Healthcare system development in the Middle East and North Africa region: Challenges, endeavors and prospective opportunities.

Background: Countries in the Middle East and North Africa (MENA) region have been investing in the development of their health systems through implementing reforms to improve health care delivery for their nations. However, these countries are still facing challenges in providing equitable, high quality healthcare services. There is limited published literature supporting the previous and ongoing attempts that have been made to improve health system performance in MENA countries. Aims: This review aims to describe experiences of health system development efforts in the MENA region, highlight progress, identify challenges that need be addressed and future opportunities to achieve responsive and efficient health systems. It also aimed to provide recommendations to further support these health systems toward evolution and performance improvement. Methods: A literature review was conducted by searching different databases including PubMed, Scopus, Google Scholar and other electronic resources to identify articles and publications describing health systems development in the MENA region from 1975 to 2022. It also included grey literature, reports and policy and planning documents by international organizations. The identified references were reviewed to extract, analyze, organize and report the findings. Results: The review revealed emerging evidence describing governmental initiatives to introduce health system reforms at different levels in the MENA countries. These include initiatives targeting the various elements controlling health system reform: financing, payment, organization, regulation and behavior of providers and consumers. There are several challenges facing the health systems of MENA countries including the rising burden of chronic diseases, inequitable access to health services, deficiency in health workforce, shortage in the use of effective health information systems and leadership challenges. The review identified several key areas that can benefit from further improvement to support health system reforms. These include improving the structure, organization and financing of health systems, health workforce development, effective data management and engagement of key stakeholders to achieve adequate health system reforms. Conclusion: The MENA countries have made significant steps to improve the performance of their health systems; yet achieving a comprehensive health reform will require collaboration of various stakeholders including health policy makers, healthcare professionals, and central to the success of the reform, the patients.

The perceptions of healthcare professionals about accreditation and its impact on quality of healthcare in Kuwait: a qualitative study.

RATIONALE, AIMS, AND OBJECTIVES: The accreditation of healthcare organizations has been applied as a quality assurance mechanism of healthcare services. Kuwait health authorities implemented a national healthcare accreditation program at the governmental healthcare system. This study aimed to explore the perceptions of healthcare professionals (HCPs) about healthcare accreditation, perceived challenges to implementing accreditation, and views on how to overcome these challenges. METHODS: A phenomenological qualitative framework was adopted to conduct focus group interviews to explore perceptions of HCPs about accreditation in governmental healthcare system. Data were collected from 30 HCPs using seven focus group interviews. The verbatim transcripts of the interviews were analysed using the framework approach. RESULTS: The HCPs indicated that accreditation enhanced patient safety culture at their organizations through staff adherence to good practices, improved documentation and patient handover practices, and incident reporting. The facilitators to the implementation of accreditation that emerged from interviews included administrative support, staff training about accreditation, and expansion in application of electronic systems. Participants reported several challenges to implementing accreditation including challenges related to staff (eg, high workload, burdens imposed by accreditation requirements), challenges related to organizational system and resources (eg, poor teamwork among HCPs, inadequate infrastructure in some facilities), and challenges related to patients (eg, poor understanding about accreditation). However, most participants expressed positive attitudes towards accreditation and appreciated its impact on quality of healthcare. Participants suggested ways to support accreditation such as increasing staff numbers to reduce workload, enhancing staff motivation and education about accreditation, developing proactive leadership and staff teamwork, and improving patients' awareness about accreditation. CONCLUSIONS: HCPs in Kuwait expressed positive attitudes towards accreditation while also recognizing the challenges that may hinder its implementation. The collaboration between different stakeholders in this process is essential to overcome these challenges and support HCPs to meet accreditation standards and improve quality of healthcare services.

Enablers and challenges to pharmacy practice change in Kuwait hospitals: a qualitative exploration of pharmacists' perceptions.

RATIONALE, AIMS, AND OBJECTIVES: The practice of hospital pharmacists in many developing countries has been changing to include the delivery of direct patient care services, but practice change can be a challenging process. This article explores the perceptions of hospital pharmacists in Kuwait about the enablers and challenges to expanding their scope of practice to include direct patient care. METHODS: A phenomenological qualitative approach was employed to conduct focus group interviews to explore pharmacists' perceptions about their professional practice at different hospitals across Kuwait. Data were collected from 110 pharmacists using 11 focus group interviews. The interviews were audio-recorded, transcribed verbatim, and analysed using framework analysis. RESULTS: The practice of most hospital pharmacists includes limited direct patient care role. However, a growing number of pharmacists have been introducing clinical pharmacy services at hospitals. Three themes about enablers to practice change emerged from data: (a) increasing physicians' acceptance to pharmacists' role in patient care, (b) patients' trust in pharmacists' knowledge about medications, and (c) pharmacists' perceived benefits of providing direct patient care. These benefits includes enhancing patients' safety and adherence to therapy and improving the professional identity of pharmacists. Participants' perceived challenges to practice change include professional, individual, and organizational challenges. Most participants welcomed assuming direct patient care role. They agreed that pharmacists need to receive adequate education and training and to be equipped with a clinical degree to responsibly provide direct patient care services at hospitals. CONCLUSIONS: Pharmacists have been increasingly attempting to provide clinical pharmacy services in Kuwait hospitals. This qualitative data revealed breadth of challenges hindering pharmacists' attempts to expand their professional practice to include direct patient care role. It also outlines facets of improvement and enablers to practice change. The collaboration between different stakeholders in the profession is essential to support pharmacists' efforts in achieving the change in the scope of pharmacy practice to improve patient care services.

Competency-based education in pharmacy: A review of its development, applications, and challenges.

RATIONALE, AIMS, AND OBJECTIVES: There has been a resurgence of interest in the application of competency-based education (CBE) in health care professionals' education in recent years, including the pharmacy profession. This model strives to prepare a competent pharmacy workforce to help meet societal needs for effective, safe, and economical health care services. The aim of this narrative review is to provide an overview of the applications of CBE in the education and training of pharmacists, the process for constructing a competency-based pharmacy curriculum, and the potential advantages and challenges associated with its implementation. METHOD: A comprehensive literature review was conducted via PubMed and Scopus databases using a variety of keywords related to the topic (from 1975 to 2019). Other electronic resources (Google Scholar and the Education Resources Information Center) were searched to identify educational outcomes of pharmacy programmes emphasizing competency development and competency frameworks/standards for the pharmacy profession that were published up to 2019. RESULTS: CBE has been increasingly adopted in pharmacy education, mainly in developed countries. A number of competency frameworks have been advanced to support the design of CBE curricula, accreditation standards of pharmacy programmes, and professional pharmacy registration/licensure. Several examples of the application of competency-based pharmacy education (CBPE) were identified at undergraduate, postgraduate, and professional development levels. Transforming a traditional pharmacy programme into CBPE offers several potential benefits but can also be associated with significant challenges. Successful implementation of CBPE programmes requires strong and supportive institutional leadership; proper curricular design, implementation, and management; and focus on faculty training and development. CONCLUSION: The adoption of CBPE can enhance the ability of pharmacy education to meet the rapidly evolving societal health care needs. This model has been applied in developed countries at different levels throughout the pharmacist's learning continuum. It has also been investigated in some developing regions.

Pharmacists' experiences and perceptions about simulation use for learning and development of clinical skills in Kuwait.

Background There has been a worldwide exponential rise in simulation use in health professions education. Most of the evidence about simulation-based education (SBE) comes from Western educational systems. Little is known about simulation use in the education and training of pharmacy students and pharmacists in the Middle Eastern countries. Objective To explore pharmacists' experiences, perceptions and attitudes toward simulation use for learning clinical skills in Kuwait. Setting Different governmental hospitals across the State of Kuwait. Method This was an exploratory descriptive study of pharmacists' perceptions about SBE. A mixed-method research design was employed whereby 110 hospital pharmacists participated in focus groups and completed self-administered surveys. The focus group interviews were audio-recorded, transcribed verbatim and analysed using framework analysis. Descriptive statistics were used to describe characteristics of study participants and survey findings. Main outcome measure Pharmacists' experiences, perceptions and attitudes toward SBE. Results A total of 110 pharmacists participated in the focus groups, of whom 88 completed the survey (80% response rate). The focus groups revealed that pharmacists had different experiences in relation to simulation use which included learning, assessment, and less frequently reported in their training as practitioners. They identified many benefits of simulation such as enhancing knowledge retention and allowing learners practice and rehearse clinical skills in safe environments. Participants' perceived barriers to simulation use in pharmacy students' training included the need for qualified faculty and simulated patients, time constrains to incorporate simulation in faculty teaching and reluctance of learners/educators to use simulation. Most participants expressed positive attitudes toward simulation and welcomed its integration in pharmacy students' learning. In response to survey, 26.1% of pharmacists reported having no prior experience in the use of simulation. The top reported barriers to using simulation for learning were time constrains (22.7%) and the need for qualified faculty (6.8%). Conclusion Pharmacists in Kuwait have diverse experiences regarding simulation use for learning. They expressed positive attitudes toward simulation use for learning clinical skills. Efforts are needed to standardize and expand simulation use in the education and training of pharmacy students, trainees and practitioners to equip them with the clinical skills essential for pharmacy practice.

Management of Low Density Lipoprotein Cholesterol at a primary care diabetes clinic in Kuwait.

AIMS: To evaluate the impact of clinical audit and focused interventions on reducing cardiovascular diseases risk by treating Low Density Lipoprotein Cholesterol (LDL-C) in patients with type 2 diabetes attending a primary care clinic in Kuwait. METHODS: Using LDL as a surrogate for cardiovascular risk, the audit team performed a clinical audit with focus on the care process indicator of statin prescription. The basic audit reviewed 100 patients' medical records retrospectively to assess patients' lipid profiles and statin prescription. A lipid management protocol and algorithm based on national clinical practice guidelines distributed to all healthcare professionals and was implemented for 3 months followed by re-audit of another 100 records. Descriptive and comparative statistics (pre and post) were performed using SPSS, version 22. RESULTS: Statin prescription increased significantly from (26%) in the basic audit to (85%) in the post-intervention audit (p<0.001). The mean LDL-C value decreased significantly from 3.37±0.67mmol/L to 2.71±0.79mmol/L, p<0.001. Mean total cholesterol was significantly reduced from 5.15±0.73mmol/L to 4.68±0.88mmol/L, p<0.001. Ten years CHD risk decreased from 18.46±11.1% to 16.8±12.23%, p=0.152. CONCLUSIONS: Implementing a clinical audit coupled with focused intervention was successful in improving management of LDL-C among patients with type 2 diabetes mellitus attending the primary healthcare sector in Kuwait.

The association of body mass index values with severity and phenotype of sleep-disordered breathing.

INTRODUCTION: To investigate the relationship between body mass index (BMI) and the severity of obstructive sleep apnea (OSA) and to determine the BMI cut-off values for sleep-disordered breathing among adult population. MATERIALS AND METHODS: Data from 515 patients were evaluated retrospectively. These included demographic data, BMI, apnea-hypopnea index (AHI), oxygen saturation (SaO2) and oxygen desaturation index (ODI). The BMI cutoff value for sleep-disordered breathing was determined and comparisons were made between two groups of patients (BMI ≤ 33 and BMI > 33). Descriptive and comparative analyses were performed using SPSS, version 24. RESULT: Higher BMI values were found to be correlated with diagnosis and severity of OSA and reduced sleep efficiency. Patients in the BMI > 33 group had significantly higher rates of co-morbid diseases than patients in the BMI ≤ 33 group. Patients with BMI ≤ 33 had significantly lower ODI values than patients with BMI > 33. In patients with BMI > 33, arousal index was significantly higher and SaO2 values were lower than those with BMI ≤ 33. In rapid eye movement (REM) sleep-related OSA, BMI values were higher than positional/classical OSA. CONCLUSIONS: Patients with higher BMI experienced frequent nocturnal oxygen desaturation periods resulting in higher arousal indexes and decreased sleep efficiency. REM sleep-related OSA and high BMI values together may lead to increased nocturnal oxygen demand. We recommend the threshold values of BMI > 33 to be considered for screening OSA among adult population.

Role of pharmacists in providing parenteral nutrition support: current insights and future directions.

BACKGROUND: Parenteral nutrition (PN) therapy is a complex and critical therapy that requires special clinical knowledge, skills, and practice experience to avoid errors in prescribing, compounding, and clinical management of patients. Pharmacists with adequate clinical training and expertise in PN therapy can have pivotal role in the care of patients receiving PN therapy. OBJECTIVE: The aim of this systematic review was to describe and evaluate the different roles of pharmacists and their provided services related to PN therapy. MATERIALS AND METHODS: A comprehensive systematic literature review on the topic was conducted via PubMed database using several keywords related to the topic (from 1975 to 2017). Additional resources included the standards of practice and clinical guidelines from recognized organizations such as the American Society for Parenteral and Enteral Nutrition (ASPEN) and the American Society of Health-System Pharmacists (ASHP). RESULTS: Pharmacists have diverse roles in relation to PN therapy including the following: the assessment of patients' nutritional needs; the design, compounding, dispensing, and quality management of PN formulations; monitoring patients' response to PN therapy; supervision of home parenteral nutrition (HPN) programs; education of patients, caregivers, and other health care professionals on nutrition support and conducting PN-related research and quality improvement activities. These services seem to be variable across clinical settings and among different countries depending on the practice environment and pharmacists' clinical practice in these settings. However, each of these practice domains helps to support the delivery of safe and effective PN therapy to patients. CONCLUSION: Pharmacists have been actively participating in providing PN-related services to patients. To fulfill the requirements of their essential role in this area of practice, pharmacists need adequate educational preparation and clinical training on nutrition support. Empowerment of pharmacists to assume a stronger leadership role in this dimension of pharmacy practice will enhance the quality of care provided to patients receiving PN therapy and improve PN services.

Medical and pharmacy students' attitudes towards physician-pharmacist collaboration in Kuwait

Objective: To assess and compare the attitudes of medical and pharmacy students towards physician-pharmacist collaboration and explore their opinions about the barriers to collaborative practice in Kuwait. Methods: A cross-sectional survey of pharmacy and medical students (n=467) was conducted in Faculties of Medicine and Pharmacy, Kuwait University. Data were collected via self-administered questionnaire from first-year pharmacy and medical students and students in the last two professional years of the pharmacy and medical programs. Descriptive and comparative analyses were performed using SPSS, version 22. Statistical significance was accepted at p<0.05. Results: The response rate was 82.4%. Respondents had overall positive attitudes towards physician-pharmacist collaboration. Pharmacy students expressed significantly more positive attitudes than medical students (p< 0.001). Medical students rated the three most significant barriers to collaboration to be: pharmacists’ separation from patient care areas (n=100, 70.0%), lack of pharmacists’ access to patients’ medical record (n=90, 63.0%) and physicians assuming total responsibility for clinical decision-making (n=87, 60.8%). Pharmacy students’ top three perceived barriers were: lack of pharmacists’ access to patients’ medical record (n=80, 84.2%), organizational obstacles (n=79, 83.2%), and pharmacists’ separation from patient care areas (n=77, 81.1%). Lack of interprofessional education was rated the fourth-largest barrier by both medical (n=79, 55.2%) and pharmacy (n=76, 80.0%) students. Conclusions: Medical and pharmacy students in Kuwait advocate physician-pharmacist collaborative practice, but both groups identified substantial barriers to implementation. Efforts are needed to enhance undergraduate/postgraduate training in interprofessional collaboration, and to overcome barriers to physician-pharmacist collaboration to advance a team approach to patient care (AU)

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Parenteral nutrition in hospital pharmacies.

Purpose - The purpose of this paper is to explore parenteral nutrition (PN) practices in hospital pharmacies of Kuwait and identify potential avenues for quality improvement in this service. Design/methodology/approach - A descriptive, qualitative study about PN practices was conducted from June 2012 to February 2013 in Kuwait. Data were collected via in-depth semi-structured interviews with the head total parenteral nutrition (TPN) pharmacists at seven hospitals using a developed questionnaire. The questionnaire obtained information about the PN service at each hospital including the existence of nutritional support teams (NSTs), PN preparation practices, quality controls and guidelines/protocols. The interviews were audio-recorded, transcribed verbatim and analyzed for content. Findings - Seven hospitals in Kuwait provided PN preparation service through TPN units within hospital pharmacies. Functional NSTs did not exist in any of these hospitals. All TPN units used paper-based standard PN order forms for requesting PN. The content of PN order forms and PN formulas labeling information were inconsistent across hospitals. Most of the prepared PN formulas were tailor-made and packed in single compartment bags. Quality controls used included gravimetric analysis and visual inspection of PN formulations, and less consistently reported periodic evaluation of the aseptic techniques. Six TPN units independently developed PN guidelines/protocols. Originality/value - This study revealed variations in many aspects of PN practices among the hospitals in Kuwait and provided recommendations to improve this service. Standardization of PN practices would enhance the quality of care provided to patients receiving PN and facilitate national monitoring. This can be accomplished through the involvement of healthcare professionals with expertise in nutrition support working within proactive NSTs.

Implementation and evaluation of a workshop on patient counseling about antidiabetic medications for final-year pharmacy students.

OBJECTIVE: To implement an interactive workshop for final-year pharmacy students on patient counseling about antidiabetic medications and to assess its impact on knowledge and self-reported confidence of students in counseling. SUBJECTS AND METHODS: The workshop was organized for all final-year pharmacy students (n = 27) during the academic year 2011-2012. It included various teaching and learning activities: interactive lectures, group work and role-playing. Pre-/postworkshop questionnaires were used to assess the impact of the workshop on students' knowledge about medications and attitudes to patient counseling, respectively. The workshop and the teaching activities were evaluated using an evaluation sheet. Data were analyzed using SPSS version 17. Paired Student's t test was used to compare the results of pre-/postintervention instruments. Statistical significance was accepted at a p value of <0.05. RESULTS: The mean ± standard deviation of the pre- and postworkshop knowledge questionnaire scores were 47.9 ± 17.6% and 70.7 ± 18.6%, respectively (p < 0.05), indicating that the workshop significantly improved students' knowledge about antidiabetic medications. It also had significant effects on students' self-reported confidence in communicating effectively with patients and counseling them on antidiabetic medications. All participants strongly agreed that the workshop was very useful. The case discussion in small groups was ranked as the most preferred learning method by the students. CONCLUSION: This workshop was successful in improving knowledge and self-reported confidence of pharmacy students in counseling patients about antidiabetic medications. Adapting the use of engaging teaching methods allowed the students to become active, independent and self-directed learners and thus enhanced their confidence in providing pharmaceutical care to patients.