The Pharmaceutical Journal
Vol 275 (Supplement) F26
October 2005

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FIP Congress 2005

Enhancing access in Tanzania

Establishing a network of non-pharmacy accredited drug dispensing outlets has greatly improved access to medicines in a region of Tanzania, reported Keith Johnson, director of the MSH SEAM programme, US. He said that in December 2000, the Management Sciences for Health (MSH) Strategies for Enhancing Access to Medicines (SEAM) programme collaborated with the World Health Organization to develop a framework for measuring access to medicines. During the development of the framework, four “dimensions of access” emerged, said Mr Johnson. They were physical accessibility, affordability, geographical accessibility and acceptability.

Physical accessibility can be defined by the relationship between the type and quantity of product or service needed, and the type and quantity of product or service provided. Affordability can be defined by the relationship between prices of the products or services and the user’s ability to pay for them. Geographical accessibility, can be defined by the relationship between the location of the product or service and the location of the eventual user of the product or service. (For example, access is restricted if a drug is available but a patient has to walk 20km to obtain it or if a person’s availability does not match the opening hours of the service provider.) Acceptability is defined by the relationship between the user’s attitudes and expectations about the products and services and the actual characteristics of products and services. (For example, if a particular treatment is available but unacceptable to a patient this will impact on their ability to access care.)

In addition, one cross-cutting characteristic of access was identified: the quality of the products and services provided. “Ultimately, what is access worth if you have poor quality drugs and services,” commented Mr Johnson.

Six countries, including Tanzania, were chosen by SEAM to field-test the framework. In Tanzania, medicines can be accessed through a number of channels, including from 339 “Part I” drug stores, which stock all medicines, or from approximately 4,000 “Part II” drug stores, which are known as duka la dawa baridi and stock only a limited list of medicines. The Part II stores operate without a pharmacist and although Mr Johnson recognised that this was an undesirable situation, he commented that it was essential to ensure that the population can access medicines.

An assessment of the country by SEAM showed that key gaps in access in Tanzania were the availability of pharmaceuticals, the quality of drug products and services and the affordability of products and services. Only 17 per cent of the Tanzanian population have access to a Part I outlet.

In light of the assessment, MSH chose to target its “access intervention” at the Part II drug outlets, which are geographically accessible and the first stop for over 60 per cent of the population for accessing medicines.

Some of the challenges faced by MSH included unqualified and often untrained staff in the Part II stores, unknown drug quality with often an unreliable source being used to obtain drugs, high drug prices, inadequate regulation and an insufficient variety of legally available drugs.

With funding from the Bill and Melinda Gates Foundation, MSH ran a pilot project in Ruvuma, a region of Tanzania, to help the Tanzanian Food and Drug Authority to establish a network of accredited drug dispensing outlets, or duka la dawa muhimus (essential drugs shop).

The project strategy included introducing regulations and standards of practice, training staff in both business and dispensing skills, introducing incentives — such as loans — for drug shop owners and mentoring and expanding the list of drugs that could be legally sold.

The project proved to be highly successful. Mr Johnson reported that the average availability of antimalarials in the region rose from 74 to 90 per cent compared with 60 to 71 per cent in Singida, the control region. Product quality improved with patients having a one in 50 chance of buying an unapproved drug in the region, compared with a one in 10 chance in the control region, and the medicine prices in Ruvuma changed to be more in line with national market prices.

MSH in partnership with the government of Tanzania is now looking to roll out the initiative nationally and is in the process of testing roll-out strategies and refining the arrangements for training and the inspection of drug shops.

The IPSF and pharmacy schools have a key role to play in helping future pharmacists gain the technical expertise needed to help improve access to health services in developing countries, said Mr Johnson.

As well as general sensitisation to issues surrounding access to medicines, pharmacy schools should include training on essential medicines in undergraduate programmes, should encourage students to undertake internships with international development organisations and, during career counselling, should support students in considering options to work in international development.

Twinning schools of pharmacy in developing and developed countries provides students with a unique insight into the challenges faced by the profession in different countries and as a means of giving pharmacy students the opportunity to gain hands-on experience of projects designed to improve access to health care services. Mr Johnson encouraged the development of village concept projects, such as the IPSF Neema project