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