Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India

Abstract

IntroductionPharmacies and drug stores are frequently patients’ first point of care in many low-income and middle-income countries, but their practice is often poor. Pharmacy retailing in India has traditionally been dominated by local, individually owned shops, but recent years have seen the growth of pharmacy chains. In theory, lower-powered profit incentives and self-regulation to preserve brand identity may lead to higher quality in chain stores. In practice, this has been little studied.MethodsWe randomly selected a stratified sample of chain and independent pharmacies in urban Bengaluru. Standardised patients (SPs) visited pharmacies and presented a scripted case of diarrhoea for a child and suspected tuberculosis (TB). SPs were debriefed immediately after the visit using a structured questionnaire. We measured the quality of history taking, therapeutic management and advice giving against national (Government of India) and international (WHO) guidelines. We used Pearson’s χ2 tests to examine associations between pharmacy type and case management.FindingsManagement of childhood diarrhoea and suspected TB was woefully substandard. History taking of the SP was limited; unnecessary and harmful medicines, including antibiotics, were commonly sold; and advice giving was near non-existent. The performance of chains and independent shops was strikingly similar for most areas of assessment. We observed no significant differences between the management of suspected TB in chains and independents. 43% of chains and 45% of independents managed the TB case correctly; 17% and 16% of chains and independents, respectively, sold antibiotics. We found that chains sold significantly fewer harmful antibiotics and antidiarrhoeals (35% vs 48%, p=0.029) and prescription-only medicines (37% vs 49%, p=0.048) for the patient with diarrhoea compared with independent shops. Not a single shop managed the patient with diarrhoea correctly according to guidelines.ConclusionOur results from Bengaluru suggest that it is unlikely that chains alone can solve persisting quality challenges. However, they may offer a potential vehicle through which to deliver interventions. Future intervention research should consider recruiting chains to see whether effectiveness of interventions differ among chains compared with independents.

Use of standardised patients for healthcare quality research in low- and middle-income countries

“…Following the validation study, these SP cases for TB were then implemented at a larger scale with representative provider and pharmacist samples in multiple Indian cities 22–26. These studies have shown, for instance, that there is little difference in quality of care between one of India’s richest and one of its poorest cities.…”

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…Ideally, patients with TB should be referred by pharmacists to specialists if patients first visit them. However, such activities can be very variable and may depend on whether patients have suspected or confirmed TB 113,114 . Development of AMR in patients with RTIs and other underlying infectious diseases can increase morbidity and mortality; consequently, antibiotic use in such patients needs to be carefully managed 115 .…”

Can community pharmacists improve tuberculosis case finding? A mixed methods intervention study in India

“…They are the first point of medical contact among up to 40% of individuals with TB symptoms in India, and 25% of patients continue to seek advice from pharmacies even after diagnosis, preferring to avoid doctor consultations 11 12. However, studies show that pharmacy providers commonly dispense cough syrups, anti-histamines, bronchodilators and antibiotics over-the-counter (OTC), rather than refer patients to a doctor for TB testing and treatment 13–15. Self-medication and poor referral practices can delay TB diagnosis 2 3.…”