Pharmacies and Drug Shops: Expanding contraceptive choice and access in the private sector
Expanding access to contraceptive methods through the private sector and community-based sources—which includes task sharing—is an important strategy to help achieve national family planning and development goals and, in particular, aims to reduce barriers to access for youth, lower-income, and other marginalized groups. Private sector pharmacies and drug shops are often the first line of health care in low- and middle-income countries, particularly for many underserved populations and especially in rural areas that have very few private or public clinics.3,4 While there are differences between pharmacies and drug shops (see box), there are also common issues around implementation and impact. For both, training and support can improve and expand the range and quality of services they offer and thereby increase access and choice for women.
Pharmacies: Retail facilities that sell both prescription and over-the-counter medicines and are overseen by licensed pharmacists.
Drug shops: “Lower-tier retail outlets, with no pharmacist on staff, that sell over-the-counter drugs, chemical products and household remedies” (also known as licensed chemical sellers, chemist, patent and proprietary medicine vendors, accredited drug distribution outlets, etc.)2
Pharmacies are generally larger than drug shops, are staffed by a licensed pharmacist, and carry a wider range of products.5 Like pharmacies, many drug shops also sell over-the-counter family planning methods, especially condoms, oral contraceptives, and emergency contraception. Drug shops typically have storefronts, product displays, and a counter. Many have a small room in the back, separated by a curtain or door, for examinations and treatment. The owners of these shops may or may not have some type of retail license, and frontline staff may or may not have family planning training, or health accreditation such as training as a nurse, nursing assistant, pharmacy assistant, or traditional medicine practitioner.
Pharmacies and drug shops, with their convenience, anonymity, and cost savings (compared to private physicians), are an essential source of health services, products, and information that is particularly important in the context of “high maternal mortality and morbidity, poorly stocked clinics, high unmet need for family planning” and critical health-worker shortages.4 In recent years, drug shops and pharmacies have been recognized in many countries for their potential to improve health across a wide area of diseases and health issues.6,7 Despite their popularity and potential, pharmacies and drug shops have often not been considered part of the larger health system; they are typically missing from countries’ health strategies, policies and regulation, and monitoring. A regulatory scan of 32 countries found that there has been more official recognition for drug retail outlets in recent years (e.g., in the form of licensure), with increasing awareness that these sources are responsible for a substantial share of modern family planning services.2
Evidence shows that with training and support, pharmacy and drug shop staff can facilitate the use of a broad range of modern contraception, especially in areas where the unmet need is high, access to family planning services is poor, and health worker shortages and other barriers prevent women, men, and youth from accessing family planning services. Access to contraceptives through pharmacies and drug shops can also be critical during emergency situations when there is added stress on the health care system and restricted mobility for many people. This brief describes the importance of these outlets for providing commodities and information, and outlines key issues for planning and implementing programs to support pharmacy and drug shop staff. While many pharmacies and drug shops already provide family planning, this high-impact practice focuses on how to strengthen and improve these services and their impact (Figure 1).
Theory of Change
Why is this practice important?
Pharmacy and drug shop staff advise clients and treat a variety of ailments in many countries, providing an opportunity to reach existing and potential family planning clients. For decades, people have routinely used drug shops and pharmacies for treatment of common ailments. Studies in Thailand,8 Nigeria,9 Indonesia,10 and Uganda10 confirm that pharmacies are primary sources when people are ill and need outpatient treatment or drugs. In some countries, drug shops are just as important, if not more so.11,12 Both pharmacies and drug shops are particularly important in countries where health system infrastructure is weak, overburdened, poorly distributed, or understaffed. Training and support for pharmacy and drug shop staff can strengthen these widely used services to ensure that users receive quality services.
Besides providing information on family planning, pharmacy and drug shop staff can safely provide a wide range of methods. Drug sellers are a major source of short-acting reversible contraception13 and an important outlet for affordable socially marketed products.
- Pharmacies and drug shops are a common source of supply for condoms in many countries (Nguyen et al., 2011).14 Female condoms are also an appropriate method for distribution at drug shops15 and a study in Nigeria found that both male and female condoms were mostly procured from patent medicine dealers and pharmacy shops.16 However, there is still generally low knowledge and use of female condoms, as well as more limited access (Ananga et al., 2017).17
- Pharmacies and drug shops are the main source for obtaining oral contraceptives (OCs) and emergency contraception (EC) in many countries.18 For example, in Ghana, 94% of EC users indicated buying it at a pharmacy or drug store.19 Studies in Tanzania and Nepal demonstrated that women obtaining contraceptives at pharmacies were able to self-screen for contraindications to combined OCs as well as nurses.20,21 Training and sensitization around EC is particularly important to update knowledge and dispel misconceptions among pharmacy and drug shop staff. In India, training led to improvements in knowledge, attitudes, and dispensing practices of EC among pharmacists in terms of correct dosage and when to take EC.22
- A significant proportion of women rely on pharmacies and drug shops for injectable contraception, including both through intramuscular (IM) and subcutaneous (SC) administration. Half of the drug shops in a study from Nigeria and Uganda had administered injectables before the training, demonstrating a demand for injectable contraceptive services from these providers.23 In Bangladesh, the Blue Star program, a social franchise network of private sector providers, demonstrated that, when trained and supported, drug shop staff can safely and effectively provide high-quality family planning services, including injectable contraceptives, and many clients preferred the option of obtaining DMPA from local drug shops.24
Drug shops, in particular, remove barriers to family planning access in underserved areas. Doctors and pharmacies are usually concentrated in urban areas.25,26 In countries where drug shops are permitted, they are usually more common than pharmacies, which can reduce travel and distance barriers. Studies show that clients often find private providers, such as drug shop operators, more acceptable than public sector clinics.27,28 Pharmacies and drug shops offer clients proximity, expediency, flexibility in operating hours, and responsiveness to the client’s needs compared to public sector clinics.29
Supporting and strengthening pharmacies and drug shops is an effective way to complement the public sector and expand the impact of a health system. The World Health Organization (WHO) global guidelines on task sharing include operators of retail outlets such as pharmacies and drug shops as important cadres to be part of task-sharing efforts for contraceptive services. This can help to alleviate the burden on the public sector and expand access to services.30 Implementing these guidelines requires policy change, which has happened in a number of countries. For example, in February 2020 the Minister of Health in Rwanda approved a change in policy that would allow the administration of injectable contraceptives by private community pharmacists, and in 2018 the National Drug Authority in Uganda allowed licensed and accredited private drug shops to stock and administer injectable contraception. Pharmacies and drug shops can also play an important role as a bridge to self-care practices—an area receiving growing attention as a way to improve health and well-being and contribute to universal health coverage.31 Recommendations for family planning in the WHO self-care guidance include making oral contraceptives available over-the-counter without a prescription and making self-administered injectable contraception available.
What is the impact?
ACCESS: Pharmacies and drug shops are an important source of supply for a range of contraceptives in many countries.
Pharmacies and drug shops were a large source of contraception in the majority of countries with a modern contraceptive prevalence rate (mCPR) of less than 20%, with use of these sources highest in Nigeria, Cote d’Ivoire, the Democratic Republic of Congo, and Cameroon, where more than 40% of women obtained their contraceptive from a pharmacy or drug shop.32 In many countries, around half of pill users and as many as 80% or more of condom users obtained their methods at pharmacies or drug shops, with a growing proportion of injectable users also using these sources (Figure 2). Pharmacies and drug shops were the main source for emergency contraception, oral contraceptive pills, and condoms in urban Nigeria and Kenya.5 A study in Uganda found that “almost half of the drug shop clients had switched from other providers, primarily from government health clinics, mostly as a result of more convenient locations, shorter waiting times, and fewer stock-outs in drug shops.”3 Social marketing programs in Africa and elsewhere enable contraceptive users to access pills, condoms, and injectable contraceptives from pharmacies and drug shops.
ACCESS: Pharmacies and drug shops are popular for short-acting contraceptive users, including hard-to-reach or underserved populations, such as unmarried women, males, and youth, due to convenience, cost, and confidentiality.
- Hard-to-reach populations in urban Kenya and Nigeria were the most likely to choose these outlets over public-health sector health facilities to obtain their short-acting methods.5 Young women (often single), who may be stigmatized in traditional family planning outlets, constitute a majority of the women who source their contraception in drug shops and pharmacies in countries with a low modern contraceptive prevalence rate.29,32
- Drug shops are convenient for men and boys who may be less willing to go to clinics or pharmacies, especially if they have to travel longer distances. Generally, men do not attend public clinics to obtain family planning information or condoms, or to accompany partners for antenatal/child health care. Family planning clinics have traditionally focused their services in provision and counseling of modern contraceptive methods on women (Maharaj, 2001).33 Those clinics, partly due to the limited number of male-centered contraceptive methods, have not sufficiently engaged male participation in family planning counseling.34,35 Men in India indicated that pharmacies are their primary source for obtaining condoms,36 and men in urban Nigeria and Kenya reported that they obtained most condoms from a pharmacy or drug shop.5
- In countries with low mCPR countries (mCPR < 20%), “over one-third of pharmacy and drug shop clients are youth.”32 In Nigeria, younger women (<25 years old) who use short-acting methods were significantly more likely to obtain their method from a pharmacy or drug shop than another type of facility.5 Youth cited convenience as a major draw of pharmacies, specifically their longer operating hours, accessible locations, and ease of family planning commodity access.37 In Delhi, a survey of pharmacists providing EC found one-third of the clients were adolescents.38
QUALITY: Training and support improve the quality of family planning services offered by pharmacies and drug shops, thereby improving client satisfaction.
With training and supportive supervision, pharmacy and drug shop staff generally provide family planning services safely, reliably, and with greater client satisfaction. A 2009 literature review of interventions to improve the quality of services provided by drug shop operators in sub-Saharan Africa found that training can improve their knowledge and practices, as well as their counseling of patients.39 Studies have shown that, after appropriate training, drug shops are more likely to use sharps disposal boxes40,41; give information on side effects of EC42; and make referrals to facilities.43 The majority of clients in a study in Nigeria reported receiving high-quality counseling with injections from drug shops and discontinuation rates were not due to the provider.40 Take-home brochures for clients and job aids for drug shop staff, such as screening and standard procedure checklists, can further improve the quality of services and information. In Nigeria, patent and proprietary medicine vendors (PPMVs)* who used at least two family planning job aids were more likely to have injectable contraceptive knowledge nine months after training compared to those who used one or no job aids.41
Social franchising and social marketing have helped expand the role of private sector pharmacies and drug shops in increasing access to a range of contraceptives, and also play a role in improving skills and quality.44 As important outlets for socially marketed products, pharmacies and drug shops benefit from the follow-up provided by these programs. For example, as part of the Goli ke Hamjoli (Friends of the Pill) campaign in India, project staff followed up on training of pharmacists with periodic detailing visits to refresh knowledge and share point-of-sale materials leading to increased knowledge among staff and increased uptake of oral contraceptives.45 For more information, see the Social Marketing and Social Franchising HIP briefs.
*In Nigeria, PPMVs are persons without formal training in pharmacy who sell pharmaceutical products on a retail basis for profit.
How to do it: Tips from implementation experience
Programmatic experience indicates that the following strategies can help support pharmacies and drug shops in strengthening their provision of a variety of family planning methods and information. A first step is understanding the specific context/enabling environment of a country and planning programmatic and policy interventions accordingly (Table 1).
- Know the legal, regulatory, and policy environment. Efforts to expand the role of pharmacies and drug shops should consider whether country policies and regulations are supportive and adequate for expanding access to family planning information and products.
- Are shops registered and operating legally?
- How is the quality of medicines or services provided by these shops monitored, and is there regulatory capacity?
- Which contraceptive methods can shops legally sell?
Technical assistance can be organized to offer evidence-based advocacy for changes in policy related to the sale of family planning methods through these outlets, and to support training and accreditation.
- Strategically support advocacy to address policy barriers. Evidence-based advocacy can support changes in policy related to the sale of family planning methods through pharmacies and drug shops, and to support training, accreditation, and regulation. Lessons from successful advocacy include the need to generate and disseminate evidence, meaningfully engage stakeholders, and link to global rationales.46
- Provide drug shop and pharmacy staff training and support on the family planning methods they offer, including promotional materials for clients and job aids for staff to improve quality of services. Training should be high quality, interactive, and customized to the learners’ needs. Because pharmacy and drug shop staff often work long hours and can be reticent to attend training sessions, training courses should be as brief as possible at convenient hours, such as in the evening. Trainings should also include mechanisms for trainees to share information with their colleagues, such as providing handouts to take back or talking points to share. Incorporating proven job aids into routine trainings is a low-cost strategy that can reinforce knowledge and help PPMVs to retain information.41 In social marketing programs, product inserts and other client materials will likely be provided by the distributor. There are also opportunities through digital health initiatives for post-training support to pharmacy and drug shop staff to respond to questions.
- Promote simple and clear processes for licensing pharmacies and drug shops.. These processes are often defined by the drug regulatory authorities, the pharmacists’ association, or a similar association. It is important to work with national authorities to seek their input into successful strategies for engagement, continuing education, and monitoring.
- Formalize and strengthen the linkages between pharmacies and drug shops and the larger health system. Pharmacies and drug shops are often overlooked in program design.32 Globally and nationally, efforts should be made to include pharmacy and drug shop provision into family planning guidance, such as service delivery guidelines. Dedicated private sector data collection tools might be needed to better include data from pharmacies and drug shops in national systems (Bunyi, 2018).47 Locally, pharmacy and drug shop staff should be comfortable referring clients to higher level clinical services and should be knowledgeable about what services are available and where. When health systems get overwhelmed during emergency situations, pharmacies and drug shops can play a key role in continuing to provide family planning methods.
- Create a quality assurance or oversight system. Quality assurance systems are desirable for providing ongoing support to drug shop and pharmacy staff, and can ensure periodic reviews, including use of regular monitoring data. Minimum quality standards, such as those adopted by the Accredited Drug Dispensing Outlets (ADDO) program in Tanzania,48 can be used to maintain standards for:
- Staff training and continuing education
- Drug/product availability
- Stock control, safe handling and storage, and record-keeping
- Sanitation and hygiene of the premises and personnel
- Shop location and building design/layout (privacy)
- Strengthen pharmacy and drug shop business practices, such as pricing, financing, and supply management, to improve sustainability of services. Profit incentives appear to have some influence on the success of interventions to improve the quality of services provided by drug shops in sub-Saharan Africa.39 Market forces will typically determine pricing, but training should also provide support to pharmacy and drug shop staff to identify the best way to price their products. In addition, pharmacies and drug shops can experience stockouts due to limited working capital to purchase supplies, indicating a need to improve financing options for these facilities.49 Promoting the stocking of generic products can potentially increase cost-efficiency (Sharma et al., 2020).50 Including pharmacies and drug shops in community health insurance schemes can also help reduce access barriers due to cost.
The following indicators are recommended for measuring implementation of the HIP, with programs needing to select appropriate indicators depending on availability of routine data. Programs could try to disaggregate pharmacies and drug shops, if possible with available data.
- % of pharmacies and drug shops providing family planning services, including at least three modern methods. The methods should be specific to the country or area where the practice is being implemented.
- % of pharmacies and drug shops with staff members trained in family planning
- % of women/men who received their last method from a pharmacy or drug shop
Drug Shop Operators Family Planning Curriculum (Uganda 2018) https://toolkits.knowledgesuccess.org/toolkits/cba2i/drug-shop-provision-family-planning
Toolkit: Expanding Access to Injectable Contraception through Pharmacies (SHOPS PLUS). https://www.shopsplusproject.org/resource-center/toolkit-expanding-access-injectable-contraceptives-through-pharmacies
Private Sector Counts (https://www.privatesectorcounts.org/) and FP Market Analyzer (http://fpmarketanalyzer.org/), two tools from SHOPS PLUS to understand where women access contraception and help with data visualization to inform advocacy
Priority Research Questions
- What kinds of training, supportive supervision, or other interventions work best to improve family planning knowledge and practice among pharmacy and drug shop staff?
- What are the best ways to facilitate effective referrals?
- What are the key issues around supply chain management to ensure a consistent supply of quality-assured products for pharmacies and drug shops?
- What are family planning consumers’ preferences regarding accessing pharmacies and drug shops?
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High Impact Practices in Family Planning (HIPs). Pharmacies and Drug Shops: Expanding contraceptive choice and access in the private sector. Washington, DC: HIPs Partnership; 2021 Aug. Available from: https://www. fphighimpactpractices.org/briefs/drug-shops-and-pharmacies/
This brief was written by: Sara Chace Dwyer (Population Council), Katy Footman (MSI), Sameh Madian (DKT), Tracy Orr (FHI 360), Laura Raney (FP2030), Vinit Sharma (UNFPA), John Stanback (FHI 360), and Julie Solo. It was updated from a previous version, available here.
This brief was reviewed and approved by the HIP Technical Advisory Group. In addition, the following individuals and organizations provided critical review and helpful comments: Mozzam Ali (WHO), Sean Calahan (Abt Associate), Jill Chanley (Population Reference Bureau), Mohammad Eslami, Rebecca Husband (PSI), Shawn Malarcher (USAID), and Tanvi Pandit-Rajani (John Snow Inc.).
The World Health Organization/Department of Sexual and Reproductive Health and Research has contributed to the development of the technical content of HIP briefs, which are viewed as summaries of evidence and field experience. It is intended that these briefs be used in conjunction with WHO Family Planning Tools and Guidelines: https://www.who.int/ health-topics/contraception.
The HIP Partnership is a diverse and results-oriented partnership encompassing a wide range of stakeholders and experts. As such, the information in HIP materials does not necessarily reflect the views of each co-sponsor or partner organization.
To engage with the HIPs please go to: https://www. fphighimpactpractices.org/engage-with-the-hips/. To provide comments on this brief, please fill out the form on the Community Feedback page.