Setting
This study was conducted in Ujjain district, Madhya Pradesh, Central India. Madhya Pradesh (MP), which is one of India's largest provinces, is divided into 50 administrative districts each with a population of a little over a million. Ujjain, spread over 6091 sq km, on the western flank of the province, is one such district (Figure 1). It has a population of 1.9 million, 61% of which is rural. A quarter of the population belongs to schedule castes [18]. Scheduled castes (and scheduled tribes) are those communities that were historically subject to social disadvantage and exclusion. They are accorded special status by the Constitution of India (they are listed in a schedule) and are recipients of special social benefits as part of a national program of positive affirmation [19]. The district literacy rate is 72% and infant mortality rate is 51.9/1000 live births, close to the national average [18]. Agriculture is the mainstay of the district economy. Ujjain city (0.5 million inhabitants) is the largest town and is the administrative headquarters of the district.
Survey of private pharmacies
This survey was a part of larger project to study and map all the health care providers in Ujjain district. As there are no existing comprehensive records of pharmacies in the province, a primary survey was necessary.
In this study, the term 'Pharmacy' included every store or shop where drugs are dispensed, bearing a sign with words "Pharmacy", "Pharmacist," "Dispensing Chemist" or "Pharmaceutical Chemist" or the term 'dawainya' (medicines) in Hindi [20, 21]. Private pharmacies refer to privately owned pharmacies that sell the drugs for profit, paid for out-of-pocket by clients. Private pharmacies in this study were classified as being 'stand alone' if they were independent pharmacies and as 'attached' if they were part of a larger institution, usually a hospital. Public pharmacies, which were excluded in the study, were state owned and attached to health institutions in the tiered public health system.
The field work was done by surveyors (total 10) who had a master's degree in social work. These surveyors were employed by the medical school for ongoing research work in the local community. The surveyors were trained by the research team at the medical school to identify private pharmacies in the district, meet persons in the pharmacy and administer a short questionnaire to them (see Additional files 1 and 2). The survey instrument was a structured questionnaire that included information on the exact location of the private pharmacy, clients, medical systems for which drugs were dispensed, the availability of certain tracer drugs, infrastructure and human resources. Five tracer medicines were selected to study availability of commonly prescribed drugs viz. cotrimoxazole, amoxicillin+clavulanate, anti-TB drugs (rifampicin/INH), inj. cefotaxime and inj. dexamethasone. Data collected from a provider survey earlier showed that these were commonly prescribed drugs in the study area; hence their selection as tracer drugs.
The basic unit of the survey was a village in rural areas and a ward in urban areas. (A ward is the smallest administrative division in a town with a population of 20,000-50,000). Rural and urban areas were defined as per classification in the Census of India [22]. Some fragmented initial information on pharmacies was available through the local district pharmacy associations, which served as a starting point for the survey. Surveyors first contacted the public health worker, cre`che worker, panchayat (village self-government), schoolteacher, or an influential person, in the village to enquire about the presence of a pharmacy in the rural areas. In urban areas, pharmacy boards are prominently displayed, surveyors in addition checked for the presence of other units in the ward from other pharmacists, besides referring to the list from the pharmacy association. If a pharmacy was closed or the person in the pharmacy was not available at the time of visit, then surveyors visited again during the working hours as mentioned on the display board. Less than 2% of such pharmacies could not be studied as they were closed after a second visit. The process was completed between June and Oct 2009.
Mapping of pharmacies onto a GIS
All private pharmacies detected in the study district were plotted onto a digitized map of Ujjain. To demonstrate the geographical distribution of pharmacies, the following two maps were used: (i) geo-referenced digitized map of Ujjain district developed by Deshpande et al. in 2004 [23] (ii) a detailed geo-referenced digitized base map of Ujjain city. The first was used to depict the location of pharmacies in rural and urban areas (excluding Ujjain city area). The second map - that was developed as a part of this study, was used to visualize pharmacy and health provider locations within the city.
Ujjain city base maps were procured from the office of the Town and Country Planning Directorate and the Ujjain Municipal Corporation. These maps were first scanned using calibrated large-size optical scanners and then onscreen digitization was done using AutoCad Map software to extract relevant features such as city boundary, ward boundary, roads, and important land marks. The Survey of India topographical sheets on the scale of 1:50,000 were used for geo-referencing. The cross verification of geo-referencing on ground was subsequently performed using hand held global positioning system (GPS) at random locations for precision. Source maps details were updated using the Google maps and CartoSAT2 satellite data. The latter is a high resolution remote sensing image availed from Indian Space Research Organization (ISRO) with some verification from Ujjain Municipal Corporation officials.
At the time of the data collection of the pharmacies, the field surveyors were provided this updated map of the city to mark the respective pharmacies by referring to the surroundings and adjoining details shown on the map. This method of marking on a geo-referenced base map helped ascertain accuracy of locations. This was further fine-tuned with the support of geopositioning. Geo-position of pharmacies as a separate layer on base map was done using AutoCAD Map GIS software. A database of pharmacies was prepared using the database management software - MS Access. The maps and data base were imported into Map info software. The data tables included unique ID codes for each pharmacy, which were used to relate pharmacy location on the map with the relevant data record from the database.
The relationship between pharmacies and providers was studied using concentric ring buffers around provider locations. In our initial mapping we visualized that most pharmacies were located within a 250 m radius from the provider clinics. Therefore a distance of 50 m was deemed appropriate for concentric ring buffers around the providers. Thus five concentric ring buffers of were plotted at a distance of 50, 100, 150, 200 and 250 meters respectively.
Data management and Analysis
The data were compiled ward wise in urban areas and village wise in rural areas. Appropriate codes were given according to each ward/village in all the blocks. The data were entered in to MS Access spreadsheets and transferred in to PASW Statistics 18.0. Basic descriptive statistics were presented. Tests of significance for proportion were run. The distribution of pharmacies as visualized in the GIS developed is presented.
Ethical approval
The study was approved by the Ethics Committee of R.D. Gardi Medical College, Ujjain.