Improving Primary Care for the Poor by Leveraging Drug Sellers at Scale: Tanzania’s Accredited Drug Dispensing Outlets Program

Improving Primary Care for the Poor by Leveraging Drug Sellers at Scale: Tanzania’s Accredited Drug Dispensing Outlets Program

 {Photo credit: MSH}A woman and her child consult with an ADDO dispenser in Tanzania.Photo credit: MSH

Cross-posted with permission from the Bill & Melinda Gates Foundation Blog, Impatient Optimists.

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 of primary health

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 well.[1]

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.[2] 

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.[3]

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 unreliable.

Access to essential medicines, Tanzania

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 country.[4] However, an assessment[5] 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.[6]

Accredited drug shops, improved health outcomes for the poor

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 percent to zero, and 99 percent of drugs passed quality testing.[7] In addition, the proportion of drug dispensers recommending incorrect medicines dropped from 39 percent to 14 percent.[8]

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,[9] 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[10] – indicating that these 6,412 shops see about 2.3 million cases of malaria per year. Before this program began, only 6 percent of malaria cases were appropriately managed in the pilot region of Ruvuma. After the ADDO program was implemented, that rose to 63 percent of cases.[11] 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.

Scalable, sustainable

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.

Dana Hovig, director of Integrated Delivery at the Bill & Melinda Gates Foundation, works with the Global Development and Global Health programs to speed up the launch, improve the delivery, enhance integration, and scale up the use of life saving and life-changing products, services, technologies, and service delivery innovations. Eva Westley, associate program officer at the Bill & Melinda Gates Foundation, works on country primary health care with the Integrated Delivery Team.


[1] Sudhinaraset M, M Ingram, HK Lofthouse, D Montagu (2013). What is the role of informal healthcare providers in developing countries? A systematic review. PLoS ONE 8:e54978.

[2] Montagu D (2008). Private healthcare in developing countries [Internet]. San Francisco, CA. Accessed Nov 10 2014 from:http://www.ps4h.org/

[3] Brieger WR (2013). The role of patent medical vendors in the management of sick children in the Africa region. Prepared for BASICS II. Arlington, VA: BASICS II.

[4] Rutta E, K Senauer, K Johnson, G Adeya, R Mbwasi, J Liana, S Kimatta, M Sigonda, and E Alphonce (2008). Creating a new class of pharmaceutical services provider for underserved areas: the Tanzania Accredited Drug Dispensing Outlet Experience. Progress in Community Health Partnerships: Research, Education, and Action. Vol. 3.2.

[5] Center for Pharmaceutical Management (2003). Access to essential medicines: Tanzania, 2001. Arlington, VA: Prepared for the Strategies for Enhancing Access to Medicines Program. Arlington, VA: Management Sciences for Health. 

[6] Rutta, E (2014). Medicines in Health Systems: Advancing access, affordability and appropriate use – Accredited Drug Dispensing Outlets. Alliance for Health Policy and Systems Research Flagship Report 2014; Chapter 5 Annex 1. 

[7] Manyanga V, et al. (2014). Survey of the Quality of Selected Essential Medicines in Districts Covered by the ADDO Program in Tanzania.

[8] Rutta, E (2014). Medicines in Health Systems: Advancing access, affordability and appropriate use – Accredited Drug Dispensing Outlets. Alliance for Health Policy and Systems Research Flagship Report 2014; Chapter 5 Annex 1. 

[9] Chalker J et al. What roles do accredited drug dispensing outlets in Tanzania play in facilitating appropriate access to antibiotics? Results of a multi-method analysis. In preparation.

[10] Rutta et al. (2011). Increasing access to subsidized artemisinin-based combination therapy through Accredited Drug Dispensing Outlets in Tanzania. Health Research Policy and Systems, 9:22.

[11] East Africa Drug Seller Initiative (EADSI) (2011). East Africa Drug Seller Initiative (EADSI) Evaluation Report. Arlington, VA. Management Sciences for Health.

Related

Watch video: Accredited Drug Dispensing Outlet (ADDO) Program: Improving Access to Medicines in Tanzania


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