Overview

Access to essential medicines is a critical building block of the health system, but many low-and middle-income countries (LMICs) continue to face major challenges in ensuring medicine accessibility, affordability and quality. The sale of medicines online (or e-pharmacy, we use the terms interchangeably) represents a major disruption to pharmacy provision across the globe. Whilst e-pharmacy was initially the preserve of high-income countries (HICs), in the past decade it has been growing rapidly in LMICs, and this growth was further catalysed by widespread lockdowns during the COVID-19 pandemic.

This rapid expansion of e-pharmacy has been largely uncontrolled and accompanied by significant public health concerns, the most commonly cited being the sale of prescription-only medicines (POMs) without a prescription, including opioids and antibiotics; the sale of substandard or falsified (counterfeit) medicines; inadequate provision of information to patients; and erosion of the doctor-pharmacist-patient relationship. While in LMICs these problems are often widespread in traditional “brick-and-mortar” pharmacies, they may be amplified in the online sphere. In addition, non-health-related risks include consumer fraud and lack of data privacy. However, e-pharmacy also presents opportunities for enhancing access to medicines, especially among the elderly, those with chronic conditions, and those living in rural areas. Regulatory systems —crucial in managing these risks and opportunities—are hampered by a lack of consensus on appropriate approaches and lack of national regulatory frameworks. With political attention focussed on health systems, online medicine sales soaring, and online scams receiving publicity, the current climate may present a ‘window of opportunity’ for policy change and enacting effective regulation for e-pharmacies in LMICs. However, this requires evidence on the performance of LMIC e-pharmacy from a public health perspective, and analysis of potential policy options.