Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania's Health System.
BACKGROUND
People in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.


METHODS
Using mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child's respiratory symptoms.


CONCLUSIONS
Of 614 household members with a recent acute illness, 73% sought outside care-30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. Although health facilities and ADDOs had similar availability of antimicrobials, ADDOs had more pediatric formulations available (p<0.001). The common perception was that drugs from ADDOs are more expensive, but the difference in the median cost to treat pneumonia was relatively minimal (US$0.26 in a public facility and US$0.30 in an ADDO). Over 20% of households said they had someone with a chronic condition, with 93% taking medication, but ADDOs are allowed to sell very few chronic care-related medicines. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child.


CONCLUSIONS
ADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.
Pharmaceuticals & Health Technologies Group, Management Science for Health, Arlington, Virginia, United States of America.
Martha
http://orcid.org/0000-0002-2556-6487
M
Embrey
Drug Policy Research Group, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, United States of America.
Catherine
C
Vialle-Valentin
Ifakara Health Institute, Dar es Salaam, Tanzania.
Angel
A
Dillip
Tanzania Consumer Advocacy Society, Dar es Salaam, Tanzania.
Bernard
B
Kihiyo
Apotheker Consultancy (T) Limited, St. Johns University of Dodoma, Dodoma, Tanzania.
Romuald
R
Mbwasi
School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
Innocent A
IA
Semali
Pharmaceuticals & Health Technologies Group, Management Science for Health, Arlington, Virginia, United States of America.
John C
JC
Chalker
Pharmaceuticals & Health Technologies Group, Management Science for Health, Dar es Salaam, Tanzania.
Jafary
J
Liana
Pharmaceuticals & Health Technologies Group, Management Science for Health, Arlington, Virginia, United States of America.
Rachel
R
Lieber
Pharmaceuticals & Health Technologies Group, Management Science for Health, Arlington, Virginia, United States of America.
Keith
K
Johnson
Pharmaceuticals & Health Technologies Group, Management Science for Health, Arlington, Virginia, United States of America.
Edmund
E
Rutta
Pharmaceuticals & Health Technologies Group, Management Science for Health, Dar es Salaam, Tanzania.
Suleiman
S
Kimatta
Pharmacy Council of Tanzania, Dar es Salaam, Tanzania.
Elizabeth
E
Shekalaghe
Pharmaceuticals & Health Technologies Group, Management Science for Health, Dar es Salaam, Tanzania.
Richard
R
Valimba
Drug Policy Research Group, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, United States of America.
Dennis
D
Ross-Degnan
D003695:Delivery of Health Care / Q000379:methods; D005191:Family Characteristics; D006297:Health Services Accessibility; D006801:Humans; D008483:Medical Assistance; D004366:Nonprescription Drugs / Q000191:economics* / Q000627:therapeutic use*; D017149:Private Sector; D055818:Public-Private Sector Partnerships; D013636:Tanzania
D004366:Nonprescription Drugs