PharmaceuticalRetailinNigeria:MarketDynamics,BusinessPractices,ChallengesandOpportunitiesinPPMVPractice

Abstract

InmanyruralandurbanareasinSub-SaharanAfricasuchasNigeria,medicationsandhealthcareservicesareoftenprovidedbyPatentandProprietaryMedicineVendors(PPMVs).Theseareentrepreneurswithretailshopsthatselldrugsandpotentiallyotherhouseholdproductsandarepatronizedbyallsegmentsofthecommunity.PPMVsareeffective inprovidingmedications, irrespectiveofquality, to far reachingareas across thecountry.Theyare,importantly,alsothefirstportofcallformostNigeriansespeciallythepoorwithregardstohealthcare,andtheirexistencecreatesaplatformthatcouldbeusedtoexpandhealthcareservicestothepoor.ThisstudywasinitiatedtobetterunderstandthebusinesspracticesofPPMVsinNigeria,asmostpreviousresearchhavefocusedonthemedicalperspectivesoftheirpractice.Thestudywascarriedout intwolargecommercialareasinNigeria-LagosandKanoStates;whichisanindicationofthesignificantamountoffundsspentonthesebusinesses.TheLagosPPMVmarketisestimatedtobeabout$71million,whichisabout30%oftheapprovedLagosStateHealthBudget;whilethatofKanoisabout$47millionandsignificantlylargerthantheKanoStateHealthBudgetofabout$29million.Atotalof73PPMVswereinterviewed-25inKanoand48inLagos.Thestudyrevealedthatinadditiontopatentdrugs,mostPPMVs provide other services such as health education and sale of non-pharmaceutical products.Inadequateelectricityandlimitedaccesstofinancewereindicatedassignificantbusinessconstraints.However,opportunitiesforgrowthandserviceimprovementexistsuchasimprovedcreditavailability,business training for PPMVs as well as brand development & improvement through commercialpartnership.Itisimportanttonotethatthisstudyisbynomeansastatisticallyrepresentativesample,butadescriptivestudytobegintounderstandthebusinessapproachesofPPMVsinNigeriaandpossiblyformthebasisofalargerstudyinfuture.ThisprojectwasfundedbytheBillandMelindaGatesFoundation.Keywords:pharmaceutical,retail,business,patentmedicinevendor,Nigeria

1. IntroductionNigeriaisthemostpopulouscountryinAfrica,andaccountsfor47%ofWestAfrica’spopulation.In2013,herestimatedpopulationwas173.6million(WorldBank,2014). Withanannualgrowthrateofabout2.4%,thenation isestimatedtobeoneof thefastestgrowingcountries in theworld (CIA,2016).Thecountry’sincreasingpopulationisaccompaniedbyahighburdenofcommunicablediseaseandagrowing

increase in prevalence of chronic conditions; Non-Communicable Diseases (NCDs) are estimated toaccountfor24%oftotaldeaths(WHO,2016).Thereisthus,ahighdemandformanagementofdiseaseconditionsincludingtheneedformedications&healthcommodities.Nigeriaaccountsfor60%ofhealthproductsconsumedintheECOWAS(EconomicCommunityofWestAfricanStates)subregionbyvolume(UNIDO,2008).In2011,thepharmaceuticalmarketinNigeriawasestimated to be approximately 1.8 billion USD, with 13% annual growth rate (PMGMAN, 2016). Theindustryislargecomprisingdifferentstakeholderssuchasmanufacturers,importers,nationalregulators,wholesalers, retailers and others. The retail sector is extremely fragmented and dominated by smallbusinessesandinformaloperators.AccordingtothePharmacistsCouncilofNigeria(PCN)in2010,therewere724drugdistributors,1,534retailpharmaciesandover200,000patentmedicinevendors(UNIDO,2008).

Patentmedicine refers todrugs that are sold inpre-packaged form to the general public. Patent andProprietaryMedicine Vendors (PPMVs) inNigeria are informal community-based drug shops that areprimarilyresponsible fortheretailofspecifiedover-the-counter (OTC)medications.Theyareprivatelyowned outlets, heavily concentrated in urban slums and rural communities and sell non-prescriptiondrugsconsideredsafeforpublicuse(CorroonM.etal,2016).Trainedmanpower shortageshave limited thenumberofpharmacies in sub-SaharanAfrica, includingNigeria,consequently,licenseddrugshopsi.e.PPMVsarepermittedtoofferalimitedrangeofmedicinestoincreaseaccessandcoverage(CorroonM.etal,2016).Theywereintendedtoactasfor-profitmedicineoutlets, not health providers, originally expected to provide basic medication in areas where nopharmacists exist and refer individualswho require complexmedications topharmacies (UCSFGlobalHealthGroup,2014).However,PPMVsareoftenthefirstlineofhealthcareprovidersformanyNigerians,particularlythepoorwhooftenpatronizethemfortreatmentandusuallypayout-of-pocket (AnadachGroup,2014).AccordingtotheNationalBureauofStatistics(NBS,2013),over200,000PPMVsserveasthefirst port of call for about 39% of the population for health services and accounts for 68% of allpharmaceutical providers. The continued lack of well managed health care facilities responsive toconsumer needs, has led to the proliferation of PPMVswho provide healthcare andmedication to asignificantshareoftheindividualsatthebottomofthepyramid.

1.1 RationaleandLiteratureReview

TheobjectiveofthisstudywastounderstandthebusinessmodelofPPMVsinNigeria.Intheirquesttoimprove access to quality medications for the poor, the Bill and Melinda Gates Foundation (BMGF)supportedanin-depthreviewofthePPMVbusinessperspectivesinselectedNigerianStates.

InformationonPPMVsislargelylimited,withpreviousresearchfocusedonmedicalperspectivesandtheirrole inhealthcareprovisionparticularlyservicesforadultmalaria(BMGF,2016).Otherstudiesprovidedata on a wide range of PPMV outcomes such as health knowledge, health practices, training, drugstockinganddispensingaswellasclient interactionandreferral (BeyelerN.etal,2016).EarlierPPMV

workfundedbyBMGFhasalsolookedatcaregiverhealth-seekingbehavior,currenttreatmentpracticesandqualityof care forprioritydiseaseareas.However, further research is required todetermine thebusiness and financial incentives underwhich PPMVs operate, aswell as to understand the range ofproductsandservicesprovidedbyPPMVs,includingstockingbehavior,salesvolumesandprofitmarginsacrossdiseaseareas(BeyelerN.etal,2016).

2. MarketResearchThestudywasconductedinthetwomajorpharmaceuticalhubsandmostpopulouscitiesinNigeria-Kanoand Lagos (figure 1). The study provides an overview of themarket size, competitive landscape andconsumer & supplier dynamics. Diverse stakeholders- selected consumers, PPMVs, wholesalers, &regulators,inruralandurbanKano&Lagoswereengaged.Atotalof73PPMVswereinterviewed-25inKanoand48inLagos.Datawascollectedviain-depthstructuredinterviewsandfocusgroupdiscussions.

2.1OverviewoftheMarket

KanostateislocatedintheNorthWestofNigeriawithpopulationofabout10millionwithagrowthrateof3.3% (FHI360,2013). 38of its44 LGAs (LocalGovernmentAreas) are rural. It hasadensityof0.2pharmacistsper10,000people.AccordingtoPCN,thereareanestimated3,000-5,000PPMVinthestate.36 of the 38 rural LGAs in Kano have no private pharmacies. A state sponsored, youth educationalempowerment programme (Lafia Jari) has trained approximately 2,700 PPMVs. The minimumrequirementistheprimaryschoolcertificate.Thereisnoaccreditedpharmacyschooland1accreditedSchoolforHealthTechnology(UNIDO,2008)(IMSHealth,2012).

Figure1:StudyLocations:LagosandKanoStates

Source:www.mapofworld.com

LagosstateislocatedintheSouthWestofNigeriawithanestimatedpopulationofover21millionpeoplewith8%growthrate.Fourofits20LGAsarerural.Thereareestimatedtobeabout1-1.5pharmacistsper10,000people,and424of1500+privatepharmaciesareregisteredinLagos.AccordingtotheMinistryofHealth(MOH),thereare2700registeredPPMVsinLagoswithanother250awaitingregistrationandatleastabout2,500unregisteredPPMVs.TheminimumrequirementforPPMVsinLagosissecondaryschoolleavingcertificate,anditisestimatedabout20%haveahealthbackground.(UNIDO,2008)(IMSHealth,2012).

Onaverage,thePPMVmarketinLagosearnedmorethanthatinKano(figure2).

Figure2:AverageSalesRevenue(PerDay):Lagosvs.Kano

Source:AnadachSurveyAnalysis2.2Marketdynamics–CustomerdynamicsThe customerbase in both cities comprisedmainly of low-earningworkers,mostly traders. ThemostcommonlypurchasedmedicationswereidentifiedasparacetamolandvitaminC.Otherdrugspurchasedwere cough syrup, anti-malarial, diarrhea and ulcer treatment (figure 3). However, family planningproductswere rarely bought from PPMVs. Aside frommedications, commonly purchased items fromPPMVincludetoiletries,biscuits,beveragesandcosmetics.Over60%ofPPMVshavenon-pharmaceuticalproductsintheirbusinesses(AnadachGroup,2014).

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Figure3:CustomerDynamics:PopularMedicationsfromPPMVPerspective

Source:AnadachSurveyAnalysis

Lowcost,easyaccessibilityandcustomer-centric service (i.e. retailerprovides justwhat thecustomerwants)werethemajorreasonswhypeoplepatronizedPPMVoverpublic/privatehealthfacilities.Otherreasonsincludeavailabilityofdrugsandcloseproximityofshops.70%ofrespondentsidentifiedPPMVsastheirpreferredplaceofdrugpurchase(AnadachGroup,2014).2.2.1MarketDynamics-Supplierdynamics:PPMVroleindrugsupplychainDrug distribution in Nigeria involves several different groups and stakeholders. In the private sector,manufacturersandimportershavetheirowndistributionchannelsandcanselltowholesalers,retailersand hospitals. The bulk of drugs sold in retail pharmacies and PPMVs are purchased from localmanufacturers,importersandwholesalers,withthedistributionchannelssimilartothatoffastmovingconsumer goodswhich are often times not suited for the storage and distribution of pharmaceuticalsupplies(UCSFGlobalHealthGroup,2014).PPMVsarekeyplayersinthepharmaceuticalchainandareinvolvedinboththeformalandinformalmarkets.Theyreceivesuppliesbothfromformalandinformalsources.Most commonmedications sold bywholesalers to PPMVs include antibiotics, anti-malarials,multivitamins and analgesics (Anadach Group, 2014). Some PPMVs operate as both wholesalers andretailers. Asmost people have to directly bear the cost of medication, Nigerians appear to be pricesensitiveandtendtoseekthecheapestoption,whichunfortunatelymaynotbethebest.ManyPPMVs,locatedbothinurbanandruralareasaremostoftentheonlymedicineproviderinsomeruralareas,andthusserveasaveryimportantintermediarybetweenthewholesalersandthepatient/end

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Analgesic Antimalaria Antihistamine Antibiotic CoughSyrup ColdMeds(Procold)

Multivitamins Mixagrip

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Rural

userintheseplaces.Approximately50%ofthepharmaceuticaloutletsservingtheruralareasareownedbyPPMVs(AnadachGroup,2014).2.3MarketSize:MethodologyThemarket sizewas estimated through several approaches, based on surveys, focus discussions andexpertinterviewoutcomes:

• Customers–basedonestimatedannualnumberofvisitstoPPMVs,andamountspentpervisit• PPMVs–basedonaverageannualrevenueperPPMV,andestimatednumberofPPMVsperstate• Wholesalers–basedonestimatednumberofwholesalersandestimateofwhatproportionof

wholesalebusiness.

Assumptions

• 300workingdaysforPPMVsandPatients• 240workingdaysforWholesalers• 20%ofrespectivewholesalemarketgoestolocalLagosandKanoPPMVs• AveragespentpervisitinLagos-N250,andaveragespentpervisitinKano-N150• 400wholesalersinLagos,and300wholesalersinKano

2.3.1MarketSize:Kano

AroughestimateoftheKanoPPMVsmarketputsitatabout$47million;thisissignificantlylargerthantheKanoStateHealthBudgetofabout$29million.Thestateisestimatedtohave5000PPMVs,withmorethanhalftrainedundertheLafiaJari Program. InKano,thesampledgroupappearedtobequitewelleducatedwhichmayberelatedtotheLafiaJariProgramespeciallyinurbanKano,andmayalsoreflectthosePPMVsmorewillingtoparticipateinthestudy.Withonly8LGAshavingpharmaciesinKano,PPMVsprovide majority of the pharmaceutical services and earn < $30/day. On average, the rural PPMVsappearedtoseeupto60customersaday,comparedtotheurbanPPMVswhosawabout30customersperday.However,giventhelackofpharmaciesoutsideKano,thehighnumberofpatientsseenbyruralPPMVsmayberealistic.Ifoneassumesthereare5000PPMVsinKanoState,whoseeanaverageof30peopleaday, itwould implythat150,000peoplevisitthePPMVdaily.Thiswould implyabout4.5millionvisitsannuallyinKano(about0.5visitperperson).

2.3.2MarketSize:LagosState

TheLagosPPMVmarketisestimatedtobeabout$71million,whichisabout30%oftheapprovedLagosStateHealthBudget. Lagos statehas2,700 registeredPPMVs (probablyanunderestimation)ofwhichabout20%havehealthcarebackgroundandthree-quartersofthemearnover$30/day.Onaverage,LagosPPMVs appeared to see about 30 patients a day with patients spending about N2,000 on average(median).Ifoneassumesthereare5000PPMVsinLagosState,whoseeonaverage30peopleaday,itwouldimplythat150,000peoplevisitPPMVsdaily.Thiswouldimplyabout4.5millionvisitsannuallyinLagos(about0.25visitsperson)whichmayreflectthegreateraccesstopharmacistsespeciallyinurbanLagos.Thiswouldcomparewithahealthfacilityoutpatientvisitof0.6-0.8perperson/yearinLagos(figure4).

Figure4:MarketSize:LagosandKanoStates

Notes:

• PPMVrevenueandnumberofpatientsperdayandaveragerevenueperpatientbasedonsurvey• WholesalerevenuesandPPMVpurchased–basedonsurveysandinterviews• Estimated5,000PPMVseachinLagosandKanoState(estimationbasedonvarioussourcesincluding

Government,NationalPharmaceuticalCouncil,RelevantAssociationsofPPMVs)• ExchangeRateof170Nto1USD• ThemarketsizeofPPMVsappearstobesignificantcomparedtotheStateHealthBudget

Lagos (US$)

Kano (US$)

PPMVs Revenues 66,176,500 44,117,600 Wholesalers Sales to PPMVs 112,941,176 76,235,300 Consumer Purchases from PPMVs 158,823,500 79,411,800 Average Market Size 112,647,100 66,588,200 2015 State Budget 262,470,500 29,117,600 Market Size/Budget 0.4 2.3

2.4KeyRetailCompetitorsThekeyformalretailcompetitorsarethepharmacistsandthephysicians.Thereare1,534registeredretailpharmacystoresinNigeria.Thegrowingmiddleclassandriseoflifestylerelateddiseaseshaveledtothegrowthofindependentpharmacystoresinurbanareas(UNIDO,2008).Pharmacistsplayanactiverolein“protecting” their profession by instituting stringent practice rules, for example, restricting the solepracticeofpharmacytechnicians.Thereisanundersupplyofpharmacistswithlessthan0.5pharmacistsper10,000comparedtoabout4pharmacistsper10,000forotherlower–middleincomecountries.Theshortageisparticularlymarkedintheruralandlessaffluentareas.Pharmacytechniciansmakeuplessthan10%ofthepharmacyworkforceinNigeriacomparedtoabout49%forAfrica(asawhole)(UNIDO,2008).

Physiciansarelicensedtosellmedicationsintheirfacilitieswhichareusuallypricedhigherthaninretailpharmacies. They usually prescribe medications by brand so they drive and influence the brands ofmedicationswithinthemarketUnlikethepharmaciesthatareabletosourcethemedicationsatalowerprice leveraging economies of scale, physicians usually source medications from pharmacists orwholesalers. During frequent doctors strike actions within the public sector however, patients oftenobtainmedicationsfromretailpharmaciesandPPMVs(AnadachGroup,2014).

Otherretailcompetitors include informalsectorplayers- roadsidehawkersanddrugvendors inpublicvehicles.Manyofthemhaveotherjobsoutsideofsellingmedicationrangingfromshoemaking,securityandcommercialmotorcycleservices.Analgesics,anti-malarialandmultivitaminsaresomeofthemostpopulardrugssoldbythisgroupofretailers.Theyarepatronizedmainlybecausetheirdrugsarecheapandreadilyavailable(onlyashortdistanceawayfrommostconsumers)(Anadach,2014).

3. RegulatoryframeworkRegulationsonPPMVsarecomplex.Patentmedicinestorescanbeownedbyindividualswithminimumqualifications-abilitytoreadandwriteEnglish,primaryschoolcertificateandevidenceofgoodcharacter.AllPPMVsshouldberegisteredwithPCN.ThePCN is responsible forPPMVregistrationand licensing,stipulates licensingrequirements,specifieseligibilitycriteriaunderwhichPPMVsoperateandprovidesguidelinesforeligibleoperatorstofollow.UponsubmissionofanapplicationtoPCN,aninspectionoftheenvironment is carried out to ensure that the shop meets PCN’s regulations, specifically regardingventilation,cleanliness,sizeanddistancefromotherPPMVsandpharmacyshops.PPMVsmustrenewtheirlicensesannuallyaswellassubmitacurrentincometaxclearancecertificate(Oyeyemietal,2014).

TheMinistryofHealth(MoH)providesoversightandmonitoringwhichvariesbyStatedependingonlocalrelationships.PPMVsapprovedbyLagosstatereceiveanorientationcourse,regulartextmessagesandannualcontinuingeducationcoursesfromtheministry.

National Agency for Food and Drug Administration and Control (NAFDAC) is responsible for drugadministrationandregulation.NAFDACofficialsaimtoensurethatalldrugssoldareapprovedandmeetNAFDACguidelines-validNAFDACnumber,manufacturingdateandexpirationdate(Oyeyemietal,2014).PPMVsareorganizedinassociationswhichoperateatward,LGA,StateandFederallevel.TheNationalAssociation of Patent and ProprietaryMedicine Dealers (NAPPMED) is the trade union that conductsmonitoringvisits, supportsbestpracticeandactsasan intermediarywithPCN,NAFDACandeventhepolice.TheyensurethatPPMVsarenotsellingexpiredorcounterfeitdrugsordrugsthattheyarenotlegally allowed to sell, suchasantibiotics& injectables, and that theapproveddrugsarepriced fairly(Oyeyemietal,2014).In reality, implementation of regulations on PPMV is variable, with actual oversight and monitoringdiffering from state to state depending on local relationships. In Kano, there are two independentumbrella organizations for PPMVs – NAPPMED and NAPPMV (National Association of Patent andProprietaryMedicineVendors)thatarerecognizedbytheKanoMoH.InLagos,therearetwoindependentumbrellaorganizationsforPPMVs–NAPPMEDandLSMDA(LagosStateMedicineDealersAssociation).ThecurrentlegaltusslebetweenPCNandNAPPMEDvis-à-vistheroleoftheministryofhealth,hasledtoweakoversightandmanyunregisteredPPMVs(AnadachGroup,2014).

4. Operatingmodel

PPMVs are usually owned by a single individual and operated in a rented facility. Many have shopassistants whom are usually recruited from family members (for urban PPMVs) or from the localcommunity(forruralPPMVs).AirconditionedstorageislargelylackinginmostPPMVstoresexceptiftheysellothernon-pharmaceuticalproducts,forinstancefood.Intermsoftechnology,useofcomputerizedinventoryisrareamongPPMVs;however,mobilebankingisquitecommonespeciallyinruralareas.Intermsofpatientreferrals,mostPPMVindicatedtheyreferredtheirpatientstoPrimaryHealthCentres(PHC).Conversely,PHCreferpatientstoPPMVstoobtainmedicationsespeciallyinruralareasduetolackofprivatepharmacies.AlthoughPPMVsarelicensedtosellbasicOTCmedicationsuchasanti-malarials,theyareincreasinglysellinganddispensingprescriptionmedication(UCSFGlobalHealthGroup,2014).InKano,rent isthetopexpenseforPPMV,followedbygeneratorfuelandsupplies.23%oftheurbanPPMVsindicatedtheyspentN1,000perdaycomparedto25%oftheruralPPMVwhospentN200perday(limitedresponses).MostPPMVsdonothaveoff-siteorairconditionedstorage,exceptiftheysellotherproducts. 25% of urban PPMVs had branches. Rural PPMVs tended to see more customers (75%interviewed saw more than 60 per day) compared to most urban PPMVs who saw under 30. Mostprofitableproductsweremultivitaminsinruralareasandanti-malarialsinurbanareas.InKano,70%ofthePPMVshadformalhealthtrainingaspharmacytechnicians,CommunityHealthExtensionWorkers(CHEW)orgraduatesofSchoolofHygiene.13%oftheruralPPMVsunderwentapprenticeshiptrainingwhilethemajority(88%)reportedcareerambitionastheirreasonandmodeofentryintothebusiness.

LikeKano,mostpatentmedicineshopsaresolelyownedbutLagosPPMVsaremorelikelytoowntheirpremises.LagosPPMVshavemoreassistantsintheshop,withanaverageofapproximately2assistants.MostPPMVsinLagosenteredthislineofworkthroughapprenticeship(85%).AveragedailyexpenseinurbanareasisaboutN2,100comparedtoN1,700inruralareasinLagos.Mainexpensesarerent,fuelandsalaries.LikeKano,ruralPPMVinLagosappeartobemoremotivatedbyprofitcomparedtourbanPPMVs.Thisisprobablyduetohigherprofitorientation&ownership.RuralPPMVsaremorelikelytohavetargetssuchassellingasetnumberofmedicinesperweek.TheurbanPPMVsthatgivetargetsandincentivestoencouragesalesonlydosowhentherearedrugsclosetotheirexpirationdates.MostruralPPMVsrewardtheiremployeeswhentargetsaremet.PPMVsinLagosappeartobemoremotivatedbyprofitcomparedtoKanoPPMVs(figure5).Inaddition,LagosPPMVsaremorelikelytoofferotherservicesthanKanoPPMVs.Perhapsbecauseofprofitorientation,LagosPPMVsaremorelikelytoinvestintheirshopcomparedtothePPMVsinKano(figure6).66%ofLagosPPMVsinvestedinexpansionorrenovationcomparedto0%inKano.

5. Revenue

50%oftheKanoPPMVsselllessthanN5000($30/day)comparedtolessthan30%ofthepatentmedicineshopsinLagos.InKano,therevenueoftheruralPPMVstendedtobehigherbuttheyalsoprobablyseemorepatientswithnolocalpharmaciesavailable.TheruralPPMVsalsotendtohavehigherprofitmarginsinKano.PPMVsinLagosearnedmorethaninKanoespeciallyinurbanareas,withbothurbanandruralPPMVshavingsimilarnumbersorfewerpatients.ThereappearedtobemorevariabilityinLagospricemarginsperhapsreflectingwiderproductranges(figure7).

Figure5:BusinessMotivation:LagosPPMVsmoreprofitorientedthanKanoPPMVs

Source:AnadachSurveyAnalysis

Figure6:BusinessInvestment:UrbanvsRural

Source:AnadachSurveyAnalysis

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Figure7:PriceMargininLagos

Source:AnadachSurveyAnalysis

6. ChallengesandPossibleSolutionsLikemanyothersmallbusinessesinNigeria,PPMVsstrugglewiththenumerousproblemsthataboundinthe business environment- lack of credit facilities, poor power supply, government regulations andpolicies,amongstothers.Major challenges for PPMVs in terms of drug supply were listed as inadequate credit facilities fromsuppliers,accurateandtimelysupplyofmedicationsandcustomerneedforcheaperdrugs.Othernotablechallenges includepatientself-medication,competition fromotherPPMVsandsecurity issues.PPMVscited rent as their greatest expenditure, followed by expenses associatedwith inadequate electricitysupplyi.e.generators,fuel,etc.From the PPMV’s perspective, the registration process is challenging for several reasons-financialconstraints,clarityontheprocessetc.ThereislimitedhealtheducationtrainingavailabletoPPMVswhoroutinelyprovidehealthadvicetocustomers.TheapproveddruglistforPPMVsisratherrestrictiveandmaynotbepracticale.g.ACT(Artemisinin–CombinedTherapy)drugsforthetreatmentofmalariaarenotonthedruglist.Also,limitedaccesstoaffordablecapitalandhighinterestratesarealsosignificantbarrierstobusinessinvestmentandexpansion.

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InKano,themajorchallengeswereaccesstocredit,cheaperdrugsforcustomers(urban)andsupplyissues(rural).ThelackofcreditforurbanPPMVsandchallengingsuppliestoruralareasmaybeduetopossibleunderlying security concerns. Despite requesting three business improvement options, the mainsuggestionwasimprovingpowersupplyinbothurbanandruralareasofKano.Improvedelectricity(byover75%)wastopsuggestionfromPPMVstoimprovebusinessoutcomes.There was limited business diversification in Kano. None of the PPMVs interviewed had a wholesaleportion to their business. There was very limited investment over the last few years – only 8% ofinterviewees had invested inmedical equipment and, cosmetics and groceries. The 50% of the ruralPPMVswithairconditionedoffsitestoragefacilitiesalsoindicated25%oftheirbusiness includednon-pharmaceuticals. This is in keeping with the profit-motive of rural PPMVs and the absence of otheremployment.LackofcapitalisthesolereasongivenfortheabsenceofbranchesinKano.InLagos,therewasawiderangeofchallengesincludingreliableelectricity,lowpatronage,lowincomecustomers,finance,andsmallshopsize.LikeKano,inadequateelectricitysupplyinLagosappearstoalsobeamajorissueparticularlyinruralareas.ThetopsuggestionfromLagosPPMVstoimprovebusinessoutcomewascapital/financialsupport(68%).6.1SuggestionstoovercomethechallengesClustersupervisionofPPMVsbylicensedpharmacistswasrecommendedtoexpandthescopeofPPMVservicestomeetacryingneedatthegrassrootsrurallevel.Aroleinthe'SupervisionChain'mayalsobeproposedforthePharmacyTechnician.Withacreativetaskshiftingarrangement,everyone's interests(includingthepharmacist's)couldbemet.AproposedMegaDrugDistributionSystemcouldalsohelpreducesubstandarddrugsincirculationandensurethatdrugssoldbythePPMVarewholesome.OthersuggestionsfromstakeholdersinterviewedincludeimprovecreditavailabilityaswellasbusinessandhealthtrainingforPPMV.

7. DiscussionThereisanincreasingrecognitionoftheimportantroleplayedbyPPMVsinhealthserviceprovisioninNigeria.However,littleisknownoftheirbusinessoperations.Mostofthepreviousresearchhasfocusedontheirroleasmajorcommunityhealthproviders.Thisstudyhighlightsthebusinessmodelsofindividualshopsandestimatesmarketsize.Italsoreviewsthedynamicsandrolesofthecustomerandsuppliers.

Although originally patent drug sellers, PPMVs provide other services including sale of non-pharmaceuticalproducts,essentialproductsandhealtheducationinformation.Theyareusuallylocatedin urban and rural settingswith primary focus on lower incomegroups. Customer attention/focus byPPMVsisrelativelyhighwhichisnecessaryinordertoremaininbusiness.PPMVsareakeypartofthe informalpharmaceuticalmarket inNigeria,whichcomprisesunregistereddistributors,vendorsandsellers.Theinformalmarketisbelievedtobe2-3timesthesizeoftheformalmarket, however, theyare interconnectedwith the informalmarket supplied from leakages from thepublicandprivatesectorsandillegalimports(UNIDO,2008).ThePPMVmodelcanbeviewedasaformofdomesticentrepreneurshipinNigeria,particularlywithinthecontextofMicro,SmallandMediumScaleEnterprises. ManyPPMVsareowner-operatedretailshopsthatselldrugsaswellasmanyotherhouseholdproducts.Liketheclassicentrepreneur,theyorganize,manageandassumetherisksoftheirbusinessventures(MetuA.,NwokoyeE.,2014).Theyhavelittleorno formal training inmedicineorpharmacyas theexisting licensure requirementsdonot includeanyformal training inmedicine or pharmacy (UCSFGlobal HealthGroup, 2014).Many receive on-the-jobtrainingthroughapprenticeshipwithamoreseniorPPMVormedicinevendor/distributor.Theyemploytraitsandqualitiessuchasresourcefulness,initiative,drive,ambitionandcouragewhicharevaluableforentrepreneurshipdevelopment,toidentifybusinessopportunitiesandmakeprofit(MetuA.,NwokoyeE.,2014).Thisformofpharmaceuticalretailhasthusledtoemploymentgenerationforasignificantnumberofpeopleinthecountry,contributingtoeconomicgrowthanddevelopment.AlthoughthisstudywascarriedoutinLagosandKano,twomajorcommercialcentresinthecountry,itwasnotdesignedtobestatisticallyrepresentativeoftheentirecountry.Itishopedthatthisstudywillencouragemorerobustresearchinfuture.

8. Conclusion

ThoughthePPMVmodelwasessentiallysetupforbusinessestowidenaccesstobasicmedication,theyareincreasinglyplayingakeyroleascommunityhealthserviceprovidersinNigeria.Withmeagercapitaland limited formaleducation, thesemedicationtradersare importantstakeholders in thedrugsupplychain and pharmaceutical sector, aswell as significant contributors to national economic growth anddevelopment.Inspiteofthenumerouschallengesandbusinessconstraints,thestandardandqualityofservices providedbyPPMV canbe improved through strategic partnership, business andprofessionaldevelopmentandregulatoryreform.

9. References

-AnadachConsultingGroup(2014).ScopingBusinessPracticesofthePPMVsinLagosandKano,Nigeria:ReviewoftheBusinessModelforPatentProprietyMedicineVendors(PPMVs).-Beyeler N., Liu J., SieverdingM. (2015). A Systematic Review of the Role of Proprietary and PatentMedicine Vendors in Healthcare Provision in Nigeria. PLoS ONE 10(1):e01171165.doi:10.1371/journal.pone.0117165-BMGF(2016).BillandMelindaGatesFoundationPPMVReferenceDocument.PreparedbyMaraHansenStaples.-CIA(2016).TheWorldFactBook.CentralIntelligenceAgency.www.cia.gov/library/Publications

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