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Official websites use. Share sensitive information only on official, secure websites. Email: vchimhutu yahoo. This article is distributed under the terms of the Creative Commons Attribution 4. The informal market for medicines has been growing. In Ivory Coast, this informal market is an unofficial core part of the health system. Given the risks associated with the informal market for medicines, it is important to understand why this market continues to grow. It becomes even more important in the context of COVID, as a huge chunk of falsified medical products end up at the informal market. A qualitative case study design was chosen for this study, with in-depth interviews IDIs and focus group discussions FGDs being the methods for data collection. Participants in this study are sellers, buyers, and pharmaceutical experts. We found out that the informal market for medicines thrives because it is highly accessible, convenient, affordable, and that it is used for various social, cultural, and religious reasons. The study concludes that although this informal market presents a clear danger to public health, it is thriving. For authorities to address this public health challenge, there is need for a holistic and multi-pronged approach, which includes addressing health systems factors and strengthening regulatory framework. Keywords: pharmaceutical drugs, sub-Saharan Africa, ivory coast, cote d'Ivoire, informal providers, qualitative case study, informal markets , informal medicines. We already know that informal providers in health care plays an important role in sub-Saharan Africa and that the informal market for medicines is growing in the region. The research looks in-depth into the factors and reasons why this market continues to be attractive to users despite the public health threat it poses considering that most substandard and falsified pharmaceutical products end up on these informal markets for medicines. The research is of significance because it provides evidence that the informal market is thriving and that the level of user acceptability is high. In this regard, the study shows that there is a ready market for substandard and falsified pharmaceutical products, something that presents a clear public health danger to the vulnerable people using these markets. In many low-income countries LICs , the informal sector plays a big role in the provision of health care. Access to health care and medicines is a human right and an obligation of the states. This study becomes imperative especially in the context where this exponential growth of the informal market for medicines is also associated with an increase in falsified medical products which provide a great risk to the population. These high figures are unsettling especially in the context of COVID and where reports of falsified vaccines are surfacing from the Africa region. To better understand the factors leading people to buy and participate in the informal market for medicines, we will use the AAAQ model Availability, Accessibility, Acceptability, and Quality. The framework comes from a rights perspective 16 and has been used in health-related research that deals with provision, access, and utilization of health services and products. In order to achieve global development goals linked to health, equitable access to medicines must be high on the agenda at local, national, and international levels. Therefore, using a framework like AAAQ from a rights perspective on this topic of informal markets for medicines, elevate the importance of the matter. Access to medicines is not a matter of choice but must be seen as a fundamental human right, equally when poor people resort to access medicines from the informal market, it must be investigated befittingly from a rights perspective. The first A in the framework represents availability, meaning services, and medical products must be available in adequate numbers. The second A represents accessibility, meaning services, and medical products must be accessible in terms of affordability, geography, and without any discrimination. The third A represents acceptability, meaning medical services and products must be acceptable socially and culturally. The Q stands for quality, meaning medical services and products must of good quality and safe to use. Quality in the context of this study is defined by the perceptions and experiences of pharmaceutical experts who participated in this study. Likewise, users and sellers of medicines at the informal markets also had their perceptions on quality. We will present these perceptions with thick descriptions to facilitate for the readers to make informed choices on whether these interpretations suit their own understanding or contexts. Although the AAAQ framework is useful in explaining these four dimensions on access to medicines it must be noted that it has serious limitations in cases where these informal markets are used for illicit recreational drug. Informal markets for medicines, such as Roxy are also known as hubs for recreational drugs that cause addiction. Our use of the AAAQ is only in health promoting ways, where vulnerable populations use informal markets in genuine attempts to improve their health statuses. Abidjan is one of the major cities in West Africa and the economic capital of Ivory Coast. This makes goods including medicines sold on the informal market easily accessible. Roxy market is exclusively dedicated to the selling of medicines. Roxy is also one of the main supply points for other informal markets in the country and region. It is against this background that we purposefully selected Roxy market in our attempt to investigate and understand the reasons why people buy medicines from the informal market. This purposeful selection of the study site also made it relatively easy for us to have access to the users of and sellers at this market. Additionally, Roxy gave us the opportunity to observe and have a deeper understanding of the activities and interactions at a market of this nature in its natural setting, which at latent level could have influenced our own interpretations in this study. A qualitative case study design was chosen for this study. The study was focusing on one of the popular informal markets for medicines in Ivory Coast, Roxy presented and described above. The study targeted three groups of participants, the sellers, the buyers, and pharmaceutical experts. The experts were selected based on having knowledge on the pharmaceutical industry, the informal market, and regulatory frameworks. Of the six pharmaceutical experts in this study, three were trained as pharmacists, two as pharmacy technicians and one as a medical doctor. In terms of gender, three of the experts were females and the other three males and their age was between 35 and 55 years. The first two pharmaceutical experts were recruited through the Directorate of Pharmacies, Drugs and Laboratories DPDL and thereafter snowballing techniques was used. Selection of the research participants was purposive. The purposive selection of the study site and research participants enabled us to have access to information that answers the study aim, which we may not have gotten had we made other choices. These three groups of participants, the sellers, buyers, and pharmaceutical experts, provided rich information to the study. This triangulation of the study participants also ensures and improves the quality of the study. Building rapport with research participants was also of importance in this study to establish trust, especially in the case of the sellers. In this study, we managed to build this rapport also because one of the authors has an in-depth understanding of the context and this insider perspective helped in the establishment of trust. Data collection for the study was done in two phases, in January of and from December to January Data that were collected for the first phase was mainly used in a master thesis of the main author, 20 however, after realizing the richness of the data and its importance in the field, we decided to collect additional data. These two methods were used because of their conversational nature, we needed to understand the reasons why people use the informal market to buy medicines, and, in that regard, the interview method was more suitable. FGDs were also used with buyers because in a somewhat sensitive topic, users of the service may feel directly targeted in an interview and therefore reluctant to share their experiences, whereas in FGD, they can give generalized experiences of the group and thus less personal. In total, 20 IDIs were conducted, six with pharmaceutical experts and fourteen with the informal medicine sellers. Eleven of these were conducted during the second phase of data collected, that is, between December of and January of , while nine were conducted during the first phase. Table 1 gives an overview of IDIs with pharmaceutical experts and sellers. A total of three FGDs were conducted with the buyers, and two of these were done during the first phase of data collection and one during the second phase. The three FGDs had thirteen participants. Of these thirteen participants, four were women and nine were men, participants were not separated by gender during the FGDs as the topic was not gender sensitive. Table 2 gives an overview of FGDs. The interview and topic guides covered the following thematic areas: experiences and perceptions of the informal drug market, the reasons, risks, and benefits attached to buying or selling at the informal market for medicines. After the data collection process, data were transcribed in French and then translated to English. After this stage the analysis of data began in NVivo 12, using thematic analysis. The first few interviews were coded separately and then we met and discussed the coding framework. This was an attempt to establish inter-coder reliability. Themes that emerged during this process constitutes the results of this study. Participation was voluntary. Most of the participants gave written consent while in few cases consent was given orally. Informants were assured of the highest possible levels of confidentiality and anonymity. We have depersonalized data by giving research participants pseudo-names. In this section we will present the study findings. The main reasons that emerged for using the informal market for medicines are that: it is cheaper, the pricing is flexible, it is used in favor of the formal market which is heavily regulated, it is used for cultural, social, and religious reasons and finally the market thrives because it is a source of employment. Throughout the FGDs, the buyers overwhelmingly expressed their favor towards buying drugs from the informal market. One of the main reasons for this was that buyers saw this market as a cheaper alternative to the formal market. For poor people like me, who do not have a stable source of income, we cannot afford to buy drugs at the pharmacy, it makes sense to buy drugs at Roxy. Joel another participant agreed with Stephane that medicines are cheaper at the informal market but also went further to state that the informal market is far more convenient to use than the formal market, with or without a health insurance:. We had to pay 18 CFA francs each, every month for a year and the insurance was also covering the drugs. One day I found the drugs I use for my treatment at Roxy and from that day I stopped paying for the insurance. Sidiki, another participant, also noted that it is this convenience of the informal market that makes it attractive and a cheaper option. He emphasized the fact that at the informal market one can buy the exact quantities they want for immediate use:. She had to take those tablets for 4 days to get better. In pharmacies, a pack of 24 of these tablets is sold for more than Franc CFA approx. The fact that the informal market allows for the selling of drugs is smaller quantities and units can be convenience and attractive for those with less income. However, the perception that drugs are cheaper on the informal market was contested by Raymond, a pharmaceutical expert:. For example, on the black market, the tablet cac is sold retail at a price of or francs approx. Thus, anyone who does not know this or cannot afford to buy the full box, will buy it at Roxy but when you consider the cumulate value you realize they spend more. This flexibility is not available in the formal market. Many buyers prefer the informal market for its convenience even if the issue of affordability can be contested. Even Raymond confirmed this:. They tell themselves that at the pharmacy there is a lot of hassle with the prescriptions, or that insurances do delay in reimbursements. In this regard when they get the drug at seemingly reasonable prices on the black market, they go for it. Solange, a participant in FGD reported that at Roxy, they can negotiate for pricing, and get some discounts or credit facilities:. When I go to Roxy, I always go to the same stall, I have a favourite seller. I have been going there for years now. Since I always go there, we now know each other well and we have even become friends. I always go to her booth because sometimes she gives me discounts. Sometimes she even gives me drugs on credit, and I can pay later when I earn money. I am also a vendor like her, so we understand and help each other. The formal drugstores do not offer this kind of service. Therefore the informal market has this substantial advantage. Although this could be considered a positive thing in many contexts, paradoxically, it emerged that the strict adherence to the protocol by the formal market was perceived by buyers as among the reason why they prefer the informal market. The informal market was associated with convenience and flexibility:. Sometimes they will tell you that the drug you are looking for is out of stock. It is very exhausting, frustrating and time consuming for people most of the time. Paul here is raising many issues related to the convenience of the informal market and costs associated with using the formal market. It also follows that due to many costs associated with formal channels, many users of the informal market indulge in self-diagnosis, something potentially fatal. Although there is a perception among the users that it is cheaper and convenient to buy drugs at Roxy , Raymond, a pharmaceutical expert emphasized that using medical products from the informal market is costly to the health of consumers. He cited a sad case of death that was recent:. This case by Raymond highlighted the dangers of self-medication and diagnosis, which naturally explains why the formal pharmaceutical industry need to adhere strictly to existing regulatory frameworks. Besides death, Raymond also raised the issue that over-consumption of non-prescribed drugs is causing a public health crisis of addiction in Ivory Coast, especially among the youths:. Tramadol is killing young people in Ivory Coast. You will see, in a few years the government will have to create hundreds of rehabilitation centers for these young people who are taking these drugs for fun. The government has opened more than dialysis centers to treat kidney failure. Specialists are saying these diseases are often due to intensive use of unapproved drug. The problem must be fixed at its source. Closing this black market would solve many problems including self-medication and the informal sale of psychotropic medication. In this vein, it is clear that perceptions of users, sellers, and pharmaceutical experts fundamentally differ on whether strict procedures to medication is good or not. The pharmaceutical experts emphasize on the dangers on if it while users mainly emphasize that the informal market which is unregulated makes the process of acquiring medicines faster and cheaper. It also emerged that there were some cultural, social, and religious reasons for using the informal market. Lassina stated that he prefers to go to the informal market because it also sells traditional herbs:. This kind of stuff is not found in pharmacies. Anyways laughing , I never tried to find them in pharmacies as Roxy is my place for that. From Lassina, we can see that traditional herbs are part of the reasons why he uses this market. Some of these traditional herbs, may be considered illegal on the formal market and yet they may have some significance in local settings. As such cultural beliefs and practices, such as boosting of virility plays a part in the utilization of the informal market. Users also raised an important issue that in cases where diseases attract social stigma, for example, sexually transmitted diseases STIs , it was much safer for them to buy medication at the informal market discreetly:. Sometimes, even the spouse may not be aware of this disease. This makes Roxy the place to buy these drugs because through formal channels they may ask for your sexual partners and ask you to inform them of the illness. The issue of trust in the informal market was also raised in relation to long family traditions of using this market. Several of our participants said the reason they used Roxy were social, they are used to the market and have been socialized to do so by family members:. I have always consumed drugs from Roxy because my family has always used them. Thus, for me it is normal to use these drugs. In recent years, people have begun saying that street drugs are harmful, yet I have always used them, and they have always been good to me. Edmond a participant in the same FGD raised the same point adding a class dimension. To him, it is those of high social economic status who can afford to buy from pharmacies, who advocate that the informal market for medicines is harmful:. My family and I have always bought our medicine here talking about Roxy. It is the people from rich residential suburbs who keep saying that these drugs are dangerous because they can afford to buy their drugs at the pharmacy. In addition to keeping up with family tradition, participants also had a perception that their life is in the hands of God, and they cannot do much to protect its longevity:. God is the one who decides the moment, but everyone will have to face death. It does not matter how someone dies, it could be an accident, it could be by being bitten by a poisonous snake, it could be anything. Are those who buy pharmacy drug immortal? Serge was in agreement with Paul and goes on to say even if there could be stories of people dying from medicines bought from Roxy , that cannot stop him from using this informal market:. God is the one who can take it back whenever he wants to. So even thought this lady who died was one of my family members, I think it would not have prevented me from using drugs from Roxy. In this case, believing in God contributes to the acceptability of using the drugs from the informal market. As a market, Roxy also thrives because it provides employment for many. The sellers see this as a form of employment, something that sustains their families. Sellers were very upfront in the interviews that the most attractive feature of the informal market for medicines is the financial aspect:. Whoever sells drugs and reinvests the money in other businesses will get rich. This is not a business in which we need to put all eggs in one basket because we do not know what tomorrow holds for this nature of business. Assia, while appreciating that the work has helped her to take care of her family and keep it going, she also stressed that the informal market for medicines is an unpredictable and not a very safe industry:. I plan to stop this activity in a few years to open a hair salon, it will be less stressful. Another seller, Roger, revealed the communal nature of the business. It is a business that allows for the strengthening of communal, social, and kinship ties. This connects to the point raised earlier that social reasons contribute to the thriving of Roxy. For the sellers and users, the enterprise is more than just a business for profit making. It offers the sellers an opportunity to help close friends and relatives in need on occasions they may not have money:. They even come to take the drugs here at my stand. The sellers expressed satisfaction about the presence of the informal market essentially because this market provides them with an income. In a country where unemployment rate is high, the informal market for medicines is a source of livelihood and this contributes as to why this market thrives. Despite repeated attempts by authorities to put an end to Roxy , it is still thriving, and it does not seem like it will stop soon. In this section we will use the AAAQ framework, our findings and literature in this field to discuss reasons why informal markets for medicines are thriving. As demonstrated with our findings, affordability ranks high on why this market is preferred. This market is mainly used by the poor 6 , 7 and it enables low-income earners to get access to medicines terms of pricing. In addition to the affordability of the informal market, another advantage is that prices are negotiable. The informal market also offers flexible terms of payment as noted in this and other studies. This flexibility makes the informal market more accessible especially to those of low social economic status. Out of pocket expenditure is one of the main reasons why health and medical products remains inaccessible to most of the poor. Sellers and buyers also develop a sense of loyalty and solidarity to one another overtime, and in this regard, buyers can choose to buy at the same place or refer their friends and families to the same vendor while sellers can also reduce prices and offer flexible payment options which may even extend to barter trading. This phenomenon of barter trading was reported in Tanzania where medicines were sold in exchange of food or electronics. Given this, it is important to note that the informal drug sellers therefore possess many social advantages over the formal market 2 and these make the informal market for medicines more accessible. The relationship between sellers and buyers at the informal market for medicines are more personal and closer, findings from this study has demonstrated the importance of this relationship. Another factor in favor of informal market for medicines is that they are conveniently located and closer to the populations they serve, we have seen this in this study. Another study from Cambodia reported the same findings. The proximity and flexibility in operating times therefore makes the informal market more accessible. It is also a common practice that users when in need can even visit houses of sellers or vice versa even deep into the night and still get or offer a service. Besides being physically and financially accessible, Roxy offers a broad range of medical products at one stop. As one of our participants Lassana noted, Roxy offers both modern and traditional medicines, a variety of products that cannot be found in pharmacies as other studies have also shown. Although medical products are available and accessible at Roxy, evidence from literature shows that these products are not of good quality, 29 however, buyers still find the quality acceptable. Something that should concern policy makers and public health experts, especially in the context of COVID and vaccines roll-out. Limitation in the current study involves the study design, data collection and selection of participants. The second phase was disrupted by COVID and this limited the amount of data we could collect during this second phase. Another possible weakness but also a strength is we used purposive sampling, this allowed us to target the informants and participants with the right information, however, this might introduce some biases or exclusion of other potential participants whose views might have enriched this study. The other limitation to this study related to the theoretical framework we used the AAAQ. The framework comes from a human right thinking and as we used it in this study presumes that the access of medicines even on the informal market is for health promoting activities. We, therefore, did not cover the dimensions where informal markets are used as hubs for recreational drugs. Additionally, the framework, did not afford us the opportunity to illuminate further on the sociocultural aspects that emerged in the findings. Another study specifically focusing on sociocultural factors and using a more expansive social theory may cover these dimensions. This study shows and demonstrates that there is a ready market for medical products on the informal market. This is very worrying considering that the bulky of substandard or falsified medical products end up in the Africa region. The challenge is exacerbated by the fact that this is a very lucrative but illicit industry. This study set out to find out the factors or reasons that is making a local informal market for medicines in Ivory Coast to flourish. We found out that the medicines at Roxy are perceived to be convenient and affordable. Additionally, there are many social and cultural reasons that make this informal market more accessible and acceptable to the local communities. Besides this fact this informal market paradoxically met most of the criteria of availability, acceptability and accessibility, the market itself is a source of livelihood for many young people. Pharmaceutical experts interviewed raised known dangers posed by these informal markets for medicines and local fatal cases including deaths were highlighted in these experiences recounted in this study. Despite these obvious dangers, sellers and buyers remained adamant that the pros of the informal market for medicines outweighs its cons. This study raises a fast-growing public health threat, which calls for a holistic and multi-pronged approach. The traditional solution of concentrating on regulatory frameworks and sanctioning the sellers may work but is proving not to be enough. Author Contributions: The authors of this manuscript all made substantial contributions to the acquisition and interpretation of the data, drafted and revised the manuscript, and approved this version of the article to be published in INQUIRY: The Journal of Health Care Organization, Provision, and Financing. As a library, NLM provides access to scientific literature. Find articles by Armel Dagrou. 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