Dashboard East Africa: Service Delivery Increasing Youth Access Through Pharmacies

East Africa Toolkit: AYSRH Services & Supply

Increasing Contraception Access for Adolescents and Youth Through Pharmacies

Pharmacies (chemists/drug shops) are convenient and popular sources for healthcare advice, treatments and supplies, and they offer an opportunity to reach existing, as well as new family planning clients. Many clients using short-term contraceptives, such as pills, condoms, injectables or emergency contraceptives, will obtain their method from a pharmacy instead of a public facility. In Tanzania, 37% of modern contraceptive users obtain their method from the private sector, including pharmacies, 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 family planning 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.

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?

Frequently, pharmacies are not well-regulated, and staff are not properly trained on family planning methods. As a result, improving the quality of services and linkages to public health facilities at pharmacies and drug shops is a promising strategy to reach more women with contraceptives, and particularly young people.
Community pharmacies can act as an alternative when there is limited access to health facilities, family planning providers, or a full range of contraceptive options (often due to supply shortages) in the public sector. Uganda is currently expanding its Volunteer 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/CHAs/VHTs, can help relieve the workload pressure on midwives and health centers as family planning demand increases.
With task sharing, a concept endorsed by WHO, providers with less training can deliver some of the same services with the same quality as providers with more training, which allows better use of highly trained workers and expands service delivery.

Evidence

The following evidence on the effectiveness of partnering with pharmacies and drug shops to reach women with family planning methods has also been observed:

A 2016 systematic review of current literature found that there is clear evidence that pharmacy provision of family planning methods increases contraceptive access for young people and is an important compliment to public health facilities. The same study, however, identified that many issues still remain in terms of the quality of family planning provision in pharmacies, citing a need for capacity building of pharmacy staff on contraceptive provision.
In the recent addendum to the Uganda National Policy Guidelines and Service Standards for Sexual and Reproductive Health on community-based access to injectables, developed with FHI, Community Pharmacies are recognized as “outlets of family planning service provision,” both as community-based and private sector outlets.
In the recently reviewed Kenya National Policy Guidelines, pharmacies are able to offer family planning counseling and services, including pills and condoms, and refer clients to health facilities for injections, implants and tubal ligation.

Guidance: How to work with pharmacies

Below is guidance on how to engage pharmacies to reach more youth with quality contraceptives and strengthen referrals to health facilities:

Identify potential key public-private sector stakeholders for family planning and AYSRH service provision, including pharmacy associations, private sector professional associations and pharmacy academic institutions.
Map the pharmacies who meet the basic criteria and perform outreach to stakeholders to gauge their interest in strengthening family planning service provision by arranging meetings to discuss potential partnership. Conduct a pharmacy visit to assess capacity and ability to sustain the community’s need for services.
Develop a Memorandum of Understanding (MOU) with interested partners that clearly outlines the pharmacy engagement approach. An MOU is a helpful tool to establish commitment on the part of the pharmacists and drug shop owners. Key components of the MOU should include:
- Designated roles and responsibilities of all parties included in the partnership.
- Criteria for pharmacy selection, which can vary based on the private sector and regulatory environment in a designated city, state or country.
  - Pharmacies should have valid license or registration, have licensed pharmacists on staff, be located in densely populated areas and in close proximity to a public health facility.
  - Pharmacies should stock at least 5 family planning methods.
  - Pharmacies should be willing and able to refer clients to TCI-supported facilities.
- Requirements for capacity building of pharmacy personnel, including which staff are to be trained, the duration of training and the materials to be used.
- Plans for monitoring service quality.
Hold capacity building sessions on family planning and youth-friendly services for relevant pharmacy staff. These trainings should include guidance on how to:
- Provide high-quality family planning services, including information about available methods, effective use and side effects.
- 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 in participating pharmacies.
- Record and report on the number and age of clients counseled on family planning methods and sales of different types of methods in pharmacies.
Establish a referral system whereby pharmacists refer clients to the closest TCI-supported health facility.
- 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 family planning method (versus going back to doctor each time) and will be less likely to discontinue, potentially leading to an increase in sales overtime.

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.

Program Implementation Team (PIT) members are best-positioned to collaborate with pharmacy stakeholders in order to identify local needs, set priorities, and develop an action plan that will advance contraception access and connection to the community.

Local and regional pharmacy organizations can help identify which pharmacies in a specific area have the highest capacity and willingness to provide contraception services. They can also provide introductions to leaders of these pharmacies.

Work with adolescents and youth to monitor service quality by conducting mystery client visits and/or completing observational checklists.

Provide youth-oriented IEC materials and job aids to pharmacies with trained pharmacists.
Conduct site visits to pharmacies to evaluate quality of services and continue to build capacity.
Monitor and evaluate the documentation and reporting tools of the pharmacy on a quarterly basis in line with the MOH policy and procedures.
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 TCI-supported facilities.

Key Outcomes

Accurate data collected on a routine basis
Improved quality of family planning service provision at pharmacies
Increased referrals to public health facilities
Established partnerships between government, stakeholders and pharmacies
Pharmacies collaborate with CHMT in provision of family planning services

Monitoring Processes

Develop a monthly reporting tool and referral forms for pharmacists 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 supportive supervision of pharmacies to monitor quality

Success Indicators

Increase in number of women and youth accessing high-quality family planning services from pharmacies and health facilities
More than 60% of the family planning referrals from pharmacies to public facilities are completed
Increased knowledge and awareness of family planning among young adults, including where they can obtain modern contraceptive methods at pharmacies and public health facilities

Cost

Meetings
Premises branding
Printing IEC materials and job aids and reporting tools
Routine feedback meeting
Supportive supervision

Sustainability

Linkages of pharmacies with ministry of health and public health facilities
Wide range of family planning methods available at pharmacies
Pharmacies receiving methods through government 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.