Performance of retail pharmacies in low- and middle-income Asian settings: a systematic review
Health Policy and Planning
Performance of retail pharmacies in low- and middle-income Asian settings: a systematic review
Rosalind Miller 0
Catherine Goodman 0
0 Department of Global Health and Development, London School of Hygiene and Tropical Medicine , London , UK
In low- and middle-income countries (LMIC) in Asia, pharmacies are often patients' first point of contact with the health care system and their preferred channel for purchasing medicines. Unfortunately, pharmacy practice in these settings has been characterized by deficient knowledge and inappropriate treatment. This paper systematically reviews both the performance of all types of pharmacies and drug stores across Asia's LMIC, and the determinants of poor practice, in order to reflect on how this could best be addressed. Poor pharmacy practice in Asia appears to have persisted over the past 30 years. We identify a set of inadequacies that occur at key moments throughout the pharmacy encounter, including: insufficient history taking; lack of referral of patients who require medical attention; illegal sale of a wide range of prescription only medicines without a prescription; sale of medicines that are either clinically inappropriate and/or in doses that are outside of the therapeutic range; sale of incomplete courses of antibiotics; and limited provision of information and counselling. In terms of determinants of poor practice, first knowledge was found to be necessary but not sufficient to ensure correct management of patients presenting at the pharmacy. This is evidenced by large discrepancies between stated and actual practice; little difference in the treatment behaviour of less and more qualified personnel and the failure of training programmes to improve practice to a satisfactory level. Second, we identified a number of profit maximizing strategies employed by pharmacy staff that can be linked to poor practices. Finally, whilst the research is relatively sparse, the regulatory environment appears to play an important role in shaping behaviour. Future efforts to improve the situation may yield more success than historical attempts, which have tended to concentrate on education, if they address the profit incentives faced by pharmacy personnel and the regulatory system.
Asia; developing countries; pharmacies; private sector; quality of care
The role of the private sector in the provision of medicines has
traditionally been neglected by governments and the international public
health community alike
(Bigdeli et al. 2014)
. Yet in most low-and
middle-income countries (LMIC) it is widely established that private
pharmacies and drug stores are typically patients’ first point of
contact with the healthcare system and the preferred channel through
which to purchase medicines
. For example, in Asia,
pharmacies have been found to be the dominant source of healthcare
for all common problems amongst poor populations in Bangladesh
(Khan et al. 2012) and in Western Nepal, amongst mothers seeking
care for their children, pharmacies were the most popular source
(Sreeramareddy et al. 2006)
. Their appeal lies in long
opening hours, availability of medicines (including the possibility of
credit and the option to purchase medicines in small quantities),
geographic accessibility and personal familiarity
(Van Der Geest 1982;
Logan 1983; Kloos et al. 1986, Greenhalgh 1987; Igun 1987; Haak
1988; Price 1989; Mayhew et al. 2001)
. Further, many patients have
neither the time nor money to consult a physician
Wolffers 1987; Haak 1988; Saradamma et al. 2000; Seeberg 2012)
These drug shops range from high end outlets staffed by
pharmacists, to small, rural, roadside stalls staffed by someone without
formal health qualifications. Unfortunately, it is all too common that
drug selling at these outlets meets the World Health Organization’s
(WHO) criteria for being ‘irrational’. That is, patients do not receive
the appropriate medicines, in doses that meet their individual
requirements, for an adequate duration, and at the lowest cost
(Holloway and Van Dijk 2011). To develop appropriate
interventions to address this, it is first necessary to understand the nature of
the problem and also the determinants of provider behaviour to
reflect on how this could best be changed.
Many papers have reported on the inadequacies of pharmacy
practice in LMIC, and some reviews have been conducted
2009b; Wafula et al. 2012)
. However, no up to date systematic
review is available on performance of pharmacies and drug stores
across Asia’s LMIC. This article aims to address that gap, and in
addition, present the first systematic review of the determinants of
poor practice in these settings, substantially updating and expanding
previous reviews in this area
(Goel et al. 1996; Radyowijati and
Scope of review
In many LMIC, there are a wide range of outlets selling medicines to
their local communities. This review is concerned with the full range
of establishments whose primary business is selling medicines.
Papers reporting on pharmacist-run pharmacies (PRPs), non
pharmacist-run pharmacies (NPRPs) and both registered and
nonregistered outlets were eligible for inclusion. Despite the legal
requirement to have a trained pharmacist on duty at all times, in
reality, in many countries in Asia, these pharmacies are typically
operated by staff who are not authorized to do so
Kamat and Nichter 1998; Chuc and Tomson 1999; Seeberg 2012;
Vu et al. 2012)
. In countries where a shortage of pharmacists exists,
NPRPs are permitted; these are registered outlets but the presence of
a graduate pharmacist is not mandatory. These pharmacies are
typically staffed by personnel with limited medical training and are
sometimes restricted in the repertoire of medicines they are
permitted to sell. Unregistered drug shops sell medicines informally and are
not legally recognized by the health system of the countries in which
(Wafula and Goodman 2010)
. From this point
onwards, ‘pharmacy’ will be used as an umbrella term to denote all
types of outlets selling medicines.
The first part of the review is concerned with performance of
pharmacies which, in this instance, is conceptualized as behaviour
relating to the sale of medicines, either with or without a
prescription, or the provision of advice (the importance of the sale of
substandard and counterfeit medicines in Asia is also recognized
(Cockburn et al. 2005; Newton et al. 2006; World Health
Organization 2006; Institute of Medicines 2013)
, but considered
beyond the scope of this review). The second part of the review
concerns the determinants of poor practice, that is, the factors that
contribute to practices that are deemed inappropriate.
A broad search strategy combining MeSH and free text terms was
used to search PubMed, Embase, Econlit, PsychInfo, Web of
Science, Global Health and International Pharmacy Abstracts with
the aim of identifying all studies of pharmacies in LMIC in Asia
(World Bank 2014)
(see Table 1).
In addition to the aforementioned databases, the International
Network for Rational Use of Drugs (INRUD) bibliography and the
WHO’s essential medicines and health products information portal
The search was restricted to English language studies published
between 1 January 1984 and 29 August 2014. A total of 21 898
papers were initially identified; after removing duplicates, 19 214
titles and abstracts were screened by R.M.; the full-text of 107
records were obtained; 53 met our inclusion criteria for part 1 of the
review and 38 met the criteria for part 2 (see Figure 1).
Bibliographies of eligible texts were scanned to identify any further
For part one, papers needed to report on performance relating to
the sale of medicines, either with or without a prescription, or the
provision of advice. This included studies employing both
quantitative and qualitative methodologies. In order to collect the most
accurate data on pharmacy practice, only studies utilising methods
that collected data at the outlet and relied on a third party
observation of practice were included (studies relying on self-reported
practice were excluded due to the risk of desirability bias and those
collecting data on medicine use through household surveys were
excluded due to the high risk of recall bias). Intervention studies
were included, only where they provided baseline data; this was
thought to reflect standard practice. Where baseline data could not
be disentangled from post-intervention results, studies were
excluded from part one.
Eligible studies for part two reported on both pharmacy
performance (applying the same method criteria as for part one) and
possible determinants of that reported performance. Where changes
in practice could be attributed to an intervention strategy, these
intervention studies were included and strategies were viewed as
determinants of practice. For example, a training intervention could
shed light on the importance of knowledge as a determinant of
practice. Additionally, qualitative studies which sought to understand
the determinants of practice behaviours were also included. Of the
studies included in part two, 31 of these were a subset of papers
from part one; three papers were intervention studies where the
baseline results were not clear; three papers were intervention
studies where the baseline results were described by other papers from
the same research study and one paper reported results from a
qualitative study solely focussing on determinants of poor practice.
Data from the included studies were extracted into an excel
database under the following headings: date and location of study, which
aspects of performance measured, sampling and study design, data
collection methods, details of intervention, main findings—performance,
main findings—determinants of performance. Key emergent themes
recurring across the data were discussed between the authors and a
Excluded references from part 1 of review (N= 54)
-no informa on on performance of drug sellers (24)
-methods did not meet inclusion criteria (14)
- outside geographical area of interest (3)
-interven on study without clear baseline data (3)
-not empirical research paper (8)
-could not access full text (2)
narrative synthesis was conducted. See Supplementary Appendix 1 for
a full list of included studies and key characteristics.
Part one: performance of pharmacies in LMIC in Asia
This literature review reveals a number of shortcomings in
pharmacy practice. We have organized our findings according to the
stages of an encounter in the pharmacy (Figure 2). Following an
overview of the included studies, we report on six key stages,
namely, the nature of requests from patients, filling of prescriptions,
history taking, referral for medical attention, sale of medicines and
Overview of included studies
This part of the review identified a total of 53 papers from 43
studies in 14 countries (some studies collected data in more than one
country). Papers coming from the same research project have been
grouped together and the term ‘study’ is used to denote distinct
pieces of research. The most researched countries were India and
Vietnam, with 10 and 9 studies, respectively. Five studies reported
on each of Thailand, Bangladesh and Nepal, three on Indonesia,
two on Sri Lanka and Pakistan and one on The Philippines,
Mongolia, Malaysia, Yemen Arab Republic, Syria and Lao PDR.
Bangladesh and Nepal are low-income countries, Thailand and
Malaysia are higher-middle and all the others are classified as
lowermiddle income economies
(World Bank 2014)
Studies reported on the full range of pharmacies. PRPs were
included in the majority of research projects. Several papers reported
on outlets legally entitled to operate without a pharmacist, including
type II pharmacies in Thailand, class II and III pharmacies in Lao
PDR, type C pharmacies in Pakistan, drug stores in Indonesia and
drug retailers in Nepal (Kafle et al. 1996; Stenson et al. 2001a; Hadi
et al. 2010; Saengcharoen and Lerkiatbundit 2010;Hussain and
Duplicate references (N = 2684)
Excluded references from part 2 of review (N= 68)
-no informa on on determinants (58)
-methods did not meet inclusion criteria (5)
-outside geographical area of interest (2)
-not empirical research paper (1)
-could not access full text (2)
Addi onal records iden fied through reference lists (N=1)
21,898 records iden fied
through database searching
Title and abstract screen (N= 19,214) Full text review (N= 107)
Presents a prescrip on
Pa ent does not
have a prescrip on
Query any discrepancies with
prescrip on is valid
Pa ent requests
Pa ent presents
symptoms / seeks
advice of pharmacist
Pharmacist sells or dispenses:
• In the appropriate dose
For an appropriate dura on
Pharmacist asks history ques ons in order to
Who the medicine is for
What is wrong with the pa ent
Whether they have a more serious condi on
that requires medical a en on
What ac on they have already taken
Whether they have any other medical
condi ons/ take any other medica ons/ have
Refer to physician
Provides pa ent with advice and counsels regarding use
of medicine including:
Explana on of what medicine is for
How much to take and when
Dura on of treatment
Possible side effects
Possible interac ons with food or other medicines
Instances in which medical advice should be sought
Any other condi on-specific advice
1 = Nature of client request
2 = Filling prescrip ons
3 = History taking
4 = Referral for medical a en on
5 = Sale of medicines
6 = Advice giving
Ibrahim 2011). Only one study from Indonesia reported on
unregistered outlets (Hadi et al. 2010).
Researchers employed a range of methods to collect data on
pharmacy practice. Simulated client methodology was used widely
(31 studies) to investigate how a range of requests and conditions
are managed. These included requests for specific prescription only
medicines (POMs), contraceptives and treatment for fever, skin
abrasions, diarrhoea, sexually transmitted infections (STIs),
respiratory tracts infections (RTIs), tuberculosis, asthma, migraine and
anaemia. 12 studies used observation in order to record the details of
transactions between pharmacy staff and customers. Exit interviews
with patients were used less frequently (seven studies) to gather
information about medicines purchased and staff behaviour.
1. Nature of client requests
Clients with health concerns visited the pharmacy for three main
reasons: to fill a prescription following a medical consultation; to
purchase a specific medicine(s) or to seek medical advice from the
pharmacy staff. In order to examine staff behaviour and to put
certain practices into perspective, it is useful to understand the
frequencies of these different types of scenarios. Eight studies
observed all transactions in sampled pharmacies for a fixed period
of time, ranging from 2 h to 2 weeks per pharmacy. The proportion
of transactions where medicines were purchased without a
prescription ranged from around half in studies from Pakistan and
(Krishnaswamy et al. 1985; Greenhalgh 1987; Kamat and
Nichter 1998; Basak and Sathyanarayana 2010; Hussain and
, to over 80% in a study from Lao PDR
Tomson 1999; Syhakhang et al. 2001)
and virtually all transactions
in studies from Vietnam and Malaysia (Chua et al. 2013). Of the
medicines purchased without a prescription, three studies reported
that around one-third were recommended by the pharmacy staff
(Syhakhang et al. 2001; Basak and Sathyanarayana 2010; Chua
et al. 2013)
. Other studies reported that the vast majority of
medicines sold without a prescription were requested by the client, with
pharmacists advising on <5% of these purchases
et al. 1985; Kamat and Nichter 1998; Chuc and Tomson 1999;
Hussain and Ibrahim 2011)
. Only studies from India reported on
common ways patients requested medicines. These were by name,
on a scrap of paper, or by bringing in an old sample
1987; Kamat and Nichter 1998; Saradamma et al. 2000)
from Vietnam, India and Bangladesh reported that at least half of
clients were buying medicines for someone other than themselves,
most commonly a family member
(Dua et al. 1994, Duong et al.
1997b; Roy 1997; Kamat and Nichter 1998)
. One study noted that
domestic servants were commonly sent to purchase medications on
behalf of their employers (Kamat and Nichter 1998).
2. Filling prescriptions
Only a few studies made reference to the handling and
processing of prescriptions in the pharmacy. Several poor practices were
reported. Prescriptions were rarely validated by dispensers
(Hussain and Ibrahim 2011), old prescriptions were frequently
honoured (at the extreme, patients were seen to be reusing
prescriptions 5 years out of date)
(Greenhalgh 1987; Kamat and
Nichter 1998; Basak and Sathyanarayana 2010)
prescriptions were returned to customers after dispensing for reuse in the
(Puspitasari et al. 2011)
. Further, doctors’ prescriptions
were not always dispensed as intended. Some studies indicated
that where patients cannot afford to buy all items on a
prescription, the pharmacists played an important role in advising
patients what they should purchase in light of their financial
(Greenhalgh 1987; Roy 1997; Kamat and Nichter
. Studies did not report a single example of a pharmacist
querying a prescription with the doctor (despite ample
description of inappropriate prescribing practices).
Part two: determinants of poor pharmacy performance
in LMIC in Asia
Overview of included studies
The literature search yielded 38 relevant papers, from 28 distinct
studies which conducted research in 11 countries: Pakistan (two),
Thailand (five), Nepal (four), India (seven), Bangladesh (three), Lao
PDR (one), Sri Lanka (one), Yemen Arab Republic (one), Vietnam
(six), The Philippines (one) and Indonesia (one). The studies
included in this review are very varied in terms of methodology and
approach but they all shed some light on the determinants of
pharmacy practice in these settings. Ten studies collected data on both
‘actual’ pharmacy practice (e.g. using mystery shopper surveys or
spending time observing transactions) and knowledge and stated
practice (through semi-structured interviews with store staff), with
discordance between the two providing insight into factors affecting
certain poor practices. In uncontrolled analyses, three studies tested
for associations between a number of predictor variables and
provider practices. Four studies conducted regression analyses using
aspects of practice as the dependent variable and tested a number of
explanatory variables (such as retailer characteristics or attitudes) as
potential predictors of behaviour. Twelve studies evaluated the
effectiveness of an intervention strategy and this provided evidence for
whether or not these were important determinants of practice.
Finally, 10 studies employed qualitative methodology, including
indepth interviews, participant and non-participant observation and
focus group discussions.
From the literature, information on determinants of poor
pharmacy practice can be distilled into three main categories: knowledge,
profit motives and state intervention. The role of each is discussed.
One possible explanation for the poor pharmacy practice
observed in Asia is simply lack of knowledge. There is wealth of
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evidence, however, to suggest that knowing what constitutes
good performance, whilst necessary, is not sufficient to ensure
that this knowledge is employed in practice. A number of studies
report vast discrepancies between knowledge or stated practice
and actual practice; the qualifications of staff or level of training
accomplished appears to make little difference to treatment
behaviour and finally, educational programmes, whilst improving
practice in the short-term, do not improve practice to a
satisfactory level in the long-term. Each of these bodies of evidence will
be examined in turn.
a. Discrepancies between knowledge and practice
Several studies employed different methods in order to elicit
information on both provider knowledge or stated practice
and actual practice. Vast discrepancies were noted between
the two, suggesting that knowledge is not the key
determinant of poor practice. Differences between stated practice and
actual practice were observed for the sale of medicines,
referral for medical advice, history taking and advice giving. For
example, in hypothetical scenarios, 32% of pharmacists said
they would sell any drugs for a man with urethral discharge
and pain on urinating (the recommended management
would be referral to a physician) (Chalker et al. 2000), 20%
antibiotics for a child with a viral upper respiratory tract
infection (Chuc et al. 2001), 40% corticosteroids and 0%
antiepileptic medicines without a prescription
(Larsson et al.
2006; Mac et al. 2006)
. In mystery shopper surveys,
however, these actions were carried out by 85%, 83%, 98% and
21%, respectively. Adherence to recommended treatment
practices was also found to be poorer in practice. Compared
to the stated medication treatments for childhood diarrhoea,
fewer pharmacy staff sold oral rehydration salts (ORS) and
more sold inappropriate antibiotics and anti-diarrhoels
(Ross-Degnan et al. 1996; Saengcharoen and Lerkiatbundit
2010; Minh et al. 2013)
. Similar patterns were observed in
the management of other conditions, such as STIs (Khan
et al. 2006). One study reported that despite 81% of
pharmacists knowing that antibiotics were not effective in
short courses, 48% of courses dispensed were for <5 days.
Stated referral practices of patients presenting with
conditions that need to be treated by a doctor were three to four
times higher than in reality
(Chalker et al. 2000; Khan et al.
. Finally, history taking and advice giving in
questionnaires was found to be superior to the service simulated
(Ratanajamit and Chongsuvivatwong
2001; Khan et al. 2006)
b. Qualifications/training and experience
Studies from Thailand and Nepal, using simulated shoppers
to investigate the management of childhood diarrhoea,
pregnancy-related anaemia and requests for contraceptives,
revealed that staff with higher levels of training or
qualifications asked more questions and gave better advice
but little differences were observed in terms of appropriate
(Kafle et al. 1996; Ratanajamit and
Chongsuvivatwong 2001; Saengcharoen and Lerkiatbundit
. Other studies found no association between
qualifications of pharmacy personnel and the quality of history
taking and counselling (Hussain and Ibrahim 2011;
Saengcharoen and Lerkiatbundit 2013). Despite, recording
no differences in actual practice, one of these papers
reported that, in interviews designed to measure their
knowledge, pharmacists achieved significantly higher scores
compared to non-pharmacists in the areas of history taking
and advice provision
(Saengcharoen and Lerkiatbundit
. Experience was shown not to be a predictor of
appropriate dispensing in the two studies which collected data on
(Apisarnthanarak et al. 2008; Saengcharoen
and Lerkiatbundit 2010)
c. Impact of education programmes
Nine studies report the findings of educational interventions.
All of these studies employed simulated client methodology
to assess the impact of training; only four assessed
performance by comparing outcomes to a control group. On the
whole, training was found to improve the treatment
behaviour of various conditions, including diarrhoea and STIs, as
well as provision of contraceptives
(Ross-Degnan et al.
1996; Kafle 1998; Tuladhar et al. 1998; Ratanajamit et al.
2002; Qidwai et al. 2006; Kafle et al. 2013; Minh et al.
2013; Pham et al. 2013)
. Despite the improvements noted,
inadequacies in treatment practice remained. For example,
in Indonesia, 46% of staff continued to sell anti-diarrhoels
for children with diarrhoea
(Ross-Degnan et al. 1996)
in Nepal, 55% of drug sellers continued to prescribe an STI
treatment regimen that was inconsistent with national
(Tuladhar et al. 1998)
. Further, most of the study
follow-up times were <6 months. One study with follow-up at
7–9 months noted the waning of effect
(Tuladhar et al.
, and another at 32 months reported no sustained
improvements in the use of ORS, anti-diarrhoels or antibiotics
for the treatment of diarrhoea, despite promising results at 6
months post intervention
(Minh et al. 2013; Pham et al.
. In Nepal, small group training led to significant
improvements in a number of aspects of management of
childhood diarrhoea, acute respiratory infection and
anaemia in pregnancy at 2 months but most of these effects
were not sustained at the 5-month follow-up (Kafle 1998).
One study did not report baseline data but the post-training
results concerning the management of STIs were very poor
(Khan et al. 2006). Another showed no significant impact of
training on ORS use for the treatment of diarrhoea or
dysentery, but it did show improvements in antibiotic dispensing,
only for drug sellers, however, not for pharmacists
(Podhipak et al. 1993)
2. Profit motives
Pharmacies are retail businesses operating within a competitive
marketplace. Several papers described the proliferation of
medicine outlets over recent decades, especially in countries that
underwent economic liberalisation. For example, in Vietnam
following the privatization of drug provision in 1986, the number
of private pharmacies increased from none to >6000 by 1996
(Chuc et al. 2002). These papers also noted the intensified
competition that resulted
(Kamat and Nichter 1998; Chuc and
Tomson 1999; Stenson et al. 2001b; Chuc et al. 2002)
illustration of the nature of competition comes from Mumbai, India,
where pharmacies hire agents to persuade patients leaving
hospitals to patronise their pharmacy (Kamat and Nichter 1998).
Qualitative work confirms that pharmacies report feeling intense
competition and staff seek to maximize profit in order to survive
in the market
(Dua et al. 1994; Kamat and Nichter 1998; Chuc
and Tomson 1999; Kotwani et al. 2012; Seeberg 2012)
Essentially there are three ways to maximize profits: maximizing
the number of customers, maximizing the revenue from each
individual customer and minimizing costs. From the literature, we
identified a number of strategies employed by pharmacy staff to
achieve these goals, each of which can also be linked to poor
a. Complying with customer demands
The literature reveals that pharmacy staff are very responsive
to patients wishes, adhering to a ‘customer is king’ mentality.
In the name of maintaining clients, inducing loyalty and
preventing customers from fulfilling their requests elsewhere,
pharmacies resort to a number of poor practices. These
include honouring improper prescriptions, such as those that
are out of date, and selling POMs without a prescription
(Dua et al. 1994; Larsson et al. 2006; Kotwani et al. 2012;
Nga et al. 2014)
. Further, incomplete courses of antibiotics
are frequently sold. Patients request these short courses due
to economic constraints, a desire to test the therapeutic
efficacy and presence of side-effects before purchasing larger
quantities, and a belief that a full course is unnecessary
(Lansang et al. 1990; Dua et al. 1994; Dineshkumar et al.
1995; Roy 1997;Duong et al. 1997b; Kamat and Nichter
1998; Mamun et al. 2006)
b. Selling medicines based on perceived efficacy
Several studies reported that pharmacy staff chose medicines
based on their ability to produce a rapid recovery or
temporary relief from symptoms, even where they were not
(Kafle et al. 1996; Van Sickle 2006; Saengcharoen and
. For example, anti-diarrhoels for the
treatment of childhood diarrhoea (Saengcharoen and
Lerkiatbundit 2010) or airway relaxers for the respiratory
symptoms associated with asthma
(Van Sickle 2006)
addition, they sold medicines in which clients were believed to
have great confidence, again, even if such medicines were not
necessary. Examples include tonics as an accompaniment to
antibiotics, and complex vitamin preparations (Dua et al.
1994; Kafle et al. 1996).
c. Mimicking doctors
Four studies reported that it was common practice for
medicine retailers to study the prescriptions bought in by patients
and then model their own prescribing on the practices of
(Greenhalgh 1987; Kafle et al. 1996;
RossDegnan et al. 1996; Seeberg 2012)
. This may simply be a
way to improve knowledge. It could, however, be inferred
that it is a strategy used by pharmacies in order to be viewed
as more legitimate by customers.
d. Maintaining good relationships with doctors
When presented with clinically inappropriate prescriptions,
pharmacies in Asia tended to dispense them rather than query
their appropriateness with the doctor. Pharmacists interviewed
in Kotwani et al’s qualitative study of irrational antibiotic use in
Delhi described their low status in the medical hierarchy and
how doctors would rebuke them for challenging their authority
(Kotwani et al. 2012)
. Other research, also in India, has
identified symbiotic relationships between doctors and chemist shops,
and doctors have been observed to mention names of shops
where patients should fill their prescriptions (Kamat and
Nichter 1998; Seeberg 2012). Further, at the request of medical
representatives, doctors reportedly prescribe more of particular
products when local pharmacies experience an overstock
(Kamat and Nichter 1998). It is understandable, in such a
context, that pharmacists do not query more prescriptions for fear
of aggravating local physicians.
e. Medicine sales
Two explicit strategies for maximizing profits from medicine
sales were identified from the literature; selling large volumes
of low priced drugs and recommending medicines that yield
the greatest profit
(Ross-Degnan et al. 1996; Chuc and
Tomson 1999; Saengcharoen and Lerkiatbundit 2010)
Antibiotics are singled out as high profit generators
and Tomson 1999; Chuc et al. 2001; Saengcharoen and
Lerkiatbundit 2010; Nga et al. 2014)
; this may partly
explain their rampant overuse.
f. Medicine purchasing
The pharmaceutical industry employs aggressive marketing
techniques which involve promotional offers to pharmacies.
This includes bonus schemes whereby the purchase of x
amount of a product includes y amount for free (Kamat and
Nichter 1998). Retailers are then incentivized to sell more of
this product, regardless of its appropriateness, because it will
yield high profits. The following quote from Kamat and
Nichter’s (1998) ethnographic study of pharmacies and
pharmaceutical-related behaviour in India gives an insight
into such practice (the product mentioned, Superaction, an
OTC product for cough, cold, fever and pain, is sold on a
buy 12 strips get 7 free basis):
I make a profit of anything between 75% and 100% on
“Superaction.” During the past 2 week, I sold two boxes (20
strips) of this item for which I got a pocket calculator worth
80 rupees from the company. I make a lot of profit on this
product, but I have to counter-push it because local doctors
do not prescribe it. I do not recommend this product to every
customer who asks for medicines for headache or body pain
but mostly to angutachapwallas (illiterates) who come and
ask me to give some medicine for cold and pain (Kamat and
Dineshkumar et al. (1995) comment on the aggressive
marketing of vitamins which are used extensively in India.
Seeberg describes how chemists in Orissa purchase
substandard medicines from local production facilities at a 50%
discount and then sell them on to customers thus making
It is important to note that there are examples in the
literature which illustrate that medicine retailers are only prepared
to go so far in risking the health of their patients in the name
of making a quick profit. Pharmacists described how it was
not suitable to use substandard medicines for patients who
had undergone surgery or faced life-threatening conditions
. Additionally, when patients sought
pharmacists’ advice in the event of not being able to afford all
medicines on a prescription, they were found to recommend the
medicines which ‘cure’ over those with the highest profit
(Kamat and Nichter 1998).
3. State intervention
A few studies in this review provide information on the impact
of government intervention on pharmacy performance.
Two intervention studies reported on the effect of
regulation on service quality. An intervention in Lao PDR
involving inspection visits, punishments in the case of gross
violations of the sanctions, up-to-date supply of regulatory
documents, and reinforcement of the rules found marked
improvements in the availability of essential medicines,
order in the pharmacy and provision of information;
and less mixing of different drugs in the same package
(Stenson et al. 2001b)
. The regulatory component of a
multi-component (sequentially applied), intervention on
dispensing practices in Bangkok (Thailand) was the only
component of the intervention that resulted in a significant
change in practice (reduced dispensing of a
prescriptiononly steroid compared to the control group). This
intervention focussed on the illegality of the act and the threat of
punishment should such practice be observed. The same
study reported that in Hanoi (Vietnam), where less focus
was placed on sanctions, the regulatory component of the
intervention did not lead to an immediate change in
behaviour (Chalker et al. 2005).
b. National Public Health Programmes
A study from Vietnam investigating the management of
tuberculosis patients in the pharmacy found, in a multivariate
analysis, that staff who were aware both of the National
Tuberculosis Programme (NTP) and that tuberculosis
medicines were provided for free were 5.8 times more likely to
refer a suspect directly to a tuberculosis facility than those
who were not
(Vu et al. 2012)
. Another study concerned
with management of childhood diarrhoea investigated
practice in three countries: Bangladesh, Sri Lanka and Yemen
Arab Republic. The authors reported that ORS was more
commonly dispensed in Bangladesh and they noted the
presence of a national ORS programme as one potential
(Tomson and Sterky 1986)
Combined, the reviews identified 60 papers reporting on pharmacy
practice and/or determinants of poor practice in 15 LMICs in Asia.
The majority of studies were from lower middle-income countries.
Asides from studies from Mongolia, Yemen Arab Republic and
Syria, all other studies focussed on countries from South and
SouthEast Asia. As such, the results tell us little about pharmacy practice
in North Asia, Central Asia, West Asia or the Middle East. Most
research was carried out on PRPs, with less on NPRPs and research on
unregistered shops was found to be practically non-existent.
Given the diversity of studies found in the search, quality
appraisal proved to be a particular challenge. Relevant papers
included a range of designs including randomised controlled trials,
cross-sectional descriptive surveys and ethnographies. The lack of
clear criteria by which qualitative studies should be judged in the
systematic review process has been raised by others but remains an
(Dixon-Woods et al. 2006)
. In light of this, it was
decided to include all papers which met the inclusion criteria
providing the methodology employed was clear. Data on both methods
and study design were extracted and any potential threats to validity
were recorded. The main concerns noted were small sample sizes
and non-random sampling (quantitative papers). The findings of
poorer quality studies, however, were found to be consistent with
more rigorously designed ones. In interpreting the findings, care has
been taken to emphasise those which were found in a number of
studies and across countries.
In terms of pharmacy performance, the findings across countries
and over time are remarkably consistent. Pharmacy practice in Asia
appears to have changed little in the past 30 years. The same
problems documented by studies in the 1980s are true of practice in
(Tomson and Sterky 1986; Greenhalgh 1987; Hussain
and Ibrahim 2012; Seeberg 2012; Vu et al. 2012; Chua et al. 2013;
Minh et al. 2013; Saengcharoen and Lerkiatbundit 2013)
appears to fall short throughout the pharmacy encounter. The key
inadequacies documented throughout the literature are: insufficient
history taking prior to the sale of medicines; a lack of referral of
patients whose management is outside of the remit of a pharmacist’s
expertise; the illegal sale of a wide range of POMs without a
prescription; the sale of medicines that are either clinically
inappropriate and/or in doses that are outside of the therapeutic range; the sale
of incomplete courses of antibiotics; and finally, limited provision of
information and counselling to accompany the sale of medicines.
Similar challenges have also been documented in Sub-Saharan
Africa (Wafula et al. 2012)
Staff working in pharmacies can be seen as the gatekeepers of
medicines. They stand at the interface between producers and
consumers of medicines and their role is to ensure that they are used
safely, effectively and rationally (Anderson 2002). When used
correctly, medicines can save lives and improve people’s health;
irrational use, however, can have harmful consequences. A number of
conditions were found to be treated inadequately in the pharmacy,
including diarrhoea, asthma, anaemia, tuberculosis, STIs, RTIs and
migraine. This mistreatment can lead to unnecessary morbidity and
mortality. For example, many studies reporting on the management
of childhood diarrhoea found under-provision of ORS and
overprovision of anti-diarrhoeals and antibiotics. The use of
antidiarrhoels in infants has been shown to be harmful
Smith 1987; Li et al. 2007)
and it is estimated that correct treatment
with ORS may prevent 93% of diarrhoeal deaths in children under
5 (Munos et al. 2010). In South Asia, diarrhoea is thought to
account for 23% of all deaths in children under 5
(Morris et al. 2003)
Overuse of antibiotics is a particular concern for public health,
as misuse of antibiotics over recent decades has led to the selection
and spread of resistant bacteria. As a result, antibacterial drugs have
become less effective and in some cases, ineffective. Earlier this year,
a WHO global report on the surveillance of antibiotic resistance
described the problem as a ‘global health security emergency’
(World Health Organization 2014)
A further concern is the economic impact of spending on
households, especially the poor. Customers typically pay for the medicines
purchased at pharmacies out of their own pocket and where these
medicines are inappropriate or ineffective this represents a waste of
scarce resources. Work in Asia has shown that, in many countries, a
large proportion of out of pocket payments is spent on medicines.
For example, in Bangladesh, Vietnam and India, this share is 70%
(Van Doorslaer et al. 2007)
. Further, in these countries, out of
pocket payments for healthcare can be ‘catastrophic’, accounting
for >25% of household resources (excluding food costs) in at least
10% of all households (ibid).
Turning to the determinants of the poor practice documented
above, the picture is less clear. Despite the importance of pharmacies
and the potential benefit for public health if practice were to
improve, efforts to understand and address the problem have been
surprisingly few. Historically, the small number of attempts to improve
pharmacy practice in Asia has focussed on training interventions.
This review finds that whilst a necessary condition, adequate
knowledge alone is not sufficient to ensure appropriate management of
patients presenting at the pharmacy. Profit motives and the
regulatory environment appear to play a role but the research evidence is
relatively sparse. In terms of the methods used to unpick the
underlying determinants of pharmacy behaviours, we found that in-depth
qualitative studies, particularly those employing an ethnographic
approach, provided the richest data
(Kamat and Nichter 1998; Seeberg
. Unfortunately, studies using this approach are rare.
Whilst a number of studies have been published in the two
decades since Goel et al. (1996) first reviewed this literature, there is
little new insight into the problem of poor pharmacy practice. They
noted that regulatory factors had been ‘strikingly neglected by
researchers’ and called for new research on the ‘impact of professional
ownership on professional freedom’. Researchers have, on the
whole, continued to neglect these areas. The pursuit of regulatory
enforcement is, however, not a straightforward solution and we
must be aware that enforcing laws surrounding the sale of POMs
would potentially deny many people access to essential medicines,
thus violating a basic principle of public health.
Based on the intervention literature both within and outside
Asia, the menu of evidence-based options for professional bodies
and policy-makers to inform improvement and development of
pharmacy services is limited
. Arguably, some cadre
of trained pharmacy workers should be in place in order to provide
a basis for improvement, yet in many settings human resource
limitations undermine the ability to provide this
from training and regulation, other schemes that have been
implemented include peer review, accreditation (such as the Accredited
Drug Dispensing Outlets scheme in Tanzania) and social franchising
(Chalker et al. 2005; Wafula and Goodman 2010)
. However, the
evidence on the impact and sustainability of these strategies remains
quite limited, highlighting this area as an important priority for
(Center for Pharmaceutical Management 2008;
Wafula and Goodman 2010; Valimb et al. 2014)
It is worth noting that new organisational arrangements of
pharmacy retail in the form of chains and franchises are a growing
phenomenon in LMIC both in Asia and elsewhere
(Lowe and Montagu
2009; IMS Consulting Group 2014)
. This phenomenon raises
important questions about the impact of professional and organised
ownership on pharmacy practice. Further, theoretical literature
suggests that the organisational structure of the pharmacy firm may
affect both the regulatory environment and financial incentives, as
well as provider knowledge
(Klein 1980; Blair and Kaserman 1994;
Frant 1996; Bloom et al. 2008)
Cross and Macgregor (2010) have criticised the current debates
around ‘informal providers’ (including drug sellers) which, they
argue, are myopically focused on ‘small time economic actors’ rather
than giving attention higher up in the pharmaceutical supply chain
(Cross and Macgregor 2010)
. This focus indeed leads to a
distraction away from the pharmaceutical industry, which, thus far, has
largely remained absent from discussions of inappropriate medicines
use. A few papers in this review touch on the pressures that
providers face from industry but this does not come out strongly.
Whilst it is necessary to study frontline behaviours, research
upstream is also a necessity.
Pharmacies are an important component of the health system in
LMIC in Asia. In many areas they act as ‘de facto primary
(Seeberg et al. 2014)
. The service they provide,
however, does not live up to international expectations of pharmacy
practice. The consequences of poor practice can have harmful effects
for public health and, as such, these outlets warrant more attention
from public health researchers. The nature of the problem with
pharmacies in Asia is well established, although more attention
could be paid to NPRPs pharmacies and unregistered drug shops.
Future research efforts should focus their attention on investigating
the underlying causes and ways to improve the current situation.
The little evidence that is available suggests that intervention
strategies should take into account the regulatory environment and profit
incentives faced by pharmacy personnel and not continue to focus
solely on improving knowledge. If efforts are focussed accordingly it
is hoped that the realities of the past 30 years of poor pharmacy
practice in Asia will not continue for the next 30.
Supplementary data are available at HEAPOL online.
Rosalind Miller’s PhD is funded by the Economic and Social Research
Conflict of interest statement. None declared.
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