Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study

Abstract

Worldwide, antimicrobial resistance is increasing rapidly and is associated with misuse of antimicrobials. The HATUA study (a broader 3-country study) investigated the antibiotic dispensing practices of pharmaceutical providers to clients, particularly the propensity to dispense without prescription. A cross-sectional study using a ‘mystery client’ method was conducted in 1148 community pharmacies and accredited drugs dispensing outlets (ADDO) in Mwanza (n = 612), Mbeya (n = 304) and Kilimanjaro (n = 232) in Tanzania. Mystery clients asked directly for amoxicillin, had no prescription to present, did not discuss symptoms unless asked [when asked reported UTI-like symptoms] and attempted to buy a half course. Dispensing of amoxicillin without prescription was common [88.2, 95%CI 86.3–89.9%], across all three regions. Furthermore, the majority of outlets sold a half course of amoxicillin without prescription: Mwanza (98%), Mbeya (99%) and Kilimanjaro (98%). Generally, most providers in all three regions dispensed amoxicillin on demand, without asking the client any questions, with significant variations among regions [p-value = 0.003]. In Mbeya and Kilimanjaro, providers in ADDOs were more likely to do this than those in pharmacies but no difference was observed in Mwanza. While the Tanzanian government has laws, regulations and guidelines that prohibit antibiotic dispensing without prescription, our study suggests non-compliance by drug providers. Enforcement, surveillance, and the provision of continuing education on dispensing practices is recommended, particularly for ADDO providers.

Antibiotic dispensing practices during COVID-19 and implications for Antimicrobial Resistance (AMR): Parallel mystery client studies in Uganda and Tanzania

“…It is clear from this study and others [22,27,28], that drug sellers in Uganda and Tanzania, like those in many other LMIC settings [40][41][42][43], do not always adhere to regulations on antibiotic dispensing, even though many conformed to other expectations of licensing and regulation. Pharmacies, where sellers might be expected to have a higher degree of training and awareness of regulation, were only marginally better at following dispensing guidelines than drug shops or ADDOs.…”

“…This cross-sectional community-based quantitative survey used a mystery client design, also referred to as a simulated client study, to assess drug-dispensing practices. Mystery client studies are commonly used to observe drug provider behaviour while minimising observation bias [21,27]. In our study, 27 male and female eld workers, unknown to the sellers, posing as clients (hereafter known as mystery clients, or MCs) visited the pharmacies, ADDOs and drug shops.…”

“…Mwanza district in Tanzania and Mbarara district in Uganda were two of nine sites investigated by HATUA. Between April and July 2019, before the COVID-19 pandemic, we comprehensively mapped drug outlets within Mwanza and Mbarara districts to create a sample frame for mystery client studies [27,31]. Trained eld assistants systematically traversed roads and pedestrian areas, using Global Positioning System (GPS) enabled tablets and phones and the software Epicollect5 [37] to record location and basic descriptive details about formal and informal outlets that sold medicine for humans [32].…”

“…Drug sellers in Uganda were aware of national regulations and rarely displayed prohibited drugs on the shelf for fear of inspectors and penalties, but would provide the client with the same on demand [22]. Mystery client studies conducted as part of our consortium's earlier work on AMR recorded widespread non-compliance with regulations prohibiting antibiotic sale without a prescription in Tanzania [27,31]. The study found that most providers across three study regions dispensed amoxicillin on-demand without question, to clients with no prescription [27].…”

“…Mystery client studies conducted as part of our consortium's earlier work on AMR recorded widespread non-compliance with regulations prohibiting antibiotic sale without a prescription in Tanzania [27,31]. The study found that most providers across three study regions dispensed amoxicillin on-demand without question, to clients with no prescription [27].…”