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.