Selling Drugs or Providing Health Care? : The role of private pharmacies and drugstores, examples from Zimbabwe and Tanzania

Abstract: Background: In low-income countries many people do not have access to formal health care because of poverty and weak health systems. Instead people seek care at private pharmacies and drugstores. Infectious diseases such as sexually transmitted infections (STI) and diarrhoea are common and access to correct management is of big importance. Assessing the quality and finding the potential for improvement of private pharmacy and drugstore practice is therefore of uttermost importance for public health. Main objective: To explore and describe the role of private pharmacies and drugstores in resourcelimited settings with a focus on antibiotics in Zimbabwe and Tanzania. Methods: Semi-structured interviews with pharmacists from nine African countries were analysed with a phenomenographic approach (I). Structured facility and staff interviews and the simulated client method (SCM) were used in private pharmacies in four Zimbabwean towns. The simulated clients presented a male and a female STI case and a child-with-acute-diarrhoea case. Statistical analysis was applied and step models were developed (II). Drugsellers in private drugstores in eight Tanzanian districts were interviewed. The SCM was used presenting a male and a female STI case. Data were analysed statistically and QATI scores were developed (III). Exit-customers of private drugstores in eight Tanzanian districts were interviewed. Drugsellers from three Tanzanian districts filled in a questionnaire with closed and open-ended questions. Mixed qualitative and quantitative analysis (IV). Results: Four different ways of perceiving the role of the pharmacist were identified: the satisfied dispenser; the dissatisfied dispenser; the health care team member and the life saver (I). A majority (69%) of the staff in the Zimbabwean pharmacies stated they would never sell an antibiotic without prescription and few actually did so, in spite of a high customer demand. Not many provided acceptable information and advice: 8% STI male, 33% STI female and 22% for the diarrhoea case (II). Although 74% of the Tanzanian drugsellers claimed there were no STI-related drugs in the store, drugs were dispensed in a majority of the SCM visits. In 80% of the male SCM visits and in 90% of the female, the client was dispensed drugs that are recommended in the Tanzanian guidelines for syndromic management of urethral and vaginal discharge syndromes. Dosage regimens were however often incorrect and complete syndromic management rarely provided. In 76% of the male SCM visits and 35% of the female, antibiotics were dispensed (III). Antibiotics were bought by 24% of the exitcustomers. Dispensed drugs were assessed to be relevant for the symptoms/disease presented in 83% of all cases and in 51% for antibiotics specifically. Thirty percent had seen a health worker before coming and almost all of these had a prescription. Non-prescribed drugs were more relevant than prescribed drugs. Of the drugsellers, 79% stated that bacterial diseases can be treated with antibiotics, of these, 24% stated the same for viral disease. Most (72%) had heard of antibiotic resistance. They described antibiotic resistance and how it occurs quite rationally from a biomedical point of view but also presented less plausible descriptions of the topics (IV). Conclusion: There is a potential to use private pharmacies and drugstores in a more formal way for the benefit of health in the low-income settings studied. Drugsellers have considerable practicalknowledge of antibiotics and other drugs. Current regulations might impede them from playing a more important role as well as improving their practice.