Fit-for-purpose pharmacy workforce development in the lower middle-income country context: a mixed methods study of Nigeria

Background The global challenge of inefficient workforce development is not equally experienced. Low and Lower-Middle Income Countries (LMICs) often have the lowest health workforce capacity yet the highest burden of disease. Pharmacists, the most accessible healthcare professionals in many LMICs, are few in number and often ill-prepared for their roles. A discrepancy between acquired and required skills are among several other challenges which continue to undermine both national health status in LMICs, as well as efforts towards the achievement of global health goals. While several studies highlight this imbalance as a major contributory factor to the poor health status in LMICs, little empiric research explores this phenomenon or identifies possible ways to address it. Aim This three-phase mixed methods study aimed to identify key domains for fit-for-purpose pharmacy workforce development in Nigeria, taking into account concerns and priorities, and hinged on stakeholder engagement to enhance an understanding of pharmacy workforce development as well as ensuring shared ownership for decisions. The first objective was to determine the current status of pharmacy workforce development in Nigeria from stakeholder perspectives, the second to identify key domains for needs-based workforce development in the LMIC context. The third objective was to highlight major barriers and facilitators to workforce development and to the proposed programme change, and the fourth to determine local and global compliance of the Nigerian pharmacy programmes. This was done by comparing the standard Basic Minimum Academic Standard (BMAS) for both programmes with a drafted composite of both locally determined and global standards. Methods Fieldwork involved both individual and group interviews with pharmacy education stakeholders in the first phase: education regulators, educators, students, interns, employers of pharmaceutical labour and pharmacists in various sectors of practice, across all geopolitical zones of the country. In the second phase, themes from stakeholder’s qualitative responses were used to develop a survey, and descriptively analysed to determine the strength and national breadth of opinions. Finally, documentary analysis complemented qualitative and quantitative results. Results Most stakeholders in academic and regulatory leadership cadres had largely positive opinions, while stakeholders in other areas of practice, pharmacists in lower cadres, employers and students had mostly neutral to negative views about the current status of pharmacy workforce development in Nigeria. Hence, views depended on demographics: the cadre, sector of practice and geopolitical zones of stakeholders in question. Throughout the study, three domains were identified: Education Capacity, Professional Relevance, and Systems Efficiency. Participants described a fit-for-purpose programme as one which meets global as well as local standards, assures and maintains these standards, prepares pharmacy students for current and future practice experiences, ensures professional recognition within an enabling environment, maximizes outcomes given available resources through equitable and efficient management, and ensures that these are fairly and impartially experienced across the country. This description was in line with global recommendations for a fit-for-purpose pharmacy programme. For stakeholders, the major barrier to a clinically focused patient-centred pharmacy programme was medical doctors’ resistance. Other barriers included poor funding worsened by corruption, leading to poor infrastructure, poor research output, poor remuneration of staff, plus other barriers and system issues. Most barriers described were socio-economic. I therefore argue that since the education sector may not rise above economic and social boundaries imposed on it, rather than attempting to solve individual problems, a systems-approach towards handling issues may lead to much needed holistic change. Some facilitators identified included a general stakeholder interest in pharmacy education improvement, and specialist training for educators being held in collaboration with American clinical pharmacists in preparation for the PharmD, an initiative which provided an uncommon improvement opportunity if appropriately implemented. Qualitative content analysis revealed a 72% match with composite standards (36 codes out of 50), and 86% match (24 codes out of 28) with curricular components. Few domains not coded by BMAS included student support, evidence-based care, social determinants of health, patient safety, policy and implementation, collaboration and teamwork, prudence and resource efficiency, specialization, research intensity, professional recognition and role specificity. Despite these discrepancies, the 72% and 86% match for standards and curricular components respectively, showed that both global and local recommendations had been taken into consideration in the development of the BMAS. The challenges of workforce development in Nigeria therefore would likely not be due to deficient recommendations or standards but non-implementation of available ones. Conclusion Stakeholders were in consensus about the need for improved workforce development in Nigeria. This would involve a fit-for-purpose pharmacy programme according to participants’ description above, as well as a commitment to life-long learning. Identified barriers would also need to be surmounted and facilitators harnessed to ensure sustainability of such a programme, as well as a focus on collaborative partnerships between education and practice in the implementation of available local and global standards. Adopting recommendations for a programme training fit-for-purpose pharmacists, based on study findings, could mean giant steps towards addressing education-practice mismatch, which could improve the national health status, and ultimately contribute to the achievement of global health goals