PATH Increasing Access to RH Services Through Pharmacists

Publication date: 2004

Volume 21 Number 2 September 2004 In This Issue • Accessibility • Pharmacists as primary health care providers • RH needs • Health care referrals • Social marketing • Training • Innovative programs • Pharmacists and youth • Pharmacists and EC • Critical considerations Outlook Increasing Access to Reproductive Health Services Through Pharmacists Many people throughout the world remain underserved by the traditional public health care system.1  is is especially true where resources are lacking, the quality of equipment and facilities is poor or disinte- grating, and the number of trained health care providers is insuffi cient. In many countries, pharmacists and pharmacy counter staff increase access to critical health information, services, and products. Even in settings where health services are broadly available, people o en rely on the pharmacy or drugstore as the fi rst and sometimes only stop for health care needs. Pharmacists and pharmacy staff are well placed to provide basic counseling and information as well as referral for clinical services that cannot be provided in the pharmacy.  ey also can assist clients with self-diagnosis and treatment services for a variety of conditions.  e degree to which people rely on the pharmacy, and the rela- tively easy access pharmacies allow, makes them an important resource for health.  is issue of Outlook explores the role of pharmacists and non-pharmacist counter staff in primary health care, with a specifi c emphasis on reproductive health. It also presents programs that build the capacity of pharmacists to provide expanded services, thus improving access to quality reproductive health services. To date, most work with the pharmaceutical sector has focused on licensed and regulated phar- macies or drugstores. Pharmacy services in many countries also are off ered by a variety of drug shops and kiosks that are usually staff ed by non-pharmacists, o en referred to as drug or chemical sellers.  ese establishments may or may not be regulated, but they all can play a produc- tive role in health care provision. Accessibility: an essential attribute  e ability to access health care services is infl uenced by economic, geographical, social, and cultural factors.2,3 Personal characteristics such as age, gender, and education also aff ect how individuals seek care, as do the symptoms and circum- stances of their health problem.3,4  e availability and location of treatment resources, as well as the psychological and monetary costs of obtaining care (including price, time, stigma, and conve- nience), also infl uence access.3 Health care policies in most developing countries emphasize public or govern- ment-run health services and rely on traditional clinic settings to reach people with vital health services and informa- tion. In many of these countries, however, people o en prefer to seek care in the private sector, particularly for outpatient treatment of illness.5,6 Pharmacies are not usually recognized as part of the network of private providers—a network usually considered to comprise private physi- cians and other clinicians—and frequently are overlooked in health program plan- ning and development. Nonetheless, the pharmacy features prominently in health care–seeking behavior because it off ers numerous benefi ts over other health facili- ties, including: • Longer or more fl exible hours. • Shorter or no waiting periods and no intimidating waiting rooms. • Convenient locations in neighbor- hoods where people live, work, and go to school. • More accessible staff . • No consultation or counseling fee. Outlook Volume 21 Number 2 2 Outlook Volume 21 Number 2 3 Pharmacies and drugstores also may have a greater availability of medicines than public clinic settings. In addi- tion, for some services, pharmacies can provide a level of anonymity preferred by clients who are reluctant to seek care in traditional settings where they may be stigmatized. Similarly, clients oen feel more comfortable with pharmacy staff than with other health care profes- sionals. Pharmacists as primary health care providers Increasingly, pharmacists are being recognized for filling some of the responsibilities of health care providers—broadly defined as indi- viduals who help in identifying, preventing, or treating illnesses or disabilities. With a tradition of giving health care advice and dispensing personal care products, pharmacies are a widely used health source in many countries.7,8 In ailand, for example, pharmacists and drugstore personnel diagnose as well as dispense drugs to clients, and pharmacy services account for 45 percent of the distribution of drugs to consumers.9 A recent study in Laos showed that in rural Luang Prabang Province, where public health care facilities can be hard to access, private pharmacies were the first choice for those seeking health care services.10 People routinely select pharmacies for treatment of common illnesses, including childhood diarrhea, respi- ratory infections, and malaria.4 For instance, a study of 418 persons in Nigeria reported that the majority of respondents were in the habit of using retail pharmacies whenever they are ill, with malaria being the most frequently reported illness.11 A similar survey in four districts of Indonesia indicated that drug sellers are the main source of outside care for more than half of child illnesses.4 Another study involving 14,000 households in Uganda indicated that, for sick chil- dren, pharmacies were one of the most popular primary sources of care outside the home.4 e World Health Organization (WHO), in a joint decla- ration with the International Pharma- ceutical Federation (FIP), states that “pharmacists all over the world are the most numerous and easily accessible ‘health outlets’ for the general public.”12 WHO and FIP affirm that pharma- cies are “a vital component of primary health care” and are in a good position to participate in health education and prevention campaigns, treatment and follow-up of patients, and health infor- mation systems. Recognizing this, they have developed Guidelines for Good Pharmacy Practice and promoted their use as a basis for establishing nationally accepted standards.12,13 Reproductive health needs As demonstrated above, people oen use pharmacies as the first, and some- times only, stop for addressing a variety of health needs. In particular, pharma- cies fill a unique niche for addressing reproductive health needs. e need for accessible and high-quality repro- ductive health care is critical as global demographic and disease trends stress public health budgets and delivery systems. e growing number of youth reaching reproductive age in need of contraceptives, the HIV/AIDS pandemic, and the increases in other sexually transmitted infections (STIs) represent significant burdens to public health care systems. Pharmacies offer critical reproductive health care services to many individ- uals, including those who may have difficulty accessing more traditional health care facilities or who fear that they may be stigmatized when doing so. Yet without theses services, they are at risk for unwanted pregnancy and STIs, including HIV. Pharmacists and their staff can address these important reproductive health needs by increasing the availability of contraception and STI information and services and offering referrals for clinical services. Family planning e importance of pharmacies as a source of contraceptives was confirmed by national demographic surveys as early as the 1970s. eir importance has continued to grow: by 1989, an esti- mated 55 million couples bought their family planning supplies at pharma- cies.14 A survey of consumers who purchase oral contraceptives and vaginal tablets distributed by the Nepal Contracep- tive Retail Sales Company found that consumers perceive drugstores to be an accessible option for their family planning needs. ese consumers reported being pleased with the short waiting times at drugstores as well as the reliable supply of their particular product.15 Recent data from Demo- graphic and Health Surveys suggest this acceptability and reliance on phar- macies for contraceptive supplies is common. In Bolivia, pharmacies were the principal providers of condoms, pills, and injections in both the private and public sector.16 Results are similar across Latin America, where a strong commercial market in family planning has evolved.17 STI management STI management is one of the most commonly sought reproductive health services at pharmacies. In many devel- An “Ask…Consult” Private Sector Project (PSP) pharmacy in Port Said, Egypt, offers contraceptive supplies. © William Mackie/CCP, courtesy of Photoshare. Outlook Volume 21 Number 2 2 Outlook Volume 21 Number 2 3 oping countries, STIs are a significant public health problem, and the primary control strategy is the immediate diagnosis and treatment of symptom- atic individuals. When clinical services are unavailable or difficult to access, STI patients seek care in alternative settings. Pharmacies offer immediate and relatively anonymous treatment. In parts of Latin America, for example, as many as 90 percent of people with STIs may go first to pharmacies for treat- ment.18 In other countries such as Peru, ailand, Brazil, Nepal, and Vietnam, pharmacists play a central role in STI diagnosis and treatment.8,19–23 Ghanaian data suggest that pharmacists in Accra are the first point of contact for STI management.8,24 In addition to providing STI diagnosis, treatment, and referral, pharmacies also can be an important resource for STI prevention through the promotion of condoms and partner notification. A syndromic approach is used to manage STI symptoms in many low- resource settings. With this approach, a client reports his or her symptoms and the STI is classified by syndrome, that is, by a combination of the symptoms experienced and observed. Pharmacy staff, if adequately educated, can manage treatment or referral for clients with certain STI symptoms. A pilot study in Peru illustrated how training pharmacy workers on STI syndrome recognition and management was both possible and acceptable. Evaluation data showed that pharmacy workers who received a training intervention for the management and prevention of four STI syndromes (male urethral discharge, vaginal discharge, genital ulcers, and pelvic inflammatory disease) demonstrated significantly better recog- nition and management (treatment or referral) for those STIs.25 e syndromic approach must be backed by scientific data on both the local prevalence of STIs and drug susceptibility of the infectious agents.26 It also should be in line with national strategies for reducing STIs. e Peru study, for example, was guided by national guidelines on syndromic STI management, thereby reinforcing national policies for treatment and reduction.25 STI management in pharmacies must be linked to a referral system for those STIs that cannot be diagnosed or treated using the syndromic approach. Health care referrals Where drugs are only available by prescription, informed pharmacists can greatly enhance patient access to, understanding of, and compliance with different contraceptive or STI-treatment regimens. Pharmacy and drugstore personnel who are providing contracep- tive and STI services also can provide referrals for services not provided in the pharmacy setting. Developing a formal referral network that links pharmacies to clinical service settings can help promote early diag- nosis and treatment of disease, reduce disease transmission, and, ultimately, encourage healthy behaviors. e study conducted in Peru included concurrent training of physicians to accept refer- rals from pharmacies of clients with suspect STI. is referral network was listed in a directory of certified physi- cians and health centers and given to the participating pharmacies.25 A study in England evaluated the use of a notification card by pharmacists with the goal of improving communication between pharmacies and general prac- titioners. It found that 71 percent of patients who had been advised by the pharmacists to see their general practi- tioner did so.27 e accessibility of contraceptive and STI informa- tion and services, as well as the ability of pharmacy staff to provide referrals, make a compelling case for further development of the pharmacy as a reli- able source of high-quality reproduc- tive health information, services, and products. Social marketing and pharmacies For years, social marketing programs— programs that publicize and sell products through retail outlets, usually at subsidized prices—have focused on product promotion and distribu- tion through pharmacies. Employing a private-sector approach to “produce, distribute and promote products and services that are considered to have a public good,”28 some social marketing programs have gone beyond simple product promotion to offer relevant training to pharmacy and drugstore personnel. ey also develop informa- tion and education materials for use by pharmacy workers and their clients. While the goal of most social marketing programs is to make sure that certain product lines are promoted, a by- product of this effort is an increase in the capability of pharmacy personnel to provide consumers with accurate, up-to-date reproductive health infor- mation. Social marketing programs have been implemented in a variety of settings. e Social Marketing for Change (SOMARC) program, for example, increased pharmacists’ and drugstore personnel’s ability to provide coun- seling and contraceptives in Ghana, Brazil, Liberia, Bolivia, the Dominican A Cambodia sales manager displays a condom for a pharmacy owner. © Population Services International (PSI), courtesy of Pho- toshare. Outlook Volume 21 Number 2 4 Outlook Volume 21 Number 2 5 Republic, Ecuador, and Colombia.14 ese seminars and training sessions improved pharmacists’ skills and under- standing of particular products. Advocates maintain that social marketing programs can be a cost- effective way to deliver reproduc- tive health services on a large scale in developing countries.29 Some critics disagree, arguing that social marketing programs—no matter how well intended—inevitably bias people’s choices30 because their objective is to sell specific consumer products. In either case, social marketing programs illustrate the potential impact that pharmacy training programs have for providing consumers with reproductive health services and information. The importance of training Despite the potential contribution of pharmacies, there is concern among clients and public health officials about the capacity of pharmacists and staff to provide high-quality services in the pharmacy sector. Pharmacy school curricula oen do not address repro- ductive health topics and may not include courses on the role of phar- macists as community health advisors. Furthermore, in many pharmacies, most client interaction is with front- line counter staff. Oen they have acquired their knowledge on the job and lack formal training on appropriate treatment regimens, medications, or dosages. erefore, the information they present on contraceptive methods, STIs, or other reproductive health topics may not be technically accurate or up-to-date. Training and education are ways to overcome these challenges so that staff can provide improved services to the greatest number of reproductive health clients. In Mexico, the Mexican Family and Population Research Institute (IMIFAP) provided HIV/AIDS preven- tion training to pharmacy staff in Mexico City. Post-training evaluations demonstrated that training programs can increase pharmacy staff ’s knowl- edge regarding condom use, HIV transmission and prevention methods, and AIDS symptoms. Furthermore, although staff do require additional or ongoing training and reinforcement, they generally are interested in partici- pating in more awareness and preven- tion training.31 Several projects and research studies have assessed the impact of providing training to pharmacy staff on specific issues. For instance, a study in Ghana found that training improved the counseling and treatment of clients with urethral discharge.24 Training in the Peru study (see page 3) resulted in significantly better practices in pharma- cies where staff had received training and support on syndromic manage- ment of STIs than in pharmacies in the control group.25 For example, 61 percent of pharmacies adequately managed simulated patients who presented with symptoms related to pelvic inflamma- tory disease, compared with 19 percent in the control group. A cost analysis found the training intervention on syndromic management of STIs to be a cost-effective program, one that is likely to be cost-saving for the community.32 e TrainPharm project in Romania is another example of how staff training and skills building help expand the role of pharmacies.33 rough this project, 1,026 pharmacists were trained in a variety of reproductive health topics. Results showed both an increase in knowledge of family planning methods and a change in the pharmacists’ delivery of services to clients. e project also introduced curriculum change, interactive teaching methods, and a process for the continuing educa- tion of pharmacists at Luliu Hatieganu University, which collaborated on the project. Strengthening the technical capacity of pharmacists and staff is important, but the pharmaceutical sector must not lose sight of what makes it attractive to clients. e people who frequent phar- macies for their reproductive health needs want clear, up-to-date informa- tion, but they also want anonymity, convenience, and cost savings. ey may not want to be counseled by or have a close professional relationship with their provider. Interventions must build on the distinct strengths of phar- macies and reinforce their singular role within the reproductive health arena. Innovative programs: build- ing pharmacist capacity Despite the potential gains that can be realized by training pharmacy staff, few large-scale training efforts have been launched. In part this is due to the diffi- culties of scaling up training efforts to reach large numbers of staff dispersed over a wide area. Improving the quality of care in private-sector pharmacies does not end with staff training. e capacity of training institutions also needs enhancement. Most such institu- tions in developing countries do not have the ability to provide in-service training for large numbers of profes- sional pharmacists, let alone the staff who ultimately provide most pharmacy services. Capacity building also involves strengthening the professional phar- macy associations, their monitoring and quality improvement systems, and A pharmacy assistant in Nicaragua reads a training brochure regarding youth-friendly pharmacy reproductive health services. The material was developed by PATH and Ixchen. © 2002 Alfredo L. Fort, courtesy of Photoshare. Outlook Volume 21 Number 2 4 Outlook Volume 21 Number 2 5 their links with the ministry of health and other community organizations that provide health services. Recognizing the need for improved access to health care, and the poten- tial of pharmacies to meet this need, reproductive health program designers and managers are creating programs that target the pharmacy sector broadly. ese programs oen involve staff training and provision of materials for clients so that pharmacists can offer a broader range of choices and more accurate information about those choices. Efforts are also under way to integrate pharmacies into the broader health care system. PATH is one of the organizations working to build the capacity of the pharmacy sector. Using an approach that helps reinforce the larger systems in which pharmacies work, PATH works with ministries of health, pharmacy schools, and local associa- tions both to institutionalize reproduc- tive health messages at the pharmacy and to strengthen and create linkages among pharmacy staff and other key service providers. PATH has worked to identify public health needs that front- line health workers such as pharmacists and their staff can help address. In particular, it has focused on developing the pharmacy as a key delivery site for reproductive health care for adoles- cents—a group that oen faces barriers to care through more traditional systems (see text box, page 6). In several countries—ailand, Cambodia, Kenya, Nicaragua, the Philippines, the United States, and Vietnam—PATH has worked with registered, mostly private-sector pharmacies to develop their capacity to deliver high-quality, effective health services. Although these projects differ significantly in their cultural settings, they share a focus on training and skills development, close collaboration with professional associations, links with other provider groups, and develop- ment of networks and collaborative partnerships. Evaluation data from the pilot projects document increases in: friendly and helpful service to youth; knowledge and provision of correct information about STIs and contracep- tion, including emergency contracep- tion (see text box, page 7); and referrals to other clinic-based service providers. By involving key local partners—phar- macy associations, pharmacy schools, and ministries of health—the work inspired enthusiasm among phar- macy staff and other stakeholders and engaged local institutions in building the capacity of pharmacy services. e Futures Group, which has exten- sive experience working with pharma- cies through years of social marketing programs, piloted an approach by which pharmacies could play a role in reducing HIV/AIDS in Kenya. e project focused on mobilizing support at the national and provincial levels for establishing small, community-owned pharmacies that could improve access to health care. It initially supplied the pharmacies with medicines, aer which time the community was expected to maintain stocks. Community commit- tees facilitated institutional strength- ening to ensure sound management of these initiatives.34 Another community-oriented approach to developing the pharmacy sector is to support country-level, public-private initiatives, including developing franchise and accredita- tion business models for distributing medicines and other essential health commodities through private retail outlets. For instance, in Ghana, the Strategies for Enhancing Access to Medicines (SEAM) Program estab- lished a network of essential medicines franchises that are monitored by the government for quality of products and services. Business owners were provided with incentives and benefits to encourage provision and delivery of high-quality medicines and services at affordable prices. is effort also has involved working with the ministry of health to strengthen its capacity to regulate drug shops. In Tanzania, SEAM works with the Tanzanian Food and Drugs Authority and the ministry of health to ensure drug quality and control. In collabora- tion with the pharmacy board, SEAM also is developing a network of accred- ited drug dispensing outlets (ADDOs). ese outlets sell only drug products for which they have market authorization from the Food and Drugs Authority. eir certified employees (non-pharma- cists) complete courses on management and medical aspects of ADDO business, including training about prescription drugs approved for sale in the shops.35 e SEAM project is developing other interesting strategies for working with pharmacies. For instance, in Brazil they have suggested working with municipal and state health authori- ties to accredit private pharmacies so that they can be contracted to provide dispensing services for the public sector. In India, they have suggested establishing a network of private phar- macies in rural areas, managed by one or more local nongovernmental orga- nizations. Although the SEAM project is not specifically addressing reproduc- tive health, it represents an innovative model for developing the pharmacy sector.36 Critical considerations ere are barriers to expanding the role of the pharmacy sector in reproduc- tive health services. For instance, some national policies prohibit or limit the practices of private providers because of concern that they may provide substan- dard or, perhaps, harmful services.4 Because pharmacists and pharmacy ”You can see how complicated these young people are. . . . Thank God I now have the information and the skill to understand and serve them better.” —Newly trained pharmacy staff member in Kenya, after coun- seling two 17-year-olds Outlook Volume 21 Number 2 6 Outlook Volume 21 Number 2 7 staff are not typically viewed as formal health care providers, ministries of health and other government agencies may lack experience in involving phar- macies in national health programs. In addition, pharmacies, as private-sector providers, must be profitable to survive. A range of commercial incentives likely is necessary if training and other capacity-building initiatives are to produce full benefits. e variety of institutions that make up the pharmacy sector worldwide also presents a challenge to regulating pharmacy practices and developing the capacity of those institutions. Besides private businesses staffed by trained professionals and their assistants, there are similar establishments without a trained pharmacist on hand, kiosk operators, small-scale drug vendors, and community drug depots, among others. Although they share many of the features that attract clients—conve- nient locations and hours of operation, reliable supplies, relatively low cost, and a measure of anonymity—their diver- sity can also present distinct challenges. Some ministries of health, for example, explicitly prohibit support to informal businesses like kiosks, even though that sector typically serves a larger propor- tion of the population than the formal pharmaceutical sector.37 Projects aimed at strengthening the pharmacy sector must consider the elements that make up this sector and set realistic priorities to address their differences. e quality of care in pharmacies and opposition from the medical estab- lishment also are concerns. Quality of care issues stem from insufficient documentation of private-sector treat- ment practices. In many countries, tensions between medical practitioners and pharmacists are seen as possible barriers to enlarging the role of phar- macists.8 For example, in South Africa exploration of how to expand the role of pharmacies found that the medical profession had significant concerns about pharmacists’ prescribing abili- ties.38 ese barriers are in part due to perceptions about pharmacists’ roles. Historically, the primary function of the pharmacy was simply as a source of drug products; pharmacists dispensed medicines to clients who had prescrip- tions from a medical practitioner.8,39 In most developing countries, however, although laws may restrict pharma- cists’ prescribing rights, pharmacists routinely provide medical information and sell drugs without prescriptions.8 Furthermore, qualitative research has Pharmacies and youth Over the past 30 years, countries have increasingly improved adults’ access to reproductive health programs. It is only more recently, however, that reproductive health programs for young people have received a broad base of support. In 1994, the International Conference on Population and Development was one of the first global forums to endorse the right of adolescents to receive reproductive health information and services. Although there is increasing awareness of this need, large numbers of adolescents throughout the world remain underserved. e lack of health care resources, limited family planning and other services available to unmarried clients, and adolescents’ fear of disapproval if they admit to sexual activity all contribute to a growing threat to the health of adolescents. Studies have shown that young people view pharmacies as critical sources of contraceptive information and methods.40,41 Pharmacists and staff can provide greater access to reproductive health care—both for geographic areas where health care resources are inadequate and for populations (such as adolescents) reluctant or unable to seek the care from clinics or physicians. One U.S. study examined adolescents’ reasons for seeking emergency contraception services from a pharmacist.42 e most common reasons for using the pharmacy were convenience (44%), lack of knowledge about alternatives (38%), and anonymity (31%). In a three-year project funded by the William and Flora Hewlett Foundation, PATH, working in Cambodia, Nicaragua, and Kenya, developed a global model for building the capacity of pharmacies to provide emergency contraception (EC) and other reproductive health information and services to youth. Working with local stakeholders and partner organiza- tions in each country, PATH established systems for training pharmacists and counter staff to provide information and services related to three needs resulting from unprotected sexual intercourse: EC, STIs, and contraception. e training emphasized understanding the needs specific to youth and developing skills in communication and counseling. Part of the project involved developing a youth-friendly services logo, which designated the pharmacy as an appropriate site for youth to seek reproductive health information and services. MexFam is another organization that has developed a youth-friendly pharmacy network. It consists of 642 pharmacies, where staff are trained in adolescent sexual and reproductive health. ese pharmacies also have a logo designating them as youth-friendly (Gente Joven) sites. e Population Council has recently initiated a project with Mexfam to increase the number of Gente Joven pharmacies, to strengthen and update the training materials, to evaluate the utility and effective- ness of these materials, and to support other types of technical assistance in training of pharmacy workers.43 A Commer- cial Market Strategies project also worked to create a network of youth-friendly pharmacies in El Salvador.44 Outlook Volume 21 Number 2 6 Outlook Volume 21 Number 2 7 shown that pharmacists and staff oen do view themselves as filling a broader community health care role.47 In the developed world, as more medicines are being reclassified from prescription- only to pharmacy or over-the-counter (OTC) status, the advisory scope of the pharmacist also is expanding.48 Internationally, the pharmaceutical profession is gradually evolving toward client-centered rather than product- centered practice.12,39 In some places, pharmacy education is responding in kind, orienting programs more toward emphasizing patient care, a concept referred to as “pharmaceutical care.” Such care involves patient-centered, outcome-oriented pharmacy practice in which the pharmacist works with the client and other health care providers to promote health; prevent disease; and assess, monitor, initiate, and modify medication use to ensure that drug therapy regimens are safe and effective.49 By combining pharmaceutical care with technical training and the strengths that already attract clients, pharmacists can offer a range of reliable services to meet clients’ reproductive health needs, from simply dispensing information and products to counseling and helping with treatment and possible referral. Conclusion Lack of public resources and limited access to services contribute to an increasing threat to the reproductive health of women and men. Pharmacies can help meet the need for better access to reproductive health, and they are accessible to the populations that repro- ductive health programs are trying to reach. Moreover, pharmacists and their staff are already providing counseling, information, and services related to many primary and reproductive health care needs. For pharmacies to offer high-quality care to the populations they serve, the products they sell must be appropriate and their staff must receive the best, most accurate information available. In addition to education and training, building networks and partnerships among formal and informal health providers is crucial to the success of these programs as is addressing legal or regulatory barriers to key repro- ductive health products. Many of the programs presented in this article have been extremely effective at working with pharmacists and their staff to improve their knowledge and health service practices. A dedicated effort to strengthen the pharmaceutical sector and enable pharmacies to play a larger role in reproductive health can expand access to essential health care. References 1. World Health Organization (WHO). e World Health Report 2003: Shaping the Future. Geneva: WHO; 2003. Available at: www.who.int/whr/2003/chapter7/en/ index7.html. 2. Brieger WR. e Role of Patent Medicine Vendors in the Management of Sick Children in the African Region [revised]. Arlington, VA: Basics II; 2003. 3. WHO. A rapid assessment of health seeking behaviour in relation to sexu- ally transmitted disease [dra protocol]. Geneva: SEF/PRS/STD-GPA/WHO; 1995. Available at: www.who.int/hiv/topics/en/ HealthcareSeeking.pdf. 4. Tawfik Y, Northrup R, Prysor-Jones S. Utilizing the Potential of Formal and Informal Private Practitioners in Child Survival: Situ- ation Analysis and Summary of Promising Interventions. Washington, DC: Support for Analysis and Resarch in Africa Project; 2002. Available at: www.aed.org/Toolsand Publications/upload/UtilizingthePotential.pdf. 5. Hanson K, Berman P. Private health care provision in developing countries: a preliminary analysis of levels and composi- tion. Health Policy and Planning. 1998; 13(3): 195–211. 6. Brugha R, Zwi A. Improving the quality of private sector delivery of public health ser- vices: challenges and strategies. Health Policy and Planning. 1998;13(2):107–120. 7. Day RD, Jinks MJ, Skaer TL, et al. Family planning and AIDS/HIV intervention from a cross-cultural perspective: enhancing the pharmacist’s role. American Journal of Pharmaceutical Education. 1993;57:221–229. 8. Mayhew S, Khonde N, Pépin J, Adjei S. Pharmacists’ role in managing sexually transmitted infections: policy issue and op- tions for Ghana. Health Policy and Planning. 2001;16(2):152–160. 9. Food and Drug Administration, Ministry of Public Health, ailand. Current situation of the drug system in ailand. Paper presented at: e Role of Pharmaco- epidemiology in Rational Use of Drug [sic], January 31–February 2, 1994; ailand. 10. Paphassarang C, Philavong K, Boupha B, Blas E. Equity, privatization and cost recovery in urban health care : the case of Lao PDR. Health Policy and Planning. 2002;17(Suppl 1): 72–84. Pharmacies and EC e pharmacy is a crucial outlet for information and services related to emergency contraception. EC is the only contra- ceptive method women can use to reduce their risk of pregnancy aer unprotected sexual intercourse. It is a safe and effective backup method for pregnancy prevention when a primary method fails or is not used. Emergency contraceptive pills (ECPs) are the most widely used form of emergency contraception and can be easily accessed through the pharmacy. In Zambia, the Population Council and local collaborators conducted a study in which peer counselors, clinic-based health care providers, pharmacists, and community sales agents were trained to provide EC information and, if possible, services. Pharmacists proved to be the lead provider of both EC information and supplies; 54 percent of ECP users first learned of EC from a pharmacist and 74 percent of users received their supplies from a pharmacy.41 Studies in the United States and the United Kingdom have also shown that EC can be effectively delivered at the pharmacy.45,46 e sooner emergency contraceptives are taken, the more effective they are—within 12–24 hours aer intercourse is optimal. Immediate access to this method can have a major impact on its potential to prevent unintended pregnancy and abortions, which makes availability at the pharmacy all the more important. ISSN:0737-3732 Outlook is published by PATH, whose mission is to improve the health of people around the world by advancing technologies, strengthening systems, and encourag- ing healthy behaviors. Selected issues are available in Chinese, French, Indonesian, Portuguese, Russian, and Spanish. Outlook features news on reproductive health issues of interest to developing-country readers. It is made possible by a grant from the Bill & Melinda Gates Foundation. Content or opinions expressed in Outlook are not nec- essarily those of Outlook’s funders, individual members of the Outlook Advisory Board, or PATH. Subscriptions Outlook is sent at no cost to readers in developing countries; subscriptions to inter- ested individuals in developed countries are US$40 per year. Please make checks pay- able to PATH. To subscribe, please contact: Jack Kirshbaum, Editor PATH 1455 NW Leary Way Seattle, WA 98107-5136 U.S.A. Phone: 206-285-3500 • Fax: 206-285-6619 Email: outlook@path.org Back issues Previous issues of Outlook are available online at www.path.org/resources/pub_ outlook.htm. For more online information on various reproductive health topics, go to the Reproductive Health Outlook (RHO) website (www.rho.org). Advisory board Giuseppe Benagiano, M.D., Ph.D., University La Sapienza, Italy • Gabriel Bialy, Ph.D, National Institute of Child Health & Human Development, U.S.A. • Willard Cates, Jr., M.D., M.P.H., Family Health International, U.S.A. • Lawrence Corey, M.D., University of Washington, U.S.A. • Horacio Croxatto, M.D., Chilean Institute of Reproductive Medicine, Chile • Judith A. Fortney, Ph.D., Family Health International, U.S.A. • John Guillebaud, M.A., FRCSE, MRCOG, Margaret Pyke Centre for Study and Training in Family Planning, U.K. • Atiqur Rahman Khan, M.D., Technical Assistance Inc., Bangladesh• Roberto Rivera, M.D., Family Health Interna- tional, U.S.A. • Pramilla Senanayake, MBBS, DTPH, Ph.D., Sri Lanka and U.K. • Melvin R. Sikov, Ph.D., Battelle Pacific Northwest Labs, U.S.A. • Irving Sivin, M.S., Population Council, U.S.A. • Richard Soderstrom, M.D., University of Washington, U.S.A. • Martin P. Vessey, M.D., FRCP, FFCM, FRCGP, University of Oxford, U.K. Contributors This issue was written by Jolene Beitz. It was edited and produced by Jack Kirshbaum and Kristin Dahlquist. Outlook appreciates the comments and suggestions of the fol- lowing reviewers: Mr. M. Clark, Dr. J. Fortney, Dr. P. Garcia, Dr. J. Gardner, Mr. N. Heltzer, and Mr. J. Skibiak. Copyright © 2004, Program for Appropri- ate Technology in Health (PATH). All rights reserved. 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