Nothing has changed at government health facilities weeks after the Minister of Health, Dr. Edwin Dikoloti, attempted to have nurses and midwives register to dispense medication.
After a long battle to get the Ministry of Health to relieve nurses and midwives of this duty, the Botswana Nurses Union (BONU) upped the ante by announcing, on June 30 this year, that beginning July 1, these health professionals will no longer dispense medication as has been the case since independence in 1966.
“This is in line with the Medicines and Related Substances Act, 2013 which prohibits anyone to operate a dispensary or pharmacy without a license from the relevant authority,” reads a statement that was put out by BONU’s National Publicity Secretary, Kenosi Mogorosi.
The statement called upon all “all stakeholders and public to support BONU in this to ensure patient safety and quality services as per the laws of Botswana.”
BONU’s statement followed an emergency meeting on the dispensing of medicines by nurses and midwives that was held on that same day between senior Ministry officials and trade union leaders at the Ministry headquarters in Gaborone. After another round of failed talks with the Union leadership, the Director of Health Services, Dr. Pamela Smith-Lawrence, issued a notice “authorising” the two health professional cadres “to dispense medicines in accordance with enabling the legislations.” Likewise and after ransacking the law, Dikoloti promulgated guidelines on the prescribing and dispensing of medicines. As he states, the purpose of the guidelines is “to provide the process of application and authorisation as per the applicable statutory provisions to practitioners other than medical doctors and pharmacists for prescribing and dispensing human medicines, in order to ensure timely access to treatment and care without compromising medication safety.” The latter assurance was certainly meant to counter the assertion made in BONU’s statement about patient safety.
Obviously acting on the basis of legal advice that he got from government lawyers, the minister’s guidelines are based on what Section 26 and Section 39 of the Medicines and Related Substances Act as well as Regulation 46 of Medicines and Related Substances Regulations stipulate.
Section 26 states that no person shall practise as a pharmacist or operate a pharmacy or dispensary on any premises unless such person has applied for and been issued with a licence to dispense medication from such premises – which have to continuously supervised by a pharmacist. A pharmacy is a store where medicinal drugs are dispensed and sold while a dispensary is a room where medicines are prepared and provided. This provision also empowers the Director of Health Services to authorise, in writing, those who can give out medication at a dispensary.
Section 39 states that acting in consultation with the Director of Health Services, the minister may authorise limited powers of prescription of medicines to pharmacists, nurses, para-professionals and other health personnel through issuing relevant regulations.
Regulation 46 says that a healthcare provider shall apply to the Director of Health Services for approval to dispense medicines and that such approval should be given on condition that such provider has competency in dispensing medication.
Seeking to cover all bases, the guidelines that Dikoloti has issued say that nurses are “eligible to prescribe medicines within their scope of practice” and that applications to do so shall be made to the Director.
BONU contests Dikoloti’s understanding of the law and through its lawyers, Bogopa, Manewe, Tobedza & Co., has written the Ministry a cease-and-desist letter. At the time the letter was written (July 6, 2023), some Ministry officials had reportedly been “intimidating and threatening” nurses who had stopped dispensing medication. On D-day itself (July 1), BONU’s Acting Secretary, Atang Thake, notified all regional and branch secretaries through a “Dear Comrades” letter that the union leadership had learnt that “some managers” who are part of District Health Management Teams and others at the Ministry headquarters, were forcing nurses and midwives to dispense medication despite the fact that such action would be against the law.
“Should any nurses or midwives find themselves in this situation, they are advised to report to BONU and necessary action will be taken, including reporting to the police,” Thake wrote in the latter.
The lawyers’ letter threatened to seek a court order that would declare that “nurses are by law, prohibited from duties of dispensing medicines”, that in directing them to do otherwise would be unlawful and that “the Ministry of Health is complicit in committing a crime.” Not only did the Ministry cease and desist, it also embarked on a large-scale (and unbudgeted-for) process to recruit 530 pharmacists. The latter action would suggest that contrary to assertions that Dikoloti made, the ministry doesn’t actually believe that it is on firm legal ground. Indeed Dikoloti’s guidelines clearly show that.
Nowhere in the 18 –page document does the minister explicitly instruct nurses and midwives to apply for authority to dispense medication. Most instructive in that regard is a heading highlighting of “wishing” in upper case letters: “For health professionals WISHING to be entered into the Director of Health Services Register for Dispensing.” The guidelines, which contain a sample application form, also state that “incomplete forms will not be processed” – which raises the possibility of a nurse or midwife not wishing to dispense medication deliberately leaving some sections blank.
BONU’s own understanding is that applying to be registered to dispense medication is discretionary. In another statement that BONU put out after both the Minister’s guidelines and the Director of Health Services’ notice were published, BONU alerted its members to the fact that “the notice by the Director of Health Services does not direct any Nurse and Midwife to dispense any medication.” Resultantly, nurses are not registering to discharge this task.
Interestingly, the Ministry has had more than a decade to resolve this matter. In 2010, then Permanent Secretary in the Ministry of Health, Dr. Kolaatamo Malefho, and trade union representatives agreed to undertake “an exercise of defining nursing duties so that ‘non-nursing’ duties are further clarified.”
Thereafter, a technical working team consisting of ministry officials as well as union representatives was established. The team was tasked “to look at the issue of nursing versus non-nursing duties.” That process tangentially led to a consultancy that was undertaken by Nelouise Geyer, the CEO Nursing Education Association in South Africa. In her report, Geyer noted that not only are the tasks of prescribing and dispensing not provided for in the education and training programme for Botswana nurses and midwives, there is also “lack of pharmacology content in the programme, which is a requirement to safely prescribe and dispense medication.”
