Clearly an important part of the solving the global health crisis is a sustainable delivery system for basic medicines. Outside of public hospitals and clinics, many of the world’s citizens’ depend on street-front shops with limited quantities of sometimes expired or even counterfeit drugs and untrained staff. Although through a concerted international effort to strengthen health care delivery systems in general (e.g., the PEPFAR Five-Year Strategy), the delivery of essential medicines has improved at the primarily urban public facilities, significant improvement is needed to create country-wide, sustainable (for-profit) pharmacy infrastructure. And for companies seeking to sell their products globally, direct-to-customer distribution channels are an important part of succeeding in emerging markets.
A leading NGO for strengthening pharmaceutical distribution systems is Management Sciences for Health (MSH), and, in 2000, MSH received a Gates Foundation grant to implement a five-year Strategies for Enhancing Access to Medicines Program (SEAM). Working in multiple countries (Brazil, Cambodia, El Salvador, Ghana, India, Kenya, and Tanzania), the program staff gathered and analyzed data and made specific recommendations for the each of the participating countries. In general, the findings were that:
-public health facilities had on hand only half the needed basic drugs, requiring patients to purchase them at private facilities, sometimes at inflated prices, or go without;
-in some locations, 15% and up to 50% of drugs sold in pharmacy shops were substandard, often ineffective;
-pharmacy staff recommended inappropriate drugs in about 20% of test cases and rarely mentioned side-effects or hazards; and
-the local distribution problem was made worse by inefficient, decentralized procurement and poor management of drug supplies by governments.
In addition to generating reports and holding conferences, SEAM conducted a pilot program with the Tanzania Food and Drugs Authority, called the “accredited drug dispensing outlet” program, through which proprietors of 150 retail drug shops were trained and certified, leading to substantial improvement in the quality, availability, and affordability of medicines, and improved financial stability of the shops (ADDO Summary Report). In 2007, with another Gates grant, SEAM continued to work with the TFDA and several other organizations to extent the original program and to include business incentives, regulatory enforcement, and customer education. Called the East African Drug Seller Initiative, the effort has the goal of creating “a sustainable model to replicate and scale‐up private‐sector drug seller initiatives in developing countries that will ultimately operate independent of donor support” (EADSI). The initial Tanzanian program is also being monitored and the vast majority of the shops opened in 2003 are still successfully operating and newly-accredited owners (more than 200) have paid for their training out-of-pocket, an endorsement of accreditation’s value (ADDO 2009). Recently, SEAM launched a pilot drug shop accreditation program in Uganda.
In another successful demonstration of the for-profit approach to pharmaceutical distribution, under the original SEAM program MSH worked with the HealthStore Foundation to support the Child and Family Wellness Shops of Kenya, a franchise system of for-profit shops initiated by the Foundation in 2000 (HealthStore Overview). The Foundation’s network comprises more than 65 stores in Kenya which served 500,000 customers in 2007. The Foundation is planning expansion to 200 more shops in Kenya and other south African countries.
It looks as if MSH and the HealthStore Foundation have successful business models and are incrementally strengthening drug distribution systems in southern Africa. Scaling up within countries and out to other regions is the logical the next step, and, given the amount of data SEAM has, it should be straightforward to get a handle on the capital requirements, risks, and ROIs for roll-outs in other countries. Perhaps at this point, enlightened pharmaceutical companies or pharma/biotech trade organizations like BIO and Bio Ventures for Global Health may get involved to accelerate the process with their business expertise. One company is getting involved. Last August, GlaxoSmithKline announced the start of a modest collaboration with the HealthStore Foundation to expand their network to another country (GSK Access Program). Not much acceleration but one can hope it is the first of many new private-public partnerships to improve drug distribution systems. SEAMs right to me.