Education of pharmacists in Ghana started in the 1880s (then the Gold Coast) and evolved along four main periods when the trainee titles, schemes and certification changed. The periods were (1)1880s to 1942 - Certificate of dispensing with the dispenser-in-training and nurse-dispenser schemes; (2) 1943 to 1960 – Diploma/Certificate of competency with the dispenser-in-training and pupil pharmacist schemes; (3) 1961 to 2017 - Bachelor of pharmacy degree and (4) 2012 to date - Doctor of pharmacy degree. These periods occurred under varied contextual factors that influenced the reforms. During these periods, dispensing and pharmaceutical care evolved. Historically, care focused on dispensing prescription, compounding, mixing of drugs and poisons with later nursing and midwifery, drug oriented care and then patient oriented care.
Certificate of Dispensing (1880s-1942)
Trainee title: Dispenser-in-training (1880s-1930)
In the colonial era, healthcare systems focused on health provisions for the Europeans who were in the Gold Coast at the time. The indigenous people begun to access public health facilities when the government built the first civil hospital in Accra (1878). As a result, by the early 1880s, individuals with minimum educational background of Standard VII school certificate (Stratmon, 1959) were trained by the government as dispensers to assist medical officers (Bennell, 1982). They were trained in the Accra Hospital for three years through practical training and apprenticeship under medical officers (Stephen Addae, 1997). Courses taught were dispensing and basic nursing. After training, the students were awarded certificate of dispensing and employed by the government as dispensers.
To streamline the practice of persons retailing, dispensing or compounding drugs and poisons, the government enacted the Drugs and Poisons Ordinance No. 14 of 1892. The Ordinance set a precedent for all dispensers to be examined by a Board of Examiners (regulatory body) created under the Ordinance. Candidates for licensure examination were to provide one of the following: (1) ‘a certificate of employment in compounding and dispensing of prescriptions in a colonial hospital in the Colony or any other of Her Majesty’s colonies or dependencies for three years’, (2) ‘a certificate of employment in the compounding and dispensing of prescription as an assistant to a duly qualified medical practitioner, apothecary, or chemist and druggist, for a period of five years’ and (3) ‘satisfactory evidence that for a period of three years preceding the commencement of this Ordinance he has been engaged in the colony in the selling, compounding and dispensing of prescriptions in some house or shop kept by him for the purpose’. Under the Ordinance, a register of all duly examined dispensers was kept and each dispenser issued a licence to practice as a druggist (Governor of the Gold Coast Colony, 1892).
By 1907, there were 18 dispensers and 16 dispenser-in-training in country. Few individuals were trained as dispensers because fewer indigenous people went to school (Stephen Addae, 1997). Additionally, the salary of the dispensers was minimal. In 1900, a senior dispenser was paid about £50 and a newly qualified medical officer paid about £400. This minute salary dissuaded indigenous people from taking up the training. By the early 1910s, some dispensers in government hospitals had left and opened their own drug stores. In 1912, the Medical Department improved conditions of services for dispensers and other supporting staff to attract individuals for training and for them to stay on the job after training (Stephen Addae, 1997).
Governor Clifford in the early 1910s with the support of the principal medical officer Dr Rice, introduced a policy to expand medical service to indigenous people through a dispensary system. Within this context, the government promoted village dispensaries as a cost-effective way to expand healthcare to the indigenous people. Government initiated the process to train more dispensers to operate village dispensaries under the supervision of medical officers and by 1919, there were 23 dispensers in training (Bennell, 1982; Medical Department, 1930a; Stephen Addae, 1997).
To restructure and amplify the training of dispensers, the dispensing school established in the Accra Hospital was moved in 1925 to the Korle Bu Hospital. Teaching was done in the wards, out-patients clinics and in the dispensing department (Bennell, 1982; Korle Bu Hospital, 1973; Stephen Addae, 1997). With the dispensing school in Korle Bu Hospital, suitable candidates with Standard VII certificate were recruited twice yearly at the end of January or July immediately after the Druggists’ examination and were on probation for three years. Dispenser-in-training were not paid for the first 18 months of their programme, but later put on pay roll upon recommendation by their instructors (Medical Department, 1930c).
Under the restructured training for dispensers the curriculum was detailed and extensive. In the first year, there was three months of lectures, reading and progress examinations in anatomy, first aid and surgical nursing; and nine months of ward training. During the ward training, students attended lectures, undertook same duty activities and examinations as nursing students. However, would-be dispensers were trained in anaesthetics. In addition, the matron and resident medical officer sent regular reports on each dispenser-in-training student to the dispenser’s instructor. In the second year, the students were taught elementary chemistry and materia medica - the various drugs in the British Pharmacopoeia i.e. appearance, taste, odour, uses, doses, incompatibilities, mode of preparation, weights, measures, symbols, prescriptions etc. Theory-based courses were supplemented by practical demonstrations in the Pharmacy room, and a progress examination held every week. In the final year, students were taught therapeutics, anaesthetics, and poisons (characters, dangerous doses, symptoms, antidotes and remedial measures) (Medical Department, 1930c). The training equipped the dispensers with knowledge and skills to diagnose and treat specific and common disease conditions such as malaria, diarrhoea and yaws in addition to the roles of dispensing and compounding of drugs (Medical Department, 1930b).
Trainee title: Nurse-dispenser (1931-1939)
By the late 1920s, requests by chiefs (traditional leaders) for dispensaries in their villages had increased and the existing numbers of dispensers were inadequate to meet the demand. Nurses on the other hand, could not adequately manage the village dispensaries because they were untrained in dispensing (Medical Department, 1930b). Therefore, the Secretary of State in 1930 introduced a policy, the “nurse-dispenser” scheme to increase training of officers for the village dispensaries. The scheme had already been implemented in Sierra Leone, another British colony (Medical Department, 1930a). The scheme combined nursing and dispensing to produce individuals to meet the needs of the projected system of village dispensaries. The dispenser-in-training course was therefore, improved to include elementary training in midwifery and sanitation (Medical Department, 1930b, 1930c). The intent of the nurse-dispenser scheme was to train an officer who could not only run a village dispensary but also act as a dispenser in a general hospital as well as a nurse if need be (Medical Department, 1939).
With the nurse-dispenser scheme in place, dispenser-in-training trainee title was abolished, and all prospective dispensers were enlisted as nurse-in-training in the first instance. Standard VII education remained the entry requirement and all students joined as nurses-in-training and spent the whole of the first year in the wards. During the second year, they spent one hour per day in the dispensing school and the reminder of the time in the wards. In the third and fourth years, students alternated between the dispensing school and the wards. At the end of three years, students sat for examination in nursing and when they passed, they were classified as 2nd division nurses. Table 2 summarises the number of students in training at the dispensing school and expected year of qualification as a nurse-dispenser between 1934 and 1938 (Medical Department, 1930b).
Table 2: Number of students and their year of completion under the Nurse-Dispenser Scheme
Year
|
1934
|
1935
|
1936
|
1937
|
1938
|
No. of students qualifying
|
6
|
11
|
7
|
9
|
17
|
As 2nd division nurses, they worked as before by alternating in the wards and in the dispensing school till they sat for the Druggist examination as required by the Druggists Ordinance (Governor of the Gold Coast Colony, 1892; Medical Department, 1939). Students who passed the Druggist examinations were classified as nurses until a dispenser position was vacant in the government hospital or village dispensary (Medical Department, 1930a). To promote males as dispensers (druggists), the grades for chief nurse and 1st division nurse were reserved for females. All senior positions for males above the grade of 2nd division nurse were held by dispensers, but they functioned in the capacity as nurses or dispensers depending on the requirement of the service (Medical Department, 1930a). The distribution of males and females over the different functions were not stated in the documents reviewed. However, estimated requirement for 1934-1935 were gender specific. For example, 50 males and 19 females for the hospital and 20 males and 10 females as staff in training were estimated for the Colony (Medical Department, 1934).
‘In the 1930s and 1940s, brilliant male nurses who were trained as dispensers worked in village dispensaries and some had their own drug stores’ (Former Pharmacy Council Board Chair:14/12/2018).
Certificate of Competency/Diploma (1943- 1960)
Trainee title: Dispenser-in-training (1940-1945)
Under the nurse-dispenser scheme most trained individuals proceeded as druggists, creating a deficiency in the number of practicing nurses. The Medical Department therefore, in 1939 reverted to the old system of recruiting and training nursing and dispensing staff separately. (Medical Department, 1939). In the revised scheme, Cambridge School Certificate (with passes in biological sciences, physics and chemistry) was required for admission in addition to passing an entrance test (Tackie, 1971). Students were trained for three years and awarded a diploma.
The training was revised to include physiology, pharmaceutical technology, practical pharmaceutics and advanced dispensing (i.e. preparation of liniments, granulation and tablet making). However, an aspect of the nurse-dispenser scheme was maintained; qualified dispensers worked in the wards for 6 months as supernumeraries (Medical Department, 1939; Tackie, 1971). A dispenser had to pass the licensure examination under the Druggist Ordinance to practice as a druggist (Governor of the Gold Coast Colony, 1892; Medical Department, 1939).
Trainee title: Pupil Pharmacist (1946-1960)
In 1946, the Drugs and Poisons Ordinance No.14 of 1892 was repealed and replaced with the Pharmacy and Poisons Ordinance No. 21 of 1946 (Ministry of Health, 1946). The regulator - Pharmacy and Poisons Board prescribed courses of instructions for pupil pharmacists and issued certificate of competency to pupil pharmacists who passed licensure examination and had satisfactory evidence of good character (Ministry of Health, 1946). The Pharmacy and Poisons Ordinance introduced the term ‘pharmacist’ and by 1947, all persons registered and licensed under the Druggist Ordinance of 1892 were also designated as pharmacists (Tackie, 1971).
‘The title pharmacist was already used in Britain and its introduction in the Gold Coast uplifted the pharmacy profession’ (Former Pharmacy Council Board Chair:14/12/2018).
In 1951, the dispensing school was relocated to Kumasi to be part of the Kumasi College of Science and Technology as a Pharmacy department (Bennell, 1982; Tackie, 1971). The Pharmacy department subsequently revised the existing pupil pharmacist curriculum. Students were no longer trained in nursing and working in wards for 6 months as supernumeraries was discontinued.
‘When the dispensing school moved to Kumasi all forms of nursing training were stopped and the focus was to align to the training of pharmacists in other settings’ (Former Pharmacy Council Board Chair: 3/12/2018).
By the early 1950s government had to train male nurses or pharmacists as clinical superintendents to ran the village dispensaries (now health centres) under the supervision of district medical officers to fill the gap that the cancellation of the nurse-dispenser scheme had created (Stephen Addae, 1997). In 1950, only 22 out of over 100 village dispensaries were run by pharmacists. Over time, the role of pharmacists in clinical service delivery reduced and their role as a dispenser-nurse disappeared from the 1960 National Health Development Plan (Ghana gained independence in 1957) (Stephen Addae, 1997). Additionally, the Medical and Dental Act, 1959 (No. 36) restricted the right to practice medicine or dentistry and to recover charges to only medical professionals (Government of Ghana, 1959). Therefore, pharmacists were legally unable to operate the village dispensaries. However, pharmacists were allowed by the Pharmacy and Drugs Act, 1961 (64) ‘to give medical or dental advise or aid by way of first aid in the case of accidents; or by way of first treatment in the case of simple ailments of common occurrence where it is not reasonably practicable for the patient to consult a medical practitioner or dentist, as the case may be’ (Government of Ghana, 1961).
Bachelor of pharmacy degree (1961-2017)
In 1960, the Kumasi College of Science and Technology gained a university status as the University of Science and Technology and this gave way to a four-year degree course in pharmacy and the award of a Bachelor of pharmacy degree (Bennell, 1982; Tackie, 1971). A pass in Advance Level Certificate chemistry, physics, biology, mathematics and general paper was a requirement for entry. The existing diploma curriculum was revised, and the degree course aligned to what pertained to the training of pharmacists in the United Kingdom. The course included pharmaceutical sciences, pharmaceutics, microbiology, pharmaceutical chemistry, pharmacology and pharmacognosy. These courses were offered at different stages during the four-year programme and the students were trained to be experts and advisers on drugs (Tackie, 1971). Upon completion of the degree course, students undertook practical training (internship) as stipulated by the Pharmacy and Drugs Act, 1961 to qualify for a licensure examination (Government of Ghana, 1961).
‘In 1963 the certificate of competency/diploma was cancelled in the University of Science and Technology’ (Former Pharmacy Council Board Chair: 3/12/2018).
Individuals with certificate of competency issued under the Pharmacy and Poisons Ordinance (Ministry of Health, 1946) or licensed and registered under the Druggists Ordinance (Governor of the Gold Coast Colony, 1892) were allowed to practice as pharmacists under the Pharmacy and Drugs Act 64 (Government of Ghana, 1961). In 1994 when the Pharmacy and Drugs Act 64 was repealed and the Pharmacy Act 489 enacted, a degree in pharmacy became the required qualification for licensure examination (Government of Ghana, 1994). Overtime, the number of newly registered pharmacists increased as the number of students intake increased. Table 3 lists the number of newly registered pharmacists per year from 1962 to 1999.
By the early 2000s, the courses were revised, and the curriculum included pharmaceutical chemistry, physiology, biochemistry, pharmaceutics, microbiology, chemical pathology, pharmacology, applied therapeutics and pharmacy practice to meet national and international expectations and demand. Though training of pharmacists as experts on drugs and less emphasis on clinical experiential learning still persisted, the Ghanaian healthcare system and the general public demanded more clinical expertise from pharmacists (Duwiejua et al., 2004) thus demanding some elements of the 1930 nurse-dispenser scheme.
Additionally, there was a global drive to upgrade education of pharmacists and train patient-oriented pharmacists. A World Health Organization (WHO) meeting on revision of undergraduate pharmacy curricula held in Nyanga, Zimbabwe (18-20 April 1997) recommended focus on patient-oriented pharmacy practice by introducing courses such as hospital pharmacy, community pharmacy, clinical pharmacy and pharmaceutical care (World Health Organization, 1998). The Faculty of Pharmacy therefore in October 2001 established a department of Clinical and Social Pharmacy to introduce courses in clinical pharmacy, social pharmacy and public health patient-oriented practice. From June 2003 students in their third year started rotations at various health care facilities for experiential learning (Duwiejua et al., 2004). The duration of training remained four years with a strong drive towards the teaching of pharmacy practice.
The University of Science and Technology now Kwame Nkrumah University of Science and Technology (KNUST) was the only public university in Ghana awarding a degree in Pharmacy, until 2007 when the School of Pharmacy in University of Ghana (UG) was established as well as a private school of pharmacy (Central University). The number of registered pharmacists increased gradually over the years. Table 4 summarizes the number of newly registered pharmacists per year from 2000 to 2010.
Doctor of Pharmacy (2012 to date)
‘Pharmacy education had evolved globally with countries such as the USA, Algeria, Thailand and Nigeria training PharmD students and there was the need to upgrade’ (UG School of Pharmacy former Dean: 30/03/2019).
‘Nationally, there were increased demands for patient-oriented pharmacists with skills for patient care needs’ (Pharmaceutical Society of Ghana past President: 18/04/2019).
With the early revisions in the BPharm curriculum by pharmacist educators towards clinical and pharmacy practice courses, the introduction of PharmD was a move towards addressing this need while expanding the role of the pharmacists in the Ghanaian healthcare system. An additional driver for the transition from BPharm to PharmD was the resolve of the Economic Community of West African States (ECOWAS) ministers of Health, through its agency the West Africa Health Organization (WAHO) to remove disparities in content and harmonise health training in the region to facilitate movement and sharing of health personnel across the region. This was seen as a solution to the brain drain and shortages in health workforce within the region. Having agreed that the four year Bachelor of Pharmacy degree could not adequately accomododate the new competencies required of pharmacists in the region. The deans of Pharmacy opted for the six years Doctor of Pharmacy Programme. This decision was also more acceptable to the francophone countries as they were already operating a structure that could not be implemented in a programme with a shorter duration.
After several consultation among pharmacist educators, the pharmaceutical society of Ghana and regulators (Pharmacy Council, the National Council for Tertiary Education and the National Accreditation Board), the KNUST started a 6-year course to award a Doctor of pharmacy degree in 2012. This was followed by the schools of Pharmacy in the University of Health and Allied Sciences (2017), University of Ghana (2018), University of Development Studies (2018), Central University (2018), and Entrance University College (2018). The minimum entry requirement is a pass in chemistry, biology either physics or elective mathematics from any of these acceptable qualification: West Africa Senior Secondary Certificate Examination (WASSCE), Combined International General Certificate of Secondary Education (IGCSE), Cambridge Advanced Level, International Baccalaureate, General Certificate of Education (GCE), American Grades 12 and 13 examinations and other equivalent external qualifications (University of Ghana, 2020).
PharmD students are trained in basic biomedical, pharmaceutical sciences and pharmacy practice courses and further exposed to longer experiential learning opportunities in both clinical and non-clinical settings. In the first 4 years, students are required to complete 480 hours of introductory professional practice in settings such as the community, hospital, industry and regulation (University of Ghana, 2018). In the final year, students undertake the advance professional practice experiences (APPE) to exposed them to extensive and specialized practical experiences in clinical, hospital, community, regulatory and management as well as industrial pharmacy (University of Ghana, 2018). A degree in pharmacy is a requirement for licensure examination, therefore both BPharm and PharmD are currently acceptable. The Pharmacy Council is yet to make PharmD the only registrable qualification for licensure (Government of Ghana, 2013). The number of registered pharmacists per year increased over the period as numbers of training institutions increased. Table 5 lists the number of newly registered pharmacists from 2011 to September 2020.
Different policy actors and varied contextual factors had over the years influenced pharmacy education and practice in Ghana from the 1880s to 2017. Table 5 summarizes the policy actors and contextual factors serving as drivers and barriers and the changes made to pharmacy education and practice over time. Pharmacy practice regulation also evolved over the period with commensurate provisions for practice. Figure 1 presents historical timeline of pharmacy education and accompanying legislations for practice.