Pharmacies in informal settlements: a retrospective, cross-sectional household and health facility survey in four countries

Abstract

Background: Slums or informal settlements characterize most large cities in LMIC. Previous evidence suggests pharmacies may be the most frequently used source of primary care in LMICs but that pharmacy services are of variable quality. However, evidence on pharmacy use and availability is very limited for slum populations.

Methods: We conducted household, individual, and healthcare provider surveys and qualitative observations on pharmacies and pharmacy use in seven slum sites in four countries (Nigeria, Kenya, Pakistan, and Bangladesh). All pharmacies and up to 1200 households in each site were sampled. Adults and children were surveyed about their use of healthcare services and pharmacies were observed and their services, equipment, and stock documented.

Results: We completed 7692 household and 7451 individual adults, 2633 individual child surveys, and 157 surveys of pharmacies located within the seven sites. Visit rates to pharmacies and drug sellers varied from 0.1 (Nigeria) to 3.0 (Bangladesh) visits per person-year, almost all of which were for new conditions. We found highly variable conditions in what constituted a "pharmacy" across the sites and most pharmacies did not employ a qualified pharmacist. Analgesics and antibiotics were widely available but other categories of medications, particularly those for chronic illness were often not available anywhere. The majority of pharmacies lacked basic equipment such as a thermometer and weighing scales.

Conclusions: Pharmacies are locally and widely available to residents of slums. However, the conditions of the facilities and availability of medicines were poor and prices relatively high. Pharmacies may represent a large untapped resource to improving access to primary care for the urban poor.

Keywords: Healthcare access; LMICs; Pharmacies; Slums; Welfare.

Fig. 1

Graphical summary of the available products and services available in the pharmacies located within each slum area. Within each plot each pharmacy is represented by a separate row, and each column is a category as described in Table 1, with yellow indicating complete availability of all items in the category and dark blue none of the items available

Fig. 2

Locations of a selection of publicly identified pharmacies in each study site. Each location is coloured according to its overall summary score (see Table 1)

Fig. 3

Pharmacy, doctor and nurse, and other consultations rates per person-year for adults and children (under 12) for both new and existing conditions with 95% confidence intervals

Fig. 4

Proportion of reported visits by reason for seeking care that were to a pharmacy with 95% confidence intervals. “High risk presentation” includes chest pain, difficulty breathing, and stroke or sudden paralysis