Abstract
Chain pharmacies are expanding in many low and middle-income countries (LMICs). Historically practices of independent pharmacies in these settings have been poor, and there is a need to understand how these new organisational arrangements are affecting the functioning of pharmacies, and the implications for public health. Drawing on economics literature, we develop a set of hypotheses as to how chains could address the quality failures that typify LMIC retail pharmacy markets, and explore these hypotheses using a set of 38 in-depth interviews, conducted in Bengaluru, India between 2014 and 2015. We look specifically at how being organised in a chain affects several key behaviours: employment of qualified staff; the ability of government authorities to focus regulation on central management structures; the propensity for firms to self-regulate; and the impact of the potentially lower-powered incentives faced by chain employees compared to independent owners. In practice, few differences were identified between chain and independent organisations in these areas. Not all chains were operating with a qualified pharmacist (akin to independent shops). Drug control authorities did not take advantage of the existing chain architecture to enforce regulation. Chains did heavily self-regulate but their focus was on customer service, rather than aspects of quality relevant to health outcomes. Additionally, widespread bribery in the sector was a barrier to effective drug control. Finally, the incentives faced by chain employees were not low-powered due to rewarding sales targets and pressure to increase sales. We observed that chains exerted strong influence over their staff but the potential to exploit this to improve quality of care is not currently being realised. A shift in focus from customer satisfaction to outcomes of public health concern is unlikely without either financial incentives or strengthened external regulation.
Highlights
Pharmacies and drug stores are the first point of care in many low and middle-income countries (LMICs) for a range of medical conditions, including respiratory infections, fever, malaria, injury, body and dental pains, skin infections, diarrhoea and sexually transmitted infections (Igun, 1987; Kamat and Nichter, 1998; Saradamma et al, 2000; Smith, 2009b; Francis N Wafula et al, 2012)
In most LMICs, pharmacy retailing has traditionally been dominated by owner-run shops, but chain pharmacies are a growing organisational arrangement for delivering pharmacy services in these settings
Considering the lack of literature on pharmacy chains in LMIC, we begin this section with a description of the pharmacies studied and the context in which they operate
Summary
Pharmacies and drug stores are the first point of care in many low and middle-income countries (LMICs) for a range of medical conditions, including respiratory infections, fever, malaria, injury, body and dental pains, skin infections, diarrhoea and sexually transmitted infections (Igun, 1987; Kamat and Nichter, 1998; Saradamma et al, 2000; Smith, 2009b; Francis N Wafula et al, 2012). Practice in these outlets is often characterised by deficient knowledge, poor adherence to treatment guidelines, inappropriate supply of medicines, and insufficient counselling With either established or growing corporate pharmacy retail sector in Mexico, Brazil, South Africa, Nigeria, Kenya, Uganda, India and The Philippines (Center for Health Market Innovations, 2014; IMS consulting group, 2014; Lowe and Montagu, 2009), there is a need to understand the effects of these new organisational forms on the functioning of pharmacies and the implications for public health
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