This study found that the majority of clients (56.5%) seeking community pharmaceutical service at the two pharmacies self medicate with not only over the counter (OTC) medicines but also other classified pharmacy and prescription drugs. About thirty percent (28.8%) also receives treatment initiated by a pharmaceutical service provider, while only 14.7% pharmaceutical service providerclient interactions involved the processing of prescriptions. These results mirror some other findings. A study done in Malta⁷ found that 31% of respondents who visited a pharmacy did so to purchase prescribed drugs while 23.3% went to a pharmacy to obtain over-the-counter products. However, the Malta study established that significantly more females visited a pharmacy compared to males, as opposed to this study in urban Uganda, which found that slightly more males visited the community pharmacies to either have prescriptions filled or to obtain over the counter products. The number of both males and females seeking pharmacy-initiated treatment from the two community pharmacies was similar as shown in table 1. This disparity in pharmaceutical service seeking patterns clearly demonstrates the need for countryspecific pharmaceutical sector interventions to maintain or improve drug use patterns amongst the public. Thus, as stressed by Okuonzi et al⁹, strengthening of national capacity for policy analysis and research in Uganda is of paramount importance.

Though the antimicrobial use rates (31.6%) found in this study were comparable to those in a peri-urban drug survey of Mexico¹⁰, and may be a true reflection of the infectious and parasitic disease burden, the 22.4% selfmedication rate with these drugs is unacceptably high. Selfmedication could be hazardous if drugs are used for the wrong reasons culminating in unnecessary adverse effects, emergence of drug resistance and wastage of meager resources. On the other hand, other workers have argued that self-medication could be an important component of primary health care¹¹. Whichever way, it is a necessary requirement that self-prescribing individuals use the drugs involved in a rational manner.

The high rates of self-medication found in this and earlier studies and high rates of pharmacy-initiated therapy coupled with very low referral rates (1.4%) partly demonstrate that there could be high public expectations of community pharmacies to offer a comprehensive range of health and pharmaceutical services. There is therefore a great demand placed on community pharmaceutical service providers from clients who cannot clearly discriminate between diagnostic and drug-dispensing services. Pharmaceutical care providers at the two community pharmacies therefore act as prescribers and advisers on use of medicines. This scenario is not surprising as estimates show that 79% of curative care in Uganda is provided by the private sector, compared with 21% by the public sector¹². These observations underscore the significant role played by the private sector in healthcare delivery. Okello et al¹³ also demonstrated that bed occupancy rates were low at peripheral health units in Uganda. This could partly offer an explanation for the high private sector rates of self-medication and pharmacy initiated therapy.

This situation is however further compounded by the fact that diagnostic and drug supply roles are not explicitly streamlined in the private health and pharmaceutical sector of Uganda. The difficulty in rationalising these roles and effectively regulating the private health and pharmaceutical sector have been underscored by Birungi et al¹⁴ who indicate that, activities of informal health care providers otherwise considered unlawful are in fact a necessary service in the eyes of both providers and consumers

Additionally, the relatively high costs of health care and pharmaceutical products might deter some clients from seeking the most appropriate form of health or pharmaceutical service as demonstrated by a 66.2% failure rate to obtain medications because of prohibitive costs, even though 80% of drug used in Uganda¹⁵ are cheaper generic dosage forms.

These findings show the need to explore benefits of pharmaceutical care interventions in community pharmacies of urban Uganda. Greater pharmacists’ involvement in pharmaceutical care, and educational interventions for community pharmacy staffs could possibly improve drug use practices at community pharmacies in urban Uganda since the greatest majority of clients either self-medicate or seek pharmacy-initiated therapy. Elsewhere, Cordina et al¹⁶ have observed the importance of considering such factors as pharmacists’ reimbursement, qualified support staff and amiable general practitioner-pharmacist co-operation among others, and the readiness of society² to accept expanded roles of the pharmacists in providing pharmaceutical care.

The human resource constraint in Uganda’s health and pharmaceutical sector is another factor that needs to be examined before comprehensive pharmaceutical care packages can be implemented. This has been corroborated by a survey in government and non-government heath facilities in Uganda¹⁷, which concluded that the number of qualified staff was grossly inadequate leaving most work in local facilities to be done by unqualified employees.

Perhaps more urgently though is the necessity for public drug use education to positively enhance these unfavorable public drug use indicators. The need to formulate interventions for appropriate antimicrobial use cannot be overemphasized. Indeed Homedes and Ugalde² underscored the justification for a global campaign to reduce inappropriate antibiotic use and promote their adequate administration. They stress further that all players in the pharmaceutical sector must be involved. The recent study by McNulty¹⁸ also showed that individual level educational campaigns and patient leaflets provided by primary care givers could help in positively modifying patients’ expectations about antibiotics.

In addition to the unfavourable drug use patterns, there was a relatively large number (32.3%) of non-patient clients-third party patients-seeking pharmaceutical services, in this study. This means that there is bound to be inadequate direct-to-patient counseling on medication use. The extent to which this negatively impacts on the quality of pharmaceutical care is however not known.

The study had limitations in that, data collected did not explicitly stratify treatment received as complete or part-treatment or whether medication dispensed was a substitution by the pharmaceutical service provider. Parttreatment has a significant impact on outcome of especially infectious diseases and subsequent development of drug resistance, while the number of substitutions made for prescribed medications could be an indication of adequate prescription review by the pharmaceutical service provider.

In cases where a diagnosis was made for a particular disease, this depended on subjective assessment of the health or pharmaceutical care provider with no verification using internationally approved criteria. This study also deliberately did not extend to cover drug shops and dispensing clinics, neither did it make an evaluation of specific pharmaceutical care components at the community pharmacies. The study nevertheless established private sector community pharmaceutical care seeking habits and demonstrated the largely unfavourable public drug patterns at the two pharmacies in Kampala.

In summary, there is a need for educational interventions targeting both the public and pharmaceutical service provider, and to explore expanded pharmaceutical care roles in Uganda’s community pharmacy facilities. Diagnostic and drug supply roles in the health and pharmaceutical sector should be rationalised in the urban places where both of these services are sufficiently developed. The strengthening of referral systems from community pharmacies is also a necessity. Additionally, on going research should be undertaken to guide in formulating and evaluating the impact of evidence based interventions in the health and pharmaceutical sector.

We would like to extend our gratitude to Opio Moses and Tusiimomwe Florence for their indispensable research assistance.