utilization of pharmacies and pharmaceutical drugs in addis ababa, ethiopia

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  • So,. Set . Med. Vol . 2 2 . No . 6, pp . 653-672 . 1986

    02277-9536,86 S, 00+0.00

    Printed in Great Britain . All rights reserved

    Copyright C 1986 Pergamon Press Ltd

    UTILIZATION OF PHARMACIES AND

    PHARMACEUTICAL DRUGS IN ADDIS ABABA, ETHIOPIA

    HELMUT KLOos', TSEGAYE CHAMA', DAWIT ABEMO',

    KEFALO GEBRE TSADIK' and SOLOMON BELAY -

    'Department of Geography, Addis Ababa University, Addis Ababa and 'Pharmacist, City Council

    Pharmacies, Addis Ababa, Ethiopia

    Abstract-This paper examines recent developments in the pharmaceutical retail trade in socialist Ethiopia

    and presents the results of two surveys on pharmacy utilization in Addis Ababa. Surveys were carried

    out in 6 private and 5 government pharmacies. Objectives are

    : (1) to examine drug retailer utilization in

    relation to locational, transportation and retailer-related factors, (2) evaluate the role of socioeconomic

    factors in pharmacy and drug utilization ; and (3) determine distance decay associated with clients' trip

    origins and the location of their residences as indicators of service areas . Although most clients originated

    in Addis Ababa, large numbers came from rural areas, especially in the pharmacies near large markets

    and other shopping areas in the inner city. Centrally located retailers also served more Addis Ababa

    residents and larger sections of the city than peripherally located retailers, largely due to a combination

    of urban structure, distribution of health care facilities, prevailing drug shopping behavior and population

    distribution . Government pharmacies had larger service areas and served larger numbers of clients than

    private pharmacies, primarily due to lower prices and greater availability of pharmaceuticals . Mean

    distance from pharmacies to places of origin of trips was smaller than mean distance from pharmacies

    to residences of the same clients . Similarly. distance decay gradients were steeper for the former than the

    latter in the 4 pharmacies studied in the second part of the survey, indicating the greater suitability of

    origin of trip as a parameter of service area . Type and price of drugs purchased were associated with

    socioeconomic factors, particularly level of education and housino'environmental health conditions in two

    districts, but there was little variation in the small number of drugs purchased per client . Several forms

    of drug-purchasing behavior of pharmacy clients and selling practices of private retailers are described

    as adaptive responses to prevailing economic and sociopolitical conditions . The study concludes that

    population-based studies of disease occurrence and health behavior are needed to better evaluate the

    health needs of the population for the planning of additional drug retailers in Addis Ababa's suburban

    districts .

    INTRODUCTION

    Health planners must consider a number of location

    and allocation parameters as well as travel time and

    cost, intervening opportunities for medical treatment,

    and the culture of the population at risk if spatially

    and functionally optimum delivery of care is to be

    provided. Although several models have been devel-

    oped by geographers with the objective of upgrading

    the location and allocation of hospital and physician

    services [I],research in one area of health care-the

    distribution and utilization of pharmaceutical drug

    retailers-has been neglected. Provision of essential

    drugs [2] in developing countries has been identified

    as an essential element of primary health care within

    the context of the Global Strategy of Health for All

    by the Year 2000 [3] . Pharmaceuticals have con-

    tributed to the improvement of living conditions and

    life expectancy in many developing countries, but

    their supply (primarily through multinational cor-

    porations) and cost fall far short of health needs and

    available resources in poor countries [4] . Although

    expenditures for pharmaceuticals in different devel-

    oping countries accounts for 25-60% of the total

    national expenditure for health care, which represents

    2 to 4 times the proportion spent in developed

    Send all correspondence and reprint requests to Dr H.

    Kloos, P.O. Box 31609, Addis Ababa, Ethiopia .

    ssa _n_o

    653

    countries, pharmaceutical products are either not

    available in appropriate quantity or they are

    unaffordable for most of the population [5]. In some

    of the least-developed countries, including Zaire and

    Ethiopia, the annual public expenditure on health is

    only about $1, compared to $450 in the United States

    [6] . The scarcity of pharmaceuticals in developing

    countries is even more clearly brought into focus

    when one considers the widespread distribution of

    disabling and killing diseases, the concentration of

    biomedical services in large cities, and lack of control

    over the distribution and utilization of drugs . Tra-

    ditional indigenous medicines are also widely used in

    many developing countries [7] . However, they are

    unlikely to reduce the growing demand for modern

    pharmaceuticals. Increasing exposure of indigenous

    populations to commercial drugs in also believed to

    be causing far-reaching changes in health behavior,

    particularly in urban areas [8 .9] .

    Problems of achieving equitable distribution and

    safe use of pharmaceuticals have also been associated

    with the various phases of their production . market-

    ing and distribution . Concerns include the pro-

    motional and sales practices of multinational com-

    panies and the utilization of drugs by retailers . health

    workers and patients [10] . Partly due to sales pro-

    motion and the patent and sophisticated pricing

    systems of multinationals, many governments have

    failed to implement World Health Organization

  • 6 5 4

    HELMUT KLOOS et a!.

    guidelines [111 for developing rational drug policies

    aimed at the procurement of essential (or appropri-

    ate) and low priced products. In the absence of

    adequate drug policies physicians tend to over-

    prescribe and at the retail level pharmacy workers

    and unqualified drug peddlers often sell pharma-

    ceuticals without doctors' prescriptions to an unin-

    formed and often illiterate public, with frequent

    harmful effects [12].

    Partly due to strong cultural, social and economic

    barriers between people and physicians in developing

    countries, pharmacists . druggists and less qualified

    retailers play a greater role in prescribing and dis-

    pensing pharmaceuticals than in developed countries .

    Self-diagnosis and self-treatment involving pharma-

    ceuticals are widespread and drug retailers freely

    advise clients on which products to use, many of

    which can be sold in developed countries only with

    prescriptions . The sale of many pharmaceuticals over

    the counter that would require prescriptions in their

    countries of origin adds to the importance of drug

    retailers in meeting health needs. Thus, the health

    status of a population encompasses not only easy and

    inexpensive access to safe and effective remedies, but

    also better understanding of the proper use of phar-

    maceuticals, including associated risks and benefits .

    Prescribing and dispensing practices influence how

    pharmaceuticals are used and who uses them [13] .

    Most critics of the production and marketing of

    pharmaceuticals in free market competition . and the

    operation of multinationals in developing countries,

    favor their regulation to facilitate more-equitable

    distribution of health services (14] . The main argu-

    ment of proponents of more moderate policies is that

    elimination of the profit motive and competition in

    the production and marketing of drugs would also

    destroy drug research and result in inefficiency and

    corruption [15] . Van der Geest [16] noted that the

    highly political character of the debate between rad-

    icals and moderates may result in strongly biased

    research and suggested that case studies be carried

    out of drug distribution at the community level . The

    present study examines the utilization of selected

    government and private pharmacies in Addis Ababa

    in relation to locational, distance, facility-related,

    socioeconomic and political factors .

    PHARMACEUTICALDRUGS

    AND

    RETAILERS IN ETHIOPIA

    The Ethiopian revolution aims to establish the

    necessary economic and social infrastructure for the

    improvement of health services in a country with

    some of the highest infant mortality rates and lowest

    life expectancy world-wide . The following statement

    by the Head of the General Planning Sector [17]

    reflects the accomplishments of the revolution and

    the change in philosophy and orientation of the

    health services toward primary health care involving

    community participation . away from a free market

    system [18] .

    Social ownership of the major means of production and

    distribution . the establishment of a strong central planning

    organization (National Revolutionary Development Cam-

    paign and Central Planning Supreme Council) with seven

    regional planning offices, the formation of peasant . work-

    ers'. youth . women's and urban associations and the pro-

    motion of producers' and service cooperatives provide ideal

    conditions for development and dissem

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