Keywords
Appropriate treatment, interrupted time series, peer-supervision,
childhood illnesses, Uganda
INTRODUCTION
Acute febrile illness is a major cause of morbidity and mortality among
children less than five years of age in low and middle income
countries1-3. In 2018,
the World Health Organization (WHO) reported that acute febrile
illnesses due to malaria and diarrhoeal diseases caused approximately
272,000 and 525,000 deaths among children less than five years of age,
respectively4,5.
An additional 808,694 deaths of children less than five years were
caused by pneumonia in 20196. Majority of the
deaths due to malaria, diarrhoea and pneumonia occur in
Africa7,8.
Uganda is one of six countries that accounted for more than half of all
malaria cases worldwide in
20195. According to the
Ministry of Health (MoH) Uganda, in 2019, pneumonia, malaria and
diarrhoea combined accounted for over 30% mortalities in children less
than five years of age making the three febrile illnesses the leading
causes of death among this age
group9.
In a bid to curtail common childhood illnesses among this vulnerable age
group, in 2010, the WHO and the United Nations Children’s Fund (UNICEF)
recommended the provision of integrated community case management(ICCM)
at community
level10,11. The ICCM is a strategy focused on enhancing equity of public health
services by providing timely and effective treatment of malaria,
pneumonia and diarrhoea to populations with limited access to
facility-based health care. In Uganda, ICCM was extended to include
private health providers comprised mainly of drug shops targeting those
who offer care to children less than five years of age.
Drug shops are small medicine outlets authorised to sell class-C
drugs over- the- counter(OTC) that do not require prescription, used for
treating minor and self-limiting conditions. Class C drugs are regarded
as relatively safe drugs. They may also sell cosmetics and sundries
deemed fit for sale by the Uganda National Drug Authority (NDA) – the
medicine regulatory
agency12.
More than half (59%) of the children less than five years of age with
febrile illness first seek care from private health providers because of
physical in access to, and sometimes health system challenges in public
health
facilities13,14.
Despite receiving iCCM training and government inspection, inappropriate
treatment of febrile children persists among drug sellers in the small
medicine outlets15.
The national professional guidelines for licensing, renewal and new
licenses for class C drug shops in Uganda stipulate that licensed drug
sellers shall be responsible for supervising drug shops which they own
and or operate 16.
Relatedly, inspection of drug shops is carried out by the NDA on behalf
of MoH. The NDA does periodic inspection through zonal inspectors. The
zonal inspectors collaborate with District Drug Inspectors (DDIs) who
derive their inspection mandate from the District Health Officer (DHO)
at district level. Other officers under the DHO’s office are illustrated
in Fig. 1
Countrywide, DDIs are required to visit every drug shop in their
district once every month17. However, inspection
of drug shops by district drug inspectors and self-supervision as is
practised by licensed drug sellers in rural settings seem not to address
the inappropriate treatment of febrile illnesses in children less than
five years.
Aim of the study
This study assessed the effectiveness of peer-supervision among drug
sellers on appropriate treatment of pneumonia symptoms, uncomplicated
malaria, and non-bloody diarrhoea among children less than five years of
age in an intervention (Luuka) and comparison (Buyende) district in
East-Central Uganda.
Methods
2.1 Design of the study
This study employed a quasi-experimental study design18-20 that assessed the
proportion of children aged five years or less appropriately treated for
pneumonia symptoms, uncomplicated malaria and non-bloody diarrhoea. The
pre-intervention period was between May and October 2016 while peer
supervision was carried out from November 2016 to May 2017.
2.2 Setting of the study