Recent Advances in Provision of

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• Recent Advances in Provision of
• Primary Care in Private
• Drug Sellers/Shops
• Catherine Goodman
• with thanks for contributions from
• Vicki Marsh, Malcolm Clark, Bill Brieger,
• Warren Stevens, Alisdair Unwin
• Shunmay Yeung

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• Retailers are a very common source of primary
  care
• High use by the poor in rural peri-urban areas
• In Nigeria 50 of child illness episodes first
  treated through drug retailers (Brieger et al)
• In rural Tanzania retailers account for 40 of
  antimalarials dispensed (Goodman et al)
• In urban India 41 of antibiotic purchases for
  adults were over-the-counter (Ray et al)

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Photos Battersby, Brieger, Yeung
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Why do people use retailers?

• Convenience
• Drug availability
• Confidentiality
• Lower costs
• Confidence in self-treatment
• Poor services in health facilities

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Poor Quality from Retailers

• Inappropriate drugs doses
• Poor drug quality
• Inadequate labelling instructions
• Inadequate diagnosis advice on care, danger
  signs referral
• Uncontrolled use contributing to drug resistance

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Strategy Mix

• Training Interventions
• workshops
• peer education, in shop
• Enabling Interventions
• pre-packaging, labeling, inserts
• policy regulatory action
• Demand Generation
• media, information, social marketing
• community promoters
• Quality Assurance
• franchising, accrediting, shop identifiers
• community accountability
• monitoring supervision

Source Brieger, Unwin et al
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Recent Advances

• Shopkeeper training programmes
• Accreditation of drug sellers
• Social marketing of pre-packaged drugs for
  treating common illnesses

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Biomedical Context
Central Regulatory Environment
Drugs, Distribution Industry
Providers
This is where a large graphic or chart can go.
Consumer or Caretaker
Photo Yeung
Source Marsh Kachur, 2002
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1. Training Programmes

• One-off knowledge-based training alone does not
  change behaviour
• Key features of successful programmes
• Regular refresher training workshops for new
  staff
• Regular monitoring visits to retailers
• Supportive job aids eg dosage charts
• Synergistic community mobilisation activities
• Behaviour change that is incentive compatible

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General Shopkeeper Training on Childhood Fevers
in Rural Kenya
Photo Marsh
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General Shopkeeper Training on Childhood Fevers
in Rural Kenya

• Children receiving adequate chloroquine dose rose
  from 2-15 (Marsh et al)
• Estimated cost for district level implementation
  (Goodman et al)
• 81,000 for set-up year, 18,000 per annum
  thereafter
• Cost-effectiveness of 0.84 per additional
  appropriately treated case
• 6 other districts begun implementation a
  further 16 plan to do so

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2. Accreditation of Drug Stores

• Collaboration between Tanzanian FDA MSH/SEAM
• Convert drug shops into Accredited Drug
  Dispensing Outlets (ADDOs) through
• Training course for dispensers owners
• Regulatory revisions e.g. expansion of permitted
  drugs to include some previously
  prescription-only medicines
• Marketing of the accredited brand
• Commercial incentives eg business skills
  training, access to microfinance
• Strengthened regulation at the local level

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Photo MSH/SEAM
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3. Social Marketing of Drugs

• Antimalarial treatment in Cambodia (Malarine),
  Myanmar (Sure), Nigeria (KidCare) Madagascar
  (PaluStop)
• STD treatment in Uganda (Clear Seven)
• Common key features
• Pre-packaged branded treatment
• Clear, locally tested labelling and instructions
• Subsidised prices
• Mass media campaign
• Educational promotional materials
• Detailing visits to wholesalers retailers

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Malarine RDTs in Cambodia
Paracheck Diptstick
Photo PSI
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Malarine RDTs in Cambodia

• Survey of early implementation revealed
• Product acceptable adherence very good
• Low penetration beyond large market centres
• Combination accounted for lt6 of antimalarial
  treatments from the informal sector (Yeung et al)
• Roughly half of these were leaked from public
  sector (Socheat et al)
• Use of diagnostic tests remained rare
• These issues will be addressed in the next phase
• Training retailers
• Review of pricing policy
• Greater emphasis on diagnosis

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Excellent Resources Available

• Reviews, eg
• Working with private sector providers for better
  health care (Options, 2001)
• Utilising the potential of formal and informal
  private practitioners in child survival (USAID,
  2002)
• Scaling up home-based management of malaria (WHO,
  2004)
• Manuals for interventions, eg
• Vendor-to-vendor education to improve malaria
  treatment (QAP, USAID)
• Manual for training drug retailers on OTC drugs
  for childhood fevers (KEMRI/Wellcome Trust
  Kenyan MOH)
• Materials for training patent medicine dealers in
  home-based care of malaria (BASICSII, JHU Abia
  State MOH, Nigeria)

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Continuing Challenges

• Defining the target behaviours we want
• Working with the regulatory system
• Scaling up to national level

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• Is a focus on retailers
• the best way to
• improve retail care?

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Biomedical Context
Central Regulatory Environment
Drugs, Distribution Industry
Providers
This is where a large graphic or chart can go.
Consumer or Caretaker
Photo Yeung
Source Marsh Kachur, 2002