Accredited Drug Dispensing Outlets Research Articles

Practices and motives behind antibiotics provision in drug outlets in Tanzania: A qualitative study.

Dispensing antibiotics without prescription is among the major factors leading to antimicrobial resistance. Dispensing of antibiotics without prescription has negative impact at the individual and societal level leading to poor patient outcomes, and increased risks of resistant bacteria facilitated by inappropriate choice of antibiotics doses/courses. Antimicrobial resistance is a global public health threat which is projected to cause 10 million deaths by 2050 if no significant actions are taken to address this problem This study explored the practices and motives behind dispensing of antibiotics without prescription among community drug outlets in Tanzania. Finding of this study provides more strategies to antibiotics stewardship intervention. In-depth interviews with 28 drug dispensers were conducted for three months consecutively between November 2019 and January 2020 in 12 community pharmacies and 16 Accredited Drug Dispensing Outlets (ADDOs) in the Mwanza, Kilimanjaro and Mbeya regions of Tanzania. Transcripts were coded and analyzed thematically using NVivo12 software. Majority of dispensers admitted to providing antibiotics without prescriptions, selling incomplete courses of antibiotics and not giving detailed instructions to customers on how to use the drugs. These practices were motivated by several factors including customers' pressure/customers' demands, business orientation-financial gain of drug dispensers, and low purchasing power of patients/customers. It is important to address the motives behind the unauthorized dispensing antibiotics. On top of the existing regulation and enforcement, we recommend the government to empower customers with education and purchasing power of drugs which can enhance the dispensers adherence to the dispensing regulations. Furthermore, we recommend ethnographic research to inform antibiotic stewardship interventions going beyond awareness raising, education and advocacy campaigns. This will address structural drivers of AMR such as poverty and inadequate government health services, and the disconnect between public messaging and/or policy and the public itself.

Antibiotic dispensing practices during COVID-19 and implications for antimicrobial resistance (AMR): parallel mystery client studies in Uganda and Tanzania

BackgroundOver-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller–client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic.MethodsResearch assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms = 415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed.ResultsAdherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client’s symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.ConclusionOur study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.

Linking the Community Health Fund with Accredited Drug Dispensing Outlets in Tanzania: exploring potentials, pitfalls, and modalities

BackgroundIn low- and middle-income countries, too, public–private partnerships in health insurance schemes are crucial for improving access to health services. Problems in the public supply chain of medicines often lead to medicine stock-outs which then negatively influence enrolment in and satisfaction with health insurance schemes. To address this challenge, the government of Tanzania embarked on a redesign of the Community Health Fund (CHF) and established a Prime Vendor System (Jazia PVS). Informal and rural population groups, however, rely heavily on another public–private partnership, the Accredited Drug Dispensing Outlets (ADDOs). This study takes up this public demand and explores the potentials, pitfalls, and modalities for linking the improved CHF (iCHF) with ADDOs.MethodsThis was a qualitative exploratory study employing different methods of data collection: in-depth interviews, focus group discussions, and document reviews.ResultsStudy participants saw a great potential for linking ADDOs with iCHF, following continuous community complaints about medicine stock-out challenges at public health facilities, a situation that also affects the healthcare staff’s working environment. The Jazia PVS was said to have improved the situation of medicine availability at public health facilities, although not fully measuring up to the challenge. Study participants thought linking ADDOs with the iCHF would not only improve access to medicine but also increase member enrolment in the scheme. The main pitfalls that may threaten this linkage include the high price of medicines at ADDOs that cannot be accommodated within the iCHF payment model and inadequate digital skills relevant for communication between iCHF and ADDOs. Participants recommended linking ADDOs with the iCHF by piloting the connection with a few ADDOs meeting the selected criteria, while applying similar modalities for linking private retail outlets with the National Health Insurance Fund (NHIF).ConclusionsAs the government of Tanzania is moving toward the Single National Health Insurance Fund, there is a great opportunity to link the iCHF with ADDOs, building on established connections between the NHIF and ADDOs and the lessons learnt from the Jazia PVS. This study provides insights into the relevance of expanding public–private partnership in health insurance schemes in low- and middle-income countries.

Profiling of antimicrobial dispensing practices in accredited drug dispensing outlets in Tanzania: a mixed-method cross-sectional study focusing on pediatric patients

BackgroundThe emergency of antimicrobial resistance due to irrational antimicrobial use has put public health under threat. Accredited Drug Dispensing Outlets (ADDOs) play an important role in enhancing availability and accessibility of antimicrobials, however, there is a scarcity of studies assessing antimicrobial dispensing practices in these outlets, focusing on children in Tanzania.ObjectiveThis study was conducted to assess the antimicrobial dispensing practices among ADDO dispensers and explore the factors influencing the use of antimicrobials for children in Tanzania.MethodsA community-based cross-sectional study utilizing both qualitative (interviews) and quantitative (simulated clients) methods was conducted between June and September 2020 in seven zones and 14 regions in Tanzania.ResultsThe study found inappropriate dispensing and use of antimicrobials for children, influenced by multiple factors such as patient’s and dispenser’s knowledge and attitude, financial constraints, and product-related factors. Only 8% (62/773) of dispensers asked for prescriptions, while the majority (90%) were willing to dispense without prescriptions. Most dispensers, 83% (426/513), supplied incomplete doses of antimicrobials and only 60.5% (345/570) of the dispensers gave proper instructions for antimicrobial use to clients. Over 75% of ADDO dispensers displayed poor practice in taking patient history.ConclusionADDO dispensers demonstrated poor practices in dispensing and promoting rational antimicrobial use for children. Training, support, and regulatory interventions are required to improve antimicrobial dispensing practices in community drug outlets.

Non-prescribed antibiotic dispensing practices for symptoms of urinary tract infection in community pharmacies and accredited drug dispensing outlets in Tanzania: a simulated clients approach

BackgroundAntibiotic dispensing without prescription is a major determinant of the emergence of Antimicrobial Resistance (AMR) which has impact on population health and cost of healthcare delivery. This study used simulated clients describing UTI like symptoms to explore compliance with regulation, variations in dispensing practices and drug recommendation, and quality of seller-client interaction on the basis of the gender of the client and the type of drug outlets in three regions in Tanzania.MethodA total of 672 Accredited Drug Dispensing Outlets (ADDOs) and community pharmacies were visited by mystery clients (MCs). The study was conducted in three regions of Tanzania namely Kilimanjaro (180, 26.79%), Mbeya (169, 25.15%) and Mwanza (323, 48.07%) in March–May 2020. During data collection, information was captured using epicollect5 software before being analyzed using Stata version 13.ResultsOverall, 89.43% (CI: 86.87–91.55%) of drug sellers recommended antibiotics to clients who described UTI like symptoms but held no prescription and 58.93% were willing to sell less than the minimum recommended course. Female clients were more likely than male to be asked if they were taking other medications (27.2% vs 9.8%), or had seen a doctor (27.8% vs 14.7%), and more likely to be advised to consult a doctor (21.6% vs 9.0%); pharmacies addressed these issues more often than ADDOs (17.7% vs 13.2, 23.9% vs 16.6%, 17.7 vs 10.9% respectively). Sellers recommended 32 different drugs to treat the same set of symptoms, only 7 appear in the Tanzanian Standard Treatment Guidelines as recommended for UTI and 30% were 2nd and 3rd line drugs. ADDO sellers recommended 31 drug types (including 2nd and 3rd line) but had permission to stock only 3 (1st line) drugs. The most commonly suggested antibiotics were Azithromycin (35.4%) and ciprofloxacin (20.5%). Azithromycin was suggested more often in pharmacies (40.8%) than in ADDOs (34.4%) and more often to male clients (36.0%) than female (33.1%).ConclusionThese findings support the need for urgent action to ensure existing regulations are adhered to and to promote the continuing professional development of drug sellers at all outlet levels to ensure compliance with regulation, high quality service and better antibiotic stewardship.

Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study.

Worldwide, antimicrobial resistance is increasing rapidly and is associated with misuse of antimicrobials. The HATUA study (a broader 3-country study) investigated the antibiotic dispensing practices of pharmaceutical providers to clients, particularly the propensity to dispense without prescription. A cross-sectional study using a ‘mystery client’ method was conducted in 1148 community pharmacies and accredited drugs dispensing outlets (ADDO) in Mwanza (n = 612), Mbeya (n = 304) and Kilimanjaro (n = 232) in Tanzania. Mystery clients asked directly for amoxicillin, had no prescription to present, did not discuss symptoms unless asked [when asked reported UTI-like symptoms] and attempted to buy a half course. Dispensing of amoxicillin without prescription was common [88.2, 95%CI 86.3–89.9%], across all three regions. Furthermore, the majority of outlets sold a half course of amoxicillin without prescription: Mwanza (98%), Mbeya (99%) and Kilimanjaro (98%). Generally, most providers in all three regions dispensed amoxicillin on demand, without asking the client any questions, with significant variations among regions [p-value = 0.003]. In Mbeya and Kilimanjaro, providers in ADDOs were more likely to do this than those in pharmacies but no difference was observed in Mwanza. While the Tanzanian government has laws, regulations and guidelines that prohibit antibiotic dispensing without prescription, our study suggests non-compliance by drug providers. Enforcement, surveillance, and the provision of continuing education on dispensing practices is recommended, particularly for ADDO providers.

Towards a digitally-enabled, community-based responsive health system in Tanzania: a formative study for the Afya-Tek digitised health initiative

BackgroundDigital innovation and technologies present vast opportunities in health care and health systems globally, especially in their potential to improve health information management and coordination between health providers. Health care outcomes in child, adolescent, and maternal health in Tanzania, a low-income country, are poor and partly the result of fragmented service provision, lack of clinical guidance to aid decision-making processes, and limited use of data. The Afya-Tek initiative aims to digitally link community members with community health volunteers, public health facilities, and private accredited drug dispensing outlets (ADDOs) to improve decision-making processes and quality of care along the continuum of care, and reduce inefficiency in referral systems. In this mixed-methods study, we aimed to investigate how digital innovation can best be integrated into communities and the local health system in the Kibaha urban and rural districts in the Pwani region of Tanzania. MethodsWe carried out quantitative and qualitative situational analyses of child, adolescent, and maternal health outcomes and related health-seeking behaviour using public health sytem indicators, alongside participant observations, in-depth interviews, and focus group discussions with community and health systems actors. Additionally, we assessed the perceived need and acceptability of digitally linking community health volunteers, public health facilities, and ADDOs. FindingsBetween November, 2019, and February, 2020, we conducted 30 participant observations, 191 in-depth interviews, and 26 focus group discussions. Respondents perceived the main disease burdens for children younger than 5 years to be diarrhoea, malaria, pneumonia, and urinary tract infections. Among pregnant women, these included anaemia, back and foot pain, headache, and bleeding, while for post-partum women respondents mentioned dizziness and frequent bleeding. Sick children younger than 5 years were taken directly to a health facility, whereas other community members primarily sought treatment and advice from ADDOs and only attended the health facility for ‘serious’ health problems. Adolescents preferred family planning services at ADDOs rather than at a health facility for reasons of privacy and stigma. Community members welcomed the idea of a digital health intervention and the possibility of biometric usage did not prompt concern. Workers from within the health system considered that digital technology could improve prompt treatment-seeking, reduce over-dispensing of medication by ADDOs, and minimise double registrations of patients at health facilities. There was a keen interest to use technology to improve care coordination between the three health system actors and assist patients as they navigate through multiple points of care. The inclusion of ADDOs in a digital platform was seen as an innovative approach and also a way to monitor their services. InterpretationThere was a general acceptance of community members and health system stakeholders towards, and hope in, the use of digital health interventions to link community health volunteers, public health facilities, and ADDOs. Our findings, including perceived burden of disease and related health-seeking behaviour, will inform the next phases of the Afya-Tek project in the co-development of the digital health intervention and its implementation, in order to ensure best practices and sustainable approaches in bringing preventive and curative care closer to communities, especially towards improving related child, adolescent, and maternal health outcomes in Tanzania. FundingFondation Botnar

Factors Impacting Tanzanian Rural and Peri-urban Drug Dispensaries' Perceived Benefits from Using an mHealth Reporting System

This study examines the factors impacting Tanzanian drug dispensaries' perceptions of the potential benefits of using a mobile health (mHealth) reporting system. Since 2003, the Government of Tanzania has implemented its Accredited Drug Dispensing Outlet (ADDO) programme in support of dispensaries in under-served rural and peri-urban areas. A core element of this ADDO programme is the dispensary use of an mHealth application for reporting on the drugs they are dispensing and the medical conditions that are being treated. This study canvassed the views of ADDO programme dispensaries using the mHealth reporting system in the Iringa, Mbeya, and Njombe Regions, through a survey questionnaire completed by 318 dispensaries and focus group discussions with 38 dispensary personnel. The data revealed that four factors-system quality, information quality, service quality, and price value-are all having a statistically significant impact on dispensaries' perceptions of the potential benefits of using the mHealth system.

Improving prompt access to malaria diagnostics and treatment in rural remote areas using financial benefit for community health workers in Kilosa district, Tanzania.

PurposeImproving access to malaria treatment in rural remote areas remains a major challenge facing innovative strategies, such as Accredited Drug Dispensing Outlets (ADDOs) and Community Health Workers (CHWs) programs in Tanzania. This study tested the effectiveness of a financial benefit approach to motivate CHWs to improve prompt access to malaria treatment.Patients and methodsWe applied a quasi-experimental study design in rural-remote areas in Kilosa district, Tanzania. Febrile children in selected intervention areas were provided access to malaria diagnostic and treatment at a minimal fee to CHWs and compared with non-intervention areas. We measured impact using difference in differences (DID) analysis.ResultsAt baseline, 870 children <5 years of age were recruited and 1,127 in post-intervention. The DID in prompt access to malaria diagnostics and treatment was 28.0% in favor of intervention. A net pre and post decrease (DID=24.1%) in seeking care from public facilities was observed, signifying decrease in workload. Incidentally, knowledge on malaria treatment increased in intervention area (DID 11%–21%).ConclusionUsing the financial benefit approach, CHWs were able to significantly improve prompt access to malaria diagnostics and treatment in rural remote areas. Scaling up of the strategy might speed up the pace toward achieving national target of accurate diagnosis and appropriate treatment by 80% in 2020.

An assessment of the malaria-related knowledge and practices of Tanzania\u2019s drug retailers: exploring the impact of drug store accreditation

BackgroundSince 2003 Tanzania has upgraded its approximately 7000 drug stores to Accredited Drug Dispensing Outlets (ADDOs), involving dispenser training, introduction of record keeping and enhanced regulation. Prior to accreditation, drug stores could officially stock over-the-counter medicines only, though many stocked prescription-only antimalarials. ADDOs are permitted to stock 49 prescription-only medicines, including artemisinin combination therapies and one form of quinine injectable. Oral artemisinin monotherapies and other injectables were not permitted at any time. By late 2011 conversion was complete in 14 of 21 regions. We explored variation in malaria-related knowledge and practices of drug retailers in ADDO and non-ADDO regions.MethodsData were collected as part of the Independent Evaluation of the Affordable Medicines Facility - malaria (AMFm), involving a nationally representative survey of antimalarial retailers in October-December 2011. We randomly selected 49 wards and interviewed all drug stores stocking antimalarials. We compare ADDO and non-ADDO regions, excluding the largest city, Dar es Salaam, due to the unique characteristics of its market.ResultsInterviews were conducted in 133 drug stores in ADDO regions and 119 in non-ADDO regions. Staff qualifications were very similar in both areas. There was no significant difference in the availability of the first line antimalarial (68.9% in ADDO regions and 65.2% in non-ADDO regions); both areas had over 98% availability of non-artemisinin therapies and below 3.0% of artemisinin monotherapies. Staff in ADDO regions had better knowledge of the first line antimalarial than non-ADDO regions (99.5% and 91.5%, p = 0.001). There was weak evidence of a lower price and higher market share of the first line antimalarial in ADDO regions. Drug stores in ADDO regions were more likely to stock ADDO-certified injectables than those in non-ADDO regions (23.0% and 3.9%, p = 0.005).ConclusionsADDO conversion is frequently cited as a model for improving retail sector drug provision. Drug stores in ADDO regions performed better on some indicators, possibly indicating some small benefits from ADDO conversion, but also weaknesses in ADDO regulation and high staff turnover. More evidence is needed on the value-added and value for money of the ADDO roll out to inform retail policy in Tanzania and elsewhere.

Irrational use of antibiotics in the Moshi Municipality Northern Tanzania: a cross sectional study.

IntroductionIrrational use of antibiotics includes prescription of incorrect doses, self-medication and treatment of non-bacterial illness. As a direct consequence of irrational antibiotic use, resistance to the commonly available antibiotics has been increasing rapidly. This phenomenon is associated with poorer health outcomes, longer hospitalization, increased cost to both the patient and government, and increased mortality. The aim of this study was to determine the prevalence of, and examine factors associated with, irrational use of antibiotics in the Moshi municipality, Northern Tanzania.MethodsWe conducted a cross-sectional descriptive study between April and May 2017 in the Moshi municipality. Twelve drug outlets, of which five were pharmacies and seven accredited drug dispensing outlets (ADDOs), were selected at random. On exiting these outlets, all adults who had purchased antibiotics were interviewed using structured questionnaires.ResultsA total of 152 adults were enrolled in this study. The median (QR) age was 31 years (25-42). The majority, 94 (61.8%), of the participants were female. ADDOs contributed 81 (53.3%) and pharmacies contributed 71 (46.7%) of all participants. Overall, 135 (88.8%) of antibiotic purchases were irrational. The most prevalent form of irrational antibiotic use was non-prescription usage; 116 of the 152 (76.3%) purchases fell in this category. Purchases of the incomplete dosage and purchases for non-bacterial illness were also widespread. Poor knowledge about the use of antibiotics had a significant association with irrational use of antibiotics (aOR=5.1, 95% CI: 1.80-15.15).ConclusionIrrational use of antibiotics is highly prevalent in this population. Non-prescription use of antibiotics is the most prevalent form. Poor knowledge about antibiotic use plays a significant role in irrational antibiotic use. There is a need to review the accessibility of antibiotics in drug outlets.

Can formalizing links among community health workers, accredited drug dispensing outlet dispensers, and health facility staff increase their collaboration to improve prompt access to maternal and child care? A qualitative study in Tanzania

BackgroundIn Tanzania, progress toward achieving the 2015 Millennium Development Goals for maternal and newborn health was slow. An intervention brought together community health workers, health facility staff, and accredited drug dispensing outlet (ADDO) dispensers to improve maternal and newborn health through a mechanism of collaboration and referral. This study explored barriers, successes, and promising approaches to increasing timely access to care by linking the three levels of health care provision.MethodsThe study was conducted in the Kibaha district, where we applied qualitative approaches with in-depth interviews and focus group discussions. In-depth interview participants included retail drug shop dispensers (36), community health workers (45), and health facility staff members (15). We conducted one focus group discussion with district officials and four with mothers of newborns and children under 5 years old.ResultsRelationships among the three levels of care improved after the linkage intervention, especially for ADDO dispensers and health facility staff who previously had no formal communication pathway. The study participants perceptions of success included improved knowledge of case management and relationships among the three levels of care, more timely access to care, increased numbers of patients/customers, more meetings between community health workers and health facility staff, and a decrease in child and maternal mortality. Reported challenges included stock-outs of medicines at the health facility, participating ADDO dispensers who left to work in other regions, documentation of referrals, and lack of treatment available at health facilities on the weekend. The primary issue that threatens the sustainability of the intervention is that local council health management team members, who are responsible for facilitating the linkage, had not made any supervision visits and were therefore unaware of how the program was running.ConclusionThe study highlights the benefits of approaches that link different levels of care providers to improve access to maternal and child health care. To strengthen this collaboration further, health campaign platforms should include retail drug dispensers as a type of community health care provider. To increase linkage sustainability, the council health management team needs to develop feasible supervision plans.

The malaria testing and treatment landscape in mainland Tanzania, 2016

BackgroundUnderstanding the key characteristics of malaria testing and treatment is essential to the control of a disease that continues to pose a major risk of morbidity and mortality in mainland Tanzania, with evidence of a resurgence of the disease in recent years. The introduction of artemisinin combination therapy (ACT) as the first-line treatment for malaria, alongside policies to promote rational case management following testing, highlights the need for evidence of anti-malarial and testing markets in the country. The results of the most recent mainland Tanzania ACTwatch outlet survey are presented here, including data on the availability, market share and price of anti-malarials and malaria diagnosis in 2016.MethodsA nationally-representative malaria outlet survey was conducted between 18th May and 2nd July, 2016. A census of public and private outlets with potential to distribute malaria testing and/or treatment was conducted among a representative sample of administrative units. An audit was completed for all anti-malarials, malaria rapid (RDT) diagnostic tests and microscopy.ResultsA total of 5867 outlets were included in the nationally representative survey, across both public and private sectors. In the public sector, availability of malaria testing was 92.3% and quality-assured (QA) ACT was 89.1% among all screened outlets. Sulfadoxine–pyrimethamine (SP) was stocked by 51.8% of the public sector and injectable artesunate was found in 71.4% of all screened public health facilities. Among anti-malarial private-sector stockists, availability of testing was 15.7, and 65.1% had QA ACT available. The public sector accounted for 83.4% of the total market share for malaria diagnostics. The private sector accounted for 63.9% of the total anti-malarial market, and anti-malarials were most commonly distributed through accredited drug dispensing outlets (ADDOs) (39.0%), duka la dawa baridi (DLDBs) (13.3%) and pharmacies (6.7%). QA ACT comprised 33.1% of the national market share (12.2% public sector and 20.9% private sector). SP accounted for 53.3% of the total market for anti-malarials across both private and public sectors (31.3 and 22.0% of the total market, respectively). The median price per adult equivalent treatment dose (AETD) of QA ACT in the private sector was $1.40, almost 1.5 times more expensive than the median price per AETD of SP ($1.05). In the private sector, 79.3% of providers perceived ACT to be the most effective treatment for uncomplicated malaria for adults and 88.4% perceived this for children.ConclusionsWhile public sector preparedness for appropriate malaria testing and case management is showing encouraging signs, QA ACT availability and market share in the private sector continues to be sub-optimal for most outlet types. Furthermore, it is concerning that SP continues to predominate in the anti-malarial market. The reasons for this remain unclear, but are likely to be in part related to price, availability and provider knowledge or preferences. Continued efforts to implement government policy around malaria diagnosis and case management should be encouraged.

Expanding access to parasite-based malaria diagnosis through retail drug shops in Tanzania: evidence from a randomized trial and implications for treatment

BackgroundTanzania has seen a reduction in the fraction of fevers caused by malaria, likely due in part to scale-up of control measures. While national guidelines require parasite-based diagnosis prior to treatment, it is estimated that more than half of suspected malaria treatment-seeking in Tanzania initiates in the private retail sector, where diagnosis by malaria rapid diagnostic test (RDT) or microscopy is illegal. This pilot study investigated whether the introduction of RDTs into Accredited Drug Dispensing Outlets (ADDOs) under realistic market conditions would improve case management practices.MethodsDispensers from ADDOs in two intervention districts in Tanzania were trained to stock and perform RDTs and monitored quarterly. Each district was assigned a different recommended retail price to evaluate the need for a subsidy. Malaria RDT and artemisinin-based combination therapy (ACT) uptake and availability were measured pre-intervention and 1 year post-intervention through structured surveys of ADDO owners and exiting customers in both intervention districts and one contiguous control district. Descriptive analysis and logistic regression were used to compare the three districts and identify predictive variables for testing.Results and discussionA total of 310 dispensers from 262 ADDOs were trained to stock and perform RDTs. RDT availability in intervention ADDOs increased from 1% (n = 172) to 73% (n = 163) during the study; ACT medicines were available in 75% of 260 pre-intervention and 68% of 254 post-intervention ADDOs. Pre-treatment testing performed within the ADDO increased from 0 to 65% of suspected malaria patients who visited a shop (95% CI 60.8–69.6%) with no difference between intervention districts. Overall parasite-based diagnosis increased from 19 to 74% in intervention districts and from 3 to 18% in the control district. Prior knowledge of RDT availability (aOR = 1.9, p = 0.03) and RDT experience (aOR = 1.9, p = 0.01) were predictors for testing. Adherence data indicated that 75% of malaria positives received ACT, while 3% of negatives received ACT.ConclusionsTrained and supervised ADDO dispensers in rural Tanzania performed and sold RDTs under real market conditions to two-thirds of suspected malaria patients during this one-year pilot. These results support the hypothesis that introducing RDTs into regulated private retail sector settings can improve malaria testing and treatment practices without an RDT subsidy.Trial registration ISRCTN ISRCTN14115509

The Quality of Selected Essential Medicines Sold in Accredited Drug Dispensing Outlets and Pharmacies in Tanzania.

IntroductionThe purpose of this study was to investigate the quality of a select group of medicines sold in accredited drug dispensing outlets (ADDOs) and pharmacies in different regions of Tanzania as part of an in-depth cross-sectional assessment of community access to medicines and community use of medicines.MethodsWe collected 242 samples of amoxicillin trihydrate, artemether-lumefantrine (ALu), co-trimoxazole, ergometrine maleate, paracetamol, and quinine from selected ADDOs and pharmacies in Mbeya, Morogoro, Singida, and Tanga regions. The analysis included physical examination and testing with validated analytical techniques. Assays for eight of nine products were conducted using high-performance thin-layer chromatography (HPTLC). For ALu tablets, we used a two-tiered approach, where tier 1 was a semi-quantitative Global Pharma Health Fund-Minilab® method and tier 2 was high-performance liquid chromatography (HPLC) as described in The International Pharmacopoeia’s monograph for artemether-lumefantrine.Results and DiscussionThe physical examination of samples revealed no defects in the solid and oral liquid dosage forms, but unusual discoloration in an injectable solution, ergometrine maleate. For ALu, the results showed that of 38 samples, 31 (81.6%) passed tier 1 testing and 7 (18.4%) gave inconclusive drug content results. The inconclusive ALu samples were submitted for tier 2 testing and all met the quality standards. The pass rate using the HPTLC and TLC/HPLC assays was 93.8%; the failures were the ergometrine maleate samples purchased from both ADDOs and pharmacies. The disintegration testing of the solid dosage forms was conducted in accordance with US Pharmacopeia monographs. Only two samples of paracetamol, 1.2% of the solid dosage forms, failed to comply to standards. The study revealed a high overall rate of 92.6% of samples that met the quality standards. Although the overall failure rate was 7.4%, it is important to note that this was largely limited to one product and likely due to poor distribution and storage rather than poor manufacturing practices.ConclusionsOver 90% of the medicines sold in ADDOs and pharmacies met quality standards. Policy makers need to reconsider ergometrine maleate’s place on the list of medicines that ADDOs are allowed to dispense, by either substituting a more temperature-stable therapeutically equivalent product or requiring those sites to have refrigerators, which is not a feasible option for rural Tanzania.

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

IntroductionPeople in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.MethodsUsing mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms.Results and DiscussionOf 614 household members with a recent acute illness, 73% sought outside care—30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. Although health facilities and ADDOs had similar availability of antimicrobials, ADDOs had more pediatric formulations available (p<0.001). The common perception was that drugs from ADDOs are more expensive, but the difference in the median cost to treat pneumonia was relatively minimal (US$0.26 in a public facility and US$0.30 in an ADDO). Over 20% of households said they had someone with a chronic condition, with 93% taking medication, but ADDOs are allowed to sell very few chronic care-related medicines. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child.ConclusionADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.

Household Knowledge of Antimicrobials and Antimicrobial Resistance in the Wake of an Accredited Drug Dispensing Outlet (ADDO) Program Rollout in Tanzania.

IntroductionPrivate sector drug shops are an important source of medicines in Tanzania. In 2003, the government introduced the accredited drug dispensing outlet (ADDO) program to improve access to good-quality medicines in rural and peri-urban areas that have frequent drug shortages in public health facilities and few or no registered pharmacies. However, increasing access may also contribute to antimicrobial resistance (AMR) due to the potential overuse and misuse of drugs.MethodsWe conducted a cross-sectional household survey in four regions in mainland Tanzaniato characterize consumer care-seeking habits and medicines use and to determine the extent to which members of the community are knowledgeable about antimicrobials and AMR. Within the regions, we applied a multistage cluster sampling design, cascading from districts, wards, and villages to households. Multivariate logistic analysis was done to determine variables influencing knowledge of antimicrobials and AMR, while controlling for confounding factors. Variables included age, occupation, level of education, membership in an insurance scheme, and wealth status.Results and DiscussionWe revealed that communities in four Tanzanian regions have low levels of knowledge of the concepts of antimicrobials and their use and AMR. Level of public understanding rose with wealth status and education. Only one-third of 1,200 respondents (33.6%) had ever heard of a medicine called an antimicrobial, and 5–15% could name at least one antimicrobial spontaneously. Some thought other medicines, such as paracetamol were antimicrobial (7.5%). People were equally likely to agree that pneumonia should be treated with an antimicrobial (21.4%) as well as common cold (28.4%). Understanding of AMR risks was better, particularly related to HIV and AIDS (32.2%) and malaria (38.6%)—most likely due to information campaigns focused on those two diseases. The level of knowledge decreased the further away respondents lived from an ADDO (p = 0.0001) and where ADDO density was lower (p = 0.001), which supports the use of ADDO dispensers as sources of community information and change agents for more appropriate medicine use.ConclusionLack of knowledge about antimicrobials and AMR in Tanzanian communities needs to be addressed through multi-pronged strategies that focus on prescribers and the public—especially those who are poorer and less educated.

Accrediting retail drug shops to strengthen Tanzania's public health system: an ADDO case study.

IntroductionRetail drug sellers are a major source of health care and medicines in many countries. In Tanzania, drug shops are widely used, particularly in rural and underserved areas. Previously, the shops were allowed to sell only over-the-counter medicines, but sellers who were untrained and unqualified often illegally sold prescription drugs of questionable quality.Case descriptionIn 2003, we worked with Tanzania’s Ministry of Health and Social Welfare to develop a public-private partnership based on a holistic approach that builds the capacity of owners, dispensers, and institutions that regulate, own, or work in retail drug shops. For shop owners and dispensers, this was achieved by combining training, business incentives, supervision, and regulatory enforcement with efforts to increase client demand for and expectations of quality products and services. The accredited drug dispensing outlet (ADDO) program’s goal is to improve access to affordable, quality medicines and pharmaceutical services in retail drug outlets in rural or peri-urban areas with few or no registered pharmacies. The case study characterizes how the ADDO program achieved that goal based on the World Health Organization’s health system strengthening building blocks: 1) service delivery, 2) health workforce, 3) health information systems, 4) access to essential medicines, 5) financing, and 6) leadership and governance.Discussion and evaluationThe ADDO program has proven to be scalable, sustainable, and transferable: Tanzania has rolled out the program nationwide; the ADDO program has been institutionalized as part of the country’s health system; shops are profitable and meeting consumer demands; and the ADDO model has been adapted and implemented in Uganda and Liberia. The critical element that was essential to the ADDO program’s success is stakeholder engagement—the successful buy-in and sustained commitment came directly from the effort, time, and resources spent to fully connect with vital stakeholders at all levels.ConclusionsBeyond improving the quality of medicines and dispensing services, availability of essential medicines, and the regulatory system, the impact of a nationwide accredited drug seller approach on the pharmaceutical sector promises to provide a model framework for private-sector pharmaceutical delivery in the developing world that is sustainable without ongoing donor support.

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

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.

What motivates antibiotic dispensing in accredited drug dispensing outlets in Tanzania? A qualitative study.

BackgroundTanzania introduced the accredited drug dispensing outlet (ADDO) program more than a decade ago. Previous evaluations have generally shown that ADDOs meet defined standards of practice better than non-accredited outlets. However, ADDOs still face challenges with overuse of antibiotics for acute respiratory infections (ARI) and simple diarrhea, which contributes to the emergence of drug resistance. This study aimed to explore the attitudes of ADDO owners and dispensers toward antibiotic dispensing and to learn how accreditation has influenced their dispensing behavior.MethodsThe study used a qualitative approach. We conducted in-depth interviews with ADDO owners and dispensers in Ruvuma and Tanga regions where the government implemented the ADDO program under centralized and decentralized approaches, respectively; a secondary aim was to compare differences between the two regions.ResultsFindings indicate that the ADDO program has brought about positive changes in knowledge of dispensing practices. Respondents were able to correctly explain treatment guidelines for ARI and diarrhea. Almost all dispensers and owners indicated that unnecessary use of antibiotics contributed to antimicrobial resistance. Despite this knowledge, translating it to appropriate dispensing practice is still low. Dispensers’ behavior is driven by customer demand, habit (“mazoea”), following inappropriate health facility prescriptions, and the need to make a profit. Although the majority of dispensers reported that they had intervened in situations where customers asked for antibiotics unnecessarily, they tended to give in to clients’ requests. Small variations were noted between the two study regions; for example, some dispensers in Ruvuma reported sending clients with incorrect prescriptions back to the health facility, a practice that may reflect regional differences in ADDO implementation and in Integrated Management of Childhood Illness training. Dispensers in rural settings reported more challenges in managing ARI and diarrhea than their urban counterparts did.ConclusionTo reduce inappropriate antibiotic use, integrated interventions must include communities, health facilities, and ADDOs. Periodic refresher training with an emphasis on communication skills is crucial in helping dispensers deal with customers who demand antibiotics. Responsible authorities should ensure that ADDOs always have the necessary tools and resources available.