Drug shops in integrated community case management of malaria, pneumonia and diarrhoea in Uganda: Appropriateness of care and adherence to treatment guidelines

Introduction. Private drug shops are an important source of care for children in sub-Saharan Africa, with about half of sick children seeking care at this level. However, these drug shops receive minimal regulation and government oversight and little is documented about the quality of care they provide, although it is generally known to be poor. A strategy recommended by WHO and UNICEF for integrated community based management of childhood illnesses through community health workers exists, within the public sector. This is the integrated community case management (iCCM) of malaria, pneumonia and diarrhoea intervention. However, this iCCM intervention is not available at the level of drug shops, which see the majority of sick children in Uganda. Aim. To determine the feasibility and effect on appropriateness of care of introducing the iCCM intervention (diagnostic tests; pre-packaged paediatric dosage drugs for malaria, pneumonia and diarrhoea; training and community awareness) within private sector registered drug shops in eastern Uganda. Methods. Three studies (1-III) were conducted using a quasi experimental design in one intervention and one comparison district between May 2011 and June 2012. Household surveys, exit interviews, focus group discussions and in-depth interviews were conducted before (at baseline) and after the intervention (at end-line) in both areas. The baseline sample size was calculated for cross sectional studies, to determine the proportion of appropriate treatment for malaria, pneumonia and diarrhoea respectively, as these were unknown. The end-line sample size was increased based on the baseline proportion of appropriate treatment and assuming 50% improvement in appropriateness of treatment for household survey and 100% improvement for exit interviews. A total of 3759 (1604 before/2155 after) households interviews and 943 (163 before/780 after) exit interviews were conducted with caretakers of children under five years of age. The role and appropriateness of care provided by drug shops in treating childhood illnesses (study I) was determined from the baseline data by computation of proportions. The effect of the iCCM intervention on appropriateness of care at drug shops was determined using generalized linear regression models and difference-in-difference analysis, comparing baseline and end-line data (study II). For study III, the proportion of adherence to treatment protocols was determined from a review of the drug shop treatment registers, which included 7,667 child visits. Results. From the baseline assessment, the majority of children with a recent illness sought care in the private sector 496 (53%) compared to the public sector (154, 16.5%). However, at the level of drug shops, only 15 (10%) received appropriate treatment for malaria and almost none for pneumonia symptoms or diarrhoea. With the introduction of the iCCM intervention at drug shops in the intervention area, 88% (95% CI 79.0 – 96.4) of children with fever received parasite diagnosis of malaria prior to treatment with appropriate drugs. Further, children with pneumonia symptoms or diarrhoea in the intervention area were 3 (2.8; 95% CI 2.0 – 3.9) and 13 times (12.8; 95% CI 4.2 – 38.6) more likely to receive appropriate treatment with amoxicillin and oral rehydration salts + Zinc, respectively. Finally, from the review of registers, 90% of children categorized as having either malaria, pneumonia or diarrhoea or a mix of these classifications were treated according to the iCCM guidelines. Conclusion. Introduction of the iCCM intervention at drug shops in rural Uganda resulted in high levels of appropriateness of care for malaria, pneumonia and diarrhoea in children and high adherence to treatment protocols by drug shop attendants