By Birger Forsberg, Karolinska Institute in Stockholm
At the 11th World Congress in Health Economics in Milan Jenny Liu from University of California San Francisco and I, both active in the Health Systems Global Thematic Working Group on the Private Sector in Health, organized a session on market challenges and low-cost solutions in increasing quality of services at retail drug shops in low-income countries. The session aimed to highlight the challenges of working with for-profit drug vendors in pursuit of public health goals.
My takeaways from the studies presented during that session:
- First, a study by Anita Shet, St Johns Medical College Hospital in Bangalore of antibiotic dispensing practices from pharmacies in India, illustrated the magnitude of irrational drug use and the potential cost-savings that could result if such practices were curtailed. The presentation concluded that in the face of lax regulatory enforcement of providers in the private sector, profit motivations can outweigh public health priorities, leading vendors to cater to customer demand.
- This aspect was also a key finding from a study by Amanda Gumpert et al from Karolinska Institutet, Stockholm. They examined the market for diarrhea treatments (ORS + zinc) in Uganda. The authors identified three economic barriers that hinder broader distribution and utilization of ORS and zinc, despite their proven clinical efficacy: prices relative to competing products, profit margins, and strong customer demand, all of which lead to noncompliance with recommended treatment guidelines. The strong market forces in the retail drug sector impede rational and optimal drug dispensing practices despite efficacy and widespread knowledge among vendors.
- The results of two intervention studies featured in the second half of the session suggested that some of these barriers may be overcome, at least on a limited pilot basis. Jenny Liu and Sepideh Modrek introduced malaria rapid diagnostic tests (RDT) among drug shop clientele in Nigeria and also tested a SMS reminder intervention to boost test result adherence. They showed that giving RDTs at drug vendors could vastly improved the quality of malaria treatment and that broader RDT rollout may meet with high acceptability among adults, but that concerted efforts to foster demand and adherence among caregivers of sick children may be needed.
- Phyllis Awor et al. from the School of Public Health, Makerere University, Kampala further examined the introduction of a larger package of services for diarrhea, malaria, and pneumonia at drugs shops in Uganda, showing exceptionally high compliance of recommended treatment protocols. They also demonstrated that it is feasible for drug shop vendors to deliver high-quality services even if strong demand exists for alternative commodities within the market.
The two last studies offer insights into the initial receptivity of drug shop clients and providers to new, low-cost products and further discuss implications for broader market expansion. Together, the four studies emphasize both the importance of working with drug shop vendors for improving access to basic healthcare services and commodities and the market dynamics that need to be considered when engaging them with public health interventions. Further collaboration between the research groups is planned. Others with interest in the role and performance of private drug vendors in health systems are most welcome to join in.
So what does this mean? My perspective is that private actors continue to be the principal providers of health care for the large majority of people in low and middle income countries. Whether we like this fact or not we cannot wish it away. Service provision issues around quality, access and equity in the private sector have to be researched and further discussed for improved health systems and services for those who have the least of knowledge and capacity to make rational decisions when seeking care. Private drug vendors can be partners in development for improved health when appropriately trained and incentivized but they can also be obstacles to such development. An important task lying ahead is to create opportunities for progressive collaboration with private actors for attainment of universal health coverage. Without such engagement the likelihood is high that such small private drug vendors as were described in this session will continue to act against the goals of reduced antibiotic resistant development and protection of the poor against impoverishment due to health care costs.