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There are ways to make informal outlets fit for quality care in poor areas, say Jafary Hassan Liana and Martha Embrey.
Many people in developing countries — up to 82 per cent in Sub-Saharan Africa — seek healthcare and medicines from retail drug shops. They do so for different reasons, including convenience and drug availability.
In Tanzania, these duka la dawa baridi are often the only place to buy drugs in rural areas. Historically, the Tanzania Food and Drugs Authority (TFDA) authorised duka la dawa baridi to sell over-the-counter medicines. However, a 2001 assessment showed that many sold prescription drugs illegally, enforcement was minimal and sellers were generally unqualified and untrained. 
These practices go beyond Tanzania. Studies show that 58 per cent of drug sellers in Laos admit to buying drugs from unauthorised sources; untrained sellers in Nepal also provide clinical services such as injections and wound dressing; and Nigerian medicine vendors know something about illness symptoms but little about treatment. [2,3,4]
Recognition of informal providers’ impact on public health has grown, with calls to bring this sector under the health system umbrella. But the interventions documented so far have been generally limited in scope: for example, training sellers in one location about one illness. Introducing and scaling up comprehensive programmes is challenging.
But it can be done. A successful public-private partnership in Tanzania is one model.
Improving existing shops
The US non-profit organisation Management Sciences for Health (MSH) started working with the TFDA to develop the partnership almost 15 years ago. It aimed to increase access to affordable, quality medicines and pharmaceutical services in underserved areas — and it did so by focusing on the existing duka la dawa baridi that people in rural areas tend to use.
The programme developed the accredited drug dispensing outlet (ADDO) — an improved type of drug shop. It combines accreditation based on government standards, training of sellers, incentives to become accredited, local government oversight and efforts to boost customer demand for quality care. The main incentive it offered owners was a broader list of drugs to stock and dispense legally, including select prescription-only medicines such as antibiotics.
In 2003, MSH piloted the ADDO programme in Ruvuma, a large, sparsely populated region in southwest Tanzania with about 115 licensed duka la dawa baridi and no pharmacies.
We evaluated the pilot using mystery shoppers to assess service quality and shop audits to check drug availability, quality and price. There were lasting improvements. For example, in 2003, before accreditation, only six per cent of mystery shopper encounters for malaria were treated with the correct drug, dose and duration. In 2004, after the programme launched, the result was 24 per cent and in 2010 reached 63 per cent.
About half the patients visit shops without a prescription, so mystery shopper results are a good indication of quality of care.
The government decided to bring all drug shops into the formal health sector through the programme. There are now ADDOs in all 25 of Tanzania’s mainland regions, with over 9,000 shops accredited (or nearly so) and over 19,000 dispensers trained.
As the programme took off, many recognised the potential for ADDOs to serve as a platform for community-based public health interventions.  Other organisations helped expand ADDOs’ services — tackling antimicrobial resistance, for example, or early detection of tuberculosis. And Tanzania’s National Malaria Control Programme incorporated ADDOs into its 2006 strategic plan as an alternative to public sector sources of first-line malaria medicines.
The programme has also expanded its geographic reach. With help from MSH, Liberia and Uganda have adapted the model. During the recent Ebola crisis in Liberia, 600-plus drug shops modelled on ADDOs continued to provide access to medicines for common conditions such as malaria even as public clinics closed under the strain.
The Ruvuma pilot showed that a drug seller initiative based on accreditation and regulation is feasible and can improve access to quality care. But it didn’t address scaleup, which required decentralised implementation and responsibility for certain components to be handed to institutions.
Efficiency and sustainability are still improving. The Pharmacy Council, the health ministry’s drug regulatory organ that now oversees ADDOs, saw lack of information as a problem: it didn’t have an easy way to keep track of the shops, including business licensing fees and inspections. MSH worked with a local information technology group to build a regulatory database for the council with information on every shop in the country.
The IT group also built mobile-phone applications that let owners pay licencing fees to the council, and allow communication between the council and shop employees or owners. From May to August 2014, the council received 3,378 messages and sent 22,818 messages.
To build capacity, it was also important to shift the responsibility for owner and dispenser training from the council to selected institutions such as St. Peter’s College of Health Sciences in Dar es Salaam. MSH worked with these institutions using the government-approved training materials, with training costs covered by ADDO owners and dispensers.
The programme also helps ADDO owner and dispenser associations to empower themselves. To generate resources for loans, for example, an association in Mbarali district bought land to rent out; a group in Bagamoyo district established a savings and credit society; and an association in the city of Mbeya is establishing a wholesale pharmacy to serve its members.
The next step
The initiative’s success has sparked growing international interest. MSH plans to launch a technical resource centre in Tanzania later this year, which other African countries can use to develop their own drug seller initiatives. This centre will include access to start-up grants and technical assistance from ADDO implementation experts, and will organise study visits.This kind of initiative requires major technical and financial support. But the primary lesson MSH learned is that the country must drive the programme, not the donor or the organisation providing technical support.
Once accredited, most shops continue to profit, and the owners and dispensers can cover the costs of training and other business expenses such as licence fees — which, in turn, contribute to the government’s costs of regulation and inspection. Crucially, once the accreditation process is running efficiently, the programme pays for itself, ending the need for donor support.
Jafary Hassan Liana is a senior technical advisor for MSH Tanzania who worked as the project lead for the country’s Sustainable Drug Seller Initiative programme. Martha Embrey is senior technical writer at MSH based in the United States. Liana can be contacted at [email protected] and Embrey at [email protected]
 Accredited drug dispensing outlets in Tanzania: Strategies for enhancing access to medicines program — Final report (Center for Pharmaceutical Management, 2008)
 Lamphone Syhakhang and others Knowledge and perceptions of drug quality among drug sellers and consumers in Lao PDR (Health Policy and Planning, 2004)
 Sudesh Gyawali and others Pharmacy practice and injection use in community pharmacies in Pokhara city, Western Nepal (BMC Health Services Research, 2014)
 Naomi Beyeler and others A systematic review of the role of proprietary and patent medicine vendors in healthcare provision in Nigeria (PLOS ONE, 28 January 2015)
 Edmund Rutta and others Creating a new class of pharmaceutical services provider for underserved areas: The Tanzania accredited drug dispensing outlet experience (Progress in Community Health Partnerships: Research, Education, and Action, 2009)