Provision of Injectable Contraceptives within Drug Shops: A Promising Approach for Increasing Access and Method Choice

Introduction

“Private medicine retailers are fast becoming key players in promoting access to medicines in low- and middle-income countries”

Wafula, Miriti, and Goodman
2012, 223

In sub-Saharan Africa, drug shops, known in some countries as chemist shops or patent medicine vendor shops, are often the most widely used source for health services, information, and products, especially in rural areas with few facilities, pharmacies, and community health workers (Stanback et al. 2011; Wafula and Goodman 2010). In these areas where there is high unmet need for health services and family planning in particular, all feasible means of increasing access and method choice must be explored to meet ambitious development and family planning goals.

Injectable contraceptives are the most popular contraceptive method in sub-Saharan Africa but can be difficult for people in rural areas to obtain from the public sector because of limited access to clinics, acute staff shortages, and stockouts. Injectables are widely available in pharmacies, often at very low prices, as part of organized social marketing programs. Pharmacies are scarce or nonexistent in rural areas where the majority of people in many low-income countries still live.

Drug shops could offer opportunities to expand access to a broader family planning method mix because they are commonplace in rural areas and privately owned and support a sustainable commercial market for health products. However, in most African countries, combined oral contraceptive pills and injectable contraceptives are classified as prescription drugs, and thus, their distribution in drug shops is prohibited by law. In addition, some countries have weak regulatory bodies, which struggle to provide the quality training and supervision needed to ensure family planning is not sold or provided by unlicensed vendors.

Purpose of Brief

This brief focuses on the use of drug shops to increase access to injectable contraceptives. This strategy has not received sufficient attention in the literature. The U.S. Agency for International Development (USAID) has developed a high impact practice brief on family planning provision through both drug shops and pharmacies. http://fphighimpactpractices.org/

June 2014

Why is the use of drug shops to provide injectable contraceptives a promising approach?

  • Drug shops are convenient and popular sources for health care advice, treatment, and supplies, especially in rural and hard-to-reach areas, and they offer an opportunity to reach new and existing injectable contraceptive users. In most countries, drug shops vastly outnumber pharmacies, and this is especially true in rural areas.
  • Shortages of family planning commodities, including injectable contraceptives, at public sector facilities are an everyday reality in many countries in Africa. Drug shops can offer an alternative when there are supply shortages in the public sector.
  • Drug shop operators already provide combined oral contraceptives in many countries. Because injectables do not contain estrogen, they have fewer medical contraindications than combined oral contraceptives. They also are arguably safer than pills for over-the-counter sales if safe injections are ensured (Chin-Quee et al. 2013).
  • Recent evidence suggests that drug shop operators can sell injectables and successfully refer women for safe injection elsewhere (Lebetkin et al. 2014).
  • Injections given outside the formal health care system have been found to be safe if the providers are trained and supervised adequately. There is some research and programmatic evidence that drug shop operators can be trained to safely provide a wide variety of family planning methods, including injectables (T. U. Khan, S. Malarcher, S. Ahmed, S. Sarker, and M. Arevalo, unpublished data; Stanback et al. 2011). In particular, training drug shop operators to support safe provision of injectables should be considered in countries where they are already illegally providing injectables and are likely to continue the practice.
  • Drug shops can help relieve the workload pressure on midwives and staff at health centers as family planning demand increases. With task sharing, a concept endorsed by the World Health Organization (WHO), persons with less training, such as drug shop operators, can deliver some health services with the same quality as providers with more training. This practice allows better use of highly trained workers and expands service delivery (WHO, USAID, and FHI 2010; Stanback et al. 2010).
  • In many countries, drug shop operators have as much or more medical training as volunteer community health workers. Thus, they could be trained to screen clients and even to give safe injections, as community health workers increasingly do across Africa and have done in Asia and Latin America for many years.

Barriers

  • Drug shop vendors’ contribution to the health system is not well understood because their activities, education, and training are not usually documented and regulated.
  • Sale and provision of hormonal contraceptives, especially injectables, are often illegal in drug shops in many African countries because they are classified as prescription drugs.
  • Both pharmacy councils and ministries of health often strongly oppose the sale and provision of injectables, and sometimes even oral contraceptives, in drug shops.
  • Referral processes for long-acting contraceptive methods as well as counseling and treatment of side effects and complications from any method are not common.
  • High staff turnover requires near constant and costly training of new drug shop staff.

What evidence exists about injectable contraceptive provision through drug shops and pharmacies?

Donors and partners are working to understand how to best support and involve drug shops as safe and reliable family planning providers. The following is a summary of recent research and programmatic evidence on expanding access to contraception and specifically injectable contraceptives through these small enterprises.

Some drug shop owners have the prerequisite knowledge and skills to be successfully trained to stock and administer injectables safely and to refer clients to health facilities, as demonstrated in a study of accredited drug-dispensing outlets in Tanzania (S. Mfinanga, C. Lasway, A. Kahwa, E. Ngadaya, S. Mujaya, and G. Kimara, unpublished data).

Research from Nigeria confirms that patent medicine vendors (PMVs) play an important role in the delivery of contraceptive services. Several studies have explored the role of PMVs in offering family planning services in general, but none have specifically assessed the contributions of PMVs to the delivery of injectable contraceptives. A study in select areas of Oyo State found that fewer than half of PMVs had ever received any form of training on how to provide family planning services. However, almost all the PMVs provided family planning services despite their lack of training, and 21 percent sold or administered injectables, although this is prohibited by pharmacy law. The majority of those who administered injections had previous experience working in a health facility as trained providers, such as community health extension workers (Ajuwon et al. 2013).

Women in Tanzania obtaining contraceptives at drug shops were able to self-screen for contraindications to combined oral contraceptives nearly as well as nurses could (Chin-Quee et al. 2013). Advocacy is occurring nationwide for the use of a self-screening poster to enable women to self-screen for hormonal contraceptives, including injectable contraceptives that have fewer medical contraindications than combined oral contraceptives.

Many countries are reluctant to allow drug shops even to sell injectable contraceptives because of safety concerns. However, in Ghana, a pilot study demonstrated that drug shop staff could sell the socially marketed injectable contraceptive depot-medroxyprogesterone acetate (DMPA) and refer clients for safe injection elsewhere (FHI 360 2013). Using this evidence, there is ongoing advocacy to expand the list of medicines sold at licensed chemical shops to include DMPA.

Drug shop operators can be trained to safely provide a wide variety of family planning methods, including injectable contraceptives. For example, the Blue Star Program in Bangladesh has demonstrated that when trained and supported, private sector workers, such as drug shop staff, can safely and effectively provide quality family planning services, including injectable contraceptives (T. U. Khan, S. Malarcher, S. Ahmed, S. Sarker, and M. Arevalo, unpublished data).

Licensed chemical seller holds a package of combined oral contraceptives in Amansie West District, Ghana. Credit: Tracy Orr, FHI 360. Licensed chemical seller holds a package of combined oral contraceptives in Amansie West District, Ghana. Credit: Tracy Orr, FHI 360.

What is needed to expand this practice?

Advocate for the Practice

  • Disseminate and discuss the evidence on drug shops to help create a supportive policy environment globally and locally and to influence stakeholders to amend prohibitive regulations.
  • Organize educational tours for key officials from ministries of health, pharmacy councils, and other regulatory councils to give them a first-hand look at drug shop operators who are safely providing injectable contraceptives.
  • Engage the national pharmacy council in removing restrictions on drug shops’ ability to sell and administer injectable contraceptives.
  • Include drug shop provision of injectables into national family planning and sexual and reproductive health policy and service delivery guidelines.
  • Support training, accreditation, and regulation of drug shop operators.

Generate More Evidence

  • Conduct a desk review and interviews with national and international stakeholders to understand the current context of injectable contraceptives sale and administration in drug shops across countries. Learn more about cadres and skills of drug shop owners and staff; products dispensed; number and types of clients; challenges to injectables provision; and the legal, regulatory, and policy environment.
  • Drug shop owners are business people. Explore ways to motivate them and explain the advantage of being trained to safely provide family planning services.
  • Gather and assess the programmatic lessons learned to gain a better understanding about how to train drug shop operators on required skills and knowledge for administering injectable contraceptives.
  • Conduct additional operations research studies to further verify the feasibility and safety of providing injectable contraceptives in drug shops. Future studies could help determine what investments are needed to make drug shops a safe means of increasing access to this family planning method, especially in hard-to-reach areas. Researchers should also assess the client’s perspective on accessing family planning products at the drug shops.

Develop Training, Quality Assurance, and Operational Guidance

  • Collect existing operational guidance and develop additional tools and resources to support this practice.
  • Train and support drug shop staff to provide a wider variety of family planning methods and information, namely injectable contraceptives.
  • Create point-of-sale information and promotional materials to improve family planning use and the quality of services. Brochures for clients and job aides for drug shop staff, such as screening and standard procedure checklists, can improve the quality of services and information. In social marketing programs, product inserts and other client materials will likely be provided by the distributor (USAID 2013).

Strengthen Regulation, Supervision, and Monitoring and Evaluation

  • Explore franchising and branded networks of drug shops and pharmacies as potential ways to increase visibility and introduce basic monitoring and quality assurance (USAID 2013).
  • Strengthen existing accreditation and training processes provided by drug shop operator associations, pharmacy councils, and social marketing organizations to ensure that clients receive timely and accurate information on contraceptives as well as safe-injection services at these outlets.
  • Develop franchise and social marketing models that build upon the existing drug shop operator associations and support development of locally-led associations where none exist.
  • Strengthen enforcement of licensing and safety regulations as opposed to policing.

Conclusion

Drug shops can help meet the growing demand for family planning, specifically injectable contraceptives, in rural and hard-to-reach areas by improving the availability of high quality and reliable services. More research, programmatic experience, and advocacy are needed regarding this promising practice to ensure that it can be implemented across different settings and has the necessary policy and operational support to successfully enable drug shops to meet the population’s family planning needs.

Reference List

Ajuwon, Ademola, John Imaledo, Frederick Oshiname, and Olayinka Ajayi. 2013. “Research and Recommendations on the Delivery of Injectable Contraceptive Services by Patent Medicine Vendors in Rural Nigeria.” Research Triangle Park, NC: FHI 360.

Chin-Quee, Dawn, Esther Ngadaya, Amos Kahwa, Thomas Mwinyiheri, Conrad Otterness, Sayoki Mfinanga, and Kavita Nanda. 2013. “Women’s Ability to Self-Screen for Contraindications to Combined Oral Contraceptive Pills in Tanzanian Drug Shops.” International Journal of Gynecology & Obstetrics 123 (1): 37–41. doi:10.1016/j.ijgo.2013.04.024.

FHI 360. 2012. “Women’s Ability to Self-Screen for COCs Compared to a Nurse’s Assessment: Drug Shops in Rural and Peri-Urban Tanzania.” Research Triangle Park, NC: FHI 360.

FHI 360. 2013. “DMPA Sales at Licensed Chemical Shops in Ghana: Increasing Access and Reported Use in Rural and Peri-Urban Communities.” Research Triangle Park, NC: FHI 360.

High-Impact Practices in Family Planning (HIP). 2013. “Drug Shops and Pharmacies: Sources for Family Planning Commodities and Information.” Washington, DC: USAID.

Khan, T. U., Malarcher, S. Ahmed, S. Sarker, S., and Arevalo, M. The Blue Star Program: Expanding Access to Injectable Contraception through Private Sector Outlets in Bangladesh. Unpublished draft.

Lebetkin, Elena, Tracy Orr, Kafui Dzasi, Emily Keyes, Victoria Shelus, Stephen Mensah, Henry Nagai, and John Stanback. 2014. “Injectable Contraceptive Sales at Licensed Chemical Seller Shops in Ghana: Access and Reported Use in Rural and Periurban Communities.” International Perspectives on Sexual and Reproductive Health 40 (1):21–7. doi: 10.1363/4002114.

Mfinanga, S., Lasway, C. Kahwa, A. Ngadaya, E. Mujaya, S., and Kimara, G. Assessing the Potential of the Accredited Drug Dispensing Outlets in the Provision of Expanded Family Planning Services in Tanzania. Unpublished draft.

Stanback, John, Conrad Otterness, Martha Bekiita, Olivia Nakayiza, and Anthony K. Mbonye. 2011. “Injected with Controversy: Sales and Administration of Injectable Contraceptives in Drug Shops in Uganda.” International Perspectives on Sexual and Reproductive Health 37 (1): 24–9. doi: 10.1363/3702411.

Stanback, John, Jeff Spieler, Iqbal Shah, and William R. Finger. 2010. “Community-Based Health Workers Can Safely and Effectively Administer Injectable Contraceptives: Conclusions from a Technical Consultation.” Contraception 81 (3): 181–4. doi: 10.1016/j.contraception.2009.10.006.

Wafula, Francis N., and Catherine A. Goodman. 2010. “Are Interventions for Improving the Quality of Services Provided by Specialized Drug Shops Effective in Sub-Saharan Africa? A Systematic Review of the Literature.” International Journal for Quality in Health Care 22 (4):316–23. doi: 10.1093/intqhc/mzq022.

Wafula, Francis N., Eric M. Miriti, and Catherine A. Goodman. 2012. “Examining Characteristics, Knowledge and Regulatory Practices of Specialized Drug Shops in Sub-Saharan Africa: A Systematic Review of the Literature.” BMC Health Services Research 12:223. doi:10.1186/1472-6963-12-223.

WHO (World Health Organization), USAID, and FHI (Family Health International). 2010. “Conclusions from a Technical Consultation: Community-Based Health Workers Can Safely and Effectively Administer Injectable Contraceptives.” Research Triangle Park, NC: FHI.