At the London Family Planning Summit in 2012, the Government of Uganda committed to providing universal access to family planning and reducing unmet need for family planning from the current 40 percent to 10 percent by 2022. To meet this ambitious goal, all potential means of increasing accessibility to family planning must be explored.
The Ministry of Health (MOH) is committed to supporting alternative distribution channels for the private sector and to scaling up innovative approaches such as community-based distribution, outreach, social marketing, social franchising, and youth-friendly service provision. The country's numerous registered and unregistered drug shops are a prime example of alternative distribution channels that could help Uganda reach its family planning goal.
Need for Injectable Contraception
Currently, 35 million women worldwide use injectable contraception to prevent pregnancy— twice as many as a decade ago. In sub-Saharan Africa, more than one-third of modern contraception users rely on injectables, making them the most-used modern method. Despite their popularity, 32 countries reported unmet need at 25 to 50 percent for injectables (WHO 2010).
The majority of injectable-using clients use depot medroxyprogesterone acetate (DMPA), an intramuscular injection of 150 mg given every 13 weeks. An increasing amount of countries have introduced Sayana Press, a subcutaneous formulation of DMPA in a small pre-filled auto-disposable device called Uniject. Both formulations have the same contraception effectiveness and safety. The World Health Organization (WHO) has identified only a few medical conditions that limit or prohibit the use of injectable contraceptives. Prior to initiating use, providers must screen clients for pregnancy and medical eligibility. They must also provide injections safely and inform women about delayed return to fertility and potential side effects, including vaginal bleeding irregularities, amenorrhea, and weight gain.
"Private medicine retailers are fast becoming key players in promoting access to medicines in low- and middle-income countries."
(Wafula, Miriti, and Goodman 2012)
In Uganda, contraceptive use in general is low. Only 23 percent of currently married women use a modern method, but unmet need among this group is 34.3 percent (20.8 percent for spacing and 13.5 percent for limiting). Uganda, at 3.2 percent per year, also has one of the fastest rates of population growth and a high fertility rate of 6.2 children per woman (UBOS 2011). Among the reasons for low use of contraceptives are barriers to access, stockout of family planning supplies, and shortage of trained health staff. These problems are more acute in rural areas, where health facilities tend to be few and far between. Not surprisingly, women in rural areas have almost twice as many children as women in urban areas.
Drug Shop as Delivery Channel
Private sector drug shops are more readily found in rural areas and are the first level of health care services for people who live in hard-to-reach areas, and offer an opportunity to reach current and new family planning clients. Uganda's 6,363 registered and many more unregistered drug shops serve 80 percent of the rural population (UBOS 2011). Oral contraceptive pills and condoms are provided legally by drug shop operators, most of whom have some medical training (Stanback et al. 2011). However, some drug shop operators stock and provide injectable contraception—the more popular method— despite the fact that the sale and administration of any injectable drug by drug shops is illegal. But given the high maternal mortality and morbidity, poorly stocked clinics, and high unmet need for family planning, this unsanctioned practice provides a needed service. In addition, because of their presence and popularity, private sector drug shop involvement increases family planning use in in underserved areas. Further, private enterprises are less likely than public sector health facilities to suffer from commodity stockouts. And finally, Uganda's MOH has already sanctioned provision of the injectable contraceptives by community health workers, who are in general far less medically qualified than typical drug shop operators.
"Train and support drug shop and pharmacy staff to provide a wider variety of family planning methods and information" is one of six family planning high-impact practices in service delivery promoted by USAID.
In other countries, drug shop operators have been trained to provide a wide variety of family planning methods, including the injectable contraceptive DMPA, to make contraceptives more accessible. 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 DMPA, and many clients preferred going to a local drug shop (Khan et al. n.d.).
A technical consultation held in Research Triangle Park, North Carolina, USA in 2013 concluded that in the developing world, drug shops have the potential to play a much greater role in helping women and couples achieve their family planning intentions (Stanback et al. 2015). The group of 15 researchers and program experts found that the sale of DMPA is common in drug shops in some countries and that training, policy, research, and advocacy interventions should be prioritized by funders and the family planning community. Recognition of the utility of drug shops in providing short-acting contraception methods is growing. Currently, WHO is interested in developing guidance on the effective integration of the drug shop and pharmacy sector into public health program strategies, planning, and budgeting.
Several organizations have worked with the MOH to conduct three investigations of drug shops operators in selected districts to assess the suitability of drug shops to sell and administer injectable contraceptives in Uganda.
Assessment of Drug Shop Suitability for Sales of Injectable Contraceptives
The recent introduction in Uganda and elsewhere of Sayana Press, a subcutaneous formulation of DMPA, increases the prospects for non-clinic provision of DMPA and may catalyze policy action in favor of DMPA provision in drug shops.
(Akol et al. 2014; Burke et al. 2014)
From November 2007 to January 2008, FHI 360 and Save the Children conducted a survey with 124 of the 157 drug shop operators who sold DMPA in Nakaseke, Luwero, and Nakasongola to assess the suitability of drug shops as sales outlets for the socially marketed "Injectaplan" (Stanback et al. 2011). The survey findings showed that:
- the majority of drug shop operators were female; most had some medical training (most often as a nurse or nursing assistant) and had completed senior 4 level of education
- drug shops were a major provider of health care, and the majority sold (85 percent) and injected (96 percent) DMPA in the shops
- drug shop operator knowledge of DMPA side effects DMPA varied
- training on injection skills and the delivery of family planning services in general was needed; fewer than half had sharps boxes and about 24 percent had needle stick injuries.
Follow-up Assessment of Subset of Drug Shop Operators
In 2009, based on the interest of stakeholders and with approval from the MOH, a pilot study was designed to train 146 of the previously surveyed drug shop operators to provide DMPA in Luwero and Nakasongola (Chin-Quee 2010). FHI 360 and Save the Children provided training on family planning, safe injection, and waste disposal procedures. In follow-up they compared 37 trained drug shop operators with 26 who did not receive the training. The study assessed knowledge, attitudes, and practice through interviews with the service providers. The findings, summarized below, demonstrated that community-level distribution through drug shops is safe and feasible if drug shop operators have been trained.
- Trained drug shop operators improved from baseline to follow-up on scores for general contraception, method provision, and DMPA knowledge; their scores for administration of DMPA also increased from baseline to follow-up. However, injection practice and knowledge improvements were not statistically significant when compared to the control group.
- In the intervention and control groups, drug shop operators demonstrated that they were able to administer injectables safely. However, their general knowledge of family planning, management of DMPA clients, and ability to counsel clients needs improvement.
Assessment of Drug Shop Contribution to Family Planning Service Provision
Drug shop vendors' contribution to the health system is not well understood because their activities, education, and training are not usually documented and regulated. In September 2011, service delivery data from 139 drug shop operators in Bugiri, Luwero, Nakasongola, and Mayuge districts were evaluated to determine drug shops' contribution to family planning service provision (Akol et al. 2014). In addition, drug shop clients were interviewed to determine their acceptance of and satisfaction with drug shop operators who provided family planning services. The evaluation resulted in several findings:
- In three of the four districts assessed, drug shop operators provided an equivalent amount of family planning services (as measured in couple years of protection) as village health teams and clinics.
- Family planning clients, who were mostly DMPA users, were satisfied with drug shop services, and more than 95 percent would recommend drug shop operators to a friend for family planning services, reflecting an overall high level of satisfaction with DMPA services from drug shop operators.
- Drug shops are a preferred source for family planning, as indicated by the fact that about one-half of family planning clients switched from clinics to drug shops for these services.
Next Steps and Recommendations
The research and programmatic findings have implications for policies on the provision of injectable contraceptives by drug shop operators. Stakeholders should discuss the programmatic and operational questions that the research raised.
- Convene a stakeholder meeting to discuss drug operators' current practices and potential role in selling and administering injectable contraceptives.
- Amend national health policies and guidelines to allow drug shop operators to provide injectable contraceptives in the community.
- Incorporate drug shop task sharing in national strategic plans.
- There is an immediate need for training and supervision on injectable provision and universal access to puncture-proof sharps containers. Make marketing and informational materials available to legal purveyors of social marketing injectables.
- Focus more attention on family planning knowledge and counseling when training experienced drug shop operators, as many already provide injections relatively well.
- Strengthen existing accreditation and training processes for drug shop operator associations by working closely with the MOH, National Drug Authority, and social marketing organizations to ensure that clients receive timely and accurate information on contraceptives and safe injection services at these outlets.
- Collect existing operational guidance and develop additional tools and resources to support injectable contraception provision.
- Create point-of-sale information and promotional materials to improve family planning use and 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).
- Give drug shop operators the service data collection forms developed by the STRIDES Project so they can incorporate the number and type of family planning clients they serve in Uganda's health management information system. Document referrals made to and by drug shops as well.
Drug shops can be a viable and convenient source for short-acting contraceptive methods, including DMPA, particularly for continuing users but also for new family planning clients. Drug shops and other private sector providers offer complementary services to help government service providers meet the growing demand for family planning, specifically injectable contraceptives, and should be included in the network of community-based family planning providers in Uganda.
Akol A, Chin-Quee D, Wamala-Mucheri P, Namwebya JH, Mercer SJ, Stanback J. 2014. Getting closer to people: family planning provision by drug shops in Uganda. Global Health Science and Practice, 2(4):472-481.
Burke HM, Mueller MP, Perry B, Packer C, Bufumbo L, Mbengue D, et al. 2014. Observational study of the acceptability of Sayana Press among intramuscular DMPA users in Uganda and Senegal. Contraception, 89(5):361–367. CrossRef. Medline
Chin-Quee D. 2010. Drug shops and private clinics as sales outlets for injectable contraception in Uganda. Research Triangle Park, NC, USA: FHI.
Khan TU, Malarcher S, Ahmed S, Sarker S, Arevalo M. No date. The Blue Star Program: expanding access to injectable contraception through private sector outlets in Bangladesh. Unpublished draft.
Stanback J, Lebetkin E, Orr T, Malarcher S. The Family Planning Provision in Drug Shops Technical Consultation. 2015. Sale and provision of injectable contraceptives in drug shops in developing countries: conclusions from a technical consultation. Contraception, 91(2):93-6.
Stanback J, Otterness C, Bekiita M, Nakayiza O, Mbonye AK. 2011. Injected with controversy: Sales and administration of injectable contraceptives in Uganda. International Perspectives on Sexual and Reproductive Health, 37(1): 24-29.
Uganda Bureau of Statistics (UBOS) and Macro International Inc. 2011.Uganda Demographic and Health Survey 2006. Calverton, Maryland, USA: UBOS and Macro International Inc.
USAID. 2013. High-Impact Practices in Family Planning (HIP). Drug Shops and Pharmacies: Sources for Family Planning Commodities and Information. Washington, DC: USAID.
Wafula F, Miriti E, Goodman C. 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
World Health Organization, U.S. Agency for International Development, Family Health International (FHI 360). 2010. Community-based health workers can safely and effectively administer injectable contraceptives: conclusions from a technical consultation. Research Triangle Park, NC, USA: FHI 360.