5) Description of health product/service offering: For nearly 30 years, PATH has worked to improve global health in the areas of children’s health, infectious diseases, maternal and reproductive health, and vaccines and immunization. In particular, we would like to highlight the RxGen project, a pharmacy-based program that worked to increase youth’s access to reproductive health services and products. The health context Worldwide, rates of sexually transmitted infections (STIs) are highest among young people aged 15 to 24 years, and complications from pregnancy, childbirth, and unsafe abortions have become the major causes of death for girls aged 15 to 19. Youth need better access to reproductive health information, services, and supplies. Pharmacies as untapped resources Licensed and regulated commercial pharmacies are an underused resource for expanding the reach of select public health interventions. Especially in developing countries, pharmacies are often a primary source of services; thus, pharmacy staff are in a good position to help their clients with reproductive health needs, such as emergency contraception, STI risk assessment and referral, and ongoing use of contraception. Pharmacies are particularly appealing to youth, who frequently avoid the formal health system because of the stigma attached to those who are sexually active and unmarried. Pharmacies offer convenience, affordability, relative anonymity, and greater availability of reproductive health supplies. Building capacity With the RxGen project, PATH built the capacity of pharmacists and their staff to provide quality reproductive health information and services, especially to youth. We implemented activities in four countries: Cambodia, Kenya, Nicaragua, and Vietnam. Evaluation data indicate that the project increased pharmacy staff’s ability to provide high-quality, youth-friendly services. Baseline data showed that 0 to 30 percent of staff provided correct emergency contraception products; after training, about 80 percent of staff gave project-trained monitors, or mystery shoppers, correct products. Similarly, mystery shopper reports showed that more than half of staff in each country spontaneously offered information about STIs when shoppers sought services after unprotected sex. Finally, nearly 90 percent of mystery shoppers reported a positive experience in the pharmacies.

6) Description of innovation: The RxGen model differs from existing programs in the field in the following ways: • Recognizes the pharmacy as a critical health care delivery site. • Works within and strengthens existing systems—pharmacies that people already use and pharmacy associations that represent the professional standards of pharmacists and pharmacy owners. • Focuses on building the capacity of pharmacy staff to deliver quality information and services, rather than to promote products. • Relies on close collaboration with and leadership by public and private stakeholders at the national, regional, and local levels in a country.

7) Operational model: Although RxGen focused on pharmacies, the ultimate goal was to get youth better access to the information and services that will help them avoid unintended pregnancies and sexually transmitted infections. In many countries, youth are underserved by the formal health system—especially when it comes to their reproductive health needs. To remedy this, PATH and our partners: • Developed a comprehensive training curriculum for pharmacists and their staff. The training was designed to build (1) participants’ capacity to provide reproductive health services, information, and when needed, referrals for clinical services and (2) counseling skills and ability to provide services in a nonjudgmental manner. • Trained the trainers of pharmacists and their staff. Trainers varied among the four countries, but included staff of the local pharmacist association and ministry of health, physicians, and academics. • Established systems for monitoring pharmacies and providing refresher training. • Developed job aids for pharmacy staff to reinforce what they learned at the training sessions. • Identified or developed collateral client materials on key reproductive health issues for pharmacies to provide to clients. • Built referral networks that linked pharmacy clients with local health care providers and services for diagnosis and treatment of sexually transmitted infections, when appropriate. • Collaborated with existing youth-serving organizations to raise young people’s awareness about the services pharmacies offer. With our local partners in each country, we developed a symbol indicating “youth-friendly pharmacy” to identify participating businesses. • Used “mystery shoppers” to monitor the reproductive health services provided at pharmacies and to evaluate the project’s success. • Tailored the approach to four countries—each representing a different cultural setting and a unique pharmaceutical sector. Our public- and private-sector partners included government ministries, universities, pharmacy associations, pharmacists, youth organizations, and youth.

8) Human resources: The RxGen project was completed at the end of 2005. Project management was a cross-site collaboration between PATH offices in each of the four countries and PATH staff at our headquarters in Seattle. Close coordination among all sites ensured comparability across the four countries and enabled country project teams to troubleshoot, share ideas, and learn from each others’ experiences. PATH staff had expertise in public health and reproductive health, training, and project development and implementation. The project also relied heavily on the expertise of local partners, which included ministries of health, pharmaceutical associations, university schools of pharmacy, youth-serving groups, and youth themselves.

9) Key operational partnerships: The project relied on close collaboration with and leadership by stakeholders at the national, regional, and local levels in a country. These stakeholders included pharmacies and pharmacy associations from the private sector, ministries of health and university schools of pharmacy from the public sector, and youth-serving organizations from nongovernmental organizations. As members of the project’s technical advisory group, stakeholders effectively guided the project strategies and activities.

10) Financial Sustainability

          • Fees charged to clients?: No

          • How do you assure affordability?: RxGen took advantage of existing commercial structures; products and services were not subsidized. A key element of the approach was the integration of reproductive health training into the existing pharmacy training courses—both the continuing education courses offered by pharmacy associations to licensed pharmacists and the training at schools of pharmacy.

The RxGen model does not introduce a new product or service. It builds on existing structures, and, because people already are going to pharmacies, it builds on existing health-seeking behaviors.

          • Earned incomes as a percentage of operating costs: N/A

          • Other funding sources: The RxGen model can be profitable for participating pharmacies if they expand and retain their customer base. Anecdotal evidence indicates that participating pharmacies strengthened their client relations because they were providing quality services and attracted more youth as clients. However, the impact needs to be measured.

          • Strategy for long-term sustainability: The RxGen approach seeks to ensure sustainability of pharmacy reproductive health services by incorporating the training curriculum into pharmacy association continuing education programs and university pharmacy schools. Likewise, monitoring and supervision can be incorporated into each country’s existing structures—usually the professional pharmacist association or a government agency.

11) Current and Future Impact

          • Total number of clients: During the 18 months of service included in the evaluation: • Participating pharmacies provided reproductive health services to approximately 100,000 youth. • Pharmacists sold nearly 60,000 doses of emergency contraception. • Nearly 260,000 brochures about emergency contraception and sexually transmitted infections were distributed to youth.

          • Clients in the past year: 100,000

          • Percentage of low-income clients: 50%

          • Impact: The primary clients of the RxGen project are youth, who are generally underserved by the formal health system and stigmatized for sexual activity. They are often still living at home and may not have access to regular income. Even if they are working, 50 percent of the general population in Kenya and in Nicaragua still fall below the poverty line. In all four countries where RxGen was implemented, the GDP per capita is below US$3,000.

          • Overall "market": The need for accessible and high-quality primary health care is as ubiquitous as it is acute, as global demographic and disease trends stress public health budgets and delivery systems to the breaking point. The burgeoning number of youth around the world reaching reproductive age in need of contraceptives, the HIV/AIDS pandemic and attendant increases in tuberculosis, and increases in other STIs have a tremendous impact on the health of the world’s population and represent significant burdens to developing-country public health systems. International organizations such as the Joint United Nations Programme on HIV/AIDS and the World Health Organization have identified the lack of adequately trained health personnel as the biggest barrier to TB and HIV/AIDS screening and treatment services. They call for multisector strategies to supplement public-sector resources. PATH believes that licensed and regulated commercial pharmacies provide a platform for extending health services in a number of areas. Through RxGen, we have demonstrated the viability of this approach for contraception as well as for STI information and referral. The approach potentially could be expanded to other areas, such as TB diagnosis and treatment, HIV prevention and referral, and STI prevention (and possibly, diagnosis and treatment).

12) Scaling up strategy

          • Stage of the initiative: Mature stage.

          • Expansion plan: Cambodia, Kenya, Nicaragua, and Vietnam continue to implement the RxGen model. The RxGen curriculum has been incorporated into the curriculum of pharmacy schools in Cambodia (the Faculty of Pharmacy at the University of Health Science), Nicaragua (National Autonomous University of Nicaragua in León), and Vietnam (the Thanh Hoa Medical College). It is also in use in continuing education programs for pharmacists in Cambodia and Kenya. To help other groups replicate and adapt the RxGen model in other areas, PATH has developed a roadmap: the Youth-Friendly Pharmacy Program Implementation Kit (available on PATH’s website at http://www.path.org/publications/pub.php?id=860). Available in both English and Spanish, the kit contains a description of start-up strategies and activities, five teaching modules, handouts and job aids, prototype materials, and evaluation instruments. We also are exploring the expansion of primary-care services offered at community pharmacies. For example, could pharmacy staff use simple, rapid diagnostics to test clients for tuberculosis?

13) Policy change: Two policy changes would greatly enhance RxGen efforts. First, continuing education for pharmacy staff and pharmacists should be routine in each country. Second, pharmacy regulations could allow for a second tier of accreditation or an expansion of pharmacies’ scope of practice that would allow them to meet other primary-care needs. For example, licensed pharmacists and accredited pharmacy staff could offer diagnosis (syndromic or rapid test, and sample collection for laboratory analysis); disease surveillance; referral; and treatment (adherence to ART, DOTS).

14) Origin of the initiative: PATH had worked with pharmacists in the US as well as in the Philippines, Thailand, and Cambodia to expand access to STI diagnosis and treatment and to emergency contraception. We knew that pharmacies had the potential to meet the needs of youth; the RxGen project began as a pilot project to test this premise. Our efforts coincided with an emerging trend in the developing world of increased governmental interest in pharmacy regulation and capacity building. As part of this trend, pharmaceutical associations, often in collaboration with the government, were taking on more responsibility for pharmacy oversight and quality assurance. To build on these changes, the RxGen project worked with licensed pharmacies and professional pharmacy associations in each of the four countries to emphasize the needs of youth, develop the capacity of pharmacies to provide critical services to this group, and link pharmacies and their clients to the formal healthcare system.

Contact Information:
Esther  Butler
Communications Assistant
PATH: A catalyst for global health
(NGO)
1455 NW Leary Way, Seattle, WA 98107 USA
United States
Tel: 206.285.3500
Fax: 206.285.6619
Email: ebutler@path.org
Website: http://www.path.org/