title: What roles do accredited drug dispensing outlets in Tanzania play in facilitating access to antimicrobials? Results of a multi-method analysis.
abstract: BACKGROUND
  People in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. Tanzania's accredited drug dispensing outlet (ADDO) program includes dispenser training, enforcement of standards, and the legal right to sell selected antimicrobials. We assessed the role of ADDOs in facilitating access to antimicrobials.
  
  
  METHODS
  We purposively chose four regions, randomly selected three districts and five wards per district. Study methods included interviews at 1200 households regarding care-seeking for acute illness and knowledge about antimicrobials; mystery shoppers visiting 306 ADDOs posing as a caregiver of a child with 1) pneumonia, 2) mild acute respiratory infection (ARI), or 3) a runny nose and request for co-trimoxazole; and audits of antimicrobial availability and prices at 84 public health facilities (PHFs) and 96 ADDOs.
  
  
  RESULTS
  Four hundred sixty seven (76 %) members from 367 (77 %) households had recently sought care outside the home for acute illness; 128 had purchased antimicrobials, of which 61 % had been recommended by a doctor or nurse and 32 % by an ADDO dispenser. Only 29 % obtained the antimicrobial at a PHF, whereas, 48 % purchased them at an ADDO. Most thought that ADDOs are convenient place for care, usually have needed medicines, and have high quality services and products, contrasting with 66 % who reported dissatisfaction with PHF waiting times and 56 % with medicine availability. One-third (34 %) of mystery shoppers presenting the mild ARI scenario were inappropriately sold an antimicrobial and 85 % were sold one on request; encouragingly, 99 % presenting a case of pneumonia received either an antimicrobial, referral to a trained provider, or request to bring the child for examination. Overall, 63 and 60 % of the 15 tracer antimicrobials were in stock in ADDOs and PHFs, respectively; ADDOs had significantly more antimicrobial formulations for children available (83 vs. 51 %). Of 369 records of antimicrobial sales in 47 ADDOs, 63 % were dispensed on prescription.
  
  
  CONCLUSIONS
  ADDOs have increased access to antimicrobials in Tanzania. Community members see them as integral to the health system. Antimicrobials are overused due to poor ADDO dispensing, poor PHF prescribing, and inappropriate public demand. Multi-pronged interventions are needed to address all determinants.
authors: Center for Pharmaceutical Management, Management Science for Health, 4301 North Fairfax Drive, Arlington, VA 22203 USA.
authors: John C
authors: JC
authors: Chalker
authors: Drug Policy Research Group, Department of Population Medicine, Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215 USA.
authors: Catherine
authors: C
authors: Vialle-Valentin
authors: Management Science for Health, Dar es Salam, Tanzania.
authors: Jafary
authors: J
authors: Liana
authors: Apotheker Consultancy (T) Ltd;, St. Johns University of Dodoma, Dodoma, Tanzania.
authors: Romuald
authors: R
authors: Mbwasi
authors: Muhimbili University of Health and Allied Sciences, P.O. Box 65015, Dar es Salaam, Tanzania.
authors: Innocent A
authors: IA
authors: Semali
authors: Tanzania Consumer Advocacy Society (TCAS), Dar es Salaam, Tanzania.
authors: Bernard
authors: B
authors: Kihiyo
authors: Pharmacy Council of Tanzania, P.O. Box 31818, Dar es Salaam, Tanzania.
authors: Elizabeth
authors: E
authors: Shekalaghe
authors: Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania.
authors: Angel
authors: A
authors: Dillip
authors: Management Science for Health, Dar es Salam, Tanzania.
authors: Suleiman
authors: S
authors: Kimatta
authors: Management Science for Health, Dar es Salam, Tanzania.
authors: Richard
authors: R
authors: Valimba
authors: Center for Pharmaceutical Management, Management Science for Health, 4301 North Fairfax Drive, Arlington, VA 22203 USA.
authors: Martha
authors: M
authors: Embrey
authors: Center for Pharmaceutical Management, Management Science for Health, 4301 North Fairfax Drive, Arlington, VA 22203 USA.
authors: Rachel
authors: R
authors: Lieber
authors: Center for Pharmaceutical Management, Management Science for Health, 4301 North Fairfax Drive, Arlington, VA 22203 USA.
authors: Edmund
authors: E
authors: Rutta
authors: Center for Pharmaceutical Management, Management Science for Health, 4301 North Fairfax Drive, Arlington, VA 22203 USA.
authors: Keith
authors: K
authors: Johnson
authors: Drug Policy Research Group, Department of Population Medicine, Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215 USA.
authors: Dennis
authors: D
authors: Ross-Degnan
keywords: ADDOs; Antibiotics; Antimicrobial resistance; Medicine shops; Tanzania