Over the counter: The potential for easing pharmacy provision of family planning in urban Senegal

Introduction

Limited access to family planning services has been linked to the high rates of unmet need for contraception found in many African countries¹. Over the years, many countries have attempted to fill gaps in health services by capitalizing on private sector facilities, including privately run clinics, social franchising, and pharmacies². Research has shown drug shops, which typically do not employ a licensed pharmacist and are normally restricted to selling only over-the-counter medications, and private sector pharmacies to be a major source for contraceptives, particularly oral contraceptive pills (OCPs), emergency contraception, and condoms, especially for hard to reach women such as those who are younger or unmarried^3–5.

Hand in hand with increasing access through the private sector is task-sharing, in which lower level cadres of health providers are trained to provide certain health services that previously were the sole purview of a higher cadre⁶. Task sharing is a mechanism used in many countries to increase access to a variety of health services, including family planning. For example, community health workers in the public sector, and pharmacy and drug shop staff in the private sector, have all been trained in various countries to provide OCPs and injectable contraception—the two most popular forms of contraception in sub-Saharan Africa—without the need for a prescription written by a higher-level clinician, even when it is the first time the woman is using the method⁷.

In urban settings in particular, task-sharing of OCPs and injectables through private sector pharmacies is promising for improving access to family planning services. Thanks to the range of possible reasons for visiting pharmacies, the purpose of the visit can be disguised, providing a layer of confidentiality to women. In addition, research has shown that direct private sector pharmacy access to OCPs poses little risk to women; appropriately trained pharmacy staff are able to counsel for and provide the pill^8,9, and further research has shown that women can even self-screen for eligibility of OCPs with relative accuracy by self-administering a checklist^10,11. Sale and provision of injectable contraceptives in private sector pharmacies and drug shops is also common in the developing world, thanks to social marketing^12,13. Lastly, new packaging of injectable contraception designed to allow women to self-inject could eliminate the need for administration by a skilled professional for many, further increasing the impact pharmacies could have in improving access to contraception¹⁴.

At the same time, there are some possible concerns associated with over-the-counter provision of family planning services through pharmacies. Historically, low-income clients have been priced out of private facility services, although several programs are working to decrease financial barriers, including by increasing access to insurance and implementing savings products and voucher systems¹⁵. Screening for underlying health conditions is always desirable, but may not occur during a pharmacy visit. Similarly, private sector pharmacies may do little to provide re-supply reminders to clients buying methods such as OCPs and injectables. And, finally, private pharmacies may not counsel and refer women for methods they do not sell, since they are not usually integrated into the larger public health system, and since there is no economic incentive for them to do so.

To date, research focused on family service provision in pharmacy settings is limited and outdated. This research focused on Senegal seeks to address this gap. Senegalese pharmacies are ubiquitous in urban areas compared to health facilities. For example, Dakar counts 490 pharmacies but only 34 health facilities. Both public and private sector pharmacists are currently forbidden from dispensing OCPs and injectable contraception without a prescription, and pharmacists are not allowed to write prescriptions themselves. However, the Senegalese National Family Planning Action Plan for 2012–2015¹⁶ acknowledged the barriers imposed by a prescription requirement as a limitation to the regulatory framework of family planning and the expansion of family planning in Senegal. The removal of prescription barriers was also noted in Senegal’s 2012 Program and Service Delivery commitment to Family Planning 2020 (FP 2020), and the updated National Strategic Framework for Family Planning 2016–2020¹⁷, calls for finalizing and validating the laws and regulations governing the pharmaceutical sector.

As an estimated 44% of Senegal’s 14 million people live in an urban setting, and 38% of the total population living on less than $1.90 per day, urban poverty is a concern^18,19. Given a total fertility rate of 5.0, a contraceptive prevalence rate (CPR) of 20.3%, and an unmet need for family planning at 25.6% overall, rising to nearly 30% for the lowest wealth quintile, increasing family planning access amongst the poorest women could help Senegal reach its commitment to FP 2020 with a CPR of 45% by 2020²⁰. Senegal sees the need and is clearly interested in updating their national policies regarding accessing family planning through pharmacies, and this research aims to provide evidence as they work to make final decisions.

This article reports on research conducted by FHI 360 under the Bill & Melinda Gates Foundation-funded Urban Reproductive Health Initiative (UHRI), led by IntraHealth International in Senegal, to assess the potential for expanding access to family planning through pharmacies. Specific objectives were to assess the quality of the services currently provided through pharmacies, and to examine pharmacy staff and client interest in pharmacy-based family planning services. This research aimed to provide evidence for a potential policy change that would help Senegal reach its family planning goals by expanding access through pharmacies.

Methods

This was a cross-sectional, descriptive study employing a pharmacy audit, a survey with pharmacy staff, and a survey with pharmacy clients.

Results

In total, we performed audits at 225 pharmacies, and interviewed 486 pharmacy personnel and 3,567 pharmacy clients. From the sample of 250 pharmacies drawn from our initial list, 20 refused to participate in the study and 11 were either permanently or temporarily closed, or in the process of being sold, four were outside of our study districts, and one was sampled twice. To meet our target size of 225, we randomly selected an additional 11 pharmacies (respecting the initial stratification by district). All 11 replacement pharmacies were open and consented to participate. Of the 486 pharmacy personnel interviewed, 182 were pharmacists, 94 were assistant pharmacists, 206 were counter staff, and 4 were interns. In total 56% of pharmacy staff respondents were men.

Survey with clients

In total 21% of the entire sample (3,567) had ever used the pharmacy to get a contraceptive. Of clients currently using a modern family planning method, 31% used OCPs, 30% used injectables, 20% used implants and 10% used IUDs. A total of 70% of users obtained their methods through a public health facility, 19% from a private sector pharmacy and 10% from another source. Current users who procured their method through a private sector pharmacy received OCP (69%), condoms (21%), emergency contraceptive pills (5%) and injectables (3%).

Among the 390 current users who obtained a method from a pharmacy, 54 (14%) reported that they or their partner had received counseling at the pharmacy the last time they procured their method. Table 6 provides further information about that experience, including privacy and details of the counseling received. When asked, 52% of clients who had ever procured family planning through a pharmacy reported receiving a method without a prescription (390 of 741); 50% reported having bought OCPs and 2% injectables.

More clients reported having visual and auditory privacy for the counseling than what we found in our own audit—83% versus 72%. A majority reported having been treated with respect, and having had the opportunity to ask questions, whereas just over half reported that the staff explained how to use the method, asked them about contraindications to the method, and/or discussed side effects. Only 44% reported that the provided had talked to them about both advantages and disadvantages of the method.

Table 6. Clients’ most recent counseling experience received at pharmacy (n=54).

Survey question	% (n)
Counseling conducted with auditory and visual privacy	83 (45)
Staff treated client/partner with respect	87 (47)
Staff explained how to use the method	52 (28)
Staff asked about health conditions that might impede use of contraception	52 (28)
Staff spoke to client/partner about side effects	52 (28)
Staff discussed both advantages and disadvantages of the method	44 (24)
Staff gave client/partner the opportunity to ask questions	89 (48)

Of potential users of the pharmacy for family planning, including current users procuring from a non-pharmacy source, users of traditional methods, and non-users of family planning who were interested in family planning (n=3,171), 47% said they would be interested in procuring a method through a pharmacy. Of those who were not interested in procuring through a pharmacy (n=1,008), 45% cited that they were dissatisfied with the quality of services through the pharmacy, and 12% reported high costs for their lack of interest. (Figure 1)

Figure 1. Client survey results flowchart.

Of the potential users of family planning who were interested in receiving a method through the pharmacy (n=1,495), half or more would not be willing to pay for their method in the pharmacy (Figure 2). A total of 62% would, however, be willing to pay for counseling from pharmacy staff. The mean amount they would be willing to pay for counseling was 1679 CFA (approximately 3 USD) with a median and mode of 1000 CFA (approximately 2 USD).

Figure 2. Percent of clients unwilling to pay for the given method at a pharmacy (n=1495).

Discussion

Findings on the current state of family planning service provision through private sector pharmacies in the UHRI project area are mixed, especially in light of information on prior programs offering training to pharmacies. Both OCPs and injectables were in good supply, and close to three-quarters of pharmacies had a private space where counseling could be performed. Results on client-provider interactions are promising, as clients who procured their method through pharmacies reported being treated with respect and having the opportunity to ask questions.

At the same time, while a little over half of pharmacies indicated providing counseling in the pharmacy audit, only 14% of clients who procured their method through the pharmacy confirmed being counseled at their last visit, and few pharmacies had access to counseling materials such as posters, flip charts, or brochures. The limited family planning training provided to pharmacists and assistant pharmacists was reflected in some knowledge gaps, particularly with regards to up-to-date and detailed information. Clients who were counseled were not systematically informed of how to use their method, advantages and disadvantages or possible side effects. More detailed training on family planning counseling as part of the pharmacy licensure training program as well as opportunities for pharmacists and assistant pharmacists to refresh their skills through more broadly offered training could help address these challenges, especially given that providers in this study expressed interest in more training on methods and counseling. This expressed interest may be enough to overcome the “know-do” gap seen in other health fields²⁵. Others have also suggested creating linkages with and accountability to other FP providers to address the know-do gap²⁶.

Pharmacy staff in our study were aware of the law requiring a prescription to purchase OCPs and injectables, but our results suggested that it was not always adhered to, especially for OCPs but more rarely for injectables. In addition to women already procuring their method through pharmacies, we found there was latent demand for accessing family planning through pharmacies. Although the study design does not support a demand forecast, there was substantial interest among women in our sample (about half of future potential users of pharmacy for family planning) to supply through pharmacies. While some women currently procuring through pharmacies were able to obtain their method despite the prescription requirement, most were OCP users and very few obtained injectables. Given that injectables are the most widely used method in Senegal, revising the prescription requirement would be important to consider in the context of informed method choice, along with strengthening of pharmacists’ competencies, to fulfill the potential of urban private sector pharmacies in meeting this latent demand.

Price also warrants attention as it appears to be an important consideration for women. Price structure across service delivery channels in Senegal could also be a challenge on the supply side given the for-profit nature of pharmacy-based service provision. The majority of women interviewed were unwilling to pay for their method, though most were willing to pay for counseling obtained through the pharmacy, which reflects the typical payment structure of public health facilities, where women pay a small fee for methods (approximately a tenth of what they pay at private pharmacies), and a separate fee for a family planning consultation (less than a dollar at public facilities). Women in our sample expressed a willingness to pay 2–3 USD for the counseling at a pharmacy. To reconcile affordability with incentivization of private sector providers, additional interventions may need to be considered in Senegal to expand the potential of private sector pharmacies to reach women of all income levels, including increasing access to insurance and implementing savings products and voucher systems. A systematic review of family planning voucher programs in low and middle income countries concluded that in terms of contraceptive use, most programs reported a significant increase with vouchers²⁷.

Our study had several limitations. The ten UHRI districts represent urban settings, and findings may not transfer to other contexts. Because the sampling of urban private sector pharmacy clients was capped for non-users of family planning, we oversampled current users of family planning who obtain services in the pharmacy setting. While our finding indicate there is latent demand for services through pharmacies, results should not be interpreted as a precise estimate. We did not collect income information and can therefore not draw conclusions on pharmacies’ ability to improve access among the urban poor. Social desirability bias may have led to an inflated proportion of staff who reported requiring prescriptions. Other design options such as directly asking pharmacy staff about their practices or conducting a mystery client study were considered at the design stage, but met with opposition from ethics committees. Nevertheless, we attempted to address this shortcoming by triangulating pharmacy staff responses of knowledge of prescription requirements with client acknowledgement of having previously purchased a method without a prescription, creating a proxy for sales without a prescription. The scoring system for the knowledge index is crude and the passing score was based on the reasonable but subjective expectation that staff should be able to correctly answer half of the questions. Results on the proportion of knowledgeable staff should be interpreted cautiously, as this criterion may have been too stringent; however, this exercise allowed us to highlight important gaps in knowledge. Administering similar questions to facility-based staff could provide a useful comparison point in future research.

Conclusion

Given high rates of success with task-sharing in other environments, the availability of contraceptive commodities and private counseling space within most urban-Senegalese pharmacies, positive client-pharmacist interactions, and client interest in receiving family planning directly through pharmacies, Senegal’s private sector urban pharmacies provide an opportunity to expand family planning service provision in urban areas. Proper training, including the use of job aids, is important to address current deficiencies in the quantity and quality of services provided. Although women reported being able to circumvent prescription requirements, they may still impose barriers to women seeking services, especially in terms of the ability of women to get their preferred method. Many medical experts consider such requirements unnecessary, and in countries in Asia, Europe, Africa and South and Central America, OCPs are available without a doctor’s prescription.

Data availability

Replication data from this study are available on Harvard Dataverse: https://doi.org/10.7910/DVN/UQ3NWN²¹

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).