# Logics of acquiring medicines from informal retailers in four African countries

## TL;DR

This study explores why people in four African countries buy medicines from informal sellers, finding that it's often due to poor access and affordability in formal healthcare systems.

## Contribution

The study reveals the complex and segmented nature of informal medicine markets and identifies multiple, context-dependent reasons for their use.

## Key findings

- The informal medicine market is composed of four distinct groups of sellers, including market stall vendors and roadside sellers.
- Patronage of informal sellers is driven by factors like payment flexibility, convenience, and cultural norms.
- Most informal medicine use stems from challenges in accessing quality-assured medicines through formal healthcare systems.

## Abstract

In sub-Saharan Africa and other low-income contexts, informal medicine markets are widespread. Understanding the drivers of consumer demand is important, especially given the concerns and risks associated with medicines in the informal sector.

This study aims to 1) describe the informal medicine sector in four anglophone African countries, and 2) understand why people patronize informal medicine sellers.

Participant observation was conducted in eight markets (37 market stalls) across Ghana, Nigeria, Sierra Leone, and Uganda, supplemented by data collected during focus group discussions (with n = 611 participants) and key informant interviews (with n = 111), in which we discussed where participants got medicines in their communities and underlying reasons.

We identified four distinct groups of actors in the informal medicine sector: sellers at weekly markets, itinerant peddlers, roadside sellers, and operators of general provision shops. There were multiple rationales for patronage of informal sellers that varied depending on the context, including flexibility in payment options, convenience and accessibility, and social/cultural drivers. Importantly, there were tradeoffs and tensions between these drivers that participants had to negotiate within the contexts of their current circumstances.

These findings suggest that the informal medicine market is segmented and complex, and that patronage is driven by multiple logics that are rooted in gaps in formal healthcare provision. Regulatory measures therefore need to go hand-in-hand with efforts to address these gaps and expand effective access to quality-assured medicines through [inter alia] offering more flexible modes of payment, reducing public-sector medicine stock-outs, and improving patient-physician trust and communication.

Main findings: The informal medicine market in anglophone African countries (Ghana, Nigeria, Sierra Leone, and Uganda) is complex, and patrons have multiple (and often competing) reasons for purchasing medicines from these outlets.Added knowledge: Most reasons for patronage stem from difficulties faced with securing quality-assured medicines from ‘official’ sources (e.g. unaffordability and inaccessibility), particularly for the poorest and most rural segments of the population.Global health impact for policy and action: Addressing limitations to medicine access within the formal sector using an equity-informed approach will reduce the demand for medicines in the informal sector.

Main findings: The informal medicine market in anglophone African countries (Ghana, Nigeria, Sierra Leone, and Uganda) is complex, and patrons have multiple (and often competing) reasons for purchasing medicines from these outlets.

Added knowledge: Most reasons for patronage stem from difficulties faced with securing quality-assured medicines from ‘official’ sources (e.g. unaffordability and inaccessibility), particularly for the poorest and most rural segments of the population.

Global health impact for policy and action: Addressing limitations to medicine access within the formal sector using an equity-informed approach will reduce the demand for medicines in the informal sector.