Intervention district with peer supervision
Investigators of this study used peer-supervision to augment the current
self-supervision being practiced by drug sellers. Peer-supervision was
aimed at supporting inspection of drug sellers by DDIs since evidence
shows that inspection coupled with supervision improves quality of
care21.
Peer-supervision is a type of supervision where supervisees encourage
and enhance learning and development as peers. Peers are people of
similar hierarchical status or who perceive themselves as
equal22. Since peer
supervision had been successful elsewhere 23-25, it
was envisaged that learning and development facilitated by peers would
improve drug seller treatment of febrile illnesses in children under
five years of age.
The intervention was carried out in Luuka district which has a total
population of 238,020 persons26. Presently, the
district has no hospital, has one health centre level IV, six health
centres level III and 16 health centres level II.
Peer-supervisors in the intervention district were chosen according to
proposed criteria. The criteria involved peer supervisors being
democratically chosen by drug sellers from that particular sub-county by
show of hands. Having higher academic qualifications compared to other
drug sellers was the second criteria. In the event that the peer
supervisors chosen had similar qualifications, the person with the
highest number of votes became the peer supervisor for that sub-county.
Each sub-county in the intervention district had a peer supervisor. The
peer supervisors underwent refresher iCCM training in October 2016. The
refresher training was carried out by the investigators of the study and
was based on iCCM guidelines by WHO/UNICEF adopted by the Ministry of
Health Uganda27. The
training lasted a total of three days for each supervisor in each
sub-county. Peer supervisors were deemed fit for supervision if they
could explain to the trainers what constituted appropriate treatment
including recognizing danger signs in children less than five years with
pneumonia symptoms, uncomplicated malaria and non-bloody diarrhoea. The
training was supplemented by clearly defining roles for peer
supervisors. These roles included; instructing and monitoring drug
sellers on how to correctly fill sick child registers. In addition, peer
supervisors were taught how to counsel drug sellers that were not giving
appropriate treatment to children under five years of age. Peer
supervisors were also mandated to cross check with drug sellers whether
the respiratory timers and brand of RDTs being used were the recommended
ones by the ministry of health.
More so, peer supervisors were taught how to be role models in their
course of supervision by advising drug sellers to adhere to treatment
guidelines. Peer supervisors were instructed to adhere to the highest
form of privacy, professionalism, integrity and empathy. In all
sub-counties of the intervention district, peer supervisors were tasked
to work with an active district drug shop association where drug sellers
met every month particularly, to attend continuous medical education
organized by the drug shop association secretariat.
Peer supervisors were then provided with supervision checklists were
they were asked to summarise treatment given to children by drug sellers
on a monthly basis. The summarised information from the checklists was
used by investigators to corroborate with information of drug shop sick
child registers filled in by drug sellers every month. This was done to
ensure accuracy of data filled in by drug sellers and data collected by
peer supervisors. To ease the work of peer supervisors, the peer
supervisors were also provided with summary extracts from iCCM treatment
and referral algorithms27.
In line with guidelines for data collectors of the school of public
health, Makerere, Uganda, every peer supervisor was given a safari day
allowance of 80,000 Uganda shillings (equivalent to USD 22 at an
exchange rate of USD 1 equal to 3,700 Uganda shillings). A safari day
allowance is paid when a data collector travels within Uganda for a
period of six hours or more and returns the same day. It is paid to
cater for lunch, transport and other incidentals. The assumption was
that each peer supervisor would visit all drug sellers within the
sub-county every month and that supervision visits would not exceed one
day.
The aim of peer supervision was to strengthen the existing health system
by supporting the district local government. During peer supervision,
the peer supervisors worked directly under the office of the DDI who
carried on his inspection role as usual.