Collaboration between private pharmacies and national tuberculosis programme: an intervention in Bolivia

Knowledge and Practices toward Tuberculosis Case Identification among Accredited Drug Dispensing Outlets Dispensers in Magu District, Northwestern Tanzania

Accredited Drug Dispensing Outlets dispensers (ADDO dispensers) have a crucial role in detecting and referring TB suspects. However, several studies highlight low knowledge of TB among ADDO dispensers. To facilitate this, the National TB and Leprosy Control Program trained ADDO dispensers on case identification and referral. Hence, this was a community-based cross-sectional study to determine the knowledge and practice of ADDO dispensers in the detection of active tuberculosis suspects in Magu Districts, Mwanza, Tanzania. This was a cross-sectional study that included 133 systematically selected ADDO dispensers. Out of 133 ADDO dispensers, 88 (66.9%) had attended TB training. About 108 (81%) participants had good knowledge of TB. The majority of ADDO dispensers 104 (78.4%) had poor practice toward the identification of TB cases. Attending training (AOR 4.49, CI 1.03-19.47), longer working experience (AOR 4.64, CI 1.99-10.81), and the presence of national TB guidelines (AOR 3.85, CI 1.11-13.34) was significantly associated with good self-reported TB case identification practices. Therefore, the study revealed adequate knowledge but with poor practice. Provisions to train ADDO dispensers in tuberculosis case detection and referral could yield great results.

Exploring the role of the private sector in tuberculosis detection and management in Lima, Peru: a mixed-methods patient pathway analysis

In Latin America, little is known about the involvement of private healthcare providers in TB detection and management. We sought to gain a better understanding of current and potential roles of the private sector in delivering TB services in Peru. We conducted a mixed-methods study in Lima, Peru. The quantitative component comprised a patient pathway analysis assessing the alignment of TB services with patient care-seeking behavior. The qualitative component comprised in-depth interviews with 18 private healthcare providers and 5 key informants. We estimated that 77% of patients initially sought care at a facility with TB diagnostic capacity and 59% at a facility with TB treatment capacity. The lack of TB services at initial care-seeking location was driven by the 41% of patients estimated to seek care first at a private facility. Among private facilities, 43% offered smear microscopy, 13% offered radiography, and none provided TB treatment. Among public sector facilities, 100% offered smear microscopy, 26% offered radiography, and 99% provided TB treatment. Interviews revealed that private providers believed that they offered shorter wait times and a quicker diagnosis, but they struggled with a lack of follow-up systems and communication barriers with the public sector. While expressing willingness to collaborate with public sector programs for diagnosis and referral, private providers had limited interest in treating TB. This study highlights the role of private providers in Peru as an entry point for TB care. Public-private collaboration is necessary to harness the potential of the private sector as an ally for early diagnosis.

Practical Models of Pharmaceutical Care for Improving Tuberculosis Patient Detection and Treatment Outcomes: A Systematic Scoping Review

Decreasing global tuberculosis (TB) notifications indicate problems related to TB patient detection and treatment outcomes. Pharmaceutical care (PC) has potential roles in managing these issues. However, PC practices have not yet become widespread in the real world. This systematic scoping review aimed to identify and analyze the current literature on practical models of pharmaceutical care for improving tuberculosis patient detection and treatment outcomes. We then discussed the present challenges and future considerations for the successful implementation of PC services in TB. A systematic scoping review was performed to identify the practice models of PC in TB. Systematic searches and screening were used to identify relevant articles in the PubMed and Cochrane databases. We then discussed the challenges and recommendations for successful implementation using a framework to improve professional healthcare practice. Our analysis included 14 of 201 eligible articles. We identified that the focuses in the PC of TB are on increasing patient detection (four articles) and improving TB treatment outcomes (ten articles). Practices cover services in the community and hospital settings, such as screening and referring people with presumptive TB, tuberculin test services, collaborative practices for treatment completion, directly observed treatment, the solution of drug-related problems, reporting and managing adverse drug reactions, and medication adherence programs. Although PC services positively increase TB patient detection and treatment outcomes, hidden challenges in the actual practice are analyzed. Several factors should be comprehensively considered in successful implementation, such as guidelines, individual pharmacy personnel, patient, professional interaction, organizational capacity, regulation, incentive, and resource factors. Hence, a collaborative PC program that involves all related stakeholders should be considered to create successful and sustainable PC services in TB.

Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions

BACKGROUND

To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB.

METHODS AND FINDINGS

In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence).

CONCLUSIONS

Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.

Community pharmacists-led interventions in tuberculosis care: A systematic review

BACKGROUND

A multidisciplinary approach is required to tackle the tuberculosis (TB) epidemic, which is one of the most pressing public health concerns worldwide. However, community pharmacists are underutilized in TB programs.

OBJECTIVE

To identify community pharmacists-led interventions in TB management with their corresponding impacts in TB case detection and treatment outcomes.

METHODS

A systematic search was performed in six electronic databases and health organization websites, from database inception to August 2, 2022. Studies which described TB screening, referral and/or treatment monitoring by community pharmacists with their corresponding outcomes were screened and reviewed independently by two reviewers. The studies were checked for the risk of bias using Cochrane risk of bias tools. All data of included studies were analysed qualitatively and presented narratively.

RESULTS

The search yielded 8,121 studies and five reports for initial screening. Sixteen studies and two case study reports were included in this review. Community pharmacists were involved throughout the TB care cascade, contributing their services in TB screening, referrals and in directly observed treatment-short course (DOTS) program. These interventions showed improvements in the effective control and prevention of further spread of TB, which improves individual, community and population level outcomes.

CONCLUSIONS

The inclusion of community pharmacists into TB program can improve the continuity of care, bridging the gaps in TB case detection and treatment monitoring. Adequate training and support are essential, to further empower the role of community pharmacists in TB control and prevention, in building a TB-free world.

Drug shops for stronger health systems: learning from initiatives in six LMICs

BACKGROUND

Private sector retail pharmacies, or drug shops, play an important role in access to essential medicines and services in low-and-middle-income countries. Recognising that they have the potential to contribute to health system strengthening efforts, many recent initiatives to engage with drug shops have been launched. These include initiatives that focus on changes in policy, regulation and training. However, the specific factors that influence their success remain poorly understood. Seven country case studies supported under the Alliance's programme of work 'Strengthening health systems: the role of drug shops' help to explore this issue.

METHODS

Country case studies from the above programme of research from Bangladesh, Indonesia, Myanmar, Nigeria, Tanzania and Zambia were used as the main sources of data for this paper. A modified version of Bigdeli et al.'s Access to Medicines framework was applied within a partially grounded approach to analyze each country case study and compare themes between countries.

RESULTS

Many factors may help initiatives targeting drug shops successfully achieve their intended outcomes. At the micro level, these include community demand for drug shops and a positive relationship between drug shops and their clients. At the meso level, facilitators of initiative success include training and positive attitudes from drug shops towards the initiative. Barriers include client pressure, procurement challenges and financial and administrative costs associated with initiatives. At the macro level, collaboration between stakeholders, high-level buy in and supervision, monitoring and regulation may influence initiative success. These factors are inter-dependent and interact with each other in a dynamic way.

CONCLUSIONS

Using a framework approach, these country case studies demonstrate common factors that influence how drug shops can strengthen health systems. These learnings can help inform the design and implementation of successful strategies to engage drug shops towards sustainable systems change.

Insights for the future of health system partnerships in low- and middle-income countries: a systematic literature review

BACKGROUND

Despite growing support for the private sector involvement in the provision of public health services in Low- and Middle-Income Countries (LMICs), a lack of clear information on the future of the provision of such services restricts the ability of managers and policy-makers to assess how feasible integration between public and private actors may be in these countries. This paper presents a systematic literature review which traces the dynamics and boundaries of public-private partnerships for the healthcare sector in LMICs.

METHODS

A total of 723 articles indexed in Scopus were initially submitted to bibliometric analysis. Finally, 148 articles published in several academic journals were selected for independent full-text review by two researchers. Content analysis was made in order to minimise mistakes in interpreting the findings of studies in the sample.

RESULTS

Public-private partnerships identified through the content analysis were categorised into four research areas: 1) Transfer of resources; 2) Co-production of health goods and services; 3) Governance networks; 4) Criteria for successful partnership development.

CONCLUSIONS

The four main research areas supply suggestions for a future research agenda, and managerial and policy implications for partnerships in LMICs.

Engaging Community Pharmacies in Early Detection of Missing Tuberculosis Patients through Public-Private Mix Intervention in Pakistan

Globally, Pakistan ranks fifth in terms of missing tuberculosis (TB) patients' burden. Missed TB cases are either undiagnosed or diagnosed but not notified to the national TB database. Public-private mix interventions are contributing significantly to the case detection, diagnosis, and treatment of TB in Pakistan. However, it is estimated that many cases of infected TB patients go undetected. It is likely that these "undiagnosed" active TB cases seek treatment from community pharmacies, among other venues. This study aimed at assessing the feasibility of community pharmacy-based TB case detection. Case detection protocol implementation in three Pakistani districts in a nonrandom selection of pharmacies was followed by a review of routinely maintained prospective records of patients referred from these private community pharmacies to general practitioner (GP) clinics. The study engaged 500 community pharmacies for referring presumptive TB patients to GP clinics. In total, 85% of the engaged pharmacies remained active in providing referrals during the study period. The community pharmacy-referral network achieved an annual referral rate of 3,025 presumptive TB patients and identified 547 active TB cases for the period January-December 2017. Every fifth referral among presumptives presenting and counseled at pharmacies was diagnosed with TB at GP clinics. This contribution was 9% of all new TB cases identified in these districts through all other private venues linked with the Greenstar Social Marketing setup. Identified barriers and facilitators to implementation and cost effectiveness of pharmacy models for TB case detection should be considered if the model were to be scaled up.

Quality of tuberculosis care by pharmacies in low- and middle-income countries: Gaps and opportunities

Pharmacies hold great potential to contribute meaningfully to tuberculosis (TB) control efforts, given their accessibility and extensive utilisation by communities in many high burden countries. Despite this promise, the quality of care provided by pharmacies in these settings for a range of conditions has historically been poor. This paper sets out to conceptualise the key issues surrounding quality of TB care in the low- and middle-income country pharmacy setting; examine the empirical evidence on quality of care; and review the interventions employed to improve this. A number of quality challenges are apparent in relation to anti-TB medicine availability, pharmacopeial quality of anti-TB medicines stocked, pharmacy workers’ knowledge, and management of patients both prior to and following diagnosis. Poor management practices include inadequate questioning of symptomatic patients, lack of referral for testing, over-the-counter sale of anti-TB medication as well as unnecessary and harmful medicines (e.g., antibiotics and steroids), and insufficient counselling. Interventions to improve pharmacy practice in relation to TB control have all fallen under the umbrella of public-private mix (PPM) initiatives, whereby pharmacies are engaged into national TB programmes to improve case detection. These interventions all involved training of pharmacists to refer symptomatic patients for testing and have enjoyed reasonable success, although achieving scale remains a challenge. Future interventions would do well to expand their focus beyond case detection to also improve counselling of patients and inappropriate medicine sales. The lack of pharmacy-specific global guidelines and the regulatory environment were identified as key areas for future attention.

Can community pharmacists improve tuberculosis case finding? A mixed methods intervention study in India

Introduction

India has the world’s highest burden of tuberculosis (TB). Private retail pharmacies are the preferred provider for 40% of patients with TB symptoms and up to 25% of diagnosed patients. Engaging pharmacies in TB screening services could improve case detection.

Methods

A novel TB screening and referral intervention was piloted over 18 months, under the pragmatic staggered recruitment of 105 pharmacies in Patna, India. The intervention was integrated into an ongoing public–private mix (PPM) programme, with five added components: pharmacy training in TB screening, referral of patients with TB symptoms for a chest radiograph (CXR) followed by a doctor consultation, incentives for referral completion and TB diagnosis, short message service (SMS) reminders and field support. The intervention was evaluated using mixed methods.

Results

81% of pharmacies actively participated in the intervention. Over 132.49 pharmacy person-years of observation in the intervention group, 1674 referrals were made and 255 cases of TB were diagnosed. The rate of registration of symptomatic patients was 62 times higher in the intervention group compared with the control group (95% CI: 54 to 72). TB diagnosis was 25 times higher (95% CI: 20 to 32). Microbiological testing and test confirmation were also significantly higher among patients diagnosed in the intervention group (p<0.001). Perceived professional credibility, patient trust, symptom severity and providing access to a free screening test were seen to improve pharmacists’ engagement in the intervention. Workload, patient demand for over-the-counter medicines, doctor consultation fees and programme documentation impeded engagement. An additional 240 cases of TB were attributed to the intervention, and the approximate cost incurred per case detected due to the intervention was US$100.

Conclusions

It is feasible and impactful to engage pharmacies in TB screening and referral activities, especially if working within existing public-private mix (PPM) programmes, appealing to pharmacies’ business mindset and among pharmacies with strong community ties.

Knowledge, attitudes and practices related to tuberculosis in pharmacy workers in a cross-sectional survey in El Agustino, Peru

Introduction

Although the worldwide incidence of tuberculosis (TB) is slowly decreasing, annual infection rates in Peru remain among the highest in the Americas. Pharmacies could play an important role in facilitating early detection of TB. However, the awareness, expertise and cooperation of pharmacy workers is fundamental. This study explored the TB-related knowledge, attitudes and practices of pharmacy workers in a district with one of the highest incidences of TB in Peru.

Methods

This cross-sectional study applied a questionnaire that was administered face to face using smartphones with one pharmacy worker at each of 45 randomly selected pharmacies in the El Agustino district of Lima, Peru.

Results

Participants were primarily female (78%) and had an average age of 31.3 years old (range 18–57 years old). Only 11% of participants were pharmacists with complete university training. The pharmacy workers’ knowledge was adequate; however, workers had important knowledge gaps and myths regarding prevention of TB transmission. Most pharmacy workers (77%) reported they would send a client with a history of cough for more than two weeks to a healthcare center, while 23% reported they would offer them antitussive medication or antibiotics. Almost all workers reported talking with clients about diseases and reported respiratory symptoms as one of the most common causes for consultation (60%). Most participants expressed interest in learning more about TB and expanding their involvement in the fight against TB in their community.

Conclusion

Pharmacy workers have adequate knowledge about TB. However, we identified gaps in knowledge with respect to prevention of TB transmission. Pharmacy workers commonly see patients with respiratory symptoms and some offer recommendations, including for treatment. Pharmacy workers are willing to learn more and contribute to TB control and could be a valuable asset in the control and prevention of TB in Peru. To achieve this integration of pharmacy workers into TB control and prevention, more research is needed.

Public-private mix for tuberculosis care and control: a systematic review

BACKGROUND

Public-private mix (PPM), recommended by the World Health Organization (WHO), was introduced to cope with the tuberculosis (TB) epidemic worldwide. In many developing countries, PPM has played a powerful role in TB control, while in others it has failed to meet expectations. Thus we performed a systematic review to determine the mechanisms used by global PPM programs implemented in different countries and to evaluate their performance.

METHODS

A comprehensive search of the current literature for original studies published up to May 2014 was done using electronic databases and online resources; these publications were then screened using rigorous criteria. Descriptive information and evaluative outcomes data were extracted from eligible studies for synthesis and analysis.

RESULTS

A total of 78 eligible studies were included in the final review. These assessed 48 PPM TB programs worldwide, subsequently categorized into three mechanisms based on collaborative characteristics: support, contract, and multi-partner group. Furthermore, we assessed the effectiveness of PPM programs against six health system themes, including utilization of the directly observed treatment strategy (DOTS), case detection, treatment outcomes, case management, costs, and access and equity, under the different collaborative mechanisms. Analysis of the comparative studies suggested that PPM could improve overall outcomes of a TB service, and multiple collaborative mechanisms may significantly promote case detection, treatment, referral, and service accessibility, especially in resource-limited areas. However, the less positive outcomes of several programs indicated limited funding and poor governance to be the predominant reasons.

CONCLUSIONS

PPM is a promising strategy to strengthen global TB care and control, but is affected by contextual characteristics in different areas. The scaling-up of PPM should contain essential commonalities, particularly substantial financial support and continuous material input. Additionally, it is important to improve program governance and training for the health providers involved, through integrated collaborative mechanisms.

Examining characteristics, knowledge and regulatory practices of specialized drug shops in Sub-Saharan Africa: a systematic review of the literature

BACKGROUND

Specialized drug shops such as pharmacies and drug shops are increasingly becoming important sources of treatment. However, knowledge on their regulatory performance is scarce. We set out to systematically review literature on the characteristics, knowledge and practices of specialized drug shops in Sub-Saharan Africa.

METHODS

We searched PubMed, EMBASE, WEB of Science, CAB Abstracts, PsycINFO and websites for organizations that support medicine policies and usage. We also conducted open searches using Google Scholar, and searched manually through references of retrieved articles. Our search included studies of all designs that described characteristics, knowledge and practices of specialized drug shops. Information was abstracted on authors, publication year, country and location, study design, sample size, outcomes investigated, and primary findings using a uniform checklist. Finally, we conducted a structured narrative synthesis of the main findings.

RESULTS

We obtained 61 studies, mostly from Eastern Africa, majority of which were conducted between 2006 and 2011. Outcome measures were heterogeneous and included knowledge, characteristics, and dispensing and regulatory practices. Shop location and client demand were found to strongly influence dispensing practices. Whereas shops located in urban and affluent areas were more likely to provide correct treatments, those in rural areas provided credit facilities more readily. However, the latter also charged higher prices for medicines. A vast majority of shops simply sold whatever medicines clients requested, with little history taking and counseling. Most shops also stocked popular medicines at the expense of policy recommended treatments. Treatment policies were poorly communicated overall, which partly explained why staff had poor knowledge on key aspects of treatment such as medicine dosage and side effects. Overall, very little is known on the link between regulatory enforcement and practices of specialized drug shops.

CONCLUSIONS

Evidence suggests that characteristics and practices of specialized drug shops differ across rural and urban locations, and that these providers are highly responsive to client demand. However, there is a dearth in knowledge on how regulatory enforcement influences their characteristics and practices, and what strategies can be employed to strengthen the governance of the retail pharmaceutical sector.

Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review

INTRODUCTION

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

METHODS AND FINDINGS

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

CONCLUSIONS

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

Can interventions improve health services from informal private providers in low and middle-income countries?: a comprehensive review of the literature

BACKGROUND There is a growing interest in the role of private health providers in low- and middle-income countries (LMICs). Informal private providers (IPPs) provide a significant portion of health care in many LMICs, but they have not received training in allopathic medicine. Interventions have been developed to take advantage of their potential to expand access to essential health services, although their success is not well measured. This paper addresses this information gap through a review of interventions designed to improve the quality, coverage, or costs of health services provided by IPPs in LMICs. METHODS A search for published literature in the last 15 years for any intervention dealing with IPPs in a LMIC, where at least one outcome was measured, was conducted through electronic databases PubMed and Global Health, as well as Google for grey literature from the Internet. RESULTS A total of 1272 articles were retrieved, of which 70 separate studies met inclusion criteria. The majority (70%) of outcomes measured proximate indicators such as provider knowledge (61% were positive) and behaviour (56% positive). Training IPPs was the most common intervention tested (77% of studies), but the more effective strategies did not involve training alone. Interventions that changed the institutional relationships and contributed to changing the incentives and accountability environment were most successful, and often required combinations of interventions. CONCLUSION Although there are documented interventions among IPPs, there are few good quality studies. Strategies that change the market conditions for IPPs-by changing incentives and accountability-appear more likely to succeed than those that depend on building individual capacities of IPPs. Understanding the effectiveness of these and other strategies will also require more rigorous research designs that assess contextual factors and document outcomes over longer periods.

The incremental cost-effectiveness of engaging private practitioners to refer tuberculosis suspects to DOTS services in Jogjakarta, Indonesia

We aimed to evaluate the incremental cost-effectiveness of engaging private practitioners (PPs) to refer tuberculosis (TB) suspects to public health centers in Jogjakarta, Indonesia. Effectiveness was assessed for TB suspects notified between May 2004 and April 2005. Private practitioners referred 1,064 TB suspects, of which 57.5% failed to reach a health center. The smear-positive rate among patients reaching a health center was 61.8%. Two hundred eighty (280) out of a total of 1,306 (21.4%) new smear-positive cases were enrolled through the PPs strategy. The incremental cost-effectiveness ratio per smear-positive case successfully treated for the PPs strategy was US$351.66 (95% CI 322.84-601.33). On the basis of an acceptability curve using the National TB control program's willingness-to-pay threshold (US$448.61), we estimate the probability that the PPs strategy is cost-effective at 66.8%. The strategy of engaging PPs was incrementally cost-effective, although under specific conditions, most importantly a well-functioning public directly observed treatment, short-course (DOTS) program.

Drugstore personnel's management of a tuberculosis suspect: consideration of actual and perceived management

Objective

To explore drugstore personnel's knowledge and practice on management of a suspected case of tuberculosis (TB).

Method

Seventy randomly selected drugstores in Songkhla province of Southern Thailand were visited by simulated clients (SCs) who asked for medication for relieving a one-month cough with fever. All questions asked by the drugstore personnel, advice given and drugs dispensed were noted and analysed. The drugstores were subsequently visited and the managers were interviewed.

Key findings

For the SC study, 55 out of 70 (79%) drugstore personnel took a history before dispensing drugs, but only 14 (20%) asked about cough duration. Only four drugstore personnel identified TB as a possible diagnosis for a case with one-month cough and fever, and only three recommended the SC to see a doctor. From the interviews, 46 (66%) perceived the probability of encountering TB at their workplace to be low. The knowledge on symptoms of suspected TB was poor. Sixty-eight (97%) would suspect TB if and only if the client with prolonged cough also had tiredness, weight loss, difficulty breathing or haemoptysis. In contrast to their practice with the SC, 46 (66%) claimed that they would recommend a client with one-month cough and fever to see a doctor.

Conclusions

The majority of drugstore personnel failed to detect suspected TB cases and did not give a proper referral. Interventions to educate drugstore personnel to recognise symptoms of suspected TB and to become aware in TB epidemics in this setting are urgently needed.

A stratified random survey of the proportion of poor quality oral artesunate sold at medicine outlets in the Lao PDR - implications for therapeutic failure and drug resistance

BACKGROUND

Counterfeit oral artesunate has been a major public health problem in mainland SE Asia, impeding malaria control. A countrywide stratified random survey was performed to determine the availability and quality of oral artesunate in pharmacies and outlets (shops selling medicines) in the Lao PDR (Laos).

METHODS

In 2003, 'mystery' shoppers were asked to buy artesunate tablets from 180 outlets in 12 of the 18 Lao provinces. Outlets were selected using stratified random sampling by investigators not involved in sampling. Samples were analysed for packaging characteristics, by the Fast Red Dye test, high-performance liquid chromatography (HPLC), mass spectrometry (MS), X-ray diffractometry and pollen analysis.

RESULTS

Of 180 outlets sampled, 25 (13.9%) sold oral artesunate. Outlets selling artesunate were more commonly found in the more malarious southern Laos. Of the 25 outlets, 22 (88%; 95%CI 68-97%) sold counterfeit artesunate, as defined by packaging and chemistry. No artesunate was detected in the counterfeits by any of the chemical analysis techniques and analysis of the packaging demonstrated seven different counterfeit types. There was complete agreement between the Fast Red dye test, HPLC and MS analysis. A wide variety of wrong active ingredients were found by MS. Of great concern, 4/27 (14.8%) fakes contained detectable amounts of artemisinin (0.26-115.7 mg/tablet).

CONCLUSION

This random survey confirms results from previous convenience surveys that counterfeit artesunate is a severe public health problem. The presence of artemisinin in counterfeits may encourage malaria resistance to artemisinin derivatives. With increasing accessibility of artemisinin-derivative combination therapy (ACT) in Laos, the removal of artesunate monotherapy from pharmacies may be an effective intervention.

Private local pharmacies in low- and middle-income countries: a review of interventions to enhance their role in public health

OBJECTIVES

To review the evidence regarding the potential of pharmacy services to play an enhanced role in contributing to health care and policy initiatives in low- and middle-income countries.

METHODS

Literature search, using computer and hand searching, to identify original research reporting the results of interventions to improve services from private local pharmacies in low- and middle-income countries.

RESULTS

Eighteen studies were identified which spanned all regions: 12 evaluations of training initiatives, three studies evaluating the impact of policy of regulatory interventions, one regarding a collaboration of pharmacy services with a national TB programme, and two evaluating a pharmaceutical care initiative for patients with hypertension. A total of 14 studies used advice and recommendations to simulated clients as the primary outcome measures. Whilst most studies reported some improvements to practice, these were often small, limited to specific outcomes and believed to be short-lived.

CONCLUSION

The studies in this review demonstrate international interest in enhancing the place of pharmacy services in the provision and delivery of health care. But the small number of studies provides inadequate evidence on how to assure the quality of local pharmacy services can be assured, or how to develop them within a wider reform framework.

Private practitioners and tuberculosis case detection in Jogjakarta, Indonesia: actual role and potential

BACKGROUND

Indonesia has a high tuberculosis (TB) prevalence and a large private health sector.

OBJECTIVES

To explore the potential of private practitioners (PP) in TB control in Jogjakarta by assessing their load of TB suspects and case-management practices.

METHODS

We conducted a cross-sectional telephone survey of a random sample of 164 PP, weighted to the local proportions of specialists, general practitioners (GP), nurses and midwives. We investigated their knowledge of directly observed treatment, short-course (DOTS), whether they see TB suspects, whether they refer such patients and how they possibly diagnose and treat TB.

RESULTS

We sampled 174 PP, of which 164 (94.3%) completed the interview. Most PP (63.4%) reported to have seen TB suspects in their private practice, and 62.8% were also employed in a DOTS facility. Specialists saw on average 18 suspects, GP 11 suspects, and nurses-midwives three suspects in a year. Many PP (45.2%) always relied on National Tuberculosis Control Programme (NTP) services for diagnosis. Fewer PP (41.5%) used, by themselves, diagnostic procedures complying with the NTP guidelines. The majority (63.6%) always referred confirmed cases for treatment, mainly (71.4%) to NTP services. Most PP (72.7%) who treated TB patients themselves did not prescribe the NTP standard regimen.

CONCLUSION

The study shows that the TB case load per PP is low in Jogjakarta, where the NTP already involves public and private hospitals besides public health centres. Initiatives to engage all PP might only marginally contribute in increasing the TB case detection.