Lisinopril 20 mg by mouth at eight AM? Check. Having already verified the patient’s identification, I scanned the medication barcodes into the computer one by one, performing the third, and final, confirmation of the “five rights” of medication administration – right patient, right drug, right dose, right route, and right time. As a new nursing student these principles of medication administration, designed to promote safety and reduce errors, had formed a foundation of my fledgling practice. They were not, however, altogether new to me. Prior to beginning my nursing education, I worked with the international nonprofit organization Management Sciences for Health. My former colleagues in Arlington, Virginia, and throughout the world have devoted their professional lives to ensuring that communities in low- and middle-income countries have access to high-quality, affordable medications. While I applied the “five rights” to ensure my patient received the correct medicine, my colleagues applied them to ensure that whole communities received the medicines and pharmaceutical services they required, all while building resilient pharmaceutical systems.
One of the puzzles facing my colleagues, and the global health community at large, is how to optimize the training and skill set of diverse health workforces. Millions of people throughout the world purchase their medicines from private-sector retail drug outlets, an umbrella term encompassing regulated and unregulated pharmacies, chemists, and informal drug vendors, among others. For individuals with a wide range of illnesses, these convenient and affordable outlets frequently serve as a first point of contact with the healthcare system. For this reason, the World Health Organization (WHO) and the International Pharmaceutical Federation have recognized the importance of partnering with private-sector retail drug outlets in efforts to decrease time to accurate diagnosis and treatment, as well as inappropriate dispensing of antibiotics. A prime example of this approach is the way in which recent pilot projects have successfully trained staff at private-sector retail drug outlets to identify and refer clients with probable TB for diagnostic testing and treatment in an effort to reach some of the three million people worldwide who have TB but remain undiagnosed. Early success in these efforts prompted the WHO and Stop TB Partnership to recommend this approach as part of a comprehensive strategy to ensuring every person with TB has access to care and treatment.
Having had central roles in the design and implementation of many of these pilot projects, my colleagues recently reflected on the global recommendations and evaluated the extent to which they have been translated into action at the country level. In our recently published research, we found that despite recognition of the importance of partnering with retail drug outlets, and despite their demonstrated willingness and ability to contribute to TB control efforts, widespread engagement of this sector has been slow. Among the countries we studied, the percentage of retail drug outlets engaged in such efforts ranged from less than 5 percent to 9 percent of all retail drug outlets in the country.
This finding has a number of important implications for TB programs. First, the feasibility of scaling up engagement of the private retail drug sector in a country depends on three key variables: the TB burden, the number of drug outlets in the country, and the size of the population. For example, Bangladesh has an annual TB incidence of roughly 227 per 100,000 population, and approximately 200,000 regulated and unregulated drug outlets nationwide, meaning there is on average one outlet for every 805 people. By comparison, Indonesia has an annual TB incidence of 399 per 100,000 population, and approximately 30,643 drug outlets nationwide, corresponding to an average of one outlet for every 8,405 people. Thus, training 20,000 drug outlets in each country would have vastly different levels of reach, covering 10 percent of the outlets in Bangladesh and 65 percent of those in Indonesia. If this seems daunting, then our paper argues that countries may rely on changing structures and incentives by better utilizing the roles of national medicines regulatory authorities and retail and wholesale pharmacy associations.
The second implication from our research is the very real need for information on the costs of engaging retail drug outlets, data that is currently missing from much of the literature. Such estimates, if modeled from pilot or small-scale initiatives, would allow TB programs to allocate limited funding to those interventions that have demonstrated optimal cost effectiveness. For example, one pilot project in Tanzania cost an estimated $176,635 to train over 700 retail drug outlet dispensers in the identification and referral of clients with TB-like symptoms. However, costs may vary considerably depending on local context.
The final implication from our research is that any intervention involving private retail drug outlets requires careful consideration of both short- and long-term solutions. In the immediate future, training staff at retail drug outlets to identify and refer individuals with probable cases of TB may offer an important adjunct to existing case identification efforts. However, long-term solutions require greater sustainability by way of integration into the existing health system. For example, a country’s national pharmaceutical association may work with pharmacy schools to redesign curricula, ensuring that education includes commonly encountered illnesses that require very standardized treatment, such as TB, as well as the appropriate use of antimicrobials.
The potential of private retail drug outlets to contribute to TB identification and treatment is well known; however, the extent to which these establishments have been engaged is insufficient given the global burden of TB and the enormous size of the private health sector. Although our paper focuses on TB, the takeaway messages have implications for malaria, reproductive health, family planning, and for those debating the issue of scale (coverage) with that of effective regulation and incentives. Whether we are nursing students administering medicine to patients in hospitals, or retail drug outlet dispensers counseling clients in our communities, our patients require a system that ensures they receive the right drug, at the right dose, via the right route, at the right time.