Utilization of pharmacies and pharmaceutical drugs in Addis Ababa, Ethiopia

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<ul><li><p>So,. Set . Med. Vol . 2 2 . No . 6, pp . 653-672 . 1986</p><p>02277-9536,86 S, 00+0.00</p><p>Printed in Great Britain . All rights reserved</p><p>Copyright C 1986 Pergamon Press Ltd</p><p>UTILIZATION OF PHARMACIES AND</p><p>PHARMACEUTICAL DRUGS IN ADDIS ABABA, ETHIOPIA</p><p>HELMUT KLOos', TSEGAYE CHAMA', DAWIT ABEMO',</p><p>KEFALO GEBRE TSADIK' and SOLOMON BELAY -</p><p>'Department of Geography, Addis Ababa University, Addis Ababa and 'Pharmacist, City Council</p><p>Pharmacies, Addis Ababa, Ethiopia</p><p>Abstract-This paper examines recent developments in the pharmaceutical retail trade in socialist Ethiopia</p><p>and presents the results of two surveys on pharmacy utilization in Addis Ababa. Surveys were carried</p><p>out in 6 private and 5 government pharmacies. Objectives are</p><p>: (1) to examine drug retailer utilization in</p><p>relation to locational, transportation and retailer-related factors, (2) evaluate the role of socioeconomic</p><p>factors in pharmacy and drug utilization ; and (3) determine distance decay associated with clients' trip</p><p>origins and the location of their residences as indicators of service areas . Although most clients originated</p><p>in Addis Ababa, large numbers came from rural areas, especially in the pharmacies near large markets</p><p>and other shopping areas in the inner city. Centrally located retailers also served more Addis Ababa</p><p>residents and larger sections of the city than peripherally located retailers, largely due to a combination</p><p>of urban structure, distribution of health care facilities, prevailing drug shopping behavior and population</p><p>distribution . Government pharmacies had larger service areas and served larger numbers of clients than</p><p>private pharmacies, primarily due to lower prices and greater availability of pharmaceuticals . Mean</p><p>distance from pharmacies to places of origin of trips was smaller than mean distance from pharmacies</p><p>to residences of the same clients . Similarly. distance decay gradients were steeper for the former than the</p><p>latter in the 4 pharmacies studied in the second part of the survey, indicating the greater suitability of</p><p>origin of trip as a parameter of service area . Type and price of drugs purchased were associated with</p><p>socioeconomic factors, particularly level of education and housino'environmental health conditions in two</p><p>districts, but there was little variation in the small number of drugs purchased per client . Several forms</p><p>of drug-purchasing behavior of pharmacy clients and selling practices of private retailers are described</p><p>as adaptive responses to prevailing economic and sociopolitical conditions . The study concludes that</p><p>population-based studies of disease occurrence and health behavior are needed to better evaluate the</p><p>health needs of the population for the planning of additional drug retailers in Addis Ababa's suburban</p><p>districts .</p><p>INTRODUCTION</p><p>Health planners must consider a number of location</p><p>and allocation parameters as well as travel time and</p><p>cost, intervening opportunities for medical treatment,</p><p>and the culture of the population at risk if spatially</p><p>and functionally optimum delivery of care is to be</p><p>provided. Although several models have been devel-</p><p>oped by geographers with the objective of upgrading</p><p>the location and allocation of hospital and physician</p><p>services [I],research in one area of health care-the</p><p>distribution and utilization of pharmaceutical drug</p><p>retailers-has been neglected. Provision of essential</p><p>drugs [2] in developing countries has been identified</p><p>as an essential element of primary health care within</p><p>the context of the Global Strategy of Health for All</p><p>by the Year 2000 [3] . Pharmaceuticals have con-</p><p>tributed to the improvement of living conditions and</p><p>life expectancy in many developing countries, but</p><p>their supply (primarily through multinational cor-</p><p>porations) and cost fall far short of health needs and</p><p>available resources in poor countries [4] . Although</p><p>expenditures for pharmaceuticals in different devel-</p><p>oping countries accounts for 25-60% of the total</p><p>national expenditure for health care, which represents</p><p>2 to 4 times the proportion spent in developed</p><p>Send all correspondence and reprint requests to Dr H.</p><p>Kloos, P.O. Box 31609, Addis Ababa, Ethiopia .</p><p>ssa _n_o</p><p>653</p><p>countries, pharmaceutical products are either not</p><p>available in appropriate quantity or they are</p><p>unaffordable for most of the population [5]. In some</p><p>of the least-developed countries, including Zaire and</p><p>Ethiopia, the annual public expenditure on health is</p><p>only about $1, compared to $450 in the United States</p><p>[6] . The scarcity of pharmaceuticals in developing</p><p>countries is even more clearly brought into focus</p><p>when one considers the widespread distribution of</p><p>disabling and killing diseases, the concentration of</p><p>biomedical services in large cities, and lack of control</p><p>over the distribution and utilization of drugs . Tra-</p><p>ditional indigenous medicines are also widely used in</p><p>many developing countries [7] . However, they are</p><p>unlikely to reduce the growing demand for modern</p><p>pharmaceuticals. Increasing exposure of indigenous</p><p>populations to commercial drugs in also believed to</p><p>be causing far-reaching changes in health behavior,</p><p>particularly in urban areas [8 .9] .</p><p>Problems of achieving equitable distribution and</p><p>safe use of pharmaceuticals have also been associated</p><p>with the various phases of their production . market-</p><p>ing and distribution . Concerns include the pro-</p><p>motional and sales practices of multinational com-</p><p>panies and the utilization of drugs by retailers . health</p><p>workers and patients [10] . Partly due to sales pro-</p><p>motion and the patent and sophisticated pricing</p><p>systems of multinationals, many governments have</p><p>failed to implement World Health Organization</p></li><li><p>6 5 4</p><p>HELMUT KLOOS et a!.</p><p>guidelines [111 for developing rational drug policies</p><p>aimed at the procurement of essential (or appropri-</p><p>ate) and low priced products. In the absence of</p><p>adequate drug policies physicians tend to over-</p><p>prescribe and at the retail level pharmacy workers</p><p>and unqualified drug peddlers often sell pharma-</p><p>ceuticals without doctors' prescriptions to an unin-</p><p>formed and often illiterate public, with frequent</p><p>harmful effects [12].</p><p>Partly due to strong cultural, social and economic</p><p>barriers between people and physicians in developing</p><p>countries, pharmacists . druggists and less qualified</p><p>retailers play a greater role in prescribing and dis-</p><p>pensing pharmaceuticals than in developed countries .</p><p>Self-diagnosis and self-treatment involving pharma-</p><p>ceuticals are widespread and drug retailers freely</p><p>advise clients on which products to use, many of</p><p>which can be sold in developed countries only with</p><p>prescriptions . The sale of many pharmaceuticals over</p><p>the counter that would require prescriptions in their</p><p>countries of origin adds to the importance of drug</p><p>retailers in meeting health needs. Thus, the health</p><p>status of a population encompasses not only easy and</p><p>inexpensive access to safe and effective remedies, but</p><p>also better understanding of the proper use of phar-</p><p>maceuticals, including associated risks and benefits .</p><p>Prescribing and dispensing practices influence how</p><p>pharmaceuticals are used and who uses them [13] .</p><p>Most critics of the production and marketing of</p><p>pharmaceuticals in free market competition . and the</p><p>operation of multinationals in developing countries,</p><p>favor their regulation to facilitate more-equitable</p><p>distribution of health services (14] . The main argu-</p><p>ment of proponents of more moderate policies is that</p><p>elimination of the profit motive and competition in</p><p>the production and marketing of drugs would also</p><p>destroy drug research and result in inefficiency and</p><p>corruption [15] . Van der Geest [16] noted that the</p><p>highly political character of the debate between rad-</p><p>icals and moderates may result in strongly biased</p><p>research and suggested that case studies be carried</p><p>out of drug distribution at the community level . The</p><p>present study examines the utilization of selected</p><p>government and private pharmacies in Addis Ababa</p><p>in relation to locational, distance, facility-related,</p><p>socioeconomic and political factors .</p><p>PHARMACEUTICALDRUGS</p><p>AND</p><p>RETAILERS IN ETHIOPIA</p><p>The Ethiopian revolution aims to establish the</p><p>necessary economic and social infrastructure for the</p><p>improvement of health services in a country with</p><p>some of the highest infant mortality rates and lowest</p><p>life expectancy world-wide . The following statement</p><p>by the Head of the General Planning Sector [17]</p><p>reflects the accomplishments of the revolution and</p><p>the change in philosophy and orientation of the</p><p>health services toward primary health care involving</p><p>community participation . away from a free market</p><p>system [18] .</p><p>Social ownership of the major means of production and</p><p>distribution . the establishment of a strong central planning</p><p>organization (National Revolutionary Development Cam-</p><p>paign and Central Planning Supreme Council) with seven</p><p>regional planning offices, the formation of peasant . work-</p><p>ers'. youth . women's and urban associations and the pro-</p><p>motion of producers' and service cooperatives provide ideal</p><p>conditions for development and dissemination of health-</p><p>related activities as well as for research efforts focused on</p><p>health promotion .</p><p>Specific measures for achieving the economic, so-</p><p>cial and health development goals are set forth in the</p><p>1984-1994 10-year plan [19] . However, although the</p><p>Ministry of Health is in the process of reorganizing</p><p>and restructuring itself to better coordinate, imple-</p><p>ment and support the new plan. one can hardly</p><p>consider this a national plan comparable to those</p><p>existing in older, more established socialist countries .</p><p>Progress toward achieving more decentralized and</p><p>equitable health services has been slow- partly due to</p><p>organizational and conceptual difficulties at various</p><p>levels of the health services and at training centers</p><p>[20] . Health services remain highly centralized in</p><p>Addis Ababa, with health facilities in the capital city</p><p>using 33% of the recurrent health budget . Some 28%</p><p>of the hospital beds, 51% of all physicians . 606 of</p><p>all pharmacies and 74% of all pharmacists in Ethi-</p><p>opia are found in Addis Ababa [21] .Moreover, the</p><p>referral system between primary care facilities and</p><p>regional and national hospitals remains under-</p><p>developed [22] .Although no pharmacy regulations</p><p>have been issued by the socialist government of</p><p>Ethiopia, due to the absence of a comprehensive</p><p>national health plan, the Ministry of Health has</p><p>taken a series of measures which have had a far-</p><p>reaching effect on the operation of drug retailers and</p><p>the distribution of pharmaceuticals throughout the</p><p>country [23] .</p><p>Recent developments in the Ethiopian drug whole-</p><p>sale and retail trade are similar to those in the other</p><p>sections of the health services . particularly in regard</p><p>to increased government guidelines and control ac-</p><p>cording to the country's health needs . the purchasing</p><p>capacity of its people, and the philosophy of social-</p><p>ism [24] . The single Ethiopian manufacturer of phar-</p><p>maceuticals and several importers wholesalers were</p><p>nationalized and recast in a state corporation re-</p><p>sponsible for the manufacture, import, quality con-</p><p>trol and distribution of drugs . Total drug sales in</p><p>Ethiopia increased from 42 .9 million Birr [25] in 1972</p><p>to 45 .8 million Birr in 1980 . The domestic share of</p><p>drug production increased from 185 to 31.0% during</p><p>the same period [26] . This increased share of the</p><p>national drug manufactures was partly due to an</p><p>increase in import taxes (from 27 to 40%) designed</p><p>to encourage indigenous production [27] .</p><p>Beginning in 1977 the Ministry of Health nation-</p><p>alized private pharmacies and druggist shops</p><p>throughout the country and by 1934 it owned 5</p><p>public pharmacies and all but one of the I I public</p><p>hospitals in Addis Ababa . Four years later the Addis</p><p>Ababa Municipality began its own pharmacy pro-</p><p>gram. By the end of 1984 it operated 5 public</p><p>pharmacies, all of them placed for rapid expansion</p><p>and maximum utilization at major traffic inter-</p><p>sections and bus stops. As part of their effort to</p><p>minimize cost of health care and to gradually take</p><p>over the private sector, both the Ministry of Health</p><p>and the municipality reduced the retail profit margin</p><p>of drugs sold in retail shops from 40 to 30% and</p><p>supplied their pharmacies with certain drugs that</p></li><li><p>private retailers were no longer permitted to sell,</p><p>including T .B. drugs, some higher antibiotics . insulin,</p><p>psychotrophic drugs and several vitamin mineral</p><p>preparations . Several private retailers responded by</p><p>lowering the prices of some drugs . especially for well</p><p>established clients, in an effort to remain competitive .</p><p>In November 1984 municipality pharmacies reduced</p><p>the profit margin by another 5% . to 25%, a move</p><p>followed by some Ministry of Health pharmacies .</p><p>with further price reductions planned for the future .</p><p>The lowest priced drugs were offered by the govern-</p><p>ment hospital pharmacies since their recent exemp-</p><p>tion from customs tax but their services were re-</p><p>stricted largely to inpatients and qualifying poor</p><p>people. Equally important, those hospital pharmacies</p><p>that do serve the public require prescriptions for</p><p>nearly all pharmaceuticals, thus eliminating from</p><p>their clients the great majority of the population,</p><p>which continues to depend heavily on self diagnosis</p><p>and self-medication . The price reductions, together</p><p>with their well selected locations in the inner city and</p><p>the wide-spread sale of over-the-counter drugs have</p><p>contributed to making the municipality-owned phar-</p><p>macies the most popular and most widely patronized</p><p>drug retailers in Addis Ababa . The municipality is</p><p>Utilization of pharmacies and pharmaceutical drugs</p><p>planning to establish pharmacies and druggist shops</p><p>along with clinics and health centers in all 9 keftegnas</p><p>(higher cooperative societies of urban dwellers) [28] at</p><p>the urban periphery that lack drug retailers (Fig . l,</p><p>Table 1) . It is not known, however, if the municipality</p><p>or the Ministry of Health will eventually control and</p><p>develop the drug retail trade in Addis Ababa.</p><p>Owners of private pharmacies and druggist shops</p><p>have developed a pessimistic attitude toward the</p><p>future of their business in view of the increasing</p><p>threat of business closures by the government. Inter-</p><p>views with pharmacy owners indicate that the Minis-</p><p>try of Health has been closing pharmacies on the</p><p>ground that owners evaded sates taxes . failed to pay</p><p>rent on time, and committed serious errors in dis-</p><p>pensing drugs . One of the various regulations issued</p><p>by the Ministry of Health as part of revised health</p><p>policy is the prohibition to treat patients in pharma-</p><p>cies, druggist shops and rural medicine vendor shops</p><p>[29] . Before the 19'4 revolution most drug retailers in</p><p>Addis Ababa (and in rural areas) commonly treated</p><p>clients for numerous ailments, giving physical exam-</p><p>inations and injections and performing surgery and</p><p>other clinical procedures, as observed by the senior</p><p>author on several occasions [30] . The prohibition to</p><p>Private pharmacy or druggist</p><p>shop</p><p>oPrivate pharmacy</p><p>studied</p><p>Government pharmacy</p><p>AGovernment pharmacy</p><p>studied</p><p>+ Hospital -</p><p>*...</p></li></ul>


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