Increasing Access to Quality Essential Medicines in Tanzania
In need of health care and medicines, many rural Tanzanians have to trek long distances to their nearest public health facility. Once there, they often find the medicines they need are out of stock, generally having to turn to private drug outlets, or duka la dawa baridi, to buy their prescribed medicines—and often paying more money for drugs of uncertain quality. This is the plight of many in Tanzania, where life expectancy had fallen to 44 years in 2001, from 50 years in 1990 (World Bank 2003), and infant mortality is 107 deaths per 1,000 and rising. Although public health facilities provide medicines free of charge, frequent stock-outs of essential medicines force patients to seek care elsewhere.
Ubiquitous throughout the countryside, duka la dawa baridi (DLDB) are licensed to sell only nonprescription medicines. However, these private stores typically provide a much broader range of products and services—outside of what the regulations allow. For example, prescribed medicines, such as antibiotics, are often being provided by people without any medical training. A 2001 assessment, conducted by Management Sciences for Health (MSH) in collaboration with the Tanzania Ministry of Health and with funding from the Bill & Melinda Gates Foundation, found that at private pharmacies, 18 percent of simulated clients presenting with symptoms of a common cold were inappropriately recommended antibiotics.
To help address these issues of appropriate access to quality medicines in underserved populations, MSH initiated the Strategies for Enhancing Access to Medicines (SEAM) Program, funded by the Bill & Melinda Gates Foundation. SEAM has worked since 2001 to improve access to and use of essential medicines in Tanzania.
To improve Tanzanian's access to quality medicines, the Ministry of Health and Tanzanian Food and Drugs Authority (TFDA), supported by MSH, have created a pilot program to establish a network of privately owned accredited drug dispensing outlets (ADDOs), or duka la dawa muhimu (essential drugs shops), to provide a selected range of prescription and nonprescription medicines to people living in the Ruvuma region in south west Tanzania. The approach combines changing the behavior and expectations of individuals, who use, own, work in, or regulate retail drug shops, transforming DLDBs into a regulated system of profitable ADDOs that provide a range of quality drugs and professional services.
ADDO owners and employees complete courses covering both management and pharmaceutical aspects of the ADDO business, including training about the drugs approved for sale in the shops and when clients need to be referred to medical clinics. The program is designed to change the ethical behavior of shop owners and dispensing staff. “When seeing a client, if I don't fully understand the symptoms or the exact remedy, I refer to my notes, because I am interested in the welfare of my clients,” reported a dispenser after going through training. In some situations, dispensers may recommend other advice if a drug is not needed, suggest a non-drug product or service related to the client's complaint (such as an insecticide treated bednet for those with presumptive malaria), or refer the client to a health care provider for services beyond the scope of ADDO shops.
Incentives are built into this initiative for shop owners to attain accreditation and become an ADDO. Participating accredited shops have the advantages of—
- Legal authorization to sell a limited list of prescription drugs
- Business and dispensing training
- A marketing campaign financed by this initiative
- Access to microfinance services
- Links to health financing schemes
To date, 150 duka la dawa muhimu have been accredited and have opened for business in the Ruvuma Region. This number represents about 100 percent of the drug shops in this remote and largely rural region. An innovative monitoring and enforcement system that uses local government officials as inspectors helps ensure that accredited shops maintain approved standards, and that non-accredited shops do not compete unfairly by continuing to sell prescription drugs illegally.
Preliminary data shows that quality, availability, and adherence to regulatory standards have all improved under the ADDO program without affecting affordability: Now, 99 percent of the pharmaceuticals sold in the duka la dawa muhimu have been approved for the Tanzanian market—a 100 percent increase. The availability of selected essential drugs has improved also; for example, at the baseline assessment, contraceptive pills had only a 29 percent availability in the Ruvuma region compared with 81 percent in May 2004. And the percentage of shops that are keeping patient records has gone from 1 percent to 100 percent.
Dr. John Budotela, Songea's District Medical Officer said, “I've been involved with pharmaceuticals from the beginning and I know where we are and where we want to arrive...I will do everything in my capacity to make sure that this project works, so that it can be rolled out to other districts in the country. It can be done.” SEAM anticipates that evolving public-private sector models—such as ADDOs—can improve access to essential medicines and be adapted for use in other countries throughout the developing world.