Abstract
BACKGROUND: 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. OBJECTIVES: This study aims to 1) describe the informal medicine sector in four anglophone African countries, and 2) understand why people patronize informal medicine sellers. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.