A first stop for family planning and health services, but what do we know about the clients they serve?
A call to involve important market actors to meet the health needs of family planning clients
Photo: Elmvh/GFDL via Wikimedia Commons
The Sustainable Development Goals will be difficult to achieve without vigorous participation from the private sector. In fact, private drug shops and pharmacies are a widely- used source for health information, products, and services, including family planning (FP), especially in sub-Saharan Africa.1 Throughout Africa, however, the burgeoning private sector is generally fragmented with little coordination and negligible regulatory oversight. This hinders the ability of governments to undertake quality assurance for services and products that are delivered through private channels. In some contexts, these challenges are exacerbated by inherent tension between government and the private sector, with few incentives to promote quality of care. At the same time, a better understanding of supply-and-demand-side factors that prompt clients to use the private sector can shape policies, incentives, and public-private dialogue to involve the private sector in the overall health system.
Numerous studies have examined the feasibility and operational aspects (quality, access, use, and cost) of providing priority health interventions through drug shops and pharmacies. Others have analyzed contraceptive-use patterns, market trends, and the role of the private sector in improving equity in access.2,3,4 Yet a critical knowledge gap about characteristics of “end users” who obtain their contraceptives from drug shops and pharmacies remains. Some key questions are: What do we know about this market segment? What patterns emerge from comparisons within and across countries? What differences do we see between countries with relatively high FP use compared with those with low FP use? While not all of these questions can be answered here, a deeper understanding of these users can inform market-shaping policies and strategies aimed at working with the private sector to meet FP and other health needs.
FP is a relatively low-cost intervention with wide-ranging health, social, and economic benefits. Information on demographic and FP use patterns is readily available through Demographic and Health Surveys (DHS). Secondary analysis of DHS surveys in sub-Saharan Africa over the last 10 years was used in this brief5 to offer insights into the characteristics of FP clients who obtain contraceptives from private drug shops and pharmacies in selected countries.
The private provider landscape is diverse
The private health sector is defined as all actors “who exist outside the public sector, whether their aim is philanthropic or commercial, and whose aim is to treat illness or prevent disease. The sector includes large and small commercial companies, groups of professionals such as doctors, national and international nongovernmental organizations, and individual providers, pharmacies, and shopkeepers.”6 Further, private health service providers can be categorized as informal or formal providers depending on how they are organized and whether they are accredited or registered with the government. However, these definitions are broad and diverse across the literature. Note that classifications var y across countries, and there is overlap. The table below provides a snapshot of terms.1,7,8
Table 1: Overview of private health sector providers
What do we know about the clients who source their contraceptives (including condoms) from pharmacies and drug shops?
Market segmentation using DHS data reveals the important role of pharmacies and drug shops in providing FP.
We examined selected countries in sub-Saharan Africa based on sample size and grouped them into two categories: low modern contraceptive prevalence rate (mCPR) (< 20%) and higher mCPR (> 20%) to identify any patterns across these categories. See the map to the left for a list of countries and year of the DHS survey used.
The majority of clients in low mCPR countries source contraception from private providers.
In Zimbabwe, Zambia, Malawi, and Madagascar, countries with a higher mCPR, over 70 percent of women last sourced their contraception from the public sector. In the majority of countries with mCPR of less than 20 percent, drug shops and pharmacies accounted for a large proportion of where women accessed their contraception, with the notable exception of Burkina Faso, where the public sector dominates as a source for FP. The use of pharmacies and drug shops was highest in Cote d’Ivoire, followed by the Democratic Republic of Congo (DRC) and Cameroon, where more than 50 percent of women last the size of these countries, this represents a significant “market” or number of drug shop and pharmacy FP clients.
In 9 out of 12 countries, the majority of clients come from urban areas.
No major patterns emerge between lower mCPR (< 20 percent) and higher mCPR (> 20 percent) countries in regards to the type of area. In Zambia and Zimbabwe, more than 70 percent of women reside in urban areas, whereas in Tanzania, Madagascar, and Kenya, the majority of women using pharmacies and shops are in rural areas. This may partially reflect the level of urbanization in Zambia and Zimbabwe and/or the effectiveness of rural distribution systems in those two countries, both of which have had rural FP programs for decades.
In low mCPR countries, over one-third of drug shop and pharmacy clients are youth.
In 5 of 12 countries—Burkina Faso, Cameroon, the DRC, Malawi, and Tanzania—the majority of FP clients who obtained a method from a pharmacy or shop were youth (ages 15 to 24). Among lower mCPR countries, over one-third of women who accessed contraception from a pharmacy or shop were youth. In higher mCPR countries, no general pattern was observed. Anecdotal and programmatic evidence suggests that young people often feel uncomfortable going to established public clinics for contraception, and the private sector offers an additional advantage of privacy and anonymity. Old-fashioned or punitive attitudes of FP providers also have shown to deter young clients, especially very young adolescents.
In low mCPR countries, over half of pharmacy or drug shop clients are unmarried.
Drug shops and pharmacies for the most part serve relatively wealthy FP clients.
Nonetheless, for the poor, drug shops and pharmacies are an important source for FP.
What do these findings tell us?
The “macro-level” findings presented here have important policy implications that can ser ve as a starting point to use client-centered data to inform policymakers, donors, and program implementers on important strategies to engage retail providers. Looking at country-specific data, for example, can point to ways of tailoring programs to clients, when supplemented with additional data collected in assessments and situation analyses. A high level of pharmacy and drug shop use in rural areas of low mCPR countries could point to weak supply chain, weak training and supervision of public sector personnel, and generally a poor public sector “offering” of FP. The fact that youth may gravitate to the private sector has implications in forward planning, particularly for availability of short-acting contraceptives and emergency contraception. Finally, price, provider-client experience, and general population awareness must be considered in national policy and strategy design.
Given the importance of the private sector, it is surprising that few African countries currently include pharmacies— and even fewer include drug shops—in their national health and FP strategies. These outlets are too important in local communities for program planners and government to ignore. Drug shops and pharmacies could easily provide more services and vital information.
Globally, the story is similar. WHO and other entities that set the stage for country decision-making have underemphasized retail outlets’ importance as FP sources. As a result, this vibrant sector is often ignored in policymaker and program manager plans.
1 Use market data to understand the role of drug shops and pharmacies in providing health products and services, the motivations and behavioral drivers of their clients, and the relationship among public and private leaders and donors to determine clear opportunities to involve the private sector, especially for improving quality and financial sustainability of health products and services.
2 Understand the specific market segments that drug shops and pharmacies serve within a country and develop strategies to reach underserved populations. Conduct in-depth assessments to understand who is accessing services where, the motivations behind their behaviors, and the interplay between the public sector program and the private sector market.
3 Identify options for retail providers to expand access to and quality of products and services; experiment with incentives for private providers and private-sector pharmacy associations to deliver high-quality services; and work with retail providers to identify and eliminate fraudulent or fake drugs and other threats to safety and health of clients.
4 Determine and mitigate policy barriers to partnerships with drug shops and pharmacies. Liberalize provision of methods and brands through various cadres (following WHO medical eligibility criteria) and price reductions on high-quality commercial brands.
5 Define “success” measures for involving drug shops and pharmacists in reaching specific market segments and providing “backup” access to contraceptives when public sector delivery systems experience stockouts. Improve convenience and increase access to a range of contraceptive options through a total market approach.
6 Approach the above efforts through a perspective that recognizes the important distinctions between drug shops and pharmacists, including the clients they serve.
In sum, as knowledge about and demand for modern contraception grows worldwide, especially in Africa, and as the private sector continues to expand, governments, private providers, donors, and clients themselves can create “win-win” scenarios. This will require using market data to understand the characteristics of current and potential private sector clients, as well as population segments that remain underserved so that interventions can be designed to reach consumers who have a range of FP needs. By creating conditions that engage and support private pharmacies and drug shops, governments and their partners can advance sustainability, equity, and universal health care through a diverse, well-functioning health market.
Tanvi Pandit-Rajani, Nancy Harris, Leanne Dougherty, Emily Stammer, John Stanback, 2017, Drug Shops & Pharmacies A first stop for family planning and health ser vices, but what do we know about the clients they serve?, Arlington, VA: Advancing Partners & Communities.
1 Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? A systematic review. PLoS One. 2013;8(2):e54978. doi:10.1371/journal.pone.0054978.
2 Hotchkiss DR, Godha D, Do M. Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia. Int J Equity Health. 2011;10(1):33. doi:10.1186/1475-9276-10-33.
3 Agha S, Do M. The quality of family planning services and client satisfaction in the public and private sectors in Kenya. Int J Qual Heal Care. 2009;21(2):87-96. doi:10.1093/intqhc/mzp002.
4 Campbell OMR, Benova L, Macleod D, et al. Who, What, Where: an analysis of private sector family planning provision in 57 low- and middle-income countries. Trop Med Int Heal. 2015;20(12):1639-1656. doi:10.1111/tmi.12597.
5 Pandit-Rajani T, Dougherty L, Stammer E, Stanback J. 2017. Drug shops and pharmacies for family planning services: Who are the clients? Arlington, VA: Advancing Partners & Communities. Manuscript submitted for publication.
6 Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? Bull World Health Organ. 2002;80(4):325-330.
7 Waters H, Hatt L, Peters D. Working with the private sector for child health. Health Policy Plan. 2003;18(2):127-137.
8 Lagomarsino G, Nachuk S, Kundra SS. Public Stewardship of Private Providers in Mixed Health Systems. Washington, DC: Results for Development Institute; 2009.