We will also hire more personnel to support growth and expansion in Nigeria. 

Revenue Sources:

1. Subscription (75%); 75% of our revenue is from subscription to our solution. We have adopted a tiered subscription model offering a Basic, Standard and Enhanced package that are relatively affordable. We also seek funding from some of our partners for early stage pharmacists and newly graduated pharmacists.

2. Partnerships and sponsorships (15%); 25% of our revenue comes from partnerships with Pharmacuetical companies and test kit suppliers in the form of discounts, rebates, product advertisement and webinar highlights.

3. Grants (10%): We will be depending on grants to continue to offer low cost services and scholarships to members of our community that really need them.

Link to our revenue projections and assumptions for the next 5 years

We have a hybrid model:

1. Selling services

2. Partnerships/Sponsorships

3. Grants

We currently have a low cost operation model that works well. Replicability will play a role in Financial Stability

We have been able to sell services even as a pilot. This demonstrates the value that providers see in the product. We have also invested personal funds. We have been financially sustainable even at this early stage because of the low cost nature of our solution.