KIBERA, Kenya — Ken Cheruiyot, a pharmaceutical technician, runs a small pharmacy wedged on a street corner near a busy bus stop in Kibera, Kenya’s largest slum. He can easily count five other pharmacies that are visible from his door. It is the antibiotics and cold and flu syrups for children that move fast during this cold season, he said.
According to Cheruiyot, most residents of Kibera would rather visit a pharmacy or clinic than a public hospital, where they typically endure long, winding queues and pay a consultation fee, in addition to the fare they would likely be charged to get there.
“Many people come here instead of going to the hospital because it is near, cheaper than the hospital, and they can be attended to faster,” he said.
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A 2014 “Kenya Household Health Expenditure and Utilisation Survey” found that private clinics and pharmacies were the main private providers and that they accounted for 23% of all outpatient visits. Others have produced even higher estimates. MaishaMeds, a company using technology to advance primary health care in Kenya, states on its website that “small clinics, pharmacies, and drug shops in East Africa provide over 60% of primary health care.”
While this kind of health care-seeking behavior often ensures accessibility and affordability for patients, it also comes with a potential cost: quality.
Many of these private pharmacies are unregistered and operated by unqualified staff. Poor regulation of the pharmacy retail space poses a threat to Kenya’s achievement of universal health coverage, and the country is struggling to find a solution that can bridge convenience, affordability, and quality.
“The regulations that have been set for licensing are stringent and just impossible to meet.”— Ken Cheruiyot, pharmaceutical technician
Kenya’s Pharmacy and Poisons Board is charged with regulating the manufacture and trade in drugs, as well as licensing for pharmaceutical technologists, pharmacists, and pharmacies. The board is also tasked with ensuring that pharmacies are adequately staffed by professionals. Each pharmacy’s license must be visibly on display.
Having worked in the slum for nine years, Cheruiyot knows of only one among hundreds of pharmacies in Kibera that has a license. He blames unrealistic requirements.
“The regulations that have been set for licensing are stringent and just impossible to meet,” he said.
These requirements include maintaining an incinerator, refrigerator, drug storage, expired drug storage, running water, and proper sanitation. For Cheruiyot and many other pharmaceutical technicians, finding a facility that meets that standard is expensive, and in Kibera, almost impossible given the slum’s infrastructure.
Many pharmacists have found ways to circumvent the official licensing process, by paying bribes or forging the license.
Nearly anyone can obtain a license code by paying for it from a legally licensed person, said Dr. Ali Maalim, a Kenyan pharmacist.
“That code does not practice pharmacy,” he quipped.
The corruption in the system, which allows unqualified people to enter the market, pushes pharmacists who do have training out.
“The training of pharmacists is so patient-focused and the ethics is so ingrained in them that a lot of them just opt out,” said Dr. Daniella Munene, CEO at the Pharmaceutical Society of Kenya.
“At best, you have technicians who have some level of training, and at worst you have quacks who superimpose their names on a license of a licensed person,” she said.
Munene described an explosion of community pharmacy retail outlets — roughly 20,000 — across Kenya, compared to only 5,000 registered and practising pharmaceutical technicians.
“There is a mushrooming of [pharmacy] shops after every meter. There is competition, they are undercutting each other, and the patient will buy from the cheapest,” she said.
That undercutting “brings down the market to the level where to succeed you may have to break some of your professional rules like giving out antibiotics without prescriptions,” she added.
Maalim knows this from personal experience.
A few years ago, he visited a pharmacy in Eastleigh, a Somali neighborhood a few kilometers east of Nairobi, where he hoped to buy medication. Being a trained pharmacist, he knew what he wanted. As the drug store did not have the particular medicine he was looking for, the attendant offered him an alternative medication which, according to Maalim, wasn’t the right one.
“This is the main problem facing the Kenyan pharmaceutical industry, and would be the Waterloo of the quest for universal health coverage,” he said.
More on UHC:
Universal health coverage is one part of the Kenyan government’s four-part, five-year development plan, known as the “Big Four Agenda.” Along with growing the manufacturing sector to 15% of gross domestic product, constructing 500,000 affordable new houses, and achieving 100% food and nutrition security, President Uhuru Kenyatta’s administration has targeted 100% universal health coverage.
That means people should be able to obtain the health services they need without facing hardship in paying for them. The Ministry of Health has acknowledged that quality control, adequate staffing, prioritizing primary health care services alongside high-cost interventions, and improving access will all be critical to achieving this goal.
When it comes to regulating the pharmacies, the government sometimes takes a heavy-handed — albeit uneven — approach.
Recognizing that the marketplace has become crowded and unmanageable, the Pharmacy and Poisons Board ordered that pharmacies need to be at least 50 meters away from each other. The governor of Machakos County, south of Nairobi, ordered that all pharmacies within 300 meters of a public health facility be shut down.
But these actions often lack follow-through, according to some experts.
Stellar Murumba, a journalist who reported on counterfeit and substandard drugs in Kenya and went on to found ChockersKe, an initiative that fights substandard drugs, decried the Pharmacy and Poisons Board’s inability to deal conclusively with the issue of unregistered pharmacies.
“They announce that they have shut down a hundred pharmacies, only for another 200 to come up,” she said.
Barely a month after Devex spoke to Murumba, on May 31, the board announced it had closed down 51 pharmacies in the South Rift region after a two-month-long crackdown.
During these periodic checks on unlicensed pharmacies, people like Cheruiyot, the unlicensed pharmacist in Kibera, are often arrested and taken to court.
“When they come here, they arrest pharmtechs or their assistants, anybody they find in the shop, and confiscate the drugs,” he said.
The arrested pharmaceutical technicians end up paying bribes to be released, or heavy fines if taken to court. This sends the message that people with no pharmaceutical training can buy their way out of an arrest and continue running the unregistered pharmacy.
“The law is not punitive enough, so you find that the accused is going to pay the fine, and they will [reopen] their shop the next Monday,” said Dr. Munene.
The problem with the pharmacy retail sector in Kenya is that there is no public awareness of what the role of the professional pharmacist is, Munene said. The combination of customers price hopping as they look for the least expensive option, poor legislation, and a regulator lacking checks and balances creates a chaotic marketplace, better suited for fruit than health commodities.
“It has become like a market for lemons,” Munene said.
Editor’s note: This article was developed with the support of the Money Trail Project from Journalismfund.eu.
For a closer look at the innovative solutions designed to push for progress on universal health coverage around the globe, visit the Healthy Access series here.