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When technology precedes regulation: the challenges and opportunities of e-pharmacy in low-income and middle-income countries
  1. Rosalind Miller1,
  2. Francis Wafula2,
  3. Chima A Onoka3,
  4. Prasanna Saligram4,
  5. Anita Musiega2,
  6. Dosila Ogira2,
  7. Ikedichi Okpani5,
  8. Ufuoma Ejughemre6,
  9. Shrutika Murthy4,
  10. Surekha Garimella4,
  11. Marie Sanderson7,
  12. Stefanie Ettelt7,
  13. Pauline Allen7,
  14. Devaki Nambiar4,
  15. Abdul Salam4,
  16. Emmanuel Kweyu8,
  17. Kara Hanson1,
  18. Catherine Goodman1
  1. 1Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Institute of Healthcare Management, Strathmore University, Strathmore Business School, Nairobi, Kenya
  3. 3Department of Community Medicine, University of Nigeria, Nsukka, Nigeria
  4. 4The George Institute for Global Health India, New Delhi, India
  5. 5National Primary Healthcare Development Agency, Abuja, Nigeria
  6. 6Delta State Government, Asaba, Nigeria
  7. 7Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  8. 8@iLabAfrica, Strathmore University, Nairobi, Kenya
  1. Correspondence to Ms Rosalind Miller; rosalind.miller{at}


The recent growth of medicine sales online represents a major disruption to pharmacy markets, with COVID-19 encouraging this trend further. While e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in low-income and middle-income countries (LMICs). Public health concerns associated with e-pharmacy include the sale of prescription-only medicines without a prescription and the sale of substandard and falsified medicines. There are also non-health-related risks such as consumer fraud and lack of data privacy. However, e-pharmacy may also have the potential to improve access to medicines. Drawing on existing literature and a set of key informant interviews in Kenya, Nigeria and India, we examine the e-pharmacy regulatory systems in LMICs. None of the study countries had yet enacted a regulatory framework specific to e-pharmacy. Key regulatory challenges included the lack of consensus on regulatory models, lack of regulatory capacity, regulating sales across borders and risks of over-regulation. However, e-pharmacy also presents opportunities to enhance medicine regulation—through consolidation in the sector, and the traceability and transparency that online records offer. The regulatory process needs to be adapted to keep pace with this dynamic landscape and exploit these possibilities. This will require exploration of a range of innovative regulatory options, collaboration with larger, more compliant businesses, and engagement with global regulatory bodies. A key first step must be ensuring that national regulators are equipped with the necessary awareness and technical expertise to actively oversee this e-pharmacy activity.

  • health systems
  • public health
  • qualitative study
  • health policy

Data availability statement

Data are available upon request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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Data availability statement

Data are available upon request.

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  • Handling editor Seye Abimbola

  • Twitter @rosalind_miller

  • Contributors Conception and design of the work: KH, CG, PA, PS, CAO, FW, SE, MS, RM; collection of data: FW, CO, PS, AM, DO, IO, UE, SM, SG; analysis and interpretation: all authors; drafting the manuscript: RM; critical revisions: all authors; final approval of manuscript: all authors.

  • Funding This study was funded by Wellcome Trust (210291/Z/18/Z).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.