Quality of tuberculosis care by pharmacies in low- and middle-income countries: Gaps and opportunities

Abstract

Pharmacies hold great potential to contribute meaningfully to tuberculosis (TB) control efforts, given their accessibility and extensive utilisation by communities in many high burden countries. Despite this promise, the quality of care provided by pharmacies in these settings for a range of conditions has historically been poor. This paper sets out to conceptualise the key issues surrounding quality of TB care in the low- and middle-income country pharmacy setting; examine the empirical evidence on quality of care; and review the interventions employed to improve this. A number of quality challenges are apparent in relation to anti-TB medicine availability, pharmacopeial quality of anti-TB medicines stocked, pharmacy workers’ knowledge, and management of patients both prior to and following diagnosis. Poor management practices include inadequate questioning of symptomatic patients, lack of referral for testing, over-the-counter sale of anti-TB medication as well as unnecessary and harmful medicines (e.g., antibiotics and steroids), and insufficient counselling. Interventions to improve pharmacy practice in relation to TB control have all fallen under the umbrella of public-private mix (PPM) initiatives, whereby pharmacies are engaged into national TB programmes to improve case detection. These interventions all involved training of pharmacists to refer symptomatic patients for testing and have enjoyed reasonable success, although achieving scale remains a challenge. Future interventions would do well to expand their focus beyond case detection to also improve counselling of patients and inappropriate medicine sales. The lack of pharmacy-specific global guidelines and the regulatory environment were identified as key areas for future attention.

Service learning in pharmacy: implementation of tuberculosis screening by second-year pharmacy students in primary health care facilities in Cape Town, South Africa

“…TB control programmes, especially in low-and middle-income countries, require early case detection, referral for testing, diagnosis and timeous initiation of TB treatment. Privately-owned community pharmacies which are easily accessible to communities serve as a key resource in improving case detection, but they have been under-utilised in TB control programmes (Miller & Goodman, 2020). In India, a mixed-methods study piloted over 18 months in 108 pharmacies employed a novel TB screening and referral intervention integrated into a public-private mix (PPM) programme, resulting in 1674 referrals and 255 cases of TB that were diagnosed (Daftary et al, 2019).…”

“…In India, a mixed-methods study piloted over 18 months in 108 pharmacies employed a novel TB screening and referral intervention integrated into a public-private mix (PPM) programme, resulting in 1674 referrals and 255 cases of TB that were diagnosed (Daftary et al, 2019). Therefore, expanding the role of South African community pharmacists would require training in line with the national TB control programme to ensure the provision of quality TB care, where collaboration among multiple stakeholders (WHO, FIP, STOP TB, regulatory authorities, ministries of health, pharmacy associations and training institutions) would be a cornerstone in establishing pharmacy-specific guidelines (Miller & Goodman, 2020). Such an expanded role for community pharmacists would form an inextricable link in strengthening TB case detection and referral to public sector facilities for further management at the primary care level.…”

“…In addition, TB treatment in South Africa is provided by the public health care system, which operates as a vertical programme, being conducted primarily by nurses with minimal integration with the rest of the health care team (Coovadia et al, 2009;Churchyard et al, 2014). While studies show that pharmacists from high burden communities indicate strong support to participate in TB programmes (Daftary et al, 2017a), to date, however, pharmacists' contributions have been restricted to their traditional role as 'drug dispensers, or at best to serve as treatment supervisors under the directly observed therapy framework (Miller & Goodman, 2020).…”

“…Symptomatic screening for TB is a low-cost venture and requires low expertise to perform. Literature from TB screening and referral interventions involving community pharmacists in high burden countries has shown promising results (Colvin et al, 2014;Daftary et al, 2019;Miller & Goodman, 2020). Indeed, a study from the USA found that second-year pharmacy students who received certification in TB screening (using the tuberculin skin test) could screen patients for TB very effectively and accurately (McKennon & Arnold, 2016).…”

Understanding dynamics of private tuberculosis pharmacy market: a qualitative inquiry from a South Indian district

“…There have been studies investigating the potential of RPPs to contribute to TB care 23–25. Attempts at involving RPPs particularly in TB control activities have not always been successful.…”