Water, air, and cleanness are the chief articles in my pharmacy - Napoleon Bonaparte


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I live in Canada. I have access to Medicare. I have few complaints, but do wish getting tests done was easier. Every few months, I need to check my blood glucose and lipid levels. While I don't need to make any co-payments, it is a fair bit of effort to go to a health facility, wait in line, and get my blood drawn. And getting my lab results can take days, since they are accessible only to physicians.

What if I could go to a pharmacy two blocks from my home, get tested and get my results via email or phone? I would find that very empowering. Last winter, I got my flu shot at my neighborhood pharmacy. So, why can I not get tests done there?

Diagnostic access: a last mile challenge in global health delivery

Access to testing is a bigger problem in low- and middle-income countries (LMIC). While many countries have made progress towards expanding access to essential medicines and vaccines, diagnosis remains a huge challenge. This is demonstrated in the analyses of cascades of care (also called continuum of care) for a variety of diseases, including HIV, tuberculosis, diabetes, and hypertension. In all these conditions, diagnosis is the biggest gap in healthcare delivery. When diseases go undiagnosed, there is little hope of curing or controlling them.

"Diagnostics are beyond the reach of a vast number of the world's people. For too long, the crucial role of diagnostics as a foundation of effective and high-quality health care has been neglected." - The Lancet Commission on Diagnostics.

Weak diagnostic capacity is one major reason why outbreaks and pandemics are often detected late. Insufficient access to tests is also a powerful driver of empirical antibiotic use that is widespread. And antibiotic abuse is directly correlated with the emergence of superbugs.

Many LMICs invest very little in diagnostics and laboratories. To address this problem, the World Health Organization (WHO) has developed an Essential Diagnostics List, to help countries prioritize and deliver essential tests at various levels of the health system. Efforts are also underway to develop simple, easy-to-use, point-of-care tests that can be used outside of hospitals and laboratories.

Even if such tests are made available via public health facilities, there is still an access issue. Health facilities are not close to people, open only for select hours, and might not have attached laboratories. Even when they do, laboratories in LMICs often lack essential tests and/or trained staff. These challenges must be addressed and laboratory networks must be made stronger.

Pharmacies: a popular source of first contact care

In the meantime, can pharmacies solve the access problem with diagnostic testing? In many LMICs, pharmacies and retail drug stores are the first point of contact with the healthcare system.

Why is this? First, there are many more pharmacies in LMICs than public health facilities. They are much closer to people than health facilities. Second, pharmacists are liked and trusted by people, and this is a big advantage with sensitive health issues (e.g. pregnancy or sexually transmitted infections). Third, pharmacies stay open for extended hours (sometimes, 24/7). Fourth, they do not charge fees for consultations (or charge much less than doctors), and wait times are short. Clients only pay for medicines (which can be purchased in small quantities). Lastly, in under-served areas, pharmacists often act as de facto healthcare providers and dispense medications without a doctor's prescription.

In some settings, pharmacists also provide vaccines, and thus have already taken on roles that go beyond dispensing medicines.

Can pharmacies offer tests?

Although pharmacies do sell tests such as pregnancy tests, blood sugar strips and glucometers, blood pressure monitors, and HIV self-tests in some countries, they rarely perform on site testing. This is a missed opportunity.

I communicated with Rosalind Miller, a researcher at the London School of Hygiene and Tropical Medicine. She has conducted extensive research on pharmacies in LMICs. "Pharmacists are an under-utilized resource in global health delivery. There is scope to expand their role from retailers and dispensers to one that includes promotion, prevention and disease management. Pharmacists have been successfully engaged to improve TB case detection in India. Other research has shown that private pharmacies in sub-Saharan Africa can incorporate rapid diagnostic tests for malaria into their practice, albeit at varying rates of uptake and influence on case management," she said.

In India, our own research work has shown that pharmacists can be incentivized to provide digital chest x-ray vouchers to clients with tuberculosis symptoms, and increase the number of TB cases detected. In Tanzania, Accredited Drug Dispensing Outlets (ADDOs) have been successfully leveraged for expanding access to malaria rapid tests.

Niranjan Konduri, a Principal Technical Advisor at Management Sciences for Health, had other examples to share with me: "Although the sale of HIV self-tests in private/community pharmacies is common, the experience of actual leveraging of pharmacies is variable across countries. For example, in some settings, approved HIV self-test kits are simply sold and in other settings private pharmacies were actively engaged to provide clients a safe space for voluntary testing, counseling and follow-up. Licensed pharmacies in urban settings in Southeast Asia (e.g. Thailand, Philippines) have been engaged diabetes screening. The major strength of engaging private pharmacies for any tests and referral is that "hidden or untapped communities" are reached," he said.

Another good reason to engage pharmacies is the growing threat of antimicrobial resistance. Since drug stores in LMICs often dispense antibiotics over-the-counter, empowering them to do simple lab tests (e.g. malaria, influenza, or perhaps a test that could help differentiate between bacterial and non-bacterial causes of acute fever) might help cut down on unnecessary antibiotic use.

Challenges to overcome

In principle, the idea of engaging pharmacies to expand access to testing is a sound one. But the devil might be in the details. These include the need for modifying or adding regulatory oversight, investment in training and supervision of pharmacy staff in doing tests, incentives to make it worthwhile for pharmacies to take on testing, establishment of referral networks for additional follow-up or confirmatory testing, and deal with any push back from laboratory professionals who might see pharmacies entering the lab space as a potential threat to their business.

A systematic review on expanding services of private medicine retail outlets to include malaria diagnostic services concluded that the approach "may hold great promise to improve malaria case management and curb overtreatment with antimalarials." However, the authors caution that "doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector."

Prashant Yadav, a global health supply chain expert at the Bill & Melinda Gates Foundation, argues that "pharmacies/drug shops can be effective agents for testing but for them to have effects at large scale, it has to be in combination with large patient/caregiver awareness/behavior change programs."

These challenges are not insurmountable, and scale is also feasible. In the US, a growing number of community pharmacies are offering CLIA-waived tests. According to one estimate, of the nearly 60000 community pharmacies in the US, approximately 18% have CLIA-waived status and can perform any of the approximately 120 CLIA-waived tests that are simple and non-technical.

New technologies might also help overcome traditional barriers. Mara Hansen Staples, an expert in global health delivery, says "New diagnostic tools now allow pharmacy staff to provide more accurate advice. For example, there are now rapid diagnostic tests for malaria which are widely used in pharmacies. Simple respiratory rate counters and pulse oximeters might allow pharmacies to identify severe pneumonia. Self-tests for HIV are already sold in pharmacies in South Africa, Belarus, the US, the United Kingdom and elsewhere. Research in Uganda has recently shown that patients are able and willing to collect their own cervical samples to test for HPV, a causative agent of cervical cancer. Samples collected by women at home could be discreetly dropped off at a local pharmacy for processing."

Indeed, new technologies (home-based & self-tests, AI, mobile apps, telemedicine, wearables, blockchain) might be key for expanding access to diagnostic testing in global health, and pharmacies are well poised to exploit them.

Source: Madhukar Pai, Can Pharmacies Improve Global Health Delivery By Taking Tests Closer to People?, Forbes, May 25, 2019.

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Last Updated : Tuesday, May 28, 2019