Welcome to the first episode of Health Systems Pathways. Making it easier for people to navigate complex health systems. Insights to inform, influence and inspire!  

I am Marina Dalton-Brown from Population Services International (more fondly known as PSI), and I am pleased to be your host for this podcast series.  

This is the shorter version of this episode, where you will hear the contributions of my guest, Ms. Hawa Godwin Milangasi, translated into English. If you would prefer to listen to the full length episode, including Ms Milangasi's contributions in Swahili, follow this link;

https://health-systems-pathways.captivate.fm/episode/-swh

In today’s episode, we talk about drug shops and the role they have in connecting people with the broader health systems.

As part of the conversation, it’s important to distinguish between “drug shops” and pharmacies.

Pharmacies are dispensers of prescription pharmaceutical products and may also sell other retail products and offer basic health services. These are owned, operated, or supervised by a registered pharmacy professional and are typically overseen by a national or regional regulator.

Drug shops are usually unregulated or poorly regulated though they may still sell prescription or over-the-counter health products. Sometimes they operate outside a formal regulatory environment. But they are an important point of care for many persons living in rural areas or outside city centres. In fact, properly integrating them into the health system – by providing training, standards, and a regulatory process – has the potential to significantly improve patient care.

In Tanzania, the National Food and Drug Administration and The Pharmacy Council have been working, with other partners, since 2005 to develop a mechanism to bring drug shops into the national healthcare system by certifying them and improving the quality of products and services being offered. This is called the ADDO Model, which stands for the Accreditation of Drug Dispensing Outlets. Since its inception, more than 14,000 drug shops have been accredited (or certified) and over 26,000 dispensers trained. And studies have shown that these drug shops perform well at many aspects of providing patient care. As a result, a number of other countries have their eye on this model and are at different stages of progress, including Bangladesh, Nigeria, Uganda, and Madagascar among others.

My guests in this episode share their perspectives of how this model has impacted their work and their families directly.

Mr. Richard Silumbe is the Malaria Case Management Officer supporting the National Malaria Control Program in Tanzania, and has first had knowledge of the implementation of the ADDO model.

Ms. Hawa Godwin Milangasi is a business woman who runs an enterprise in Chamazi, just over 28 km from Dar es Salaam, and she has sought care for her family at an ADDO retailer.

To find out more about the development and future of this model, check out our PSI blog (HOW COULD PRIVATE SECTOR PHARMACIES AND DRUG SHOPS ADVANCE PROGRESS TOWARDS UNIVERSAL HEALTH COVERAGE?);

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Health Systems Pathways is an SCL Agency Production

Hello, welcome to Health Systems

Pathways and thanks for tuning in.

This podcast is designed to share insights that inform, inspire, and

invite discussion about what's being done to make it easier for people

to navigate complex health systems in different parts of the world.

I am Marina Dalton Brown from Population Services International, more fondly

known as PSI, and I am pleased to be your host today, so let's get right into it.

In today's episode, we talk about drug shops and the role they have in

connecting people with the broader health system, but before we go

there, it's important to distinguish between pharmacies and drug shops.

So, pharmacies are dispensers of prescription pharmaceutical products

and may also sell other retail products and offer basic health services.

These are owned, operated, or supervised by a registered pharmacy

professional and are typically overseen by a national or regional regulator.

Drug shops, on the other hand, are usually unregulated or poorly regulated,

though they may still sell prescription or over the counter health products.

Sometimes, they operate outside of a formal regulatory environment, but

they are an important point of care for many persons living in rural

areas or outside of city centers.

And in fact, properly integrating them into the health system by

providing training standards and a regulatory process has the potential

to significantly improve patient care.

In Tanzania, the National Food and Drug Administration and the Pharmacy

Council have been working, along with other partners, since 2005, to develop

a mechanism to bring drug shops into the national healthcare system by certifying

them and improving the quality of products and services being offered.

This is called the ADDO model, which stands for the Accreditation

of Drug Dispensing Outlets.

Since its inception, more than 14,000 drug shops have been accredited, or

certified, and over 26,000 dispensers trained, and studies have shown that

these drug shops perform well at many aspects of providing patient care.

As a result, a number of other countries have their eye on this

model and are at different stages of progress, including Bangladesh, Nigeria,

Uganda and Madagascar, among others.

My guests today share their perspectives of how this model has impacted their

work and their families directly.

Mr.

Richard Sulimbe is the Malaria Case Management Officer supporting the

National Malaria Control Program in Tanzania, and has firsthand knowledge

of the implementation of the ADDO model.

Miss Hawa Godwin Milangasi is a businesswoman who runs an enterprise in

Chamazi, just over 28 kilometers from Dar es Salaam, and she has sought care

for her family at an ADDO retailer.

So let's hear from them about how accredited drug shops are changing

the lives of Tanzanians and strengthening the health system there.

Richard, welcome, tell us about yourself and tell us about what you do...

Thank you so much for your invitation.

My name is Richard Silumbe, the officer supporting the National Malaria Control

Program here in Tanzania, for more than a decade now, and I've been working

to support malaria case management through the private sector as well.

That's where we connected with the ADDO model.

Currently, we are doing a lot of intervention through malaria and our

country is aiming at elimination stage.

We are aiming to reach less than, uh, 1% at the end of the targeted year.

Currently we are almost in 8.5, but we are comfortable we'll be there.

Yeah...

Thank you so much, Richard.

So, drug shops have been an important part of the health landscape of Tanzania

for a long time, and as we mentioned, the ADDO model was introduced in 2005.

So, paint us a picture of what was happening then and why it was important to

introduce this mechanism, this approach...

To be honest, Marina, basing on the data that we have before

2005, there was a lot of challenges in health systems, especially how

we access the essential healthcare to the communities where they are

located, the hard to reach areas.

So, at that time majority of our population were located in the

rural settings and we didn't have enough health care facilities to

provide that essential health care.

So majority were depending on the drug shops that were there before, and these

were established everywhere and were less regulated and, uh, even the ones

that we are providing the service were not clearly regulated by government.

So with the enactment of Tanzania's Food and Drug and Cosmetics of 2003,

at least they provided a room to start regulating the drug shops.

The government started to think how best we can improve these shops and

we can make intensive regulations with these existing law and how we

can transform them to become a better point of care that can assist to

increase access to essential medicines.

Um, so that's where the transformation come in terms of policy and the

establishment of regulation through Tanzania food and drug authority back

then, uh, but now it's called Tanzania Medicines and Medical Devices Authority.

So to start with, we started with one region to establish that model.

I remember that was heavily supported with our partner, Management Science for

Health, MSH, worked with the government, worked with the Ministry of Health and

TMDA to transform them, that model, to impinge to at least one region, and that

was Ruvuma, and then we made a rollout to the countrywide through the other

partners, including Global Fund and USAID.

So up to now, as you mentioned earlier, more than 14 thousand newly

transformed accredited drug dispensing outlets are there in country.

And through this model, we are happy to say we have at least found a solution

of bringing back or ensuring the access of essential medicines to the rural

settings and hard to reach areas.

So we are utilizing that model to provide services to

reach easier to the communities.

For instance, insecticide treated nets distribution and also, um, bringing

the family planning medicines and other health programs that they have

been penetrated through this model to make sure that the communities

reach easily, even the insurance.

I mean, the people who have been insured by national health insurance funds and,

uh, they want to access the medicines once they miss from the, the formal health

facilities, they allowed also to go to those subspace, selected ADDOs, to access

medicine, uh, through the being a member of the national health insurance funds.

So this model, it has been a game changer and we are very happy being

innovative as Tanzania because we are aware that other countries came and,

uh, and also learned from this model and they replicated in their countries.

So that's really fascinating, Richard, and

thank you for painting that picture.

It seems to be an impactful mechanism that has been put in place.

I actually wanted to open to Hawa.

So Hawa, thank you so much for joining us.

We appreciate your time, tell us about yourself, um, tell us about what you do.

And then we're interested to hear about how this mechanism has impacted you.

Alicia Kahumuza (translating for Hawa): My name is Hawa Godwin Milangasi, and

I'm happy to be here with all of you.

I live in Dar es Salaam, outside of the city, in a place called Mbagala Chamazi.

So, I have three children.

I'm a mother with three children, one boy and two girls, and

I'm a small business owner.

In my business, I buy secondhand clothes from Kariakoo, and I sell them in Chamazi.

And in the community where I live, most people are middle

class and low class people.

They wake up in the morning every day to go and hustle and, you know, see if they

can earn an income to feed their children and their families, and basically that's

the life that, um, I live in Chamazi.

Oh, that's beautiful.

Thank you so much for sharing.

So drug shops have been a part of the health system where you are.

How has it been interacting with the ADDO model and with the drug shop in this

new kind of dispensation where there's more certified drug shop retailers?

How has that experience been for you?

Hawa Godwin Milangasi: [Hawa answers in Swahili]

Alicia Kahumuza (translating for Hawa): Okay.

ADDO has contributed very much in our communities in our everyday life.

For example, in the past, we used to walk very long distances to be able to access

health facilities, but now that we have ADDOs in the community, in the vicinity

of the areas where we live, we're able to get professional advice and essential

medicines, and even when you get a prescription from the health facility,

we're able to fill it from the ADDO shops.

So ADDO has contributed very much in our everyday life, in our communities.

So walk us through a real life experience

of when maybe your family or yourself, you had to access care.

What was that experience like?

[ Alicia Kahumuza (translating for Hawa): So there was one time when one of my

family members got sick and we went to an ADDO shop and the healthcare

provider, the ADDO, advised us to go to the health facility so that the,

so that my relative can be tested, and we were able to go to the health

facility and the doctor prescribed anti malaria drugs, the ALU anti-malaria

drugs, and we went back to the ADDO shop where they were dispensed to us.

And so because of that, we're able to access, because we have ADDO shops in

our communities, we're able to access medicine more easily than it was before.

That sounds like it, it really makes an impact as, as

we are hearing this, I could feel it.

I could feel as a mother myself, you know, wanting to access care

for my children or my relative and what it means to be able to do that.

Richard, I'm gonna come back to you.

Um, you are hearing this, you are a member of the Tanzanian population as well.

Have you interacted in a personal way as well with the

ADDO model, with the retailers?

How has that been for you?

Yes, Marina, I think, as just a citizen, I have interacted a lot.

One of the study that was provided is say more than 60% of population,

um, were preferring to go to the drug shops once they get fever.

So I cannot isolate myself on those days.

It's like once I get fever, then you say the closer drug shop you

have, that's where you can get your medicines and something like that.

We should also see at the end of economic point of view.

Uh, how the community are also benefiting like my colleague, Hawa, she's saying,

uh, now she can be able to get the right medicines at the cheaper price and she

doesn't want to walk for a distance to the health facilities for over the counter

medicine so they can be able to kind of access near to their, their homes.

Apart from that being a citizen, I've been interacting with ADDO as a regulator,

as a partner from the National Malaria Control Program, where our interventions

are also embedded through the ADDO model.

We had a lot of plans, how we can utilize this ADDO model to

improve malaria case management.

And we did a lot of pilots to make sure that the people who are missing

from the facilities can also access at the very affordable, um, uh,

manner to get these medicines from the drug shops, including ADDOs.

So I think, yeah, for malaria point of view, also, the ADDO has been very

helpful because it ensure the government, the Ministry of Health, the NMCP, to

reach the rural settings in a very formal way and since they're very close

to the house settings, it's easier to make sure that our health programs are

benefiting the people through them.

Thank you, Richard.

It really seems like the vision is clear, that there is benefit, and we

know that with any intervention, with any movement, there are challenges.

There are areas for improvement.

It has come a tremendous way.

Could you summarize for me, Richard, from a Ministry of Health point of view?

I think we cannot achieve malaria elimination in Tanzania, maybe,

if we are not also bringing intensive interventions through the private sector.

Another thing is to make sure that government partners who wish to

utilize the ADDO model to penetrate their programs, they have to speak

the same language in terms of if we bring the surveillance system

through ADDO, not every program has to bring its own checklist, its own

tools, and so we need to harmonize all these surveillance systems.

Thank you for those contributions.

Hawa, what are your, what are your thoughts?

What are your recommendations?

Hawa Godwin Milangasi: Hawa answers in Swahili

Alicia Kahumuza (translating for Hawa): I have one question for Mr Richard.

I would like to ask him because he is from the government.

Why doesn't the government maybe train the health care providers who are in the

ADDO shops to be able to provide testing services for diseases like malaria.

This would really help us in the community so that we don't have to travel very long

distances to go to the health facility and then come back to the ADDO shops.

That would really, um, make it easy for us.

Thank you so much Hawa for that nice question.

So, just, to make sure, we are aware that, National Malaria Control Program

is not a regulator for the, um, ADDOs or drug shops in the country, and,

uh, the role of National Malaria Control Program is to implement the

interventions that will increase the quality of malaria case management, both

in the public and the private sector.

We were aware, basing on the Tanzania Malaria Indicator Surveys of 2012 that

our population prefer to go to the private sector once they have fever

and preferably on the drug shops.

So in 2012, that's where as National Malaria Control Program, together with

the partners, we thought that if we can provide or to make sure that people are

not accessing or taking the anti malarial drugs from the drug shops without being

tested, so it's nice to introduce Malaria Rapid Diagnostic Tests, which is easier.

We did a pilot in two districts within the region in 2014 and also we roll

out to that model region in 2016, uh, with together with other partners like

CHAI, Clinton Health Access Initiative, and also PSI, and also involved a lot

of government partners, including the Pharma's Council themselves and TFDA of

those days, but now it's called Tanzania Medicines and Medical Devices Authority.

The results that we got in 2016 was really promising, but, uh, the Ministry

of Health of Tanzania thought that maybe the more studies are needed

to ensure that there is safety.

So for our malaria program, we would wish to increase malaria testing

because currently we are less than 60% total malaria testing and

we want to achieve over the 85%.

So we cannot reach that one if we do not increase, um, malaria

testing strategy through the communities, through the drug shops.

As a Ministry of Health, we are will keep on improving the ADDO model to

provide, uh, the services at high quality, including even some health

programs that were not deployed before, but we need to have a very

good, justification and evidence saying maybe there will be provided at high

level of safety so that the community they can keep on accessing the high

quality services from the ADDO models.

Thank you so, so much, Richard.

And Hawa, any last thoughts from you?

Hawa Godwin Milangasi: [Hawa answers in Swahili]

Alicia Kahumuza (translating for Hawa): I would like to recommend that the

government provides more training to the health personnel in ADDOs, so

that they're able to deal with the challenges that we face when we go to

see them while we're in the communities.

So, once they're well trained, we can be able to access more meaningful,

um, and more helpful health services.

In that way, it can improve the services that we are getting right now, and

because ADDO has been very helpful, it would make more sense to build on

what we are getting at the moment.

So in general, I would like to propose to the government to find ways to

improve ADDO services, services that we, we get at the ADDO shops.

Powerful.

Thank you so much, Asante.

Our guests have spoken and shared their perspective, working with drug

shops can pose a great opportunity to help fill a gap in the health system.

Though there are challenges to overcome along the way, so raising

their quality and credibility is advantageous, particularly for

those in rural and remote areas.

But this requires leadership at a national level, continuous engagement

with multiple stakeholders, and it demands patience, trust, and a willingness

to genuinely listen to those affected by and those influencing the change.

So much thanks to my guests today, Richard and Hawa, for sharing your

experiences and your perspectives and your insights on how we can make it

easier to navigate complex health systems.

To learn more about this topic and other health systems strengthening

work, head to our website, psi.

org.

There you can read about this blog post, this theme, and other topics

related to health and development.

Get in touch with us about your ideas and insights.

So, stay tuned for our next episode of Health Systems Pathways.