Pharmacists’ disclosure of medicine availability and price information in low income countries: A qualitative case study of policies, subjective perspectives and promising digital innovations.

Background: Despite the contentious nature of the subject of medicine information transparency, the importance of information as an enabler of timely access to affordable medicines is well-established. Patients’ access to medicines availability and price information facilitates price comparisons and the swift identification of pharmacies where particular medicines are available. This access was especially critical in Zimbabwe - a lower-middle income country in Southern Africa experiencing widespread medicine shortages and medicine price variations. Zimbabwe was the study context for this PhD. Direct and indirect consumer access to information depends on pharmacists disclosing their real-time inventory and price information to patients or other pharmacists. Promising digital innovations intending to facilitate this disclosure are arising in some parts of the world including Zimbabwe. To be effective, these innovations have to be accepted and used by pharmaceutical system actors who supply their inventory and price information. However, clarity and cogent theories around what enhances these innovations’ adoption by pharmaceutical system actors, and what promotes their longevity, lack. This PhD aimed to help remedy this lack and explored the potential for digital innovations to improve patient access to medicine availability and price information in the health systems where this information is crucial. The PhD adopted sociotechnical and critical realist approaches and drew from neo-institutional theory concepts that explain behaviour, change and persistence. Using case studies from Zimbabwe, these three strands of inquiry were pursued and ultimately integrated: 1. factors that influence pharmacists’ tendency to supply of inventory and price information, 2. how an example of an institutionalised barrier to digital innovations for sharing medicine inventory and price information can be overcome and 3. how some digital workarounds for crowdsourcing and sharing real-time medicine inventory and price information achieve persistence. Methods: Three qualitative studies corresponding to each of the three strands of inquiry, respectively, were conducted. For the first study, data from 36 hours of interviews with Zimbabwean pharmacists was analysed. The second study involved the application of autoethnographic techniques to 53 documents co-produced by the researcher, state regulators, media and legal practitioners, and court judges. It examined how a formal digital Medical Information Service (MIS) for sharing medicines information in Zimbabwe was proposed by the researcher and opposed by regulators based on their subjective interpretation of Zimbabwe’s medicines advertising laws. Through intersectoral-sector advocacy, this inhibiting interpretation was ultimately invalidated in court. Meanwhile, some pharmacists used ‘pharmacists-only’ groups on WhatsApp (a popular social media application) to share information about their inventory and the prices thereof. This information would then be relayed to individual patients. 5 111 chat messages from these pharmacists’ were analysed for the third study. Findings: When disclosing information about their inventories and prices, Zimbabwean pharmacists’ decisions were shaped by three sets of factors related to three levels of analysis: 1. actors’ subjective perspectives, 2. Intra-organizational arrangements within pharmacies and 3. the broader health system. Subjective perspectives are factors pertaining to the perceptions pharmacists had regarding the impact of disclosure on: sales, their social approval (legitimacy), exposure to scrutiny, decision making autonomy, and their relationships with stakeholders they considered important. Subjective perspectives regarding the interpretation of advertising laws also influenced the capacity of pharmacists to disclose inventory data. These subjective perspectives were shaped by the principles that actors used to guide their decisions and actions in social interactions. These principles are known as institutional logics. The norm therefore, was for pharmacists to decide whether or not to disclose inventory information on a case by case basis after making these considerations. Organizational arrangements are factors to do with the how, if at all, pharmacy owners and managers enforce or motivate their employees to disclose inventory information through available information-sharing interventions. Factors relating to the broader health system include: the medicine advertising laws in force in a given jurisdiction, the state of the supply chain for medicines (stable vs unstable), the extent to which a centralized actor exists and collects inventory data from pharmacies and the extent to which information disclosure is enforced by law and accompanied by a data verification plan. Digital interventions have the potential to facilitate the under-provision of medicines availability and price information in weakened health systems. This potential however depends on the interaction between the already-mentioned features of the intervention and the factors shaping pharmacists’ decisions to disclose inventory information. Digital interventions must be compatible (and be perceived as being compatible) with the information management legal framework and pharmaceutical information sharing norms entrenched in the jurisdiction of use. When alignment with laws is unclear, opposition from law enforcement entities may ensue and advocacy campaigns become necessary. Strong institutions, (e.g. an impartial judiciary) and alliances beyond the health sector, are instrumental in these advocacy campaigns. Digital tools for disseminating medicines availability and price information must also achieve high utilization levels by having several uses. Lastly, they must possess features that allow multiple and diverse data providers to co-use them without creating disruptive conflicts or inconveniences amongst themselves. Conclusions: Digital interventions can facilitate the provision of information about where medicines are available in real-time and the prices thereof. However, to become effective and sustainable, these interventions must be perceived as useful by a critical number of pharmaceutical service providers, be compatible with information sharing laws and norms, and be usable by diverse users without generating disruptive tensions