The Accredited Medicine Stores in Liberia: Their Role in the Ebola Crisis

Funded by the Gates Foundation and led by MSH, the Sustainable Drug Sellers Initiative (SDSI) project worked to ensure the sustainability of public-private drug seller initiatives in Tanzania and Uganda, and to roll-out the initiative in Liberia.

The Ebola outbreak in 2014 decimated Liberia’s already weak health system. Not only was much of the health system in Monrovia shut down due to fears of Ebola among staff and patients, but health care providers themselves were hit proportionally harder by the disease. In a country with only 1 physician per 100,000 people, those deaths exacerbated the health provider deficit. However, Montserrado County, which includes the capital city of Monrovia and is home to a million people, has more than 600 medicine stores and 112 retail pharmacies, where community members go to buy drugs for common conditions. These stores generally remained open throughout the outbreak.

In 2012, the Gates Foundation-supported Sustainable Drug Sellers Initiative (SDSI) worked with the Liberian Medicines and Health Products Regulatory Authority (LMHRA) to create the AMS program in Montserrado County. This program is based on public-private accreditation programs in Tanzania and Uganda that improve access to quality pharmaceutical products and services in underserved areas. Although Tanzania and Uganda’s programs focus on rural shops, Liberian authorities perceived the densely populated area around Monrovia as likely to benefit more from the initiative. As part of Liberia’s AMS model, dispensers are allowed to legally sell select prescription medicines to treat ordinary conditions, while the government sets and enforces standards related to personnel and premises.

Recognizing the potential for medicine stores and retail pharmacies to help ease the health system burden during the Ebola outbreak, inspectors from LMHRA and the Pharmacy Board of Liberia and pharmacy students visited medicine stores and pharmacies to raise awareness among the retail drug outlets dispensers about what to look for and how to respond to potential cases of Ebola. The outreach increased dispensers’ knowledge of Ebola and helped them counsel customers about the disease, but stores also continued to provide access to medicines for other commonplace yet deadly diseases, such as malaria and pneumonia. After the Ebola situation had eased somewhat in December 2014, SDSI conducted a survey to characterize the services that retail drug outlets in Montserrado County provided during the crisis.

Interviewers visited 112 of 113 pharmacies and 453 of 637 medicine stores—75 percent of the total. Of the 453 medicine stores 126 had been accredited and retail drug outlets dispensers from 174 other stores had completed the AMS training, but their stores had not yet received official accreditation. The survey assessed dispensers’ knowledge of Ebola, whether drug outlets expanded their role during the epidemic, and what they needed to be prepared in future outbreaks. Interviewers also looked at the availability and cost of essential medicines in the outlets, with a focus on medications used for the Ebola response.

When we asked the 565 retail drug outlets dispensers about the number of customers that they saw per day before and during the outbreak, the proportion who reported a high number (defined as more than 76 customers per day) almost quadrupled during the crisis (7 percent of shops before Ebola and 27 percent during the outbreak). The dispensers reported that their high-demand products during the outbreak were oral rehydration solution and metronidazole, which are used for diarrhea; paracetamol for fever; antibiotics, doxycycline and amoxicillin; and the recommended antimalarial, a combination of artesunate and amodiaquine. These products, not surprisingly, were also subject to stock-outs. More than 80 percent of the respondents said their stock-outs were due to stock-outs at wholesalers, while just over 20 percent said they thought it was because of the increase in demand.

Almost all the pharmacy and drug store staff knew that Ebola was spread through contact with body fluids, and about half knew that burial rituals that required handling the body were dangerous. We also asked what drug sellers did when customers came to the store with Ebola-like symptoms, and 70 percent of the medicine store employees said they referred people to the Ebola treatment unit, while 51 percent said they called the Ebola hotline for advice. When asked what they would like to have to help prepare for the next outbreak, three-quarters wanted more training.

Pharmacy and medicine store employee suggestions for outbreak preparedness (N=565)

The results of our survey make it clear that retail drug outlets played an important role by providing advice and medicines to a community afraid to visit public health facilities. By staying open, dispensers risked their own health as well; one in 10 of those we interviewed said they knew of a fellow drug seller or owner who had been infected with the Ebola virus. To help dispensers be better prepared, SDSI bought and distributed 460 non-contact thermometers to dispensers who had been trained in how to use them. The thermometers will be used in surveillance for Ebola and other disease outbreaks and in their routine work.

Arthur Loryoun is a Liberian pharmacist who has dedicated more than 10 years to strengthening pharmaceutical systems in his country. He served as a senior technical advisor at MSH.