Improving malaria diagnosis and treatment in the private retail sector in uganda a mbonye

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Improving malaria diagnosis & treatment in the private health sector in Uganda

Anthony Mbonye (MB ChB, PhD) Director of Health Services -Ministry of Health, Uganda & Associate Professor, School of Public Health, Makerere University

Answering key questions on malaria drug delivery 2

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Malaria diagnosis in Uganda Rapid diagnostic tests (RDTs) were introduced in public health facilities

in Uganda in 2010 Up to 80% of malaria cases are treated in the private sector

Two-arm trial to compare feasibility and impact of using RDTs vs current practice (presumptive treatment of fever) in 65 registered drug shops

Improved targeting of ACTs as primary endpoint: Impact and cost-effectiveness of the intervention on proportion of patients receiving appropriate ACT treatment [with microscopy as gold standard]

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What is a registered drug shop?

• Registered with Ministry of Health (National Drug Authority), licensed to sell Class C drugs, including antimalarials, but not antibiotics or injections

• Most located in or around trading centres (rural and built-up areas)

• Typically comprise 1-2 rooms with 1-2 staff • Most have appearance of pharmacies, with

drugs displayed on shelves or in glass cabinets• Drug shop vendors smartly dressed, some with

white coats• Subject to periodic inspection by District

Assistant Drug Inspector

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Intervention Design and Outcomes

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What did the intervention include?

RDT training based on WHO generic RDT training materials


Trial findings: Adherence to RDTs and targeting of ACTs


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Improved targeting of ACTsControl group RDT group

Use of RDTs in drug shops: significant increase in proportion of ACT treatment decisions that were consistent with “true” malaria status [microscopy], p<0.001

33% appropriate 75% appropriatevs.

Qualitative Evaluation


Aim: To understand more about the processes involved with the introduction of RDTs at drug shops

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Support for RDTs in drug shops

Research participants were broadly supportive of the introduction of RDTs into drug shops:

• Community members liked RDTs because they allow them to “know the truth about their illness” and stated that they sought out drug shop vendors who could test for malaria and recommended drug shops who carried out RDTs to other community members.

• Drug shop vendors reported that they liked to use RDTs and that the availability of RDTs in their shops increases the number of clients, their profitability, their status and diagnostic skills.

• Government health-workers were generally in favour of drug shops using RDTs - as long as vendors were well trained, properly supervised and their practice was limited by knowing when to refer patients who they were unable to manage.

its not that we studied much but the patients themselves know that

we are real health workers, they no longer know us as people only selling drugs. Now they know that we also test

what.. even blood.

So for us we no longer accept to have our

children given treatment before having their blood taken off, because I see

now that it is very cheap

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Effect on reputation of shops

……there are those (project supervisors)

who usually come here now. If they come and

they do not disturb him and they do not close his drug shop, we also

get encouraged to remain supporting that

facility

The businesses are up to date and have life in them. You can’t spend a day without working. Even he (the patient) who hadn’t come for testing gets to know that this health provider knows what he is doing - even if he had come with another ailment. After he develops trust in the DSV he brings his children and they get tested and you treat them. Whenever he gets any ailment, he comes, because he has confidence in you.

They [patients] see that we are really health

workers. This has a way it puts life in us and we feel big, ehhe [yes] and

you see yourself becoming big.

• Patients were pleased diagnosis was available in drug shops, and felt reassured by the training and supervision of providers with otherwise uncertain credentials

• Vendors welcomed the opportunity to demonstrate a new skill and a status more akin to a qualified health worker

• Together, the views of drug shop vendors revealed that the intervention had a profound effect on how drug shops were perceived and used.

• Highlights the need to consider wider effects of RDT training interventions in the private sector

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ConclusionsSummary findings RDTs are likely to be popular in the private

retail sector

Clients are willing to buy RDTs at subsidised prices, and trained drug shop vendors can use RDTs and comply with results

RDT training in drug shops can improve targeting of ACTs to malaria patients, and reduce overuse of these drugs

Training to perform tests can also change the reputation of drug shops

RDTs are likely to be financially viable for drug shops: profit from enhanced reputation, increased clientele and sale of other medicine to RDT-negative clients

Referral from shops is uncommon and faces multiple challenges

Issues for consideration by program managers It is feasible to collaborate with the private

retail sector to improve malaria treatment There may be multiple benefits to drug shop

vendors in being part of an RDT training programme

Visible government involvement may help promote compliance with guidelines

RDTs could increase popularity of drug shops and affect where patients seek care

RDT use may give a false impression of vendors’ other skills, and could expose patients to less desirable practices.

RDTs should only be introduced within broader accreditation programmes aiming to improve standard of care in private retail sector. Effective regulation by authorities is also needed

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What has since taken place

National dissemination meeting of results in Kampala, Sept 2015

The study results were discussed at an international meeting, on introducing RDTs in the private health sector, in Entebbe, Oct 2015

Two meetings have been held involving the Uganda National Drug Authority that registers and regulates drug shops to discuss RDTs in the private sector

A road map has made drawn to draft a guideline for introducing RDTs in the private sector

Draft guidelines have been discussed in the Technical Working Group, Ministry of Health

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The Policy Environment

Changing epidemiology of malaria: prevalence reduced from 42% to 9%. Some areas like Kampala have less than 1%. Thus increasing need for testing before treating malaria

Discussions with Ministry of Finance to increase funding for malaria control (for ACTs & IRS) in highly endemic districts of North and Eastern Uganda

Application to Global Fund to purchase RDTs for the community level

A results-based financing strategy could help introduce RDTs in the private sector

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Acknowledgments

Principal InvestigatorsAnthony Mbonye, Ministry of Health, UgandaSiân Clarke, LSHTM, UKPascal Magnussen, University of Copenhagen, Denmark

Research Team in LondonKristian Hansen Sham LalEleanor Hutchinson Clare ChandlerBonnie Cundill Caroline Lynch

Field Team in UgandaField co-ordinator: Stephen KalakeMicroscopists: Francis Adome, Betty Nabette, Annette EnzaruSocial scientists: Miriam Kayendeke, James Kizito, Christine Nabirye,Jonathan Ngobi, Josephine Nabukeera

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@ACTconsortium

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Improving malaria diagnosis and treatment in the private retail sector in uganda a mbonye

Healthcare