Drug seller adherence to clinical protocols with integrated management of malaria, pneumonia and diarrhoea at drug shops in Uganda

This analysis of treatment registers shows high adherence to the iCCM guidelines by drug shop attendants. Over 90% of all children with pneumonia-related symptoms, fever or diarrhoea were appropriately assessed, classified and treated according to guidelines. This is likely to represent an enormous step up in quality of care as illustrated by our previous paper where exit interviews and household surveys were used to assess appropriateness of treatment of children at the drug shops. That study found 3–13 times better management of children at drug shops with the introduction of iCCM [4]. Beside these two studies, there is limited additional evidence on the utilizing the iCCM strategy at the level of drug shops as studies at drug shops in low income countries have focused on single diseases especially malaria, at the expense of other febrile illness [16].

Similarly high levels of adherence to malaria RDT results by community health workers (97%) have been demonstrated in Uganda and other African countries [12, 13, 17]. However, in two of these studies, the classification and treatment of pneumonia by CHWs was demonstrated to be poor with for example, only 40% of children with pneumonia symptoms being prescribed an antibiotic [12]. One child in three (31%) received treatment for both malaria and pneumonia. While this confirms earlier findings by Källander et al. of a 30% symptom overlap [18], it also means that there was little further reduction in drug use from inclusion of RDTs compared to presumptive management. However, this was a high malaria transmission area with estimated parasite prevalence of 60% in school-age children [19, 20] and the RDT positivity rate at the drug shops from this study was 77%. Limited penetration of malaria bed nets in this high malaria transmission area is likely to explain the high RDT positive rate, which will further have been augmented by the inherent problem of false positivity with malaria RDT—due to persistence of Plasmodium falciparum histidine-rich protein 2 (PfHRP2) antigens four up to 1 month in the blood stream, following elimination of parasites [21, 22]. In comparison, Nankabirwa et al. reported 51% malaria parasite prevalence using the gold-standard, microscopy, in children 0–59 months at public health facilities in regions with moderate-high malaria transmission in Uganda [23].

The high malaria positivity rate and the 45% of children whose respiratory rate was found high after assessment, meant that the drug shops could have continued, and perhaps even increased, the number of drugs sold per child, which coupled with the 25% increased utilization of these drug shops [4] likely increased their total financial turnover. Exactly how this affected total profits is not clear since we do not know profit margins of drugs earlier sold, although it was noted anecdotally that shopkeepers were almost uniformly happy saying “this has increased my business”. However, how drug shop attendants would react in lower malaria endemic settings where a lower proportion of RDTs were positive and an increasing proportion of children are supposed to be treated with lower-profit-margin paracetamol is not clear, but needs to be subject to further study.

While we followed up 40 drug shops for the entire study period, care seeking tended to concentrate around particular drug shops. Five drug shops saw nearly half of all the children, during the entire study period. While this was unexpected, it is logical that parents may prefer certain characteristics of health workers/drug shop attendants and thus choose to take their children to these health workers. This concentration of care seeking has the potential to allow closer supervision, and also gaining more experience.

The discourse around governance of the private sector in pluralistic health systems emphasizes balancing both regulation and incentives [24, 25]. Regulation alone may be insufficient as state regulation is weak and the processes for self-regulation are lacking. Incentives available to drug sellers for example through this iCCM intervention can improve quality of care, but there are limits to positive incentives alone. Community awareness to enable demand for quality service is also very important. This will likely need to involve aspects of asking for, and respecting test results, and an acceptance of treatment of children not with anti-malarials or antibiotics, but with for example paracetamol only if they have no malaria and no pneumonia.

This study has two important limitations that should be considered. First, the analysis is based on data from drug shop registers, which was not validated. However, this data was collected during a prospective experimental study and these results are very similar to results from the main study which used different data collection techniques like exit interviews and household surveys [4]. Secondly, the case definition of “pneumonia” in this study is not for confirmed pneumonia diagnosis, but for the iCCM classifications of ‘pneumonia’—cough with fast/difficult breathing. This classification tends to result in more children being classified as having “pneumonia” than in reality.