Dashboard East Africa: Service Delivery Increasing Youth Access Through Pharmacies and Drug Shops

East Africa Toolkit: AYSRH Services & Supply

Increasing Contraception Access for Adolescents and Youth Through Pharmacies & Drug Shops

Coaching on data capture and reporting for a drug-shop attendant at Buikwe District, Uganda. Photo courtesy: Buikwe Family Planning health team.

Pharmacies, including chemists and drug shops, play an important role in increasing access to contraceptive services among women and men, boys and girls because they are easily accessible, convenient and popular sources for health care information.

They offer an opportunity to reach existing as well as new family planning (FP) clients. Many clients using short-term contraceptives, such as pills, condoms, injectables or emergency contraceptives, obtain their methods from a pharmacy instead of a public facility. For example, in Tanzania, 37% of modern contraceptive users obtain their method of choice from the private sector, which includes pharmacies and accredited drug dispensing outlets or shops (SHOPS Plus Project 2018). Studies have found that marginalized and difficult to reach groups are more likely to obtain FP methods from pharmacies or drug shops.

A 2016 analysis of data from the Urban Reproductive Health Initiative (URHI) in Kenya found that unmarried women and those without children—compared to married women and those with children—were significantly more likely to go to pharmacies for contraceptives than public health facilities. In Uganda, 41% of FP users are served by the private sector, including drug shops with 50% of short-term method contribution (RH supplies coalition 2020).

This webinar was held on December 3, 2020 with the aim of sharing East Africa’s experience implementing TCI’s high-impact intervention on pharmacy engagement to increase access to contraceptive services by young people. The webinar slides can be found here.

Why use pharmacies and drug shops?

Pharmacies and drug shops offer convenience, anonymity and privacy for clients.
Frequently, pharmacies are not well-regulated, and staff are not properly trained on FP methods. As a result, improving the quality of FP services at pharmacies and drug shops and linking them to public health facilities is a promising strategy to reach more women and men, girls and boys with contraceptives, reducing unmet need.
In addition, they act as the first line of health care in East Africa for underserved populations. There is limited access to public health As a result, Uganda has expanded its Village Health Team (VHT) strategy to bring family planning, including DMPA, to the doorsteps of clients who do not have access to nearby public health centers. Community pharmacies, along with CHVs/CHWs/VHTs, can help to relieve the workload pressure on midwives and health centers as FP demand increases.
Pharmacies and drug shops provide opportunities for task sharing which can aid in the achievement of national FP goals by reducing barriers to access, especially for adolescents and youth.
Despite being recognized for their potential to improve health indicators, pharmacies and drug stores are largely missing from countries’ health strategies, policies and regulation and monitoring. Consequently, remaining as an untapped source of data.
Stronger linkages between pharmacies and drug shops offer a great opportunity for referrals to the public sector for long-acting reversible contraceptives (LARCs).

Evidence

Between October 2019 and November 2022, TCI has enrolled 1,053 pharmacies from 24 cities (470 Kenya – 9 cites; 133 Uganda – 6 cities and 450 Tanzania – 9 cities) in East Africa into its partnership. A total number of 510 pharmacies/drug shops have reported serving 98,483 clients. Out of which, 68,587 (approx. 69.64%) are female and 28,924 (appx. 29.37%) are male. 69,625 (70.7%) of the clients are above 24 years of age and 28,858 (29.3%) are 15-24 years of age.

“The family planning training improved my contraceptive knowledge; it’s no longer about money but service delivery. I now counsel on all available methods and let them decide the method of their choice. The MEC wheel also helps me to guide my clients make the right decisions regarding their contraceptive method of choice and my clients are very happy and satisfied with my services. I have noticed an increase in clients coming to my drug shop for FP and other services and am very happy”. — Lydia Nanyonjo, God First Line drug shop – Iganga District.

Guidance: How to work with pharmacies and drug shops

Below is guidance on how to engage pharmacies/drug shops to reach more potential clients with quality FP services and strengthen referrals to health facilities.

Identify key private sector stakeholders for FP and AYSRH service provision. This will depend on the country context but may include pharmacy associations, individual pharmacies and drug shops, national drug authorities, district drug inspectors, drug shop associations, private sector professional associations and pharmacy academic institutions.
Organize and hold meetings with the local government for buy-in and planning on the engagement of the institutions and development of selection criteria for pharmacies/drug shops.
In collaboration with the local government, plan a meeting with the stakeholders to discuss the need to strengthen contraceptive service provision through pharmacies/drug shop and discuss potential partnerships.
Map and select the pharmacies/drug shops that meet the basic criteria, which can vary based on the private sector and regulatory environment in a designated city, state or country. The basic criteria is:
- Have an up-to-date certificate of registration and valid operating license.
- Have more than one provider with at least one licensed pharmacist on staff.
- Stock at least 2 to 5 contraceptive methods.
- Be located in a densely populated areas and in close proximity to a public health facility.
- Be willing and able to refer clients to TCI-supported facilities
Conduct a pharmacy/drug shop visit to assess capacity and ability to sustain the community’s need for services. During the visits to the pharmacies/drug shops, work with the local government to administer a checklist.
Develop a Memorandum of Understanding (MOU) with interested stakeholders that clearly outlines the pharmacy engagement approach. A MOU is a helpful tool to establish commitment on the part of the pharmacists and drug shop owners. The MOU should include:
- Designated roles and responsibilities of all parties included in the partnership, including reporting guidelines.
- Requirements for capacity building of pharmacy personnel, including which staff are to be trained, the duration of the training and the materials to be used according to Ministry of Health (MOH) guidelines.
- Monitoring and supportive supervision activities.
In collaboration with the Ministry of Health, hold capacity building sessions on FP and youth-friendly services for relevant pharmacy These trainings should include guidance on how to:
- Provide high-quality FP services, including information about available methods, effective use and side
- Counsel and communicate with youth about modern contraceptive methods, including emergency contraceptives and sexually transmitted infections.
- Establish an active referral system for clients seeking contraceptives that may not be available.
- Record and report on the number and age of clients counseled and provided with FP methods and those referred. Coach the pharmacists on data capture and reporting in relevant reporting tools.
Establish a referral system whereby pharmacists/drug shop owners refer clients to the closest health. Provide list of nearby health facilities to the pharmacy and drug shops.
- Incentive for client: If they bring referral form to TCI-supported clinics, they will be prioritized by providers and receive quick counseling.
- Incentive for provider: Satisfied first-time client can return to them for FP method versus going back to doctor each time and will be less likely to discontinue, potentially leading to an increase in sales overtime.
Identify key FP policies within the country context and key institutions that are required to engage the pharmacies/drug shops.
Provide informational and educational materials and job aids to pharmacies/drug shops with trained pharmacists/drug shop operators.
Monitor and evaluate the documentation and reporting tools of the pharmacies/drug shops on a quarterly basis in line with the program and MOH policy and procedures. At the local level, include the pharmacists in stakeholder meetings to share their experience.
Conduct quarterly supportive supervision visits to pharmacies/drug shops to evaluate quality of services, identify gaps and continue to build capacity in line with the national guidelines.
Establish a feedback mechanism (i.e., monthly, or quarterly meetings) to inform pharmacy personnel of the results of the evaluation and discuss areas of strengths and weaknesses. Pharmacy partners can help identify best practices and provide insight on how to improve reach to adolescents and youth. Discuss outcomes of clients who were referred to and accessed services at supported facilities. Pharmacies/drug shops may be involved in various meetings at the geography.

Tips

Youth outreach workers can act as a link between young adults who may have health questions and the services being provided by pharmacies with trained personnel.
Health Management Team (HMT) members are best positioned to collaborate with pharmacy stakeholders to identify local needs, set priorities, and develop an action plan that will advance contraception access and connection to the community.
Private sector stakeholders can help identify which pharmacies/drug shops in a specific area have the highest capacity and willingness to provide contraception services. Work with adolescents and youth to monitor service quality by conducting mystery client visits and/or completing observational checklists.

Key Outcomes

Increased uptake of modern contraception through pharmacies and drug shops
Improved referral of clients from pharmacies and drug shops to nearby public health facilities
Strengthened linkages and collaboration between private and public facilities

Monitoring Processes

Develop a monthly reporting tool and referral forms for pharmacies/drug shops to use
Monitor family planning service provision in pharmacies, including methods provided, clients referred and clients that completed referrals
Review data reported from pharmacies on a monthly basis
Provide quarterly supportive supervision of pharmacies to monitor quality

Success Indicators

Number of pharmacies that are reporting into the health management information system (HMIS)
Number of pharmacies with providers/staff trained on FP
Number of referrals made

Cost

Training costs
Meeting costs (engagement, data review and supportive supervision)
Branding and informational leaflets
Reporting and referral tools

Sustainability

Linkages of pharmacies with Ministry of Health and public health facilities
Pharmacies receiving methods through the government’s supply chain

SPOTLIGHT: Partnering with District Pharmacists in Arusha, Tanzania

In Arusha, Tanzania, like in many other cities in East Africa, youth frequent pharmacies for short-term methods. Their visits to pharmacies are critical touchpoints with the health system and offer an opportunity to provide them with helpful information about contraceptives and, in some cases, refer them to a health facility for counseling. In January 2019, the TCI Tanzania team decided to work with the District Pharmacists in Arusha to improve young people’s experiences when accessing pills and condoms at local pharmacies and connect them with TCI trained health facilities. Together with TCI, the District Pharmacists identified 300 high-volume registered pharmacies in Arusha that would be eligible to receive training on providing quality family planning counseling to men and women of all ages, but in particular, young people.

Key outcomes following the initial TCI-supported training include:

Pharmacists are now more motivated to counsel on contraceptives and are sharing user data on time with the District Pharmacists to show that they are reaching their targets for the month.
The District Pharmacists are also motivated to ensure that the monthly data is collected and that the quality of services being provided are monitored at each pharmacy in their district.
Pharmacists provide a monthly report on the number of (1) clients counseled by age, (2) clients accepting a modern method by age and method, and (3) clients referred to a TCI health facility by age. The District Pharmacists collect the data and share with the Arusha government and TCI for programming on a monthly basis.
Pharmacists are more aware of their contraceptive sales and, as a result, are less prone to stockouts and can plan commodity needs based on monthly data.

Since the initial capacity building session in March, TCI trained pharmacists have provided 422 condoms and 223 pills to clients and referred 1,812 clients to TCI health facilities. Estimates conclude that 55% of the clients referred to health facilities were youth between the ages of 15-24. TCI health facilities have completed 636 referrals from pharmacies since the partnership began, leading to a 20% increase in youth acceptors between April 2018 and 2019.