“It is very difficult in this business if you want to have a good conscience”: pharmaceutical governance and on-the-ground ethical labour in Ghana

Abstract

The governance of pharmaceutical medicines entails complex ethical decisions that should, in theory, be the responsibility of democratically accountable government agencies. However, in many Low- and Middle-Income Countries (LMICs), regulatory and health systems constraints mean that many people still lack access to safe, appropriate and affordable medication, posing significant ethical challenges for those working on the “front line”. Drawing on 18 months of fieldwork in Ghana, we present three detailed case studies of individuals in this position: an urban retail pharmacist, a rural over-the-counter medicine retailer, and a local inspector. Through these case studies, we consider the significant burden of “ethical labour” borne by those operating “on the ground”, who navigate complex moral, legal and business imperatives in real time and with very real consequences for those they serve. The paper ends with a reflection on the tensions between abstract, generalised ethical frameworks based on high-level principles, and a pragmatic, contingent ethics-in-practice that foregrounds immediate individual needs – a tension rooted in the gap between the theory and the reality of pharmaceutical governance that shifts the burden of ethical labour downwards and perpetuates long-term public health risks.

Antimalarial procurement in private-sector pharmaceutical outlets: decision-making complexities and implications for medicine quality in Tanzania

“…For example, Bate et al argue that relying on price as the main signal of quality carries significant risks. Somewhat counterintuitively, they find that among generics a higher price could imply a higher chance of falsification 16 17. But the mere fact that consumers in our study cannot afford to take quality into account in purchasing decisions is worrying.…”

Antimalarial stocking decisions among medicine retailers in Ghana: implications for quality management and control of malaria

“…This finding is intriguing considering the dire economic situation in rural parts of Ghana, with outlets operating on small margins and many people unable to afford anything but the cheapest medicines, where one might expect that economic imperatives would be particularly pressing. Other work suggests that outlets in rural areas are often operated by persons from those communities who are highly trusted and widely known, and thus may be particularly motivated to ensure their clients receive effective treatment wherever possible 36–38…”

“…Other work suggests that outlets in rural areas are often operated by persons from those communities who are highly trusted and widely known, and thus may be particularly motivated to ensure their clients receive effective treatment wherever possible. [36][37][38] The impact of financial considerations on stocking decisions came to the fore in two other situations: price bracket and presence/absence of a pharmacist. However, H2 was not accepted as there were no significant differences in financial consideration stocking decisions between OTCs and pharmacies.…”

Can a Smartphone Application Help Address Barriers to Reporting Substandard/Falsified Medical Products? A Pilot Study in Tanzania and Indonesia

“… 9 , 10 Experience of ineffective treatment may also undermine trust in formal health systems, perhaps pushing patients toward unregulated sources. 1 , 2 , 11 …”