Recent Advances in Provision of Primary Care in Private Drug Sellers/Shops Catherine Goodman with thanks for contribut

2. 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

4. 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)

5. Photos: Battersby,Brieger, Yeung

6. Why do people use retailers? • Convenience • Drug availability • Confidentiality • Lower costs • Confidence in self-treatment • Poor services in health facilities

7. 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

8. 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

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

10. 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

11. 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

12. General Shopkeeper Training on Childhood Fevers in Rural Kenya Photo: Marsh

13. 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

14. 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

15. Photo: MSH/SEAM

16. 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

17. Malarine & RDTs in Cambodia Paracheck Diptstick Photo: PSI

18. Malarine & RDTs in Cambodia Survey of early implementation revealed: • Product acceptable & adherence very good • Low penetration beyond large market centres • Combination accounted for <6% 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

19. 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)

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

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

22. 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