Chowdhury, H.R.

Goergen, R.

Mwengee, W.

English

Digital Library of the Tanzania Health Community

STD case management in private 
pharmacies assessed by simulated 
patients with urethral discharge in
Tanga Municipality
H.R.Chowdhury, R.Goergen, W.Mwengee
May/June 1999
Picture taken from the poster “Je, apambana na magonjwa ya zinaa”, PSI et al A study based on simulated client interviews aimed assessing the medical practice and 
drug prescribing behavior of pharmacists. 
 
Four male students aged 20-25 were trained to visit private pharmacies as simulated 
clients with symptoms of urethral discharge. In 96% of the visits the pharmacists offered 
treatment. Only 4% were advised to consult a doctor. In 85% of the visits, the 
pharmacists inquired about the patient’s history other than the stated complaints 
(discharge and burning micturation only). Eleven percent of the clients were asked to 
expose their genitals and in one case the pharmacist examined the penis before offering 
treatment. Pharmacist provided at least one advice in 75% of the visits. 
 
In 96% of the visits the pharmacists offered treatment. Only 4% were advised to consult a 
doctor. In 85% of the visits, the pharmacists inquired about the patient’s history other 
than the stated complaints (discharge and burning micturation only). Eleven percent of 
the clients were asked to expose their genitals and in one case the pharmacist examined 
the penis before offering treatment. Pharmacist provided at least one advice in 75% of the 
visits (see table 1). Advises given were “your illness is sexually transmitted, your illness 
increases the risk of HIV infections, your partner must be treated, you should use a 
condom during sexual. 
 
It is recommended to offer a training program for private drug sellers to increase their 
knowledge on appropriate choice and dosage for STD treatment and on the importance of 
partner treatment and condom use. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
A study was done to assess the quality of STD case management in Tanga Municipality 
(May/June 1999). The study consisted of interviews and observations in private and 
public health facilities (described elsewhere
1) and of simulated client interviews in 
private pharmacies 
 
In this article the research findings in private pharmacies are presented: 
The objective of the study was  
To assess the medical practice and drug prescribing behavior of pharmacists. 
 
Setting and Study population 
Tanga municipality is the headquarters of Tanga Region and second largest port in 
Tanzania. The town is well linked with other regions and the neighbouring country, 
Kenya. The total population is 241,487 with an average size of 4.6 people per household. 
The population growth rate is around 2.6%. Public and private facilities serve the 
population of Tanga municipality. The types of facilities include hospital, health centers, 
dispensaries and pharmacies. 
There are two types of pharmacies selling drugs to patients. The Type 1 pharmacies (6 in 
number) are officially allowed to sell antibiotics but require a medical practitioner's 
prescription and the supervision of a graduate pharmacist. The Type 2 pharmacies - 
known as DUKA LA DAWA - are allowed to sell harmless “Part 2” drugs (non-
prescription drug) e.g. aspirin, paracetamol, anti-allergic, anti-helmintics etc. 
All Part 1 drug-selling pharmacies (six) were included with two simulated client visits 
and most part 2 drug-selling pharmacies "DUKA LA DAWA" (43) with a single visit. A 
total of 55 visits were made. 
 
                                                 
1 Hafiz Rahman Chowdhury : An assessment of the quality of STD case management in Tanga 
Municipality 1999, Tanzania, Msc Thesis, University of Heidelberg in Germany Methodology 
Four male students aged 20-25 were trained to visit private pharmacies as simulated 
clients with symptoms of urethral discharge. They entered the pharmacy, exchanged 
greetings and informed the pharmacist that, they were not well. In reply to the pharmacist 
question asking them what the problem was, they said that they had observed burning 
sensation and white fluid like pus from the penis after micturation. Depending on the 
questions asked by the pharmacist, they answered according to the role play script (see 
Box ).  
 
“The simulated client is an unmarried man who had sex with a ‘friend’2 weeks ago 
without condom. About 3 days back he noticed burning sensation during micturation and 
some white discharge from the penis. There are no sores, pain or itching in the area of 
genitalia. He has taken no drugs and had never suffered from this illness before. So far he 
had not heard of any problem from his girl friend” 
 
The simulated clients were instructed to purchase 50% of all drugs recommended by the 
pharmacist/drug seller. If any injection was recommended, the client was instructed to 
inform the pharmacist that he did not have enough money and to leave promptly.  
 
The simulated patients completed a semi-structured questionnaire immediately following 
the consultation. They were also instructed to judge whether the pharmacist appeared to 
suspect the authenticity of the interaction. 
 
Results 
In 96% of the visits the pharmacists offered treatment. Only 4% were advised to 
consult a doctor. In 85% of the visits, the pharmacists inquired about the patient’s 
history other than the stated complaints (discharge and burning micturation only). 
Eleven percent of the clients were asked to expose their genitals and in one case 
the pharmacist examined the penis before offering treatment. Pharmacist 
provided at least one advice in 75% of the visits (see table 1). Advises given 
were “your illness is sexually transmitted, your illness increases the risk of HIV infections, your partner must be treated, you should use a condom during sexual 
contacts’’. In 63% condom use was recommended. 
 
Table 1:  Management of urethral discharge by pharmacist (n=55 visits). 
Indicators Number  (%) 
Number of visits offered treatment   53 (96) 
Number of visit advised to consult doctor  2 (4) 
Number of visits enquired about more history   47 (85) 
Number of visits exposed genitalia for examination  6 (11) 
Number of visits provided at least one structured advice  41 (75) 
 
In 11% of the visits pharmacists offered right drug combinations with doses 
recommended for syndrome management whereas in 89% of the visits, either wrong drug 
combination or wrong doses were offered. Although the pharmacists offered antibiotics 
in all but one visit, these antibiotics were non-recommended antibiotics in 62% visits (not 
even a single recommended drug). In 9% of the visits, clients were given at least one 
recommended antibiotic combined with other drugs. The most frequently offered 
antibiotic drugs either single or in combination were co-trimoxazole(8/53), ampicillin 
(8/53) amoxycillin (8/53), rifampicin (7/53) and doxycline (5/53) and other harmful drugs 
like chloramphenicol. Injection crystalline penicillin was offered either single or in 
combination on three occasions (for details see Table in the Annex ).  
Table 2: Medication offered for urethral discharge syndrome by pharmacist (n=53) 
 Indicators  Number  (%) 
Number of visits offered recommended drugs and doses for syndromic 
management  
6 (11) 
Number of visits offered wrong or incorrect combination of drugs  47 (89) 
Number of visits offered at least one recommended and other antibiotics  5 (9) 
Number of visits offered non recommended antibiotic drugs only  33 (62) 
   
STD guidelines recommend Tab.Co-trimoxazole 5 Tablets twice daily 2-3days or Tab Ciprofloxacin 500mg single dose 
and doxycycline 100mg twice daily for 7 days for syndromic management. 
 
Discussion and recommendation  
This study showed that all drug shops kept antibiotics and were providing STD 
treatment, 96% without a prescription. The correct treatment according to the 
guidelines for the syndromic approach was low (11%). Our study results support 
similar findings on treatment in pharmacies documented in other developing 
countries (Tuladhar et al., 1998; Garcia et al., 1998). 
Antibiotic sensitivity pattern from Mwanza region of Tanzania indicates that Gonococci 
are resistant to low doses of penicillin (50%), tetracycline (96%) and co-trimoxazole 
(Mayaud et al.,1998). We conclude that STD patients in private pharmacies often get 
inappropriate treatment. 
 
This inappropriate and irrational drug use has at least two major consequences:  
   Part of the patients are likely to remain infected and may have to invest additional 
time and resources for treatment elsewhere and  
   This kind of treatment promotes the development of antibiotic resistance, a major 
concern for treatment of infectious diseases (Hook et al., 1989; Dallabetta et al., 
1996; Buve et al., 1993). 
 Condom use is critical in preventing transmission of HIV and STD. Advice on 
condom use was given in 63% cases only. Improvement in this area of 
counseling could contribute to the success of HIV/STD prevention programme.  
We recommend a training program for private drug sellers to increase there knowledge 
on appropriate choice and dosage for STD treatment and on the importance of partner 
treatment and condom use.  
 
Bibliography 
 
Buve A, Laga M and Piot P. Where are you now? Sexually transmitted diseases. Health Policy 
Planning  8, 277-81 (1993). 
Dallabetta G A, Gerbase A and Holnes K. Problems, solutions, and challenges in syndromic 
management of sexually transmitted diseases. Sex Transm Inf. 74, S1-S11 (1998). 
 
Garcia P J, Gotuzzo E, Hughes J P et al., Syndromic management of STDs in pharmacies: 
evaluation and randomised intervention trial. Sex Transm Infect 74, S153-8 (1998). 
 
Hook E W et al. Determinants of emergence of antibiotic resistance to Neisseria gonorrhoea. J 
infect Dis 159, 900-7 (1989). 
 
Mayaud P, Grosskurth H, Changalucha J et al. Risk assessment and other screening options for 
gonorrhoea and chlamydial infections in women attending rural   Tanzanian antenatal clinics. Bull 
WHO 73, 621-30 (1995). 
 
Tuladhar S M, Mills S, Acharya S et al. The role of pharmacists in HIV/STD prevention: 
evaluation of an STD syndromic management intervention in Nepal. AIDS 12, S81-87 (1998). 
 Annex 
 
List of drugs prescribed by pharmacist: 
(n=53) 
Name of drug 
combinations 
N (%) 
Amoxycillin only  6 (11) 
Amoxycillin+In X-penicillin  1 (2) 
Amoxycillin+Nitrofurantoin 1  (2) 
Ampicillin only  7 (13) 
Ampicillin+Inj X- Pen  1 (2) 
Ampiclox only  5 (9) 
Ampiclox+Co-trimoxazole 2  (4) 
Chloramphenicol 1  (2) 
Chloramphenicol+Metronidazole 1  (2) 
Ciprofloxacin only  2 (4) 
Ciprofloxacin+Doxycycline 2  (4) 
Co-trimoxazole only  3 (6) 
Co-trimoxazole+Ampicillin 1  (2) 
Co-trimoxazole+Doxycycline 4  (8) 
Doxycycline+Metronidazole 1  (2) 
Erythromycin+Nitrofurantoin 1  (2) 
Inj Crystapen  1 (2) 
Metronidazole 2  (4) 
Rifampicin 6  (11) 
Rifampicin+Nitrofurantoin 1  (2) 
Tetracycline 4  (8) 
Tetracycline+Metronidazole 1  (2) 
Tinidazole+Antibiotic 1  (2) 
 

Determinants of emergence of antibiotic resistance to Neisseria gonorrhoea.

Gerbase A and Holnes K. Problems, solutions, and challenges in syndromic management of sexually transmitted diseases.

Risk assessment and other screening options for gonorrhoea and chlamydial infections in women attending rural Tanzanian antenatal clinics.

Syndromic management of STDs in pharmacies: evaluation and randomised intervention trial.

The role of pharmacists in HIV/STD prevention: evaluation of an STD syndromic management intervention in Nepal.

Where are you now? Sexually transmitted diseases. Health Policy Planning 8,

STD Case Management in Private Pharmacies Assessed by Simulated Patients with Urethral Discharge in Tanga Municipality

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STD Case Management in Private Pharmacies Assessed by Simulated Patients with Urethral Discharge in Tanga Municipality

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