Public good through private drug shops: Improving access to medicines in Uganda

Phyllis Awor, Phd Candidate – University of Bergen, Norway & Research Fellow – Makerere University School of Public Health, Uganda

In this blog post, Phyllis Awor reports on her research project in Uganda where quality of care for children was greatly improved at drug shops after implementation of a modified integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea program.

 At the regional conference on health districts in Africa, (Dakar 21-23 October 2013) vibrant discussions were held revisiting the health districts model, 25 years after the Harare declaration.

The issue of a rapidly changing Africa with pluralistic health systems and widespread urbanization was an important observation, with calls for and demonstration of innovative ways to work with and mainstream the private sector.

 The private-for-profit health sector especially drug shops notoriously proliferate across most LMICs due to a weak public health sector. In Uganda and Nigeria, 50-70% of febrile children are treated at drug shops. These drug shops are largely unregulated, function independent of the health district and worse still, provide poor quality care.

Here is a good example of what can be done to mainstream and improve management of malaria, pneumonia and diarrhoea in children through drug shops in Africa.

In a study in Eastern Uganda, we set out to determine how feasible it would be to introduce and promote diagnostics (malaria rapid diagnostic tests and respiratory times) as well as pre-packaged paediatric drugs for malaria, pneumonia and diarrhoea within private sector drug shops. Such an intervention could contribute to improved quality of care, rational drug use at drug shops and child survival.

In order to achieve our objectives, we adopted and implemented the WHO/UNICEF recommended integrated community case management (iCCM) intervention for community health workers within registered drug shops. Using a quasi-experimental design in one intervention and one control district, we conducted before and after surveys using exit interviews at drug shops for drug seller practices in treatment of malaria, pneumonia and diarrhoea in children and using community household interviews for treatment seeking practices in May-June 2011 and May-June 2012. To inform project implementation, in-depth interviews were also conducted with drug sellers and focus group interviews with child care-takers at the beginning and end of the project.

 Our findings were overwhelmingly positive. The main result is that the iCCM strategy can be effectively adopted and utilized in registered drug shops to improve access to quality treatment for children less than 5 years of age and move towards rational drug use. This was not at the expense of utilization of the public sector by sick children.

From very low quality of treatment at baseline,  we improved quality of treatment for malaria, pneumonia and diarrhea tremendously. After 8 months of the  intervention, nearly 90% of febrile children who sought care at registered drug shops in the intervention area had a malaria rapid diagnostic test performed on them and over half of children with cough and fast breathing first had their respiratory rate counted prior to receiving treatment. No child in the control area received any diagnostic testing prior to treatment. Also, three quarters of children with diarrhoea received the recommended treatment with ORS/zinc in the intervention and almost none in the control.

Apart from the profit that the drug sellers made from sale of medicines, being seen as professional by the community (especially because of the use of diagnostics) was an important incentive for drug sellers to continue to provide quality care. With this intervention, the majority of drug sellers who previously dreaded visits from the district drug inspector now actually looked forward to supervision visits.

Well, that is how we worked to improve access to quality care for febrile children and mainstream drug shops in Uganda. What do you think? Let us know. There were also other positive examples of how countries have engaged with the private sector at the conference including incentivising the private sector using performance based financing in Cameroon and mainstreaming health information from private facilities into the national HMIS in Rwanda. Look out for these!