Developing innovative approaches to improve treatment provision for childhood infection in peri-urban settings: A pilot study in accredited drug shops

Pneumonia, malaria and diarrhoea are major causes of death in African children under 5 years of age, yet if diagnosis and treatment are available the majority of these deaths can be prevented. Children with these diseases should be seen and treated within 24 hours of becoming ill but affordable diagnosis and treatment are often not available close to home. Patients who do seek help often do so from retailers who sell medicines but do not provide diagnosis. In these situations, many children with serious diseases either receive the wrong treatment or the severity of their illness goes unrecognised. A simple solution, called integrated Community Case Management (iCCM), has shown encouraging results in improving diagnosis and treatment of these diseases when it is used by community health workers (volunteers who provide health services) in rural areas.

The iCCM strategy has not been tested in urban areas, but this is increasingly important because the population of African cities is expanding. Generally, this urban expansion is unplanned so living conditions and sanitation are poor, placing children at increased risk of disease. Providing better services through retail outlets is one possible way to ensure access to affordable basic health services. However, this is subject to some debate on whether retailers can provide health services of acceptable quality and price.

We plan to conduct a study in order to develop a community-based mechanism to deliver iCCM services that is suitable for urban areas. The study will be conducted in unplanned urban areas surrounding the Ugandan city of Kampala This site was chosen because it has many features of rapidly expanding cities: low socioeconomic status, unplanned housing, poor sanitation, poor provision of clean water and limited access to health services.

During the study, we shall consult with local stakeholders (local communities, drug shop vendors, health staff and national authorities) to explore which of two alternative strategies to improve access to health care in urban areas would be most feasible and acceptable to the local population and national health authorities. In these two strategies, either community health worker volunteers (CHWs) or drug shop vendors would be trained by the Ministry of Health to diagnose and treat three key childhood diseases: pneumonia, malaria and diarrhoea, and to refer patients with severe or unknown illness to local health centres. A key aim of the study is to identify the most suitable way to supervise and support community volunteers and drug shop vendors, how to integrate them into the local health system, and how to assure the quality of the services they provide.

We shall also conduct a small pilot study in 10 drug shops to measure the accuracy of diagnosis and quality of service provided after training. Drug shop vendors will be asked to record details of patients they see, including the symptoms, diagnosis and what actions were taken. This will be backed up by other methods of assessment by health professionals to assess whether the drug vendor used the iCCM guidelines and prescribed drugs correctly. The research team will also observe what happens when a sick child is treated in a drug shop, and carry out interviews to learn what providers, patients and local leaders thought of the treatments received in trained drug shops, and to explore the benefits and costs of the new approach to patients and drug shop vendors. We shall also measure how much it costs the Ministry of Health to support this approach.

The data collected will be used to inform the development of a new intervention strategy to improve access to treatment for children living in unplanned urban areas, which will be tested in future studies.

Aim: To develop a health systems strategy and community-based mechanism to deliver integrated Community Case Management (iCCM) services to increase access to prompt effective treatment for childhood infections in peri-urban areas

Objectives:
i. Investigate the feasibility of two alternative community-based mechanisms (community health workers or licensed private sector drug retail outlets) to deliver iCCM in peri-urban areas
ii. Develop mechanisms for governance, quality assurance, regulation, linkage with public health system (supervision, referral, health management information system) and financial sustainability, that are acceptable to treatment providers, patients, local and national authorities and regulators
iii. Explore the acceptability and perceptions of a private sector delivery strategy amongst providers, users, national authorities and policy makers
iv. Assess quality of iCCM services provided by trained drug retailers through a small pilot study, with focus on accuracy of diagnosis and adherence to treatment guidelines

Methods: Formative research, key informant interviews, and stakeholder consultations to adapt iCCM approach and explore mechanisms to support two alternative community-based mechanisms (community health workers or drug retail outlets) to deliver iCCM services in peri-urban settings. To be followed by a small pilot study in which 10 licensed drug shops will be trained to diagnose and treat pneumonia, malaria and diarrhoea according to iCCM guidelines. The ability of drug vendors to diagnose and treat children will be evaluated through a mix of methods including: record review, clinical vignettes, participant observation, and re-assessment of a sample of patients by a qualified health worker. Participant observation and focus group discussions will explore the effects of the pilot intervention from the perspective of drug vendors, and exit interviews will examine acceptability to patients and costs incurred by households.

In low income countries, malaria, pneumonia, diarrhoea and malnutrition remain major causes of under-five child mortality. In 2012, WHO/Unicef recommended integrated Community Case Management (iCCM) by community health workers as a means to increase access to health care for these preventable childhood deaths. iCCM is now accepted policy, and is currently being put into practice in health systems across the African continent. However, it has yet to reach unplanned urban areas which have rapidly expanding populations, and where use of community health workers is low. There are few studies that have examined how best to deliver services to prevent severe disease and death amongst children in these settings, and the results of this study will help fill an important gap in evidence.

By providing detailed evidence based on a multi-disciplinary approach and extensive local consultation, the study will have a beneficial impact in expanding the limited evidence base on the operational delivery of iCCM in urban settings. The study will also generate new evidence on the potential role of the private sector, which has not been widely examined. Because our study addresses a major challenge in the delivery of health services it is likely to generate high interest. Our multi-disciplinary approach will give a comprehensive assessment of quality of the medical service, costs and acceptability of the strategy, giving it a high degree of credibility.

Providing timely evidence to inform iCCM delivery in impoverished urban and peri-urban areas will have an impact in a variety of arenas.

1) Health service delivery:
The most important impact will be to provide evidence on inform the development of delivery strategies to improve access to diagnosis and treatment for the marginalised urban poor, whose estimated population will double by 2025 and encompass an estimated 50% of Africa's population.

2) Policy and strategy:
Policy makers at national, regional and international levels will be able to better assess the role of the private sector in providing care for the major childhood diseases: malaria, pneumonia and diarrhoeal disease. The evidence generated will also enable policy makers to better compare the feasibility, strengths and limitations of two alternative strategic approaches (community health workers or private sector licensed drug shops) to improve access to treatment in unplanned urban areas.

3) Changing perceptions:
By assessing evidence on the quality of service provision, the study will inform a broader debate on the role of private sector licensed drug shops in service provision, and may impact on changing perceptions of including the private sector as an active partner in the health system. This is of high relevance to Uganda and elsewhere, as there are few countries in Africa which do not share the characteristics of the study site: rapid and unplanned urban growth and gaps in public service provision filled by private providers.

4) Academia:
The research will benefit the academic community through opening up new avenues for further research in other African cities, and expanding the limited body of research on how the private sector can be harnessed to effectively advance public health goals. The cross disciplinary approach used will enhance the design and evaluation of complex public health interventions, generate novel insights, with potential to stimulate new research directions and contribute to methodological development.

In summary, this study will provide a comprehensive and timely set of evidence of relevance to both the national and global community interested in treatment provision, iCCM and child health, including major international organisations and policy makers.