Primary health care has many different definitions, but can
be defined simply as the first place where people seek care.
Within this definition, private sector providers constitute an important source
of primary health care in many parts of the world.
Private providers can run the spectrum – from private
hospitals, pharmacies, and non-profit clinics, to informal providers such as
faith-based healers and drug shops. A 2013 review suggests that informal
providers account for as much as two-thirds of health care visits in Bangladesh
and Thailand, and a substantial percentage of visits in Nigeria and Kenya as
In developing countries, especially in rural areas where
access to health care and pharmacies are limited, private drug shops play a
particularly important role. They provide access to essential medicines for
many of the illnesses and diseases that burden the poor, and can also provide
referrals to local clinics for more serious health issues. In Sub-Saharan
Africa people in the lowest wealth quintile seek primary care from drug shops
five times more often than people in the highest wealth quintile.
Private drug shops may even be a preferred source of health services, as
caregivers often use private drug shops even when cheaper alternatives, such as
community health workers, are available to them.
With so many of the world’s poor seeking care from private
drug shops it is important to ensure that these shops provide safe medicines
and the best possible advice and care. Historically, that has been difficult
due to limited government oversight, regulation, or standards. As a result,
available medicines have often included counterfeit, substandard, and expired
drugs, and lack of training and knowledge has made diagnosis and treatment
Recognizing the extent of the problem with drug sellers in
Tanzania, in 2001 the Ministry of Health and Social Welfare (MOHSW) began to
work to address this challenge. With 9,226 local retail drugs shops in Tanzania
these outlets represented the largest retail source of medicines in in the
However, an assessment
showed that a quarter of these shops illegally sold unapproved or prescription-only
drugs, such as broad-spectrum antibiotics, including some that were counterfeit
or of substandard quality.
It was in this context that the Tanzanian government and the
non-profit organization, Management Sciences for Health (MSH) – with support
from the Gates Foundation – launched the Accredited
Drug Dispensing Outlet (ADDO) Program. This program aimed to improve access
to affordable, quality medicines and pharmaceutical services in retail drug
outlets in areas where few or no registered pharmacies existed. The ADDO
Program took a holistic approach to upgrading private drug shops that combined
training, accreditation, business incentives, and regulatory enforcement with
efforts to increase consumer demand for quality products and services.
After a successful
pilot in the Ruvuma region from 2003-2005, the ADDO Program was rolled out
in additional districts with the support of the Tanzania Food and Drugs
Authority (TFDA) and later the Pharmacy Council of Tanzania. Today, more than
two thirds of Tanzania’s informal drug shops had been upgraded and accredited, with
an average of thirty upgraded shops per district.
These upgrades represent real changes in quality of care –
and thus, real improvements in health outcomes for the poor in Tanzania. The
percentage of accredited shops selling unapproved drugs dropped from 26% to
zero, and 99% of drugs passed quality testing.
In addition, the proportion of drug dispensers recommending incorrect medicines
dropped from 39% to 14%.
Applying utilization rates from a 2008 survey to today’s
numbers shows that Tanzania’s 6,412 accredited shops have approximately 7.6
million case visits every year.4 The ADDO Program has increased the availability
of quality medicines to underserved populations in Tanzania. Care management in
ADDOs has also improved, particularly related to malaria and pneumonia.8,
These successes have improved care and medicine quality for thousands of
patients in Tanzania that use these drug shops as their source of primary care.
For some illnesses, these changes
can have major implications for health outcomes. Recent data suggests that each
ADDO sees an average of 7.2 cases of malaria each week
– indicating that these 6,412 shops see about 2.3 million cases of malaria per
year. Before this program began, only 6% of malaria cases were appropriately
managed in the pilot region of Ruvuma. After the ADDO program was implemented,
that rose to 63% of cases.
This translates to approximately 1.3 million more people receiving appropriate
medicines for malaria, who might have previously received inappropriate
medicines or care. The forthcoming introduction of rapid diagnostic tests in
the ADDO shops will improve these results even more.
A decade after the launch of this effort, the ADDO program
represents one of the best examples of success integrating informal private
sector health providers into the formal health system at a national scale.
With support from the Bill & Melinda Gates Foundation,
MSH is working with the Ministries of Health in scaling up similar programs in
Uganda and in Liberia. Even as the Ebola crisis unfolds in Liberia, the drug
shops that are already accredited and operating in the country have seen
increased foot traffic as public facilities are overwhelmed. Accredited drug
shops can play an instrumental role in health
service delivery in primary health care, and a key
supporting role in times of crisis.
Tanzania’s ADDO Program demonstrates that accreditation
schemes and public-private partnerships can impact health access and health
equity on a national scale, and improve the quality of medicines and health
care that is provided by drug shops.
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play in facilitating appropriate access to antibiotics? Results of a
multi-method analysis. In preparation.
Rutta et al. (2011). Increasing access to subsidized artemisinin-based
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