RPM Plus: Africa: Increasing Access to Essential Medicines through the Private Sector: The ADDO Program

Background

For a number of years, Duka la dawa baridi (DLDB), or private drug shops, had been authorized by the Tanzania Food and Drugs Authority (TFDA) to provide nonprescription drugs in the private sector.

With an estimated 6000+ stores, DLDB constituted the largest licensed retail outlets for purchasing medicines in Tanzania.

However, DLDB are plagued with several problems such as a limited list of medicines that can be legally sold, not including basic essential prescription medicines, lack of adequate facilities for storing medicines properly, lack of basic qualifications and training for dispensing staff, lack of business skills for shop owners, and inadequate or non-existent regulation and supervision by inspectors.

A systematic and holistic approach to the problems of DLDBs was used to develop the Accredited Drug Dispensing Outlets (ADDO) program during the pilot program under the Strategies for Enhancing Access to Medicines (SEAM) Program funded by the Bill & Melinda Gates Foundation in 2000.

The goal of the ADDO program was to increase access to essential medicines through utilization of the private sector.

All aspects of the DLDB enterprise—including the physical premises, stock maintained by the owner, consumer choices, interactions with dispensers, and recommended treatments—had to be improved. In addition, the larger systems in which DLDBs are embedded, which include licensing, supply, training, and inspection, involving ward, district, regional, and national authorities, also had to be changed and strengthened.

After gaining support from key stakeholders, TFDA and the government of the region of Ruvuma, in collaboration with MSH, implemented the pilot ADDO initiative in 2003. Quality of both products and services was ensured through a combination of government accreditation and regulation mediated through routine monitoring by district/local government and community structures.

Accreditation as applied to the ADDO program aims to improve the availability of essential medicines and the quality of services by working with independent shop owners and dispensing staff via provision of education, training and supervision; commercial incentives combined with decentralized regulatory oversight. Accreditation is granted on achievement and maintenance of a set of pre-established standards.

Rolling out the ADDO Program

The SEAM Tanzania country program ended in 2005 but because of the success in Ruvuma and the Government of Tanzania’s decision to adopt the ADDO model for the entire country (along with some budgetary allocation), the MoH, through the TFDA with support from MSH/RPM Plus and the Mennonite Economic Development Associates (MEDA) is expanding the ADDO model into other regions of Tanzania.

The TFDA, with technical assistance from MSH, is providing program planning and regulatory oversight; MEDA is directing business development and training and facilitating linkage of ADDOs with Microfinancing institutions (MFI).

The ADDO program rollout is funded by USAID in the Morogoro region, the Government of Tanzania in Rukwa and Mtwara regions.Funding for integrating child health, malaria and HIV/AIDS components into already established ADDOs comes from USAID. Additional program support is also provided through the Danish International Development Agency (DANIDA).

In order for Duka la dawa baridi to be accredited as ADDO or Duka la dawa muhimu (DLDM), they must meet minimum required standards in the following areas—

Shop location and building design/layout
Personnel training and continuing education
Drug availability—All medicines sold must be on the list of ADDO-authorized medicines, which includes a limited number of prescription-only medicines and selected lifesaving drugs such as certain intravenous (IV) fluids
Drug quality—All medicines sold must be registered by TFDA and stored in an appropriate manner to lessen the likelihood of contamination or degradation
Stock control, handling, and record-keeping—In particular, ADDOs are required to account for the purchase and sale of all prescription drugs
Sanitation and hygiene of the premises and personnel

ADDOs’ Role in Strengthening Community-based Health Care Interventions and Public Health Initiatives

In collaboration with the Tanzanian MOH and the TFDA, RPM Plus has initiated work in strengthening community-based health care interventions and public health initiatives building on the ADDO platform. Specific activities to date include:

Supporting child health—A strategy for an expanded focus on child health has been developed and piloted in Ruvuma region. This component builds on the already-strong ADDO program in Ruvuma. The child health package consists of demand creation, capacity building, and oversight and regulation, drawing on documented successful strategies such as integrated management of childhood illnesses (c-IMCI) targeted information, education, and communication (IEC) materials and job aids; and community activities such as theater and song contests.

RPM Plus is working in partnership with the Basic Support for Institutionalizing Child Survival (BASICS) project on the design and implementation of this package.

Distribution of subsidized ACT—Under the US President’s Malaria initiative, ACT (Artemether-Lumefantrine) treatment is being procured for distribution through the ADDO network. RPM Plus supports the implementation of this strategy by assisting in quantification of the number of ACT treatments needed, development of a distribution plan, and strengthening the ADDO supportive supervision and monitoring system.

Support for HIV/AIDS initiatives—Dissemination of HIV/AIDS information through ADDO shops has been implemented in Morogoro. Pending evaluation, incorporation of this activity into the basic ADDO package of services will be considered by the MOH. Use of ADDO shops for distribution of home-based HIV/AIDS care kits in remote and rural areas and the role of ADDOs in supporting referrals to HIV/AIDS services are being explored. ADDO shops already provide medicines for opportunistic infections such as Cotrimoxazole and antifungal medicines.