Friend or foe? Private sector sales of anti-malarial drugs in rural Tanzania

Malaria treatment policy in Africa has focused mainly on government-run health systems. But many episodes of fever are treated at home using shop-bought drugs. Does the private sector threaten effective malaria treatment? Research involving the London School of Hygiene and Tropical Medicine looked at retailers selling drugs in four districts in Tanzania.

Good quality treatment practices at retail outlets areessential because:

• Malaria can progress very quickly to severeillness and death.
• Uncontrolled drug use can increase the spread ofanti-malarial drug resistance.
• Policy-makers are considering the use ofcombination therapy (using two or more drugs) to improve malaria treatment andslow the development of drug resistance, but effective implementation maydepend on retail sector treatment practices.

Researchers interviewed staff at 808 retail outlets,covering nearly all of the private drug retailers in the area. 718 had drugs instock – 43 drug shops and 675 general stores. The study took place in 2000 whenchloroquine was the first line anti-malarial treatment.The researchers found that:

• Almost all drug shops stock anti-malarials. Nearly all have chloroquine,42 percent stocked quinine, 37 percent sulphadoxine-pyrimethamine(SP) and 30 percent amodiaquine. Only a third ofgeneral retailers stocked anti-malarials.
• Chloroquine productsinclude nine brands of tablets, three of syrup and one injectable,plus unbranded versions of each. There were five brands each of SP and amodiaquine tablets. Many shops stocked several brands ofeach drug.
• Drug shops tended to use dedicated drugsuppliers, mostly in Dar es Salaam – several hundredkilometres away. Most general retailers used more local general wholesalers. Afew wholesalers supply a high proportion of all shops.

This study shows that private retailers are an importantsource of anti-malarial drugs in these poor rural areas, despite relativelygood coverage of health facilities. This poses several potential problems:

• Chloroquine was widelyavailable despite high levels of drug resistance; so many patients probablyreceived an ineffective drug.
• SP and amodiaquine arepotential components of combination therapy, but were sold as single tablets.If this promotes resistance to these drugs, the benefit of combination therapymay be lost.
• Many drug stores had illegal stocks of drugs,suggestion that regulation is weak. This may reduce the ability of thegovernment to work openly with the private sector.
• The many different brand names may confusecustomers.

But the private sector also provides opportunities forimproving malaria treatment and distributing drugs to remote rural areas. Shopsoften have faster service, better drug availability and more convenient openingtimes than the public sector. Interventions targeting all retailers are likelyto be costly and difficult to deliver due to the large number, diversity andhigh turnover of shops. The researchers recommend some more cost-effectiveapproaches including:

• shaping demand through consumer education
• improving the quality, packaging and price ofproducts entering the distribution chain
• focusing on drug stores as there are relativelyfew of them and their staff have primary education and some health-relatedtraining
• targeting the mostpopular general wholesalers through training, information and regulation.