What roles do accredited drug dispensing outlets in Tanzania play in facilitating access to antimicrobials? Results of a multi-method analysis

Abstract

BackgroundPeople in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. Tanzania’s accredited drug dispensing outlet (ADDO) program includes dispenser training, enforcement of standards, and the legal right to sell selected antimicrobials. We assessed the role of ADDOs in facilitating access to antimicrobials.MethodsWe purposively chose four regions, randomly selected three districts and five wards per district. Study methods included interviews at 1200 households regarding care-seeking for acute illness and knowledge about antimicrobials; mystery shoppers visiting 306 ADDOs posing as a caregiver of a child with 1) pneumonia, 2) mild acute respiratory infection (ARI), or 3) a runny nose and request for co-trimoxazole; and audits of antimicrobial availability and prices at 84 public health facilities (PHFs) and 96 ADDOs.ResultsFour hundred sixty seven (76 %) members from 367 (77 %) households had recently sought care outside the home for acute illness; 128 had purchased antimicrobials, of which 61 % had been recommended by a doctor or nurse and 32 % by an ADDO dispenser. Only 29 % obtained the antimicrobial at a PHF, whereas, 48 % purchased them at an ADDO. Most thought that ADDOs are convenient place for care, usually have needed medicines, and have high quality services and products, contrasting with 66 % who reported dissatisfaction with PHF waiting times and 56 % with medicine availability. One-third (34 %) of mystery shoppers presenting the mild ARI scenario were inappropriately sold an antimicrobial and 85 % were sold one on request; encouragingly, 99 % presenting a case of pneumonia received either an antimicrobial, referral to a trained provider, or request to bring the child for examination. Overall, 63 and 60 % of the 15 tracer antimicrobials were in stock in ADDOs and PHFs, respectively; ADDOs had significantly more antimicrobial formulations for children available (83 vs. 51 %). Of 369 records of antimicrobial sales in 47 ADDOs, 63 % were dispensed on prescription.ConclusionADDOs have increased access to antimicrobials in Tanzania. Community members see them as integral to the health system. Antimicrobials are overused due to poor ADDO dispensing, poor PHF prescribing, and inappropriate public demand. Multi-pronged interventions are needed to address all determinants.Electronic supplementary materialThe online version of this article (doi:10.1186/s13756-015-0075-2) contains supplementary material, which is available to authorized users.

Stretching the Boundaries: Tanzanian Pharmacy Workers’ Views and Experiences of Providing STI Services for Men Who Have Sex with Men

“…The TFDA therefore initiated the accredited drug dispensing outlet (ADDO) programme in 2003 to capacitate personnel at Part II pharmacies in the area of essential drug provision [21, 22]. Accredited Part II pharmacies are locally called Duka la Dawa Muhimu and are allowed to dispense some prescription-only drugs such as antimicrobials [22]. In 2013 there were approximately 9000 accredited stores spread across the country [22].…”

“…Accredited Part II pharmacies are locally called Duka la Dawa Muhimu and are allowed to dispense some prescription-only drugs such as antimicrobials [22]. In 2013 there were approximately 9000 accredited stores spread across the country [22]. …”

Community knowledge and attitudes on antibiotic use in Moshi Urban, Northern Tanzania: Findings from a cross sectional study

“…However, current and previous studies have indicated that infringement of policies although reduced, are still very common (Chalker et al, 2015;Goodman et al, 2007). A recent community based study on antimicrobial use among 1,200 household done by Chalker et al (2015) indicated that ADDOs were the more convenient source of medicines by most community members but such sourcing was associated with poor ADDOs dispensing practices and over use or incomplete dosages of antimicrobials in response to incorrect public demand (Chalker et al, 2015).…”

“…A recent community based study on antimicrobial use among 1,200 household done by Chalker et al (2015) indicated that ADDOs were the more convenient source of medicines by most community members but such sourcing was associated with poor ADDOs dispensing practices and over use or incomplete dosages of antimicrobials in response to incorrect public demand (Chalker et al, 2015). Inappropriate antimicrobial selling was common, for example, more than one-third of requests by investigators who presented as "mystery shoppers" with acute respiratory infection were approved and also, 85% of prescription-only antimicrobials were sold just on verbal requisition.…”

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System

“…Differences existed across regions, but varied by product. For example, in Mbeya antimicrobials in ADDOs were 30% more expensive than in public health facilities, while they were 4% more expensive in public health facilities than ADDOs in Tanga; suspensions in Mbeya were 1% less costly in ADDOs, but 60% more expensive in ADDOs in Morogoro [18]. Using the regimen recommended in Tanzania’s standard treatment guidelines as an illustration [19], the average cost to treat pneumonia in an adult would be TSh444 based on prices of medicines at a health facility (~US$0.26) and TSh528 at an ADDO (~US$0.30) (amoxicillin); and treating a sexually transmitted infection would cost TSh1398 at a health facility (~US$0.81) and TSh1470 at an ADDO (~US$0.85) (benzyl penicillin + co-trimoxazole).…”