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 are essential because:

• Malaria can progress very quickly to severe illness and death.
• Uncontrolled drug use can increase the spread of anti-malarial drug resistance.
• Policy-makers are considering the use of combination therapy (using two or more drugs) to improve malaria treatment and slow the development of drug resistance, but effective implementation may depend 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 in stock – 43 drug shops and 675 general stores. The study took place in 2000 when chloroquine 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 of general retailers stocked anti-malarials.
• Chloroquine products include 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 of each drug.
• Drug shops tended to use dedicated drug suppliers, mostly in Dar es Salaam – several hundred kilometres away. Most general retailers used more local general wholesalers. A few wholesalers supply a high proportion of all shops.

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

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

But the private sector also provides opportunities for improving malaria treatment and distributing drugs to remote rural areas. Shops often have faster service, better drug availability and more convenient opening times than the public sector. Interventions targeting all retailers are likely to be costly and difficult to deliver due to the large number, diversity and high turnover of shops. The researchers recommend some more cost-effective approaches including:

• shaping demand through consumer education
• improving the quality, packaging and price of products entering the distribution chain
• focusing on drug stores as there are relatively few of them and their staff have primary education and some health-related training
• targeting the most popular general wholesalers through training, information and regulation.

Source(s):
‘Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities’, Tropical Medicine and International Health 9(6): 655-663, by C. Goodman, S.P. Kachur, S. Abdulla, E. Mwageni, J. Nyoni, J.A. Schellenberg, A. Mills and P. Bloland, 2004
HINARI subscribers can access the full-text article here. Full document.

Funded by: US Agency for International Development; Wellcome Trust; US Centers for Disease Control and Prevention; UK Department for International Development

id21 Research Highlight: 18 March 2005

Further Information:
Catherine Goodman
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK

Tel: +44 (0) 20 7927 2275
Fax: +44 (0) 20 7637 5391
Contact the contributor: catherine.goodman@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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'Private sector drug retailers and malaria control in Kenya'

'No place like home – treating childhood malaria in The Gambia'

'Value for money: cost-effective options for malaria control'

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