Understanding health system linkages: Formative research to develop strategies to support quality improvement in treatment in the private sector

Prompt antibiotic therapy for an infected patient can make the difference between cure and death or long-term disability. Unfortunately, all around the world, some infections are becoming resistant to the antibiotic medicines used to treat them. This could lead to a future scenario in which illnesses last longer, deaths increase, and the cost of treatment rises. Under this scenario, the greatest impacts are likely to be felt in low-income countries where infectious diseases are most common and many families lack financial security. Antibiotic resistance is now considered to be one of the biggest threats to global health. The World Health Organization has called for urgent action, research and investment to counter this threat, through the development of new antimicrobial drugs and through more responsible use of existing drugs. In September 2016, global leaders met at the UN General Assembly - only the fourth time in the history of the UN that a health topic was discussed at the General Assembly - to call for concerted action by every national government to limit the development and spread of drug resistance.

Poor prescription practices by health workers, such as overuse of drugs, sale of partial doses, or non-adherence by patients to the full treatment course, all create situations which are conducive to the selection and spread of resistant mutations. Health workers and pharmacists can help tackle resistance by only dispensing antibiotic drugs when they are truly needed; and by prescribing the right drug in the right quantities to treat the illness. Improving the use of antibiotic medicines thus ultimately involves guiding the treatment decisions made by health workers and patients to discourage indiscriminate use. Therefore, if effective intervention strategies are to be developed, better knowledge and understanding of the factors that influence the prescribing practices of health workers will be essential.

The private sector plays an important role in provision of health care in many African countries, with many patients seeking care from private clinics and drug shops, and cannot be overlooked in strategies to control misuse of antibiotics. Neither can treatment practices and standards be addressed by focusing on one sector in isolation. The private sector interacts with, and is shaped by the organisation and performance of the public sector, demand from patients and regulatory controls. Poor practices in one sector can easily undermine or disincentivize behavioural change in another. Yet regulation of the private sector is an acknowledged weakness of the health system in many low income countries.

The proposed research aims to address this challenge. We shall investigate the situations, norms, experiences, and motivations that affect health care practices in private clinics and drug shops in rural Uganda, including the influence of interactions between private providers, government health workers and public health officials, in order to generate improved understandings of how the health system can more effectively control treatment practices, and improve the quality of care that patients receive from private providers.

We intend to use the knowledge and insights gained from this research to develop a comprehensive intervention strategy to improve patient care and combat irresponsible use of antibiotics in private clinics and drug shops in Uganda. This intervention strategy will be tested in future studies. We hope that our findings will also be of value to Ministries of Health and national governments in other low-income countries, and can be used to help inform the development of national plans to counter the threat of antimicrobial resistance.

Qualitative research with a specific focus on antibiotic treatment will be used to shed light on broader processes affecting quality of care in private clinics and drug shops in Uganda. Through improved understandings of how health system factors can be instrumental in shaping treatment practices by small-to-medium sized private providers (SMPPs), the study will generate novel insights on how health system levers could be used more effectively to (i) support and improve quality of care in the private sector, and (ii) promote responsible prescribing and use of antibiotics in Uganda and other low income settings.

The study aims to provide evidence relevant for strategy development in four main areas:
1) Regulation of SMPPs, and improved understandings of the opportunities, challenges, and consequences for the health system.
2) Design of interventions to improve quality of care in SMPPs (provider training/CPD, accreditation, social franchising)
3) Strengthening of linkages between private providers and public health workers, public health officials and regulators to foster partnership, oversight and knowledge exchange
4) Refinement of Uganda's first National Action Plan for Antimicrobial Resistance, and development of specific policies and interventions deriving from the Plan.

This knowledge will be timely for strategic planning by the Ministry to Health to develop its national plan to counter antimicrobial resistance. The study will also identify opportunities to build synergy across sectors, inform current debates on the role of the private sector in healthcare provision in Uganda, and help shape models for future implementation.

The findings will be used to engage with local stakeholders to co-design a comprehensive strategy to promote responsible prescribing and use of antimicrobials, and support quality improvement in health care services in SMPPs in Uganda. Evaluation of this intervention strategy will form the basis of a future grant application.

Antimicrobial resistance is recognized as one of the greatest threats facing global health, with potential to endanger human development across the world. WHO has called for urgent public health action, research and investment to counter this threat. In Sept 2016, global leaders met at the United Nations General Assembly to commit to fighting antimicrobial resistance together - only the fourth time in the history of the UN that a health topic has been discussed at the General Assembly. National authorities, including UK government agencies, are committing significant resources to battling the threat of antimicrobial resistance both at home and abroad. Research on how to contain the emergence and spread of antimicrobial resistance, generating evidence that can be translated into immediate and concrete public health actions, is urgently needed by policy makers and national health authorities.

This study will provide policy-relevant evidence on how health system factors influence and shape antibiotic prescription and use in private health care settings, and how interconnections between private providers and the wider health system affect treatment practices. Specifically, the results will shed light on how health system levers could be used more effectively, thereby helping inform development of workable solutions to reduce misuse of antimicrobials. Results will also provide insights into the role of the private sector in healthcare provision in Uganda and other low-income countries in sub-Saharan Africa, and help shape models for future implementation.

The research findings should be of interest to a wide audience, with potential for both immediate and longer-term public health impact in two ways:

1) Of immediate relevance, from early 2017, Uganda is expected to benefit from a large, sustained investment (to be publicly announced in the later part of January) in surveillance and other control measures to address antimicrobial resistance. Coupled with the development of Uganda's first National Action Plan for Antimicrobial Resistance, prompted by the WHO and currently underway (led by the Ugandan co-PI on this application, Dr A Mbonye), this opportunity both increases the urgency for good-quality evidence on factors that affect antimicrobial use, and enhances the potential benefit of the proposed research by providing a ready space for application of findings. In turn, results from formative research, and subsequent interventions and evaluations in Uganda, will also be valuable for work in other countries with similar health care systems and challenges.

2) The research will expand the limited evidence base on regulatory mechanisms to improve treatment practices amongst private providers. There is as yet a limited body of research on how the private sector can be harnessed to effectively advance public health goals, although there is growing interest amongst researchers, policy makers and donors in developing new models of working with SMPPs (such as franchising systems and accreditation schemes). Improved understanding of the factors which shape and control provider behaviour could be particularly valuable in informing the design of future interventions.

The research has relevance for:

Health service delivery: The most important impact will be to provide evidence to inform the development of intervention strategies to improve prescribing behavior and promote responsible use of antibiotics and other medicines, within a broader context of strategies which seek to expand access to treatment services through use of retail drug shops.

Policy and strategy: The evidence generated will enable policy makers at national, regional and international levels to better evaluate the feasibility, strengths and limitations of different interventions aimed at improving quality of treatment in the private sector. Policy makers will also be able to better assess the role of the private sector in stewardship of antimicrobials