Drug Shops and Pharmacies: Sources for family planning commodities and information
Small commercial drug shops and pharmacies are often the first line of health care in poor countries, especially in rural areas that have very few private or public clinics (Stanback et al., 2011). Drug shops (also known in some countries as chemist shops or patent medicine vendors), in contrast to pharmacies, are usually more numerous, do not typically employ a trained pharmacist, and are legally allowed to sell only nonprescription drugs and prepackaged medicines. Education and training of drug-shop staff vary widely from country to country and within countries. Like pharmacies, many drug shops also sell over-the-counter family planning methods, especially condoms and oral contraceptives. 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 are typically literate and may or may not have some type of retail license, family planning training, or health accreditation such as training as a nurse, nursing assistant, pharmacy assistant, or traditional medicine practitioner.
Drug shops and pharmacies, with their convenience, anonymity, and cost-savings (compared to private physicians), are an important source of health services, products, and information that is particularly important in the context of high maternal mortality and morbidity, critical health-worker shortages, poorly stocked clinics, and high unmet need for family planning (Stanback et al., 2011). In sub-Saharan Africa, drug shops are often the most widely used source for health services, information, and products (Wafula and Goodman, 2010). 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 (Brieger et al., 2004; Smith, 2009). Despite their popularity and potential, pharmacies and drug shops are not generally considered part of the larger health system; they are largely missing from countries’ health strategies, policies and regulation, and monitoring. As a result, little is known about the type and quality of services and information provided by pharmacists and drug-shop staff.
Evidence shows that with appropriate training and support, pharmacy and drug-shop staff can facilitate the use of modern contraception, especially in urban slums and rural areas where the unmet need is high, access is poor, and health-worker shortages and other barriers prevent men, women, and youth from accessing family planning services. This brief describes the importance of these outlets for distributing commodities and information and outlines key issues for planning and implementing programs to support pharmacy and drug-shop staff. Drug shops are emphasized, as they are less familiar to the family planning community as potential outlets for contraception.
Training and supporting pharmacy and drug-shop staff to provide an expanded mix of family planning commodities and information is one of several promising “high-impact practices in family planning” (HIPs) identified by a technical advisory group of international experts. A promising practice has limited evidence, with more information needed to fully document implementation experience and impact. The advisory group recommends that these interventions be promoted widely, provided they are implemented within the context of research and are carefully evaluated in terms of both impact and process (HIP, 2013). For more information about HIPs, see http://www.fphighimpactpractices.org/overview.
Why is this practice important?
Drug-shop and pharmacy staff already advise patients 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 (FDA Thailand, 1994), Nigeria (Igun, 1994), Indonesia (Tawfik et al., 2002), and Uganda (Tawfik et al., 2002) 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 (Wafula et al., 2012). Both venues are particularly important in countries where health system infrastructure is weak, over-burdened, or poorly distributed. Training, support, and regulation for pharmacy and drug-shop staff can be thought of as a “harm-reduction” strategy because, in some countries, they routinely provide services that may not be legal and have the potential to cause harm through incorrect use or unsafe practices.
Drug-shop and pharmacy staff can safely provide a wide range of methods.
- Pharmacies and drug shops are a common source of supply for male condoms in many countries.
- Studies in Tanzania and Nepal demonstrated that women obtaining contraceptives at pharmacies were able to self-screen for contraindications to combined oral contraceptives about as well as nurses (Chin-Quee et al., 2013; Rai et al., 1999).
- In Bangladesh, the Blue Star program demonstrates that, when trained and supported, drug-shop staff can safely and effectively provide high-quality family planning services, including injectable contraceptives (DMPA), and many clients preferred the option of obtaining DMPA from local drug shops (Khan et al., 2012). In Ghana, a pilot study demonstrated that drug-shop staff could sell the socially-marketed DMPA product and refer clients for safe injection elsewhere (FHI 360, 2013).
- A review of 24 studies, mostly from developed countries, included a study from South Africa that found that “pharmacy supply of emergency contraception (EC) improves access and enables most women to receive it within 24 hours of unprotected sexual intercourse. Women were generally satisfied with pharmacy EC supply and the information that they received from pharmacists” (Anderson and Blenkinsopp, 2006). Another study that looked at provision of EC through community pharmacies in two communities in rural England found that “community pharmacies had become the largest provider of EC. The supply of EC through community pharmacies provided clients with wider choice of sources and improved access to services, which resulted in increased overall provision of EC in this rural area” (Lloyd and Gale, 2005).
Drug shops, in particular, remove barriers to family planning access in underserved areas. Doctors and pharmacies are usually concentrated in urban areas (Battersby et al., 2003; Jacobs et al., 2004). 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 (Chuc et al., 2001; Stenson et al., 2001). Private providers offer clients proximity, expediency, flexibility in operating hours, and responsiveness to the client’s needs compared to public sector clinics (Okonkwo and Okonkwo, 2010; van der Geest, 1987).
What is the impact?
Drug shops and pharmacies are an important source of supply for contraceptives in many countries. Oral contraceptives are available over-the-counter in the majority of countries (Grindlay et al., 2013) and data on supply sources for pill and condom users indicate that pharmacies play an important role in meeting the increasing demand for temporary family planning methods (Figure 1). Social marketing programs in Africa and elsewhere routinely encourage contraceptive users to access pills, condoms, and even injectable contraceptives from pharmacies and other retail outlets.
Drug shops and pharmacies are preferred by some marginalized or underserved populations, including males and youth.
- 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 (Okonkwo and Okonkwo, 2010). 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). Those clinics, partly due to the limited number of male-centered contraceptive methods, have not sufficiently engaged male participation in family planning counseling (Chakrapani et al., 2011; Wambui et al., 2009). Men in India cited pharmacies as their primary source for obtaining condoms (Nanda et al., 2011).
- Studies show that young people view pharmacies as critical sources of contraceptive information and methods (Achmad and Westley, 1999; Ahmed, 1998; Shah and Nkhama, et al., 1996). Studies from Zambia, El Salvador, the United States, and the United Kingdom have shown that youth are more comfortable obtaining contraceptives from pharmacies than from clinics, which they consider more intimidating and judgmental (Ahmed, 1998; Bullock, 1997; Sucato, 2001). Okonkwo and Okonkwo (2010) specified that community pharmacists and patent medicine vendors “display non-judgmental attitudes towards young people’s sexual reproductive healthcare needs” and “are preferred by young patrons because they are diplomatic and keep their confidences.” In Bangladesh, the majority of adolescents aged 10-18 use socially marketed contraceptives obtained through pharmacy outlets compared to less than a third of women 19 years of age and older (Karim et al., 2007; see Figure 2). Another study in the United States examined adolescents’ reasons for seeking emergency contraception services from a pharmacist. The most common reasons were convenience (44%), lack of knowledge about alternatives (38%), and anonymity (31%) (Sucato, 2001).
How to do it: Tips from implementation experience
Programmatic experience indicates that the following strategies can help support drug shops and pharmacies in providing a wider variety of family planning methods and information.
- Know the legal, regulatory, and policy environment. Efforts to expand the role of drug shops and pharmacies should consider whether country 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?
- 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.
- Promote simple and clear processes for licensing drug shops and pharmacies. 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 and continuing education.
- Integrate drug shops and pharmacies as a part of the larger health system. Globally and nationally, efforts should be made to include pharmacy and drug shop provision into family planning guidance, such as service delivery guidelines. Locally, drug-shop and pharmacy staff should be comfortable referring clients to higher level clinical services and should be knowledgeable about what services are available and where.
- 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 (Center for Pharmaceutical Management, 2008), can be used to maintain standards for:
- Staff training and continuing education
- Drug availability
- Drug quality
- Stock control, handling, and record-keeping
- Sanitation and hygiene of the premises and personnel
- Shop location and building design/layout (privacy)
- Seek to price contraceptive supplies so they are affordable for clients yet offer sufficient profit to motivate the drug-shop and pharmacy owners to stock and sell a range of modern contraceptives. Profit incentives appear to increase sales and use (Wafula et al., 2010).
- Provide drug-shop and pharmacy staff sufficient training and support on the family planning methods they offer. Training should be high-quality, interactive, and customized to the learners’ needs. 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 (Wafula et al., 2010). In 2008, data from 272 pharmacists (22% response rate) in Florida found that 56% of respondents thought that EC causes birth defects and 46% thought that it causes abortion. Only 22% said that EC can be purchased in advance of need. Many felt uncomfortable dispensing to adolescents (61%) and men (58%). Knowledge about EC was the most important predictor of dispensing (Odds Ratio [OR]=1.57, 95% confidence interval [CI]=1.22-2.03). Pharmacists who knew EC is not an abortifacient were more likely to dispense it (OR=4.64, 95% CI 2.15-10.00) (Richman et al., 2012). Because pharmacy and drug-shop staff often work long hours and are reticent to attend training sessions, training courses should be as brief as possible at convenient hours, such as in the evening. Also consider mechanisms for trainees to share information with their colleagues. For example, provide handouts to take back or talking points to share.
- Create point-of-sale information and promotional materials to improve family planning use and the quality of services. Take-home brochures for clients and job aides for drug-shop staff, such as screening and standard procedure checklists, can improve the quality of services and information. In social marketing programs, product inserts and other client materials will likely be provided by the distributor.
- Explore franchising and branded networks of drug shops and pharmacies as potential ways to increase visibility and introduce basic monitoring and quality assurance. Several programs are seeking ways to include drug shops in a wider network of providers, such as Licensed Chemical Shops in Ghana, Blue Star clinical social franchising efforts in Bangladesh, ADDOs in Tanzania, and ProFam programs in several African countries. See Social Marketing: Leveraging the Private Sector to Improve Product Access, Choice, and Use.
ments That Facilitate Successful Programs
- Staff possess adequate family planning knowledge and counseling skills.
- Routine staff support and quality control systems are in place to promote minimum standards for provision of family planning.
- Data are collected and used to help ensure quality family planning services, supplies, and information.
- A range of family planning commodities is kept in stock and offered at affordable prices.
Elements That Inhibit Successful Programs
- Turnover of pharmacy and drug-shop staff is high, requiring constant and costly training of new staff.
- Staff promote products based on profit margin, rather than client need and safety.
- Clients are not satisfied with the quality of services.
- Restrictive regulations limit the family planning choices available in these outlets.
Youth-Friendly Pharmacy Program Implementation Kit: Guidelines and tools for implementing a youth-friendly reproductive health pharmacy program. The kit provides guidelines, ideas, and prototype materials for designing and implementing a pharmacy capacity-strengthening project. This kit is intended to guide program managers in the development of a pharmacy training initiative and can be adapted as needed to ensure suitability in a variety of environments. It includes a pharmacy personnel training curriculum and prototype materials. http://www.path.org/publications/files/RH_PPIK.pdf
Good Pharmacy Practice: Joint FIP/WHO guidelines on good pharmacy practice: standards for quality of pharmacy services. http://www.fip.org/files/fip/WHO/GPP%20guidelines%20FIP%20 publication_final.pdf
- What is the safety and quality of providing contraceptives services through drug shops?
- What kinds of supportive supervision or other support mechanisms work best to improve knowledge and counseling skills?
- What are the best ways to facilitate effective referrals?
- Is there a difference in family planning discontinuation rates between users who source their methods from pharmacies or drug shops compared to health facilities?
- Does providing a range of contraceptive methods through pharmacies and drug shops increase use among new users or increase overall contraceptive prevalence?
For more information about High-Impact Practices in Family Planning (HIPs), please contact the HIP team: [email protected].
An asterisk (*) denotes an item that was particularly useful in the preparation of this Brief.
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Available from http://www.fphighimpactpractices.org/briefs/drug-shops-and-pharmacies
This document was originally drafted by Chris Parker, John Stanback, and Bill Finger. Critical review and helpful comments were provided by Moazzam Ali, Aysha Asifuddin, Christine Bixiones, Peggy D’Adamo, Monica Dragoman, Mario Festin, Mary Lyn Gaffield, Gwyn Hainsworth, Karen Hardee, Catherine Lane, Ricky Lu, Shawn Malarcher, Nithya Mani, Erin Mielke, Sharon Philips, Jennifer Pope, Suzanne Reier, Marcela Rueda, Shefa Sikder, Patricia Stephenson, and John Townsend.
This HIP brief is endorsed by: Abt Associates, Chemonics, EngenderHealth, FHI360, Futures Group, Georgetown University/Institute for Reproductive Health, International Planned Parenthood Federation, IntraHealth International, Jhpiego, John Snow, Inc., Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, Management Sciences for Health, Marie Stopes International, Pathfinder International, Population Council, Population Reference Bureau, Population Services International, the United Nations Population Fund, the United States Agency for International Development and University Research Co., LLC.
The World Health Organization/Department of Reproductive Health and Research has contributed to the development of the technical content of this document, which is viewed as a summary of evidence and field experience. It is intended that this brief be used in conjunction with WHO Family Planning Tools and Guidelines: http://www.who.int/topics/family_planning/en/.