Tropical Medicine and International Health volume 14 no 3 pp 362372 march 2009

doi:10.1111/j.1365-3156.2009.02232.x

Systematic Review

Private local pharmacies in low- and middle-income countries: a review of interventions to enhance their role in public health
Felicity Smith
School of Pharmacy, University of London, UK

Summary

objectives To review the evidence regarding the potential of pharmacy services to play an enhanced role in contributing to health care and policy initiatives in low- and middle-income countries. methods Literature search, using computer and hand searching, to identify original research reporting the results of interventions to improve services from private local pharmacies in low- and middle-income countries. results Eighteen studies were identied which spanned all regions: 12 evaluations of training initiatives, three studies evaluating the impact of policy of regulatory interventions, one regarding a collaboration of pharmacy services with a national TB programme, and two evaluating a pharmaceutical care initiative for patients with hypertension. A total of 14 studies used advice and recommendations to simulated clients as the primary outcome measures. Whilst most studies reported some improvements to practice, these were often small, limited to specic outcomes and believed to be short-lived. conclusion The studies in this review demonstrate international interest in enhancing the place of pharmacy services in the provision and delivery of health care. But the small number of studies provides inadequate evidence on how to assure the quality of local pharmacy services can be assured, or how to develop them within a wider reform framework. keywords private pharmacies, future services, low-income countries, public health, health care systems, review

Introduction Strengthening health care systems so they can more effectively meet the needs of the populations they serve is currently high on the agenda of governments in many low- and middle-income countries. A feature of many reforms is the preparedness of policy makers to consider new and diverse ways of delivering care. In many countries, this includes involving private sector practitioners including pharmacists (Palmer 2000; Brugha 2003; Bustreo et al. 2003; Prata et al. 2005). Although there is limited evidence of the feasibility or effectiveness of reforms, there are examples of small studies which have evaluated specic proposals at a local level (Palmer et al. 2003; Soeung et al. 2008). It has been recognised that systematic review of such research may be helpful in documenting existing evidence and identifying future research priorities (Bennett et al. 2008). 362

Many organisations, including the WHO, the International Pharmacy Federation, national governments and professional bodies as well as individual practitioners, believe local pharmacy services are an underused resource that could and should contribute more extensively and effectively to the health care of individuals as well as public health agendas (WHO 1988, 1996; FIP 1998; Smith 2004). Because of their presence in many communities and frequently long opening hours, they are often seen as a rst port of call for many people in low- and middle-income countries, especially in urban areas. In some settings, and for many illness episodes, local private pharmacies may constitute the only health service with which people make contact. Throughout the world, particularly in high-income countries, the roles of pharmacists and pharmacies have diversied. Pharmacists responsibilities may include monitoring medication for people with chronic disease, operating repeat prescription services, reviewing medication for

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long-term users, prescribing under protocols, advising on the management of common conditions and participating in local and national health promotion or disease prevention activities (Smith et al. 2005; RPSGB 2008). In low- and middle-income countries health care needs are arguably more acute. Both human and nancial resources are more stretched. Many of these countries are reviewing their systems of health service organisation, provision and delivery. This has led to greater diversity in patterns of provision of health care in many countries, notably partnerships between the public and private sectors, in some cases developments which involve local private pharmacies. The aim of this paper is to review the evidence base regarding the potential of pharmacy services to play an enhanced role in contributing to health care and policy initiatives in these countries. In many low- and middleincome countries there is a diversity of medicine outlets which span the formal and informal sectors and employ differing cadres of professional and non-professional staff. The focus of this review is private pharmacies in which a pharmacist is either present, or has responsibility for services. Whilst there are many descriptive studies which focus on aspects of pharmacy practice and medicine use, there are few which evaluate potential interventions to improve services. Thus, the evidence regarding the benets of the development of pharmacy services to the health needs of individuals and communities in low- and middleincome countries is unclear. Methods Literature searches (19902008) were conducted on MEDLINE, PubMED, EMBASE, International Pharmaceutical Abstracts, Pharm-line. Studies were also searched from within the citations of review and other articles. The contents pages of pharmacy and related journals in which studies might be expected to be reported were also handsearched. These included pharmacy journals not abstracted on databases and journals that were identied during the search as forums for the publishing of relevant material. Keywords for the database searches included pharmacy, pharmacist, developing countries, low-income countries, Africa, Asia, South America. Further searches were undertaken combining pharmacy and pharmacist with names of 35 countries in sub-Saharan Africa, Asia and America; including all those in the UKs Department for International Development priority list (DFID 2008). For the purposes of the review, eligible studies were: testing an intervention based at least in part in private local pharmacy(ies) to evaluate the impact on some

aspect of health care, medicines use of service provision and delivery; studies in which the authors indicated the involvement of pharmacists. Thus, studies of drug stores in which a pharmacist was neither present in premises, nor responsible for services, were excluded. conducted in a country commonly classied low or middle income; reporting the ndings of original research; employing an experimental design [e.g. randomisedcontrolled trial (RCT)] or quasi-experimental design (e.g. before and after studies, with or without a control group).

To achieve the study aim, the analysis focused on the aims, objectives and nature of the intervention, and the methods employed in the evaluation. Assessment of the quality of the studies took into account study design, sampling procedures and sample sizes, data collection procedures and measurement of outcomes; all of which would be important for the generalisability, reliability and validity of the study ndings. This enabled the question of the extent, range and strength of evidence regarding the potential for pharmacy services to contribute to health agendas in developing countries to be addressed. Results Eighteen studies were identied (Table 1). For two studies, the results were reported in two separate papers each focusing on different aspects of the work (hence there are 20 entries in Table 1). The studies spanned countries in all regions of the developing world: seven in Asia (Lao PDR, Vietnam, Thailand, Nepal, Indonesia), six in Africa (Nigeria, Ghana, Kenya, Tanzania), including one study in both Kenya and Indonesia, and six in South or Central America (Bolivia, Brazil, Peru, Mexico). Twelve were evaluations of training initiatives to improve the management of prevalent infectious diseases. Three studies evaluated the impact of policy or regulatory interventions on the quality of pharmacy services. One study investigated the potential value of collaboration between private pharmacies and the national TB programme in Bolivia. These studies also included a training component although this was not the main focus. Two studies evaluated a pharmaceutical care intervention for patients with hypertension. Evaluation of training initiatives Educational interventions were the most common. Of the 12 interventions, seven were for sexually transmitted

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Table 1 Summary of intervention studies involving private pharmacies

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Intervention Education: management of STIs. One-day training session for pharmacists 50 intervention, 50 control pharmacies. Randomisation between groups. Follow-up 6 months post intervention Simulated clients (male) pre senting with symptoms of urethral discharge; advice and medicines supplied by pharmacy staff Study design Method of data collection and outcome measures Principal ndings conclusions Education: management of STIs. One-day training session for pharmacists 248 in total: intervention group those who had received training, control group those yet to receive training Education: management of STIs. Pharmacists and employees; 8 h training session, but low uptake so 2 h onsite sessions offered also Education: management of STIs. Three or four 90 min seminars for pharmacy workers 400 pharmacies, around 2000 pharmacy staff , Randomization by district, Follow-up at 1, 3, 6 months 90 intervention, 90 control pharmacies Random selection allocation Follow-up after 23 months Education: management of STIs assessment of cost-effectiveness of intervention in Garcia et al. (2003) (above) Cost-effectiveness analysis Some improvements where pharmacists had received training, but still >50 cases receiving inappropriate treatment. Extend training to non-pharmacist staff Improvements in treatment for urethral discharge in pharmacies where pharmacists had attended, but little change in prescribing practices for genital ulcers Small but signicant increase in some components of counseling advice by intervention pharmacies, but treatment provided generally ineffective Better recognition and management (antimicrobial regimens and referral advice) for all conditions in intervention group; authors concluded training feasible and effective Training pharmacists is cost effective when only programme costs are included Education: management of STIs. Two-day training programme 160 male pharmacists randomly selected from all in study area. 38 who had attended training 79 months earlier before-and-after study Simulated clients (male) pre senting with symptoms of urethral discharge or genital ulcer; advice and treatment to provided to clients and its cost Simulated clients presenting with symptoms of genital ulcer urethral or vaginal discharge, pelvic inammatory disease; advice provided by pharmacy staff Simulated clients presenting with symptoms of genital ulcer urethral or vaginal discharge, pelvic inammatory disease; advice management of symptoms Costs and cost savings based on direct costs of intervention, societal costs (costs of medicine) number of cases adequately managed calculated from patients seeking treatment and impact of intervention Simulated clients (male) presenting with urethral discharge; drugs dispensed, doses, costs, condom use, questions asked symptoms, partner advice Following intervention more appropriate drugs dispensed and advice given and drugs costs were lower. Differences less pronounced after 79 months. Authors concluded educational interventions can improve services, but benets may be time limited

Study and location

Adu-Sarkodie et al. (2000) Accra, Ghana

Tropical Medicine and International Health

Mayhew et al. (2001) Greater Accra, Ghana

Garcia et al. (1998) Lima, Peru

F. Smith Private local pharmacies in low- and middle-income countries

Garcia et al. (2003) Lima, Peru. linked with Adams et al. (2003), (below)

Adams et al. (2003) [inked with Garcia et al. (2003) above]

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Tuladhar et al. (1998) Central region, Nepal (pharmacies on transportation routes)

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Table 1 (Continued)

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Study and location Education: management of STIs. Pharmacists and employees, Three-day training programme 18 pharmacies in intervention group; 52 in control (some self-selection).Study also compared pharmacists and non-pharmacist employees 166 pharmacy workers into four groups: to receive training and or supporting materials or neither. follow-up at 3 months Simulated clients (male) visits to pharmacies; advice and treatment suggested, including advice regarding partners and referral

Intervention

Study design

Method of data collection and outcome measures

Principal ndings conclusions

Naves et al. (2008) Brazilia and Taguatinga, Brazil

Tropical Medicine and International Health

Pick et al. (1996) Mexico City

Education: management of STIs. Eight hour training course and supporting materials

No signicant improvement following intervention in pharmacist or non-pharmacist group. Authors concluded that more comprehensive approach is required When given together, the course and materials increased short-term knowledge about AIDS and condom use. No evidence of longer term impact on knowledge, advice to clients or on condom sales

F. Smith Private local pharmacies in low- and middle-income countries

Podhipak et al. (1993) Administrative area of Bangkok, Thailand

Education: management of diarrhoea training sessions with pharmacy staff and provision of educational materials Education: management of diarrhoea following WHO guidelines; pharmacists and counter attendants; training in 23 h interactive sessions and posters supplementary materials Education: management of diarrhoea diarrhoea following WHO guidelines; seminar and posters supplementary materials

Small improvements in pharmacist and drug seller management in intervention compared with control but not statistically signicant Some improvements in knowledge and practice: sales and communication with clients at least in the short term

Ross-Degnan et al. (1996) Nairobi and three other towns, Kenya; Jakarta and neighbouring areas, Indonesia Oshiro & Castro (2002) Corumba and Ladario cities, South-western Brazil

121 pharmacies and 60 drug stores in intervention group, 60 pharmacies and 60 drug stores in control group. Randomisation by district Follow-up at 1 month 107 pharmacies in Kenya, 87 in Indonesia. Sampling strategies determined by locality generally random and census approaches; before-and-after assessment: follow-up after 1 month Staff in 13 pharmacies, pharmacists and employees. Before and after comparison Follow-up after 4 months

Pre- and post-workshop questionnaires to assess short-term and longerterm (after 3 months) knowledge retention. Simulated clients (male and female): advice provided with sales of condoms; condom sales tracked over 6 months Simulated clients: mothers of children with watery diarrhea or dysentery; medication supplied before-and-after intervention especially if antibiotics or ORT Questionnaire before at after training to assess knowledge; simulated clients: mothers of children with watery diarrhoea or dysentery; sales advice re. medicines, ORT, symptom management Questionnaire interviews, and simulated clients; knowledge of participants, before and after medicines supplied for diarrhea, antibiotics, ORT, advice to patients

Acquisition of knowledge regarding management of diarrhea did not prevent pharmacy workers from suggesting anti-diarrhoeals instead of ORS alone. Authors concluded interventions should include regulatory measures and review of roles

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Table 1 (Continued)

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Intervention Education: malaria and other childhood illnesses; poster, individual information and one-to-one training sessions lasting for one hour, posters only given to controls 40 drugs stores: 20 intervention 20 control; randomization Before and after comparison Follow up after 6 months Simulated clients: nurses posing as caretakers of sick <5 year children. Questionnaires to assess knowledge of anti-malarials and national guidelines for management of malaria Structured interviews with retailers to assess knowledge. Simulated client three scenarios: parent of child with diarrhea, parent of child with cough (pneumonia), symptoms of anaemia in pregnancy; safe dispensing, correct advice and appropriate referral for the three conditions Study design Method of data collection and outcome measures Principal ndings conclusions Education and education with audit feedback: training with reinforcement materials and with or without audit-feedback on dispensing practices 352 randomly selected drug retailers (baseline), 325 rst follow-up, 314 second follow-up four groups: small-group training, small group training followed by audit feedback, mailed printed materials followed by audit feedback, and control. Follow-up at 2 and 5 months Government regulation of pharmacies comprising: inspections, sanctions, information feedback, distribution of documents Pharmacies (92) in 14 districts; randomised trial comparing two levels (active and regular) of intervention regarding regulation Interviews with owners and visits to pharmacies. Facility and dispensing indicators: storage of drugs, availability of essential drugs, materials and hygiene, dispensing and labelling practices, information to clients A multi-component intervention to improve private pharmacy practice; sequential delivery of regulatory enforcement + education + peer-inuence based on four tracer conditions 29 matched pairs of pharmacies, one of each randomly assigned intervention or control group Simulated patients with four tracer conditions ARI in a child, urethral discharge in adult male, requests to purchase two tabs or antibiotic or steroid without a prescription; responses of staff to simulated client requests One-to-one educational sessions had some impact on knowledge and compliance with treatment guidelines regarding the types and brands of drugs sold, dosages sold, questions asked of clients and advice given Some improvements in knowledge and practices in trained groups compared with control. For some conditions an association between knowledge and practice was observed. Most improvements observed for 2 months only therefore is issue of how to sustain. Small group training alone can improve retailers practices, similar results obtained when combined with audit feedback. Audit alone not effective Improvements in both groups on most indicators, with non-signicant trend of greater improvement in active group. Concluded argument for governments in low-income countries to expand regulatory efforts to improve pharmacy practice Improvements in dispensing practices and symptom management in intervention pharmacies compared with control on all tracer conditions. Concluded possible to improve pharmacy practice with a multicomponent intervention

Study and location

Tropical Medicine and International Health

Nsimba (2007) Kibaha district urban and peri-urban towns, Tanzania

F. Smith Private local pharmacies in low- and middle-income countries

Kae 1998 Three regions (12 districts) jungle, plain and hill areas of Nepal;

Stenson et al. (2001) Lao PDR

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Chuc et al. (2002) Hanoi, Vietnam. Study linked with Chalker et al. (2002); (below)

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Table 1 (Continued)

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Study and location A multi-component intervention to improve private pharmacy practice [as above: Chuc et al. (2002)] A multi-component intervention to improve dispensing practices at private pharmacies; sequential delivery of three stages of intervention: regulatory enforcement + education + peer-review 70 pharmacies Before and after study Follow-up after 2 months Decrease in availability of TB drugs for sale in pharmacies; numbers of referrals recorded by TB programme 68 pharmacies in Hanoi, 78 in Bangkok; randomly selected and assigned to intervention and control groups; assessment of impact at baseline, and after each stage of intervention 22 (after drop-outs) matched pairs of intervention and control private pharmacies

Intervention

Study design

Method of data collection and outcome measures

Principal ndings conclusions Interventions were effective in changing knowledge and reported practice

Tropical Medicine and International Health

Chalker et al. (2002); Hanoi, Vietnam Study linked with Chuc et al. (2002); (above)

Chalker et al. (2005) Hanoi, Vietnam. Bangkok, Thailand (urban)

Knowledge and reported practice regarding the four tracer conditions (see above) gathered in structured questionnaires Simulated clients requesting steroids and a few caps of a selected antibiotic; change in supply patterns of prescription-only steroids and low dose antibiotics

F. Smith Private local pharmacies in low- and middle-income countries

Lambert et al. (2005) Cochabamba, Bolivia

Oparah et al. (2006) Warri, southern Nigeria, Urban

36 patients from one pharmacy; before-and-after study. Follow-up over 6 months

Aguwa et al. (2008) Port Harcourt, capital or Rivers (oil producing) state, Nigeria

Feasibility and impact of collaboration between private pharmacies and national TB programme. Meetings and educational presentation with pharmacists; implementation of protocol for referral of clients with cough Pharmaceutical care intervention for hypertensive patients on antihypertensive medication comprising information and advice to individual patients Pharmaceutical care intervention for hypertensive patients on antihypertensive medication comprising monthly goal-directed counselling 24 patients from one pharmacy with two pharmacists. Crossover design: 5 months usual care, 5 months intervention

Blood pressure measurement: changes in blood pressure Interviews with clients: self re ports of lifestyle change, adherence, knowledge, satisfaction Blood pressure measurement: changes in blood pressure Questionnaire for secondary outcomes: quality of life measures (WHOQOL-BREF) and self reports smoking, adherence exercise

Improvements in Hanoi sample following regulatory stage and sustained through other stages. In Bangkok sample, only signicant change was reduction in sales of steroids following the regulatory stage Decrease in availability of TB drugs was achieved. Some increased referral of patients, but conclusion that this collaboration with pharmacies was not an efcient way of increasing referral to national TB programme Signicant reductions in BP and some other self-report measures were reported. Pharmaceutical care interventions are feasible and probably effective Signicant reductions in BP and some quality of life and self-reported secondary outcomes

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infections: in Ghana, Peru, Nepal, Mexico and Brazil (Pick et al. 1996; Garcia et al. 1998, 2003; Tuladhar et al. 1998; Adu-Sarkodie et al. 2000; Mayhew et al. 2001; Naves et al. 2008). Four focused on the management of diarrhoeal disease: in Thailand, Kenya Indonesia, Nepal and Brazil (Podhipak et al. 1993; Ross-Degnan et al. 1996; Kae 1998; Oshiro & Castro 2002) of which one in Nepal (Kae 1998) focused on diarrhoea, symptoms of pneumonia and anaemia in pregnancy. One study in Tanzania (Nsimba 2007) focused on symptoms of malaria and other childhood illnesses. In all cases the intervention included face-to-face training at seminars or at pharmacy premises. These were generally 1- or 2-day seminar programmes, or one or more shorter sessions delivered over a period of time. Training sessions were sometimes supplemented with other material such as printed information or posters. All educational interventions focussed on the management and or advice for conditions common in developing countries. The outcome measures related to advice and products recommended or sold by pharmacy staff, especially the supply of antibiotics, recommendation of oral rehydration therapy for diarrhoea, referral advice, and for STIs advice to partners and use of condoms. One study included a cost-effectiveness analysis, concluding that the training of pharmacists was cost-effective when only the programme costs were included (Adams et al. 2003). Of these 12 studies evaluating an educational intervention, 10 assessed the outcomes by comparing performance between the intervention and a control group. In all 10 studies, pharmacies were randomised between groups, in three of the studies randomisation was by district, in two the control group comprised pharmacies yet to receive the intervention; in one study the control group included pharmacies both randomly assigned as well as those which chose not to participate in the intervention. Two of the studies were before-and-after designs: a comparison of performance prior to, and following, the intervention. The sample sizes for these studies ranged from 13 to 400, with eight studies involving at least 100 pharmacies, with similar numbers in the intervention and control groups. In most studies participation rates were high. In all studies of educational interventions, the outcomes were measured using simulated client methodology. This is a relatively cheap and convenient means of assessing practice. It involves an individual entering the pharmacy, posing as a client whilst not disclosing their true purpose, describing symptoms, requesting information or medication and answering any questions according to a predetermined protocol. Then immediately following the encounter they note the details of the responses and actions of the pharmacy staff. In some studies, the simulated client approach was combined with questionnaires or 368

interviews with pharmacy staff to assess their knowledge or obtain self-reports regarding their practice. Combined analyses of these data-sets enabled researchers to comment on the extent to which knowledge is translated into practices (sales, recommendations and advice-giving). These combined analyses also conrmed doubts regarding the accuracy of self-reports as an indicator of practice (Igun 1994; Ross-Degnan et al. 1996; Oshiro & Castro 2002). Together these studies, which are generally robust in terms of design and methodology, provide consistent evidence regarding the effects of educational interventions. Almost all studies reported some positive impacts of the intervention and authors argued that educational initiatives were feasible and effective in improving practice and should be extended. However, the impacts were sometimes described as limited, relating to only certain outcome measures. This led some researchers to conclude that educational initiatives should be delivered as part of broader multi-component interventions. The impact of training was also recognised as possibly short-lived, the evaluation often being conducted on a single occasion following the intervention. One study which followed-up a subset of participants 79 months after the intervention found that the initial effects, although still noticeable, had waned (Tuladhar et al. 1998). The potential impact of government intiatives Three studies evaluated policy or regulatory interventions on a range of indicators of quality in pharmacy services and or management of symptoms (Vietnam, Thailand and Lao PDR). These studies were more wide-ranging in terms of the complexity of the intervention and or their goals to promote more comprehensive improvements to practices in private pharmacies (Stenson et al. 2001; Chuc et al. 2002; Chalker et al. 2005). A randomised trial on Lao PDR compared the effects of two levels of intervention for the implementation of regulation (Stenson et al. 2001). Pharmacies in 14 districts were randomly assigned (by district) to active or regular intervention groups. The intervention for the active group involved four visits comprising high-quality inspections, enforcement of regulations including the application of sanctions, ensuring a supply of up-to-date regulatory documents in each pharmacy, and using the inspections as an opportunity to provide information to drug sellers about any need for improvement. For pharmacies in the regular group, the intervention comprised similar components but a lower intensity, involving two visits. Outcome measures relating to the quality of services were based on the concept of good pharmacy practice as dened by the International Pharmaceutical Federation (FIP 1993), and

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comprising storage of drugs, availability of essential drugs, materials and hygiene, dispensing and labelling practices and information provided to customers. Service quality on most indicators improved in both groups after the intervention. Although there was a trend for greater improvement in the active group, for most indicators the difference between the groups did not reach statistical signicance. The authors concluded that there is a strong argument for governments in low-income countries to expand regulatory efforts to improve pharmacy services. An RCT design involving matched pairs of pharmacies in Hanoi, Vietnam, tested the impact of a three-stage intervention comprising sequential delivery of intensive regulatory enforcement, education and peer inuence (participation in discussion groups) (Chalker et al. 2002; Chuc et al. 2002). Four tracer conditions relating to the management of symptoms and supply of medicines without a prescription provided the focus for the interventions and the outcome measures. The intervention was assessed rst by simulated patient method, which found signicant improvements in advice and treatment for the four tracer conditions in the intervention group (Chuc et al. 2002); and second, knowledge and reported practice based on data gathered in structured questionnaires with participants, which also reported improvements in the intervention group compared to controls (Chalker et al. 2002). In a subsequent and similar study, the intervention was evaluated in randomly selected pharmacies in both Hanoi and Bangkok (Chalker et al. 2005). This study focused on the supply of steroids and low-dose antibiotics without a prescription. Signicant improvements were found in the Hanoi sample in relation to both scenarios from the rst regulatory stage of the intervention, whilst in the Bangkok sample, improvements were observed only in relation to the supply of steroids. All three studies were randomised controlled trials involving 44146 pharmacies, employing sampling strategies to ensure comparability between groups. The use of a range of methods to evaluate the impact of the interventions enabled an assessment that reected their broad aims. Dependence on the simulated client method (Chuc et al. 2002; Chalker et al. 2005) may have limited the extent to which a comprehensive and contextual assessment of the outcomes could be obtained, although it does provide information on important aspects of practice. An intervention study in Bolivia investigated the feasibility and effectiveness of a collaboration between private pharmacies and the national TB programme (Lambert et al. 2005) The study aimed to reduce the availability of TB drugs for sale in pharmacies, on a voluntary basis, and to promote referral of clients to the national TB programme. The intervention included meetings with

pharmacists with a presentation on TB and TB programme and use of referral slips. Outcome measures were the availability of TB drugs in private pharmacies before and after the intervention, and numbers of referrals. The intervention was successful in reducing the availability of TB drugs in private pharmacies, but the researchers concluded that with 26 of 70 participating pharmacies referring only 41 clients, collaboration with pharmacies was not an efcient way of increasing referrals to the National TB programme. The design and methods of the study allowed an assessment of the feasibility of, a novel service development. On the basis of the ndings, the project was not extended to all pharmacies in the city. Pharmaceutical care interventions Two studies evaluated interventions for patients with hypertension. These were before-and-after studies, in which patients acted as their own controls, undertaken in single pharmacies in different states of Nigeria (Oparah et al. 2006; Aguwa et al. 2008). These studies offered a pharmaceutical care intervention involving discussions, information and advice for individual patients regarding the nature of the condition, risk factors, role of medication, over a 5- or 6-month period. In both studies blood pressure was the primary outcome measure. Secondary outcomes included self-report of lifestyle change, quality of life, satisfaction with services. Both studies reported a statistically signicant reduction in blood pressure in addition to a variety of other impacts. These studies demonstrated that the provision of pharmaceutical care from pharmacies may be feasible. However, in both studies, the delivery of the interventions was restricted to single sites and the pharmacies and or staff may in some ways be untypical of wider pharmacy service provision. Thus, caution is required before suggesting that these ndings may be replicable in other pharmacies or settings. Although the outcomes included some objective measures, their assessment was not undertaken independently of the intervention. Also, the reliability of selfreports on subjective measures can be questionable. However, together the studies demonstrate that, at least in certain settings and for some groups of patients, pharmacybased pharmaceutical care interventions are feasible and probably effective. Discussion The studies identied in this review spanned continents, addressed current health priorities of infectious, and chronic disease in developing countries, including those identied in the millenium development goals (MDGs), 369

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and together indicated an interest in the potential for pharmacy services to contribute to public health priorities, in different ways, across the different regions of the developing world. However, a relatively small number of studies which evaluated interventions to enhance local pharmacy services were found. Thus, evidence on ways in which the quality and effectiveness of local pharmacy services can be enhanced is limited. Current literature provides little data for professional bodies and policymakers to inform potential directions for the development of pharmacy services that will improve the effectiveness, efciency and standards of services in meeting local health needs. Together the studies in this review demonstrate that robust studies to evaluate potential interventions in private local pharmacies are feasible. Many found pharmacy staff willing to take part in initiatives to develop their knowledge and skills. Although researchers aimed to adopt a scientic approach to sampling and recruitment, some studies were open to potential participation bias in that the intervention group may have been open to some degree of self-selection by pharmacists. However, differing sampling strategies, procedures and response would not necessarily compromise the value of the work. Even if not representative of all settings, such interventions could produce positive outcomes in a high proportion of pharmacies within a particular study population. All educational initiatives and many other interventions were evaluated using the simulated client method, which has been subjected to discussion regarding its strengths and weaknesses in measuring the quality of practice (Madden et al. 1997; Watson et al. 2006). It requires development of a realistic and feasible scenario, careful training of the researchers, detailed protocols to ensure a standardised approach to what may be very varied environments and responses of staff, and high-quality eldwork with some assurances of the reliability of researchers in adhering to protocols. In some pharmacies, requests for advice from a stranger might raise suspicion which could result in an untypical response. Also, opportunities in getting to know important explanatory factors in the background are very limited. Staff encountered by the simulated clients may not have been those who participated in the intervention. The ethical issue of gathering research data from known individuals without their consent has also been questioned. Quality assurance procedures to address potential problems in the validity, reliability and acceptability were rarely discussed in the papers in this review. Although the reliability of the method is sometimes questionable, it is argued that data generated using these methods are more likely to be an accurate reection of usual practices than alternatives such as self-reports. 370

The majority of the interventions identied in this review were educational initiatives. These studies, in terms of the format and delivery, the measures and methods of assessing outcomes had many similarities. Virtually all educational interventions aimed to improve the supply of medicines and advice to patients in relation to prevalent conditions which is seen as one of the most important functions of local pharmacy services. The studies in this review show that educational interventions can lead to improvements in the quality of care, although these were often limited to specic outcomes and be probably short-lived. Consequently many researchers concluded that educational interventions alone were insufcient in achieving the wideranging improvements to practice that may be desired. This highlights the need for wider inuences on the behaviours of pharmacists and their staff to be taken into account. These may include commercial pressures and potential conicts of business and professional roles, relationships with other health care organisations and providers, consumer factors and societal perspectives (Cerderlof & Tomson 1995). Face-to-face delivery was a feature of all educational interventions. In the future methods may be more diverse, reecting the increased interest and experiment with new technologies such as on-line and other distance and combined approaches. New methods and programmes may improve access and uptake and so support effective and relevant learning activities. They may also assist in addressing the issue of sustainability (PCF5 2008). A continual evaluation of these developments will be important. Notably, the ndings of these studies had much in common despite being conducted in different and diverse countries across the continents. Thus, together they indicate a context-independent impact of education on pharmacy services. That is, the relationship between educational initiatives and outcomes would be expected to hold across settings. Whilst the multi-component interventions generally resulted in some positive outcomes, the one multicentre study (in Vietnam and Thailand) highlights the potential context-sensitivity of these interventions. That is, the impact of an initiative will depend on the presence of particular features or conditions that may not be characteristic of all settings; and thus, the interventions need to be tailored to local circumstances. Similarly, two studies focusing on pharmaceutical care for individual patients, each in a single pharmacy, demonstrated that in a particular setting such an intervention can be feasible and effective; however, further work is required to demonstrate the requirements for success in a more diverse range of settings.

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Virtually all studies were undertaken in cities or urban areas. The discrepancies in the extent of service provision, access to medicines and information, and the presence of pharmacy services between urban and rural areas is welldocumented (Owusu-Daaku 2002). The health needs of urban populations in developing countries are undoubted. Possibly because of the small number of pharmacies, no studies focused on services in the rural areas, which in many developing countries is where there is greatest need. The delivery of many interventions, and their evaluation, may be less feasible in rural areas, where travel is more difcult and health care infrastructure is more limited. Only one study in this review undertook a formal assessment of the costs of delivering an intervention (Adams et al. 2003). Thus, there is also a lack of an evidence to enable policy-makers to make decisions regarding the relative efciency and cost-effectiveness of enhanced pharmacy services in achieving health policy objectives. Conclusion A greater body of knowledge is required to determine the potential value of pharmacy services in the provision of health care in low- and middle-income countries. Further research is required to identify the environmental, organisational, cultural or other contextual factors that may be pre-requisites for the success of any interventions, and how the quality of local pharmacy services can be enhanced within a wider reform framework. References
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Corresponding Author Felicity Smith, School of Pharmacy, University of London, UK. E-mail: felicity.smith@pharmacy.ac.uk

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