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.
Highlights
People in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription
Of the 93 who went to an accredited drug dispensing outlet (ADDO) first, 28 (30 %) were referred to a public facility
The 467 individuals took a total of 581 medicines (Table 1 top), of which 128 were antimicrobials; 23 % of sick individuals took an antimicrobial. The majority of these antimicrobials were recommended by a doctor or nurse (61 %) and 32 % were recommended at an ADDO (Table 1 middle)
Summary
People in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. In low- and middle-income countries, only 70 % of pneumonia cases receive an appropriate antimicrobial and about half of all acute viral upper respiratory tract infection and viral diarrhea cases receive antimicrobials inappropriately [3]. In low-resource countries, consumers often seek care and purchase medicines, including antimicrobials, at small retail drug shops [4, 5]. In a review of 51 low- and middle-income countries the cost of medicines accounted for 100 % of health care costs for 41 to 56 % of households; 40 % of poor households used savings, borrowed money, or sold assets to pay for care [9]
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