Private and public health care in rural areas of Uganda

Understanding the delay in identifying Sudan Virus Disease: gaps in integrated disease surveillance and response and community-based surveillance to detect viral hemorrhagic fever outbreaks in Uganda, September 2022

BACKGROUND

Early detection of outbreaks requires robust surveillance and reporting at both community and health facility levels. Uganda implements Integrated Disease Surveillance and Response (IDSR) for priority diseases and uses the national District Health Information System (DHIS2) for reporting. However, investigations after the first case in the 2022 Uganda Sudan virus outbreak was confirmed on September 20, 2022 revealed many community deaths among persons with Ebola-like symptoms as far back as August. Most had sought care at private facilities. We explored possible gaps in surveillance that may have resulted in late detection of the Sudan virus disease (SVD) outbreak in Uganda.

METHODS

Using a standardized tool, we evaluated core surveillance capacities at public and private health facilities at the hospital level and below in three sub-counties reporting the earliest SVD cases in the outbreak. Key informant interviews (KIIs) were conducted with 12 purposively-selected participants from the district local government. Focus group discussions (FGDs) were conducted with community members from six villages where early probable SVD cases were identified. KIIs and FGDs focused on experiences with SVD and Viral Hemorrhagic Fever (VHF) surveillance in the district. Thematic data analysis was used for qualitative data.

RESULTS

Forty-six (85%) of 54 health facilities surveyed were privately-owned, among which 42 (91%) did not report to DHIS2 and 39 (85%) had no health worker trained on IDSR; both metrics were 100% in the eight public facilities. Weak community-based surveillance, poor private facility engagement, low suspicion index for VHF among health workers, inability of facilities to analyze and utilize surveillance data, lack of knowledge about to whom to report, funding constraints for surveillance activities, lack of IDSR training, and lack of all-cause mortality surveillance were identified as gaps potentially contributing to delayed outbreak detection.

CONCLUSION

Both systemic and knowledge-related gaps in IDSR surveillance in SVD-affected districts contributed to the delayed detection of the 2022 Uganda SVD outbreak. Targeted interventions to address these gaps in both public and private facilities across Uganda could help avert similar situations in the future.

Preventing zoonotic and zooanthroponotic disease transmission at wild great ape sites: Recommendations from qualitative research at Bwindi Impenetrable National Park

Employees at wild great ape sites are at high risk of transmitting infectious diseases to endangered great apes. Because of the significant amount of time employees spend near great apes, they are a priority population for the prevention and treatment of zoonotic and zooanthroponotic spillover and need adequate preventive and curative healthcare. Qualitative, semi-structured interviews with 46 staff (rangers and porters) at Bwindi Impenetrable National Park, Uganda (BINP) and key informants from five other wild great ape sites around the world were performed. The objectives of the study were to 1) evaluate health-seeking behavior and health resources used by staff in contact with great apes at Bwindi Impenetrable National Park; 2) evaluate existing occupational health programs for employees working with great apes in other parts of the world; and 3) make recommendations for improvement of occupational health at BINP. Results show that BINP employees do not frequently access preventive healthcare measures, nor do they have easy access to diagnostic testing for infectious diseases of spillover concern. Recommendations include assigning a dedicated healthcare provider for great ape site staff, providing free annual physical exams, and stocking rapid malaria tests and deworming medication in first aid kits at each site.

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Uptake of community health care provision by community health entrepreneurs for febrile illness and diarrhoea: a cross-sectional survey in rural communities in Bunyangabu district, Uganda

OBJECTIVE

To assess the uptake of services provided by community health workers who were trained as community health entrepreneurs (CHEs) for febrile illness and diarrhoea.

DESIGN

A cross-sectional survey among households combined with mapping of all providers of basic medicine and primary health services in the study area.

PARTICIPANTS

1265 randomly selected households in 15 rural villages with active CHEs.

SETTING

Bunyangabu district, Uganda.

OUTCOME MEASURES

We describe the occurrence and care sought for fever and diarrhoea in the last 3 months by age group in the households. Care provider options included: CHE, health centre or clinic (public or private), pharmacy, drug shop and other. Geographic Information Ssystem (GIS)-based geographical measures were used to map all care providers around the active CHEs.

RESULTS

Fever and diarrhoea in the last 3 months occurred most frequently in children under 5; 68% and 41.9%, respectively. For those who sought care, CHE services were used for fever among children under 5, children 5-17 and adults over 18 years of age in 34.7%, 29.9% and 25.1%, respectively. For diarrhoea among children under 5, children 5-17 and adults over 18 years of age, CHE services were used in 22.1%, 19.5% and 7.0%, respectively. For those who did not seek care from a CHE (only), drug shops were most frequently used services for both fever and diarrhoea, followed by health centres or private clinics. Many households used a combination of services, which was possible given the high density and diversity of providers found in the study area.

CONCLUSIONS

CHEs play a considerable role in providing care in rural areas where they are active. The high density of informal drug shops and private clinics highlights the need for clarity on the de facto roles played by different providers in both the public and private sector to improve primary healthcare.

Engagement with Traditional Healers for Early Detection of Plague in Uganda

In rural Uganda, many people who are ill consult traditional healers prior to visiting the formal healthcare system. Traditional healers provide supportive care for common illnesses, but their care may delay diagnosis and management of illnesses that can increase morbidity and mortality, hinder early detection of epidemic-prone diseases, and increase occupational risk to traditional healers. We conducted open-ended, semi-structured interviews with a convenience sample of 11 traditional healers in the plague-endemic West Nile region of northwestern Uganda to assess their knowledge, practices, and attitudes regarding plague and the local healthcare system. Most were generally knowledgeable about plague transmission and its clinical presentation and expressed willingness to refer patients to the formal healthcare system. We initiated a public health outreach program to further improve engagement between traditional healers and local health centers to foster trust in the formal healthcare system and improve early identification and referral of patients with plaguelike symptoms, which can reflect numerous other infectious and noninfectious conditions. During 2010-2019, 65 traditional healers were involved in the outreach program; 52 traditional healers referred 788 patients to area health centers. The diagnosis was available for 775 patients; malaria (37%) and respiratory tract infections (23%) were the most common diagnoses. One patient had confirmed bubonic plague. Outreach to improve communication and trust between traditional healers and local healthcare settings may result in improved early case detection and intervention not only for plague but also for other serious conditions.

Medium-to-long term sustainability of a health systems intervention to improve service readiness and quality of non-communicable disease (NCD) patient care and experience at primary care settings in Uganda

BACKGROUND

With the double burden of rising chronic non-communicable diseases (NCDs) and persistent infectious diseases facing sub-Saharan Africa, integrated health service delivery strategies among resource-poor countries are needed. Our study explored the post-trial sustainability of a health system intervention to improve NCD care, introduced during a cluster randomised trial between 2013 and 2016 in Uganda, focusing on hypertension (HT) and type-2 diabetes mellitus (DM) services. In 2020, 19 of 38 primary care health facilities (HFs) that constituted the trial's original intervention arm until 2016 and 3 of 6 referral HFs that also received the intervention then, were evaluated on i) their facility performance (FPS) through health worker knowledge, and service availability and readiness (SAR), and ii) the quality-of-patient-care-and-experience (QoCE) received.

METHODS

Cross-sectional data from the original trial (2016) and our study (2020) were compared. FPS included a clinical knowledge test with 222 health workers: 131 (2016) and 91 (2020) and a five-element SAR assessment of all 22 HFs. QoCE assessment was performed among 420 patients: 88 (2016) and 332 (2020). Using a pair-matched approach, FPS and QoCE summary scores were compared. Linear and random effects Tobit regression models were also analysed.

RESULTS

The mean aggregate facility performance (FPS) in 2020 was lower than in 2016: 70.2 (95%CI = 66.0-74.5) vs. 74.8 (95%CI = 71.3-78.3) respectively, with no significant difference (p = 0.18). Mean scores declined in 4 of 5 SAR elements. Overall FPS was negatively affected by rural or urban HF location relative to peri-urban HFs (p < 0.01). FPS was not independently predicted but patient club functionality showed weak association (p = 0.09). QoCE declined slightly to 8.7 (95%CI = 8.4-91) in 2020 vs 9.5 (95%CI = 9.1-9.9) in 2016 (p = 0.02) while the proportion of patients receiving adequate quality care also declined slightly to 88.2% from 98.5% respectively, with no statistical difference (p = 0.20). Only the parent district weakly predicted QoCE (p = 0.05).

CONCLUSIONS

Four years after the end of research-related support, overall facility performance had declined as expected because of the interrupted supplies and a decline in regular supervision. However, both service availability and readiness and quality of HT/DM care were surprisingly well preserved. Sustainability of an NCD intervention in similar settings may remain achievable despite the funding instability following a trial's end but organisational measures to prepare for the post-trial phase should be taken early on in the intervention process.

Barriers to accessing malaria treatment amongst school-age children in rural Malawi

BACKGROUND

Over the last two decades, many countries have moved from malaria control toward malaria elimination. However, some sub-Saharan African countries, like Malawi, have recently seen a reversal in malaria control progress with reported increases in confirmed malaria cases. This may be the result of inadequate access to effective malaria control interventions by key population groups that perpetuate transmission. This study aimed to assess the barriers to accessing malaria treatment among school-aged children (SAC) in Malawi.

METHODS

A qualitative study was conducted between September and October 2020, where data were gathered in rural Malawi using free-listing interviews, key-informant interviews, semi-structured interviews and focus group discussions. Purposively sampled participants included SAC, parents of SAC, health workers and key stakeholders at community and district levels. Interviews were digitally recorded and transcribed verbatim. Data were organized using NVivo 12 software and analysed using the thematic method.

RESULTS

The study recruited 252 participants, with 156 being SAC, equally divided between boys and girls. Health system barriers to malaria treatment included long waiting hours and queues at clinics, frequent stock-outs of medical supplies, and travel time to the facility. Provider barriers included negative attitude and limited service hours. Individual and cultural barriers included fear of malaria tests and beliefs associating witchcraft as the best treatment for malaria. In addition, COVID-19-related barriers included the inability to follow preventive measures, a shift in focus from malaria to COVID-19, and fear of contracting COVID-19 and/or being tested for COVID-19 at the facility.

CONCLUSIONS

This study shows most of the barriers to accessing malaria treatment among SAC are similar to those experienced by other population groups. Furthermore, COVID-19 adversely affected SAC's access to treatment. Interventions that support SAC access to prompt diagnosis and treatment are urgently needed to improve the effective control of malaria.

Impacts of the COVID-19 Lockdown on Healthcare Inaccessibility and Unaffordability in Uganda

Several studies have reported adverse consequences of the COVID-19 lockdowns on the utilization of healthcare services across Africa. However, little is known about the channels through which lockdowns impacted healthcare utilization. This study focuses on unaffordability as a reason for not utilizing healthcare services. We estimate the causal impacts of the COVID-19 lockdown on healthcare inaccessibility and affordability in Uganda relative to the nonlockdown periods of the pandemic. We use nationally representative longitudinal household data and a household fixed-effects model to identify the impact of the lockdown on whether households could not access medical treatment and whether the reason for not getting care was the lack of money. We find that the lockdown in Uganda was associated with an 8.4% higher likelihood of respondents being unable to access healthcare when treatment was needed relative to the nonlockdown periods. This implies a 122% increase in the share of respondents unable to access healthcare. As lockdown restrictions eased, the likelihood of being unable to access medical treatment decreased. The main reason for the increase in inaccessibility was the lack of money, with a 71% increase in the likelihood of respondents being unable to afford treatment. We find little evidence that the effects of the lockdown differed by wealth status or area of residence. Our results indicate the need for policymakers to consider immediate social support for households as a strategy for balancing the disruptions caused by lockdowns.

Starting at the community: Treatment-seeking pathways of children with suspected severe malaria in Uganda

Community health workers (CHW) usually refer children with suspected severe malaria to the nearest public health facility or a designated public referral health facility (RHF). Caregivers do not always follow this recommendation. This study aimed at identifying post-referral treatment-seeking pathways that lead to appropriate antimalarial treatment for children less than five years with suspected severe malaria. An observational study in Uganda enrolled children below five years presenting to CHWs with signs of severe malaria. Children were followed up 28 days after enrolment to assess their condition and treatment-seeking history, including referral advice and provision of antimalarial treatment from visited providers. Of 2211 children included in the analysis, 96% visited a second provider after attending a CHW. The majority of CHWs recommended caregivers to take their child to a designated RHF (65%); however, only 59% followed this recommendation. Many children were brought to a private clinic (33%), even though CHWs rarely recommended this type of provider (3%). Children who were brought to a private clinic were more likely to receive an injection than children brought to a RHF (78% vs 51%, p<0.001) and more likely to receive the second or third-line injectable antimalarial (artemether: 22% vs. 2%, p<0.001, quinine: 12% vs. 3%, p<0.001). Children who only went to non-RHF providers were less likely to receive an artemisinin-based combination therapy (ACT) than children who attended a RHF (odds ratio [OR] = 0.64, 95% CI 0.51-0.79, p<0.001). Children who did not go to any provider after seeing a CHW were the least likely to receive an ACT (OR = 0.21, 95% CI 0.14-0.34, p<0.001). Health policies should recognise local treatment-seeking practices and ensure adequate quality of care at the various public and private sector providers where caregivers of children with suspected severe malaria actually seek care.

Nearly half of adults with symptoms of sexually transmitted infections (STIs) did not seek clinical care: A population-based study of treatment-seeking behavior among adults in Rakai, Uganda

Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment seeking in low-resource settings is rare. This population-based study aimed to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among adults with STI-related symptoms in rural Uganda. The STI prevalence study (STIPS) conducted a survey and STI testing among all consenting adults aged 18-49 in two communities in rural south-central Uganda. Of 1,825 participants, 962 individuals self-reported STI symptoms in the past six months; we present descriptive data on treatment seeking and STI prevalence among these individuals. We used multivariable Poisson regressions with robust variance to determine the sociodemographic and symptom-related factors independently associated with seeking STI treatment at a clinic and assessed the association with previous clinic treatment seeking and current STI diagnosis. Forty-three percent of adults who reported STI-related symptoms in the past six months said they did not seek any treatment. Among those who did, 58% sought treatment at a private clinic, 28% at a government clinic, 9% at a pharmacy/drug store, 3% at a traditional healer, 2% at a market/shop, and 5% at another location. Among both males and females, having multiple STI related symptoms was positively associated with clinic treatment seeking (males = PRR: 1.73, 95%CI: 1.36-2.21; females = PR: 1.41, 95%CI: 1.12-1.78). Approximately one-third of males and females who reported previously seeking clinic treatment for their symptoms were diagnosed with a curable STI at the time of the survey. In this setting, nearly half of adults with STI-related symptoms are not seeking clinical care and many who report having sought treatment for recent STI symptoms have curable STIs. Future studies should explore barriers to care-seeking and strategies to improve STI services.

Antibiotic dispensing practices during COVID-19 and implications for antimicrobial resistance (AMR): parallel mystery client studies in Uganda and Tanzania

BACKGROUND

Over-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller-client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic.

METHODS

Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms =  415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs  = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed.

RESULTS

Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client's symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.

CONCLUSION

Our study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.

Macro environment determinants affecting the availability of artemisinin-based combination therapies in Uganda

Purpose

Artemisinin-based combination therapies (ACTs) have been developed to treat uncomplicated malaria. However, scanty studies exist to inform the role of macro factors in explaining the nonavailability of ACT in developing countries. Therefore, this paper aims to evaluate the different macro-environment factors affecting the availability of ACTs in the public hospital setting.

Design/methodology/approach

This study applied a quantitative methodological approach and structural equation modeling (SEM) to test hypotheses statistically. SEM examines linear causal relationships among variables while accounting for measurement error. Confirmatory factor analysis (CFA) was used to assess model reliability. CFA and SEM were used to determine the shared variance-covariance of variables, define the latent construct and provide a more precise way to account for the error variances associated with the variables, which, if untested, could lead to biased parameter estimates. This was guided by the data collected from 40 general public hospitals with 283 respondents.

Findings

This study’s results support a model for promoting social-cultural, technological and legal factors. The availability of ACTs is significantly affected by legal factors. Improving legal aspects by a unit can enhance ACT availability by 0.59. Political factors scored the least, and they do not influence the availability of malaria drugs.

Research limitations/implications

The design was quantitative and cross-sectional. Future research could be longitudinal with a mixed-method approach and consider other external stakeholders.

Practical implications

Reducing the impact of the nonavailability of antimalarial drugs in general public hospitals requires a holistic concerted and coordinated supply chain approach that tackles the political, economic, social-cultural norms, technological and legal factors.

Originality/value

The authors develop and test a model using macro factors: political, economic, social, cultural, technological and legal factors. This model is relevant for many developing countries to supply chain coordination perpetually experiencing medicine shortages.

Girl child marriage and its association with maternal healthcare services utilization in sub-Saharan Africa

Background

Previous studies on child marriage have revealed its association with adverse health behaviors and outcomes, such as increased fertility, reduced modern family planning, less safe delivery, mental health disorders, suicidal attempt, and ideation, poor socio-economic status, morbidity, and mortality of children under- five. In this study, we investigate the association between child marriage and the utilization of maternal healthcare services in sub-Saharan Africa.

Methods

We utilized data from 29 sub-Saharan African countries’ Demographic and Health Surveys conducted between 2010 and 2018. A total of 36,215 childbearing young women between the ages of 20-24 years constituted our sample size. A multilevel binary logistic regression analysis was carried out to examine the association between child marriage and the utilization of maternal healthcare services, and the results were presented as crude and adjusted odds ratios at 95% confidence interval.

Results

Young women who experienced child marriage were less likely to have  ≥4 antenatal care visits during pregnancy [cOR = 0.60, CI = 0.57-0.63] compared to those who did not experience child marriage, and this was persistent after controlling for individual and community-level factors [aOR = 0.88, CI = 0.84-0.93]. Young women who experienced child marriage were less likely to use skilled birth attendance during delivery [cOR = 0.45, CI = 0.43-0.48] compared to those who did not experience child marriage, and this was persistent after controlling for individual and community-level factors [aOR = 0.87, CI = 0.82-0.93]. Young women who experienced child marriage were less likely to use postnatal care services [cOR = 0.79, CI = 0.75-0.82] compared to those who did not experience child marriage, but this was insignificant after controlling for individual and community-level factors.

Conclusion

Our study found child marriage to be a major contributor to the low use of maternal healthcare services, including antenatal care visit and the use of skilled birth attendance during child delivery. Hence, there is a need to develop an intervention to address child marriage in sub-Saharan Africa and strengthen existing ones. In addition, framework that considers child marriage as a key determinant of maternal healthcare utilization must be developed as part of policies in sub-Saharan African countries to enable universal achievement of low maternal mortality ratio by 2030 as a target of the Sustainable Development Goals.

Lay Health Workers in Community-Based Care and Management of Dementia: A Qualitative ‘Pre’ and ‘Post’ Intervention Study in Southwestern Uganda

Background

The global need for efficient and cost-effective use of healthcare resources in low-income countries has led to the introduction of lay health workers (LHWs) as a link of the community to healthcare services. As such, the LHWs perform a variety of tasks such as education, support for care delivery, and social support across all disease types. However, little is known about their ability to support dementia care and management in the community.

Purpose

The goal of the pilot intervention was to evaluate the 5-day training intervention for LHWs in rural southwestern Uganda in community-based care and management of people with dementia, and implementation of the knowledge and skills gained.

Methods

This was a “pre” and “post” pilot intervention study which involved a qualitative assessment of LHWs' knowledge on community-based management and care for people with dementia. We focused on four core competency domains in the WHO dementia toolkit. The intervention included a five-day training of the LHWs on dementia care, eight weeks of implementation, and an evaluation of the experiences. Analysis focused on the needs assessment, early detection and management, community engagement, support for people with dementia; and evaluation of the eight weeks implementation.

Results

Before the training, the LHWs did not know much about what dementia-related support to provide in the community. Activities were limited to general support, including nutrition, and health education. After the training, LHWs had a basic understanding of dementia and began sensitizing the communities. They felt more comfortable working with people with dementia and reported a notable change in the attitude of family members. However, they reported challenges in differentiating the signs of early dementia from superstitious beliefs.

Conclusion

With enhanced capacity, LHWs may be able to support community-based management for people with dementia. A larger study is needed to explore potential roles for LHWs and further assess effectiveness of the LHWs' skills.

Health supply chain system in Uganda: current issues, structure, performance, and implications for systems strengthening

Background

The health supply chain system is essential for the optimum performance of the healthcare system. Despite increased investments in the health supply chain system, access to quality Essential Medicines and Health Supplies remain a big challenge in Uganda. This article discusses the structure, performance, and challenges of the health supply chain system in Uganda. It provides reflections and implications for ongoing interventions for system strengthening.

Discussions

The findings highlight several issues and challenges affecting the health supply chain system from functioning optimally across all levels of the health system. The challenges identified include an ineffective structure to support planning, coordination and management, inadequate funding, shortage of skilled staff, weak regulatory and governance structures at national and sub-national levels, and slow adoption and use of Electronic Logistics Information Systems to support supply chain processes and functions. Overcoming these challenges will require greater investments to improve policy development and implementation, infrastructure, equipment and support systems, knowledge and skills of supply chain personnel, increased funding and improving governance and accountability.

Dual Use of Public and Private Health Care Services in Brazil

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose–response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Exposure to different types of mass media and timing of antenatal care initiation: insights from the 2016 Uganda Demographic and Health Survey

BACKGROUND

Early initiation of antenatal care (ANC) within the first trimester is highly recommended in the current 2016 World Health Organization (WHO) guidelines. Mass media has the potential to promote early initiation of ANC because it has been used successfully in several programs. However, there is paucity of literature on the effect of exposure to different types of media on the timing of ANC initiation in Uganda. Our study aimed at exploring associations between exposure to different types of mass media and timing of ANC initiation among women in Uganda.

METHODS

We used a cross sectional study design, to conduct a secondary analysis of data collected in the 2016 Uganda Demographic and Health Survey (UDHS). We included weighted data of all the 10,152 women of reproductive age (15-49 years). Multistage stratified sampling was used to select study participants. Multivariable logistic regression was used to determine the association between exposure to different types of mass media and early initiation of ANC.

RESULTS

Almost a third of the women (2953/10,152, 29.1%, 95% CI 27.9-29.6) initiated their first ANC contact in the first trimester. Women who listened to radio at least once a week (adjusted OR (aOR 1.14, 95% CI 1.01-1.30) and those who watched television less than once a week (aOR 1.28, 95% CI 1.07-1.53) had higher odds of initiating ANC earlier compared to their counterparts not exposed to radio and television respectively.

CONCLUSION

Exposure to radio and television is associated with timing of ANC initiation in Uganda. Importantly, the two types of mass media have the potential to reach women with low levels of education and encourage them to utilize maternal health services. The Ugandan government needs to prioritize and intensify the use of radio and television to promote the benefits associated with timing of ANC initiation.

Lived experiences of frontline healthcare providers offering maternal and newborn services amidst the novel corona virus disease 19 pandemic in Uganda: A qualitative study

BACKGROUND

The COVID-19 pandemic has brought many health systems in low resource settings to their knees. The pandemic has had crippling effects on the already strained health systems in provision of maternal and newborn healthcare. With the travel restrictions, social distancing associated with the containment of theCOVID-19 pandemic, healthcare providers could be faced with challenges of accessing their work stations, and risked burnout as they offered maternal and newborn services. This study sought to understand the experiences and perceptions of healthcare providers at the frontline during the first phase of the lockdown as they offered maternal and newborn health care services in both public and private health facilities in Uganda with the aim of streamlining patient care in face of the current COVID-19 pandemic and in future disasters.

METHODS

Between June 2020 and December 2020, 25 in-depth interviews were conducted among healthcare providers of different cadres in eight Public, Private-Not-for Profit and Private Health facilities in Kampala, Uganda. The interview guide primarily explored the lived experiences of healthcare providers as they offered maternal and newborn healthcare services during the COVID-19 pandemic. All of the in depth interviews were audio recorded and transcribed verbatim. Themes and subthemes were identified using both inductive thematic and phenomenological approaches.

RESULTS

The content analysis of the in depth interviews revealed that the facilitators of maternal and newborn care service delivery among the healthcare providers during the COVID-19 pandemic included; salary bonuses, the passion to serve their patients, availability of accommodation during the pandemic, transportation to and from the health facilities by the health facilities, teamwork, fear of losing their jobs and fear of litigation if something went wrong with the mothers or their babies. The barriers to their service delivery included; lack of transport means to access their work stations, fear of contracting COVID-19 and transmitting it to their family members, salary cuts, loss of jobs especially in the private health facilities, closure of the non-essential services to combat high patient numbers, inadequate supply of Personal Protective equipment (PPE), being put in isolation or quarantine for two weeks which meant no earning, brutality from the security personnel during curfew hours and burnout from long hours of work and high patient turnovers.

CONCLUSION

The COVID-19 Pandemic has led to a decline in quality of maternal and newborn service delivery by the healthcare providers as evidenced by shorter consultation time and failure to keep appointments to attend to patients. Challenges with transport, fears of losing jobs and fear of contracting COVID-19 with the limited access to personal protective equipment affected majority of the participants. The healthcare providers in Uganda despite the limitations imposed by the COVID-19 pandemic are driven by the inherent passion to serve their patients. Availability of accommodation and transport at the health facilities, provision of PPE, bonuses and inter professional teamwork are critical motivators that needed to be tapped to drive teams during the current and future pandemics.

Healthcare Seeking and Access to Care for Pneumonia, Sepsis, Meningitis, and Malaria in Rural Gambia

Children with acute infectious diseases may not present to health facilities, particularly in low-income countries. We investigated healthcare seeking using a cross-sectional community survey, health facility-based exit interviews, and interviews with customers of private pharmacies in 2014 in Upper River Region (URR) The Gambia, within the Basse Health & Demographic Surveillance System. We estimated access to care using surveillance data from 2008 to 2017 calculating disease incidence versus distance to the nearest health facility. In the facility-based survey, children and adult patients sought care initially at a pharmacy (27.9% and 16.7% respectively), from a relative (23.1% and 28.6%), at a local shop or market (13.5% and 16.7%), and on less than 5% of occasions with a community-based health worker, private clinic, or traditional healer. In the community survey, recent symptoms of pneumonia or sepsis (15% and 1.5%) or malaria (10% and 4.6%) were common in children and adults. Rates of reported healthcare-seeking were high with families of children favoring health facilities and adults favoring pharmacies. In the pharmacy survey, 47.2% of children and 30.4% of adults had sought care from health facilities before visiting the pharmacy. Incidence of childhood disease declined with increasing distance of the household from the nearest health facility with access to care ratios of 0.75 for outpatient pneumonia, 0.82 for hospitalized pneumonia, 0.87 for bacterial sepsis, and 0.92 for bacterial meningitis. In rural Gambia, patients frequently seek initial care at pharmacies and informal drug-sellers rather than community-based health workers. Surveillance underestimates disease incidence by 8-25%.

Healthworker preparedness for COVID-19 management and implementation experiences: a mixed methods study in Uganda's refugee-hosting districts

Background

The negative impact of COVID-19 on population health outcomes raises critical questions on health system preparedness and resilience, especially in resource-limited settings. This study examined healthworker preparedness for COVID-19 management and implementation experiences in Uganda’s refugee-hosting districts.

Methods

A cross sectional, mixed-method descriptive study in 17 health facilities in 7 districts from 4 major regions. Total sample size was 485 including > 370 health care workers (HCWs). HCW knowledge, attitude and practices (KAP) was assessed by using a pre-validated questionnaire. The quantitative data was processed and analysed using SPSS 26, and statistical significance assumed at p < 0.05 for all statistical tests. Bloom's cutoff of 80% was used to determine threshold for sufficient knowledge level and practices with scores classified as high (80.0–100.0%), average (60.0–79.0%) and low (≤ 59.0%). HCW implementation experiences and key stakeholder opinions were further explored qualitatively using interviews which were audio-recorded, coded and thematically analysed.

Results

On average 71% of HCWs were knowledgeable on the various aspects of COVID-19, although there is a wide variation in knowledge. Awareness of symptoms ranked highest among 95% (p value < 0.0001) of HCWs while awareness of the criteria for intubation for COVID-19 patients ranked lowest with only 35% (p value < 0.0001). Variations were noted on falsehoods about COVID-19 causes, prevention and treatment across Central (p value < 0.0356) and West Nile (p value < 0.0161) regions. Protective practices include adequate ventilation, virtual meetings and HCW training. Deficient practices were around psychosocial and lifestyle support, remote working and contingency plans for HCW safety. The work environment has immensely changed with increased demands on the amount of work, skills and variation in nature of work. HCWs reported moderate control over their work environment but with a high level of support from supervisors (88%) and colleagues (93%).

Conclusions

HCWs preparedness is inadequate in some aspects. Implementation of healthcare interventions is constrained by the complexity of Uganda’s health system design, top-down approach of the national response to COVID-19 and longstanding health system bottlenecks. We recommend continuous information sharing on COVID-19, a design review with capacity strengthening at all health facility levels and investing in community-facing strategies.

Capacity to provide care for common childhood infections at low-level private health facilities in Western, Uganda

BACKGROUND

Low-level private health facilities (LLPHFs) handle a considerable magnitude of sick children in low-resource countries. We assessed capacity of LLPHFs to manage malaria, pneumonia, diarrhea, and, possible severe bacterial infections (PSBIs) in under-five-year-olds.

METHODS

We conducted a cross-sectional survey in 110 LLPHFs and 129 health workers in Mbarara District, Uganda between May and December 2019. Structured questionnaires and observation forms were used to collect data on availability of treatment guidelines, vital medicines, diagnostics, and equipment; health worker qualifications; and knowledge of management of common childhood infections.

RESULTS

Amoxicillin was available in 97%, parental ampicillin and gentamicin in 77%, zinc tablets and oral rehydration salts in >90% while artemether-lumefantrine was available in 96% of LLPHF. About 66% of facilities stocked loperamide, a drug contraindicated in the management of diarrhoea in children. Malaria rapid diagnostic tests and microscopes were available in 86% of the facilities, timers/clocks in 57% but only 19% of the facilities had weighing scales and 6% stocked oxygen. Only 4% of the LLPHF had integrated management of childhood illness (IMCI) booklets and algorithm charts for management of common childhood illnesses. Of the 129 health workers, 52% were certificate nurses/midwives and (26% diploma nurses/clinical officers; 57% scored averagely for knowledge on management of common childhood illnesses. More than a quarter (38%) of nursing assistants had low knowledge scores. No notable significant differences existed between rural and urban LLPHFs in most parameters assessed.

CONCLUSION

Vital first-line medicines for treatment of common childhood illnesses were available in most of the LLPHFs but majority lacked clinical guidelines and very few had oxygen. Majority of health workers had low to average knowledge on management of the common childhood illnesses. There is need for innovative knowledge raising interventions in LLPHFs including refresher trainings, peer support supervision and provision of job aides.

An assessment of the knowledge, practices and resources during the delivery of malaria health care services among private health care practitioners: a cross section study in the Mid-Western Region of Uganda

BACKGROUND

Approximately 50 % of the population in Uganda seeks health care from private facilities but there is limited data on the quality of care for malaria in these facilities. This study aimed to document the knowledge, practices and resources during the delivery of malaria care services, among private health practitioners in the Mid-Western region of Uganda, an area of moderate malaria transmission.

METHODS

This was a cross sectional study in which purposive sampling was used to select fifteen private-for-profit facilities from each district. An interviewer-administered questionnaire that contained both quantitative and open-ended questions was used. Information was collected on availability of treatment aides, knowledge on malaria, malaria case management, laboratory practices, malaria drugs stock and data management. We determined the proportion of health workers that adequately provided malaria case management according to national standards.

RESULTS

Of the 135 health facilities staff interviewed, 61.48 % (52.91-69.40) had access to malaria treatment protocols while 48.89 % (40.19-57.63) received malaria training. The majority of facilities, 98.52 % (94.75-99.82) had malaria diagnostic services and the most commonly available anti-malarial drug was artemether-lumefantrine, 85.19 % (78-91), followed by Quinine, 74.81 % (67-82) and intravenous artesunate, 72.59 % (64-80). Only 14.07 % (8.69-21.10) responded adequately to the acceptable cascade of malaria case management practice. Specifically, 33.33 % (25.46-41.96) responded correctly to management of a patient with a fever, 40.00 % (31.67-48.79) responded correctly to the first line treatment for uncomplicated malaria, whereas 85.19 % (78.05-90.71) responded correctly to severe malaria treatment. Only 28.83 % submitted monthly reports, where malaria data was recorded, to the national database.

CONCLUSIONS

This study revealed sub-optimal malaria case management knowledge and practices at private health facilities with approximately 14 % of health care workers demonstrating correct malaria case management cascade practices. To strengthen the quality of malaria case management, it is recommended that the NMCD distributes current guidelines and tools, coupled with training; continuous mentorship and supportive supervision; provision of adequate stock of essential anti-malarials and RDTs; reinforcing communication and behavior change; and increasing support for data management at private health facilities.

Appropriateness of Care for Common Childhood Infections at Low-Level Private Health Facilities in a Rural District in Western Uganda

In Uganda, >50% of sick children receive treatment from primary level-private health facilities (HF). We assessed the appropriateness of care for common infections in under-five-year-old children and explored perspectives of healthcare workers (HCW) and policymakers on the quality of healthcare at low-level private health facilities (LLPHF) in western Uganda. This was a mixed-methods parallel convergent study. Employing multistage consecutive sampling, we selected 110 HF and observed HCW conduct 777 consultations of children with pneumonia, malaria, diarrhea or neonatal infections. We purposively selected 30 HCW and 8 policymakers for in-depth interviews. Care was considered appropriate if assessment, diagnosis, and treatment were correct. We used univariable and multivariable logistic regression analyses for quantitative data and deductive thematic analysis for qualitative data. The proportion of appropriate care was 11% for pneumonia, 14% for malaria, 8% for diarrhea, and 0% for neonatal infections. Children with danger signs were more likely to receive appropriate care. Children with diarrhea or ability to feed orally were likely to receive inappropriate care. Qualitative data confirmed care given as often inappropriate, due to failure to follow guidelines. Overall, sick children with common infections were inappropriately managed at LLPHF. Technical support and provision of clinical guidelines should be increased to LLPHF.

Immediate postnatal care following childbirth in Ugandan health facilities: an analysis of Demographic and Health Surveys between 2001 and 2016

Introduction

Progress in reducing maternal and neonatal mortality, particularly in sub-Saharan Africa, is insufficient to achieve the Sustainable Developmental Goals by 2030. The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,<50% of women reported receiving such care. This paper describes the coverage, changes over time and determinants of immediate postnatal care in Uganda after facility births between 2001 and 2016.

Methods

We analysed the 2006, 2011 and 2016 Ugandan Demographic and Health Surveys, including women 15–49 years with most recent live birth in a healthcare facility during the survey 5-year recall period. Immediate postnatal care coverage and changes over time were presented descriptively. Multivariable logistic regression was used to examine determinants of immediate postnatal care.

Results

Data from 12 872 mothers were analysed. Between 2006 and 2016, births in healthcare facilities increased from 44.6% (95% CI: 41.9% to 47.3%) to 75.2% (95% CI: 73.4% to 77.0%) and coverage of immediate maternal postnatal care from 35.7% (95% CI 33.4% to 38.1%) to 65.0% (95% CI: 63.2% to 66.7%). The majority of first checks occurred between 1 and 4 hours post partum; the median time reduced from 4 hours to 1 hour. The most important factor associated with receipt of immediate postnatal care was women having a caesarean section birth adjusted OR (aOR) 2.93 (95% CI: 2.28 to 3.75). Other significant factors included exposure to mass media aOR 1.38 (95% CI: 1.15 to 1.65), baby being weighed at birth aOR 1.84 (95% CI: 1.58 to 2.14) and receipt of antenatal care with 4+Antenatal visits aOR 2.34 (95% CI: 1.50 to 3.64).

Conclusion

In Uganda, a large gap in coverage remains and universal immediate postnatal care has not materialised through increasing facility-based births or longer length of stay. To ensure universal coverage of high-quality care during this critical time, we recommend that maternal and newborn services should be integrated and actively involve mothers and their partners.

Effectiveness of peer-supervision on pediatric fever illness treatment among registered private drug sellers in East-Central Uganda: An interrupted time series analysis

RATIONALE AIMS AND OBJECTIVES

Appropriate treatment of pediatric fever in rural areas remains a challenge and maybe partly due to inadequate supervision of licensed drug sellers. This study assessed the effectiveness of peer-supervision among drug sellers on the appropriate treatment of pneumonia symptoms, uncomplicated malaria, and non-bloody diarrhea among children less than 5 years of age in the intervention (Luuka) and comparison (Buyende) districts, in East-Central Uganda.

METHODS

Data on pneumonia symptoms, uncomplicated malaria, and non-bloody diarrhea among children less than 5 years of age was abstracted from drug shop sick child registers over a 12-month period; 6 months before and 6 months after the introduction of peer-supervision. Interrupted time series were applied to determine the effectiveness of the peer-supervision intervention on the appropriate treatment of pneumonia, uncomplicated malaria, and non-bloody diarrhea among children less than 5 years of age attending drug shops in East Central Uganda.

RESULTS

The proportion of children treated appropriately for pneumonia symptoms was 10.84% (P < .05, CI = [1.75, 19.9]) higher, for uncomplicated malaria was 1.46% (P = .79, CI = [-10.43, 13.36]) higher, and for non-bloody diarrhea was 4.00% (P < .05, CI = [-7.95, -0.13]) lower in the intervention district than the comparison district, respectively.Post-intervention trend results showed an increase of 1.21% (P = .008, CI = [0.36, 2.05]) in the proportion appropriately treated for pneumonia symptoms, no difference in appropriate treatment for uncomplicated malaria, and a reduction of 1% (P < .06, CI = [-1.95, 0.02]) in the proportion of children appropriately treated for non-bloody diarrhea, respectively.

CONCLUSIONS

Peer-supervision increased the proportion of children less than 5 years of age that received appropriate treatment for pneumonia symptoms but not for uncomplicated malaria and non-bloody diarrhea. Implementation of community-level interventions to improve pediatric fever management should consider including peer-supervision among drug sellers.

A qualitative study of the perspectives of health workers and policy makers on external support provided to low-level private health facilities in a Ugandan rural district, in management of childhood infections

BACKGROUND

With the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda should accelerate measures to reduce child deaths to achieve the Sustainable Development Goal 3. While 60-70% of frontline health services are provided by the private sector, many low-level private health facilities (LLPHF) are unregistered, unregulated, and often miss innovative and quality improvement strategies rolled out by the Ministry of Health. LLPHF need support in order to provide quality health care.

OBJECTIVE

To explore the perspectives of health workers and policy makers on external support given to LLPHF providing health care for children in Mbarara District, Uganda.

METHODS

We carried out a qualitative study, in which 43 purposively selected health workers and policy makers were interviewed. The issues discussed included their views on the quantity, quality, factors determining support received and preferred modalities of support to LLPHF. We used thematic analysis, employing an inductive approach to code interview transcripts and to identify subthemes and themes.

RESULTS

The support currently provided to LLPHF to manage childhood illnesses is inadequate. Health providers emphasised a need for technical capacity building, provision of policies, guidelines and critical supplies as well as adopting a more supportive supervisory approach instead of the current supervision model characterised by policing, fault finding and apportioning blame. Registration of the health facilities and regular submission of reports as well as multi-stakeholder involvement are potential strategies to improve external support.

CONCLUSION

The current support received by LLPHF is inadequate in quantity and quality. Capacity building with emphasis on training, provision of critical guidelines and supplies as well as and supportive supervision are key strategies for delivering appropriate external support to LLPHF.

Regulatory inspection of registered private drug shops in East-Central Uganda-what it is versus what it should be: a qualitative study

Background

Regulatory inspection of private drug shops in Uganda is a mandate of the Ministry of Health carried out by the National Drug Authority. This study evaluated how this mandate is being carried out at national, district, and drug shop levels. Specifically, perspectives on how the inspection is done, who does it, and challenges faced were sought from inspectors and drug sellers.

Methods

Six key informant interviews (KIIs) were held with inspectors at the national and district level, while eight focus group discussions (FGDs) were conducted among nursing assistants, and two FGDs were held with nurses. The study appraised current methods of inspecting drug sellers against national professional guidelines for licensing and renewal of class C drug shops in Uganda. Transcripts were managed using Atlas ti version 7 (ATLAS.ti GmbH, Berlin) data management software where the thematic content analysis was done.

Results

Five themes emerged from the study: authoritarian inspection, delegated inspection, licensing, training, and bribes. Under authoritarian inspection, drug sellers decried the high handedness used by inspectors when found with expired or no license at all. For delegated inspection, drug sellers said that sometimes, inspectors send health assistants and sub-county chiefs for inspection visits. This cadre of people is not recognized by law as inspectors. Inspectors trained drug sellers on how to organize their drug shops better and how to use new technologies such as rapid diagnostic tests (RDTs) in diagnosing malaria. Bribes were talked about mostly by nursing assistants who purported that inspectors were not interested in inspection per se but collecting illicit payments from them. Inspectors said that the facilitation they received from the central government were inadequate for a routine inspection.

Conclusion

The current method of inspecting drug sellers is harsh and instills fear among drug sellers. There is a need to establish a well-recognized structure of inspection as well as establish channels of dialogue between inspectors and drug sellers if meaningful compliance is to be achieved. The government also needs to enhance both human and financial resources if meaningful inspection of drug sellers is to take place.

Factors influencing the inappropriate use of antibiotics in the Rupandehi district of Nepal

INTRODUCTION

Antimicrobial resistance is a global public health crisis. A major driver of resistance is inappropriate antibiotic use, resulting from practices of prescribers, dispensers and patients. The purpose of this study was to identify the perception of service providers and policymakers about the inappropriate use of antibiotics in Nepal.

METHODS

A qualitative study was conducted to explore factors influencing antibiotic use. Participants included 17 service providers and policymakers from the Rupandehi district in Nepal, with a semi-structured interview schedule adopted. Data were analysed using thematic analysis to identify themes relating to the inappropriate use of antibiotics.

RESULTS

Inappropriate use of antibiotics was found to result from the interaction of demand and supply factors, together with a weak regulatory environment. Lack of knowledge by consumers and financial constraints resulted in practices such as self-medication and pressure being placed on providers to prescribe or dispense antibiotics. An insufficient choice of antibiotics, and health services not having investigation facilities, was also factors leading to inappropriate use of antibiotics. Additionally, in the private sector, the profit motive arising from incentives provided by pharmaceutical companies contributed to prescribing or dispensing antibiotics inappropriately.

CONCLUSION

Promoting appropriate antibiotic use is critical to reduce the growing public health threat of antibiotic resistance. A multi-faceted approach involving policymakers, providers, and the general public using both educational and regulatory measures is required to address this problem in Nepal, and potentially also in other low-income countries with a similar healthcare system.

What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments

BACKGROUND

Monitoring progress towards Universal Health Coverage (UHC) requires an assessment of progress in coverage of health services and protection of households from the impact of direct out-of-pocket payments (i.e. financial risk protection). Although Uganda has expressed aspirations for attaining UHC, out-of-pocket payments remain a major contributor to total health expenditure. The aim of this study is to monitor progress in financial risk protection in Uganda.

METHODS

This study uses data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17. We measure financial risk protection using catastrophic health care payments and impoverishment indicators. Health care payments are catastrophic if they exceed a set threshold (i.e. 10 and 25%) of the total household consumption expenditure. Health payments are impoverishing if they push the household below the poverty line (the US$1.90/day and Uganda's national poverty lines). A logistic regression model is used to assess the factors associated with household financial risk.

RESULTS

The results show that while progress has been made in reducing financial risk, this progress remains minimal, and there is still a risk of a reversal of this trend. We find that although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, it increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line (US$1.90/day) has decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varies across socio-economic status, location and residence. In addition, certain household characteristics (poverty, having a child below 5 years and an adult above 60 years) are more associated with the lack of financial risk protection.

CONCLUSION

There is need for targeted interventions to reduce OOP, especially among those affected so as to increase financial risk protection. In the short-term, it is important to ensure that public health services are funded adequately to enable effective coverage with quality health care. In the medium-term, increased reliance on mandatory prepayment will reduce the burden of OOP health spending further.

Peer supervision experiences of drug sellers in a rural district in East-Central Uganda: a qualitative study

BACKGROUND

Support supervision improves performance outcomes among health workers. However, the national professional guidelines for new licenses and renewal for Class C drug shops in Uganda prescribe self-supervision of licensed private drug sellers. Without support supervision, inappropriate treatment of malaria, pneumonia and diarrhoea among children under 5 years of age continues unabated. This study assessed experiences of drug sellers and peer supervisors at the end of a peer supervision intervention in Luuka District in East Central Uganda.

METHODS

Eight in-depth interviews (IDIs) were held with peer supervisors while five focus group discussions (FGDs) were conducted among registered drug sellers at the end of the peer supervision intervention. The study assessed experiences and challenges of peer supervisors and drug sellers regarding peer supervision. Transcripts were imported into Atlas.ti 7 qualitative data management software where they were analysed using thematic content analysis.

RESULTS

Initially, peer supervisors were disliked and regarded by drug sellers as another extension of drug inspectors. However, with time a good relationship was established between drug sellers and peer supervisors leading to regular, predictable and supportive peer supervision. This increased confidence of drug sellers in using respiratory timers and rapid diagnostic tests in diagnosing pneumonia symptoms and uncomplicated malaria, respectively, among children under 5 years. There was also an improvement in completing the sick child register which was used for self-assessment by drug sellers. The drug shop association was mentioned as a place where peer supervision should be anchored since it was a one-stop centre for sharing experiences and continuous professional development. Drug sellers proposed including community health workers in monthly drug shop association meetings so that they may also gain from the associated benefits. Untimely completion of the sick child registers by drug sellers and inadequate financial resources were the main peer supervision challenges mentioned.

CONCLUSION

Drug sellers benefitted from peer supervision by developing a good relationship with peer supervisors. This relationship guaranteed reliable and predictable supervision ultimately leading to improved treatment practices. There is need to explore the minimum resources needed for peer supervision of drug sellers to further inform practice and policy.

Factors Motivating Traditional Healer versus Biomedical Facility Use for Treatment of Pediatric Febrile Illness: Results from a Qualitative Study in Southwestern Uganda

Febrile illnesses, such as malaria and pneumonia, are among the most common causes of mortality in children younger than 5 years in Uganda outside of the neonatal period. Their impact could be mitigated through earlier diagnosis and treatment at biomedical facilities; however, it is estimated that a large percentage of Ugandans (70-80%) seek traditional healers for their first line of medical care. This study sought to characterize individual and structural influences on health care-seeking behaviors for febrile children. Minimally structured, qualitative interviews were conducted for 34 caregivers of children presenting to biomedical and traditional healer sites, respectively. We identified six themes that shape the pathway of care for febrile children: 1) peer recommendations, 2) trust in biomedicine, 3) trust in traditional medicine, 4) mistrust in providers and therapies, 5) economic resources and access to health care, and 6) perceptions of child health. Biomedical providers are preferred by those who value laboratory testing and formal medical training, whereas traditional healer preference is heavily influenced by convenience, peer recommendations, and firm beliefs in traditional causes of illness. However, most caregivers concurrently use both biomedical and traditional therapies for their child during the same illness cycle. The biomedical system is often considered as a backup when traditional healing "fails." Initiatives seeking to encourage earlier presentation to biomedical facilities must consider the individual and structural forces that motivate seeking traditional healers. Educational programs and cooperation with traditional healers may increase biomedical referrals and decrease time to appropriate care and treatment for vulnerable/susceptible children.

Social networks for health communication in rural Uganda: A mixed-method analysis of Dekabusa Trading Centre, Luwero County

To reach the most vulnerable individuals in under-resourced countries, health communication interventions increasingly move towards the community level. However, little is known about how health information spreads through local social networks. This paper maps the health information network of a rural trading centre in Uganda. As part of a five-year ethnographic study of sustainable community health resources, ego networks were obtained for 231 village residents in March 2014. Using both ethnographic and social network data, we analyze how the village social network is structured, and how this structure may influence the transmission of health information. Results show a network with low average proximity, with a small number of individuals, notably key administrative officials, much closer connected to many other community members than average. However, because of social partitioning in the village network, a number of people are outside the social clusters in which the top influencers are located.

Sputum smear non-conversion among adult persons with bacteriologically confirmed pulmonary tuberculosis in rural eastern Uganda

Rationale

Failure to convert sputum at two months of treatment among persons with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) indicates poor response to treatment but data are limited on its assessment.

Objective

We determined the frequency and factors associated with sputum smear non-conversion at two months among persons with BC-PTB in eastern Uganda.

Methods

We abstracted data of adult persons with BC-PTB, from routinely available records from TB registers at 10 clinics in eastern Uganda. We determined factors that are independently associated with sputum smear non-conversion using logistic regression analysis. We expressed the results as odds ratio (OR) with 95% confidence interval (CI).

Measurements and main results

Of 516 persons with BC-PTB, 81 (15.7%) did not achieve sputum smear conversion at two months of TB treatment. Higher Mycobacteria tuberculosis (MTB) load and treatment at a private-not-for-profit (PNFP) facility compared to government health facility were significantly associated with sputum smear non-conversion. A one unit (+1) increase in MTB load based on ZN stain counts was associated with a 48% increase in the odds of sputum smear non-conversion with adjusted odds ratio (AOR), 1.48 (95% CI, 1.02-2.18). TB treatment at private-not-for-profit health facility was associated with a two-fold increase in the odds of sputum smear non-conversion (AOR, 2.03; 95% CI, 1.01-3.92).

Conclusions

Our study shows that sputum smear non-conversion is common at two months of treatment in this population. It is more likely among patients with higher baseline MTB load and those treated at PNFP facilities. Strategies targeting patients with these risk factors are needed to enhance sputum smear conversion.

Conceptual model for pluralistic healthcare behaviour: results from a qualitative study in southwestern Uganda

INTRODUCTION

Medical pluralism, or concurrent utilisation of multiple therapeutic modalities, is common in various international contexts, and has been characterised as a factor contributing to poor health outcomes in low-resource settings. Traditional healers are ubiquitous providers in most regions, including the study site of southwestern Uganda. Where both informal and formal healthcare services are both available, patients do not engage with both options equally. It is not well understood why patients choose to engage with one healthcare modality over the other. The goal of this study was to explain therapeutic itineraries and create a conceptual framework of pluralistic health behaviour.

METHODS

In-depth interviews were conducted from September 2017 to February 2018 with patients seeking care at traditional healers (n=30) and at an outpatient medicine clinic (n=30) in Mbarara, Uganda; the study is nested within a longitudinal project examining HIV testing engagement among traditional healer-using communities. Inclusion criteria included age ≥18 years, and ability to provide informed consent. Participants were recruited from practices representing the range of healer specialties. Following an inductive approach, interview transcripts were reviewed and coded to identify conceptual categories explaining healthcare utilisation.

RESULTS

We identified three broad categories relevant to healthcare utilisation: (1) traditional healers treat patients with 'care'; (2) biomedicine uses 'modern' technologies and (3) peer 'testimony' influences healthcare engagement. These categories describe variables at the healthcare provider, healthcare system and peer levels that interrelate to motivate individual engagement in pluralistic health resources.

CONCLUSIONS

Patients perceive clear advantages and disadvantages to biomedical and traditional care in medically pluralistic settings. We identified factors at the healthcare provider, healthcare system and peer levels which influence patients' therapeutic itineraries. Our findings provide a basis to improve health outcomes in medically pluralistic settings, and underscore the importance of recognising traditional healers as important stakeholders in community health.

Assessing Providers' Approach to Hypertension Management at a Large, Private Hospital in Kampala, Uganda

Background:

Hypertension is increasingly prevalent in Uganda and its clinical management remains suboptimal across the country. Prior research has elucidated some of the factors contributing to poor control, but little is known about providers’ approaches to hypertension management and perceptions of barriers to care. This is particularly true in private health care settings – despite the fact that the private sector provides a substantial and growing portion of health care in Uganda.

Objective:

Our exploratory, pragmatic qualitative study aimed to examine the factors affecting the quality of hypertension care from the perspective of providers working in an urban, private hospital in Uganda. We focused on the organizational and system-level factors influencing providers’ approaches to management in the outpatient setting.

Methods:

We conducted interviews with 19 health care providers working in the outpatient setting of a 110-bed, private urban hospital in Kampala, Uganda. We then coded the interviews for thematic analysis, using an inductive approach to generate the study’s findings.

Findings:

Several themes emerged around perceived barriers and facilitators to care. Providers cited patient beliefs and behaviors, driven in part by cultural norms, as a key challenge to hypertension control; however, most felt their own approach to hypertension treatment aligned with international guidelines. Providers struggled to collaborate with colleagues in coordinating the joint management of patients. Furthermore, they cited the high cost and limited availability of medication as barriers.

Conclusions:

These findings offer important strategic direction for intervention development specific to this Ugandan context: for example, regarding culturally-adapted patient education initiatives, or programs to improve access to essential medications. Other settings facing similar challenges scaling up management of hypertension may find the results useful for informing intervention development as well.

Biomedical drugs and traditional treatment in care seeking pathways for adults with epilepsy in Masindi district, Western Uganda: a household survey

BACKGROUND

Many patients with epilepsy in sub-Saharan Africa do not receive adequate treatment. The purpose of the study was to identify the health care providers where patients with epilepsy sought care and what treatment they received.

METHODS

A cross sectional study was conducted across 87 out of 312 villages in Masindi district. A total of 305 households having patients with epilepsy were surveyed using an interviewer administered questionnaire. Data was entered and analysed in Epi-info ver 7 for univariate and bivariate analysis, and in Stata SE ver 15.0 for multivariable analysis. Sequences of health providers consulted in care seeking, rationale and drugs used, and factors associated with choice of provider were assessed.

RESULTS

A total of 139 out of 305 (45.6%) households offered some treatment regimen at home when patients got symptoms of epilepsy with 44.6% (62/139) giving herbs and 18.0% (25/139) offering prayers. Eight different types of providers were consulted as first contact providers for treatment of epilepsy. Health centres received the highest percentage 35.4% (108/305) followed by hospitals 20.9% (64/305). A total of 192 of 305 (63.0%) households received anti-epileptic drugs, 13.1% (40/305) received prayers and 21.6% (66/305) received herbs at the first contact care seeking. Compared to a health centre as the first choice provider, other facilities more significantly visited were; hospitals if they were perceived as nearer (adj. Coeff 2.16, 95%CI 0.74, 3.59, p = 0.003), churches / mosques if cure for epilepsy was expected (adj. Coeff 1.91, 95%CI 0.38, 3.48, p = 0.014), and traditional healer for those aged ≥46 years (adj. Coeff 5.83, 95%CI 0.67, 10.99, p = 0.027), and friends/neighbour for traders (adj. Coeff 2.87, 95%CI 0.71, 5.04, p = 0.009).

CONCLUSION

Patients with epilepsy seek treatment from multiple providers with the public sector attending to the biggest proportion of patients. Engaging the private sector and community health workers, conducting community outreaches and community sensitization with messages tailored for audiences including the young, older epileptics, traditional healers as stakeholders, and traders could increase access to appropriate treatment for epilepsy.

Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study

Objective:

A qualitative study was conducted to gain insight into challenges reported by Butaleja households during a previous household survey. Specifically, this paper discusses heads of households’ and caregivers’ perceptions of challenges they face when seeking care for their very young children with fever presumed to be malaria.

Methods:

Eleven focus groups (FGs) were carried out with household members (five with heads of households and six with household caregivers) residing in five sub-counties located across the district. Purposive sampling was used to ensure the sample represented the religious diversity and geographical distance from the peri-urban center of the district. Each FG consisted of five to six participants. The FGs were conducted at a community centre by two pairs of researchers residing in the district and who were fluent in both English and the local dialect of Lunyole. The discussions were recorded, translated, and transcribed. Transcripts were reviewed and coded with the assistance of QDA Miner (version 4.0) qualitative data management software, and analyzed using thematic content analysis.

Results:

The FG discussions identified four major areas of challenges when managing acute febrile illness in their child under the age of five with presumed malaria (1) difficulties with getting to public health facilities due to long geographical distances and lack of affordable transportation; (2) poor service once at a public health facility, including denial of care, delay in treatment, and negative experiences with the staff; (3) difficulties with managing the child’s illness at home, including challenges with keeping home-stock medicines and administering medicines as prescribed; and (4) constrained to use private outlets despite their shortcomings.

Conclusions:

Future interventions may need to look beyond the public health system to improve case management of childhood malaria at the community level in rural districts such as Butaleja. Given the difficulties with accessing quality private health outlets, there is a need to partner with the private sector to explore feasible models of community-based health insurance programs and expand the role of informal private providers.

Understanding the context of delays in seeking appropriate care for children with symptoms of severe malaria in Uganda

Introduction

A large proportion of children with uncomplicated malaria receive appropriate treatment late, contributing to progression of illness to severe disease. We explored contexts of caregiver delays in seeking appropriate care for children with severe malaria.

Methods

This qualitative study was conducted at the Children’s Ward of Jinja Hospital, where children with severe malaria were hospitalized. A total of 22in-depth interviews were conducted with caregivers of children hospitalized with severe malaria. Issues explored were formulated based on the Partners for Applied Social Sciences (PASS) model, focusing on facilitators and barriersto caregivers’promptseeking and accessing ofappropriate care. The data were coded deductively using ATLAS.ti (version 7.5). Codes were then grouped into families based on emerging themes.

Results

Caregivers’ rating of initial symptoms as mild illness lead to delays in response. Use of home initiated interventions with presumably ineffective herbs or medicines was common, leading to further delay. When care was sought outside the home, drug shops were preferred over public health facilities for reasons of convenience. Drug shops often provided sub-optimal care, and thus contributed to delays in access to appropriate care. Public facilities were often a last resort when illness was perceived to be progressing to severe disease. Further delays occurred at health facilities due to inadequate referral systems.

Conclusion

Communities living in endemic areas need to be sensitized about the significance of fever, even if mild, as an indicator of malaria. Additionally, amidst ongoing efforts at bringing antimalarial treatment services closer to communities, the value of drug shops as providers ofrationalantimalarialtreatment needs to be reviewed.

Reaching for the low hanging fruits: One health benefits of joint crop-livestock services for small-scale farmers

The benefits of joint health service delivery remain under-explored in One Health. Plant clinics are known to provide ad hoc, undocumented advice on animal health and production to farmers. To understand the scope of this activity, 180 plant doctors (extension workers) in Uganda, Kenya, Zambia, Peru and Costa Rica were surveyed and a workshop involving key stakeholders was organized in Uganda. Most (81%) plant doctors regularly received queries from farmers on livestock topics. This shows that the single sectoral approach to service delivery often does not match small-scale farmers' needs. There is growing interest among service providers, ministry officials and researchers to improve integration of farmer services to reduce operational costs and make better use of existing capacities. The workshop supported the proposal for the first ‘crop-livestock clinics’ to be trialled and evaluated in Uganda. This will inform other countries on the potential of joint services to mixed crop-livestock farming communities.

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81% of the interviewed plant doctors had received animal queries from farmers.

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The potential for creating health synergies by integrating farmer services is vast.

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There is a favourable environment in Uganda for trialling ‘crop-livestock clinics’.

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New joint crop-livestock services should be designed and evaluated with inputs from key stakeholders.

Pathways to diabetic care at hospitals in rural Eastern Uganda: a cross sectional study

Background

Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals.

Methods

Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another.

Results

Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals’ diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another.

Conclusions

Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.

A cross-sectional study to identify the distribution and characteristics of licensed and unlicensed private drug shops in rural Eastern Uganda to inform an iCCM intervention to improve health outcomes for children under five years

Introduction

Malaria, pneumonia and diarrhea are leading causes of death in young children in Uganda. Between 50–60% of sick children receive treatment from the private sector, especially drug shops. There is an urgent need to improve quality of care and regulation of private drug shops in Uganda. This study was conducted to determine the distribution, the licensing status and characteristics of drug shops in four sub-districts of Kamuli district.

Methods

This study was part of a pre-post cross sectional study that examined the implementation of an integrated Community Case Management (iCCM) intervention for common childhood illness in rural private drug shops in Kamuli District in Eastern Uganda. This mapping exercise used a snowball sampling technique to identify licensed and unlicensed drug shops and collect information about their characteristics. Data were collected using a questionnaire. GPS data were collected for all drug shops.

Analysis

Quantitative data were analyzed using SPSS for descriptive statistics. Open ended questions were entered into NVivo 10 and analyzed using thematic analysis strategies.

Results

In total, 215 drug shops in 284 villages were located. Of these, 123 (57%) were open and consented to an interview. Only 12 (10%) drug shops were licensed, 93 (76%) were unlicensed, and the licensing status of 18 (15%) was unknown. Most respondents were the owner of the drug shop (88%); most drug sellers reported their qualification as nursing assistants (70%). Drug sellers reported licensing fees and costs of contracting an “in-charge” as barriers to licensing. Nearly all drug shops sold drugs for malaria (91%) and antibiotics (79%).

Urban-Rural Disparities in Chronic Obstructive Pulmonary Disease Management and Access in Uganda

Introduction: Almost 90% of chronic obstructive pulmonary disease (COPD) deaths occur in low- and middle-income countries (LMICs), where there are large rural populations and access to health care for COPD is poor. The purpose of this study was to compare urban-rural provider experiences regarding systemic facilitators and barriers to COPD management and treatment access. Methods: We conducted a qualitative study using direct observations and in-depth semi-structured interviews with 16 and 10 health care providers in urban Kampala and rural Nakaseke, Uganda, respectively. We analyzed interviews by performing inductive coding using generated topical codes. Results: In both urban and rural districts, exposure to evidence-based practices for COPD diagnosis and treatment was limited. The biomedical definition of COPD is not well distinguished in rural communities and was commonly confused with asthma and other respiratory diseases. Urban and rural participants alike described low availability of medications, limited access to diagnostic tools, poor awareness of the disease, and lack of financial means for medical care as common barriers to seeking and receiving care for COPD. While there was greater access to COPD treatment in urban areas, rural populations faced more pronounced barriers in access to diagnostic equipment, following standard treatment guidelines, and training medical personnel in non-communicable disease (NCD) management and treatment. Conclusion: Our results suggest that health system challenges for the treatment of COPD may disproportionately affect rural areas in Uganda. Implementation of diagnostic and treatment guidelines and training health professionals in COPD, with a special emphasis on rural communities, will assist in addressing these barriers.

Variation in the quality and out-of-pocket cost of treatment for childhood malaria, diarrhoea, and pneumonia: Community and facility based care in rural Uganda

BACKGROUND

A key barrier to appropriate treatment for malaria, diarrhoea, and pneumonia (MDP) in children under 5 years of age in low income rural settings is the lack of access to quality health care. The WHO and UNICEF have therefore called for the scale-up of integrated community case management (iCCM) using community health workers (CHWs). The current study assessed access to treatment, out-of-pocket expenditure and the quality of treatment provided in the public and private sectors compared to national guidelines, using data collected in a large representative survey of caregivers of children in 205 villages with iCCM-trained CHWs in mid-Western Uganda.

RESULTS

The prevalence of suspected malaria, diarrhoea and suspected pneumonia in the preceding two weeks in 6501 children in the study sample were 45%, 11% and 24% respectively. Twenty percent of children were first taken to a CHW, 56% to a health facility, 14% to other providers and no care was sought for 11%. The CHW was more likely to provide appropriate treatment compared to any other provider or to those not seeking care for children with MDP (RR 1.51, 95% CI 1.42-1.61, p<0.001). Seeking care from a CHW had the lowest cost outlay (median $0.00, IQR $0.00-$1.80), whilst seeking care to a private doctor or clinic the highest (median $2.80, IQR $1.20-$6.00). We modelled the expected increase in overall treatment coverage if children currently treated in the private sector or not seeking care were taken to the CHW instead. In this scenario, coverage of appropriate treatment for MDP could increase in total from the current rate of 47% up to 64%.

CONCLUSION

Scale-up of iCCM-trained CHW programmes is key to the provision of affordable, high quality treatment for sick children, and can thus significantly contribute to closing the gap in coverage of appropriate treatment.

The Burden of Adverse Drug Reactions Due to Artemisinin-Based Antimalarial Treatment in Selected Ugandan Health Facilities: An Active Follow-Up Study

Introduction

Uganda has rapidly increased access to antimalarial medicines in an effort to address the huge malaria disease burden. Pharmacovigilance information is important to guide policy decisions.

Objectives

The purpose of this study was to establish the burden of adverse drug reactions (ADRs) and associated risk factors for developing ADRs to artemisinin-based antimalarial treatment in Uganda.

Methods

An active follow-up study was conducted between April and July 2017 in a cohort of patients receiving treatment for uncomplicated malaria in the Iganga, Mayuge, and Kampala districts.

Results

A total of 782 patients with a median age of 22 years (58.6% females) were recruited into this study, with the majority recruited from public health facilities (97%). Diagnostic tests before treatment were performed for 76% of patients, and 97% of patients received artemether/lumefantrine. The prevalence of ADRs was 22.5% (176/782); however, the total number of ADRs was 245 since some patients reported more than one ADR. The most commonly reported reactions were general body weakness (24%), headache (13%), and dizziness (11%). Women were more likely to develop an ADR (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1–2.9), urban dwellers were more likely to develop an ADR than rural residents (aOR 9.9, 95% CI 5.4–17.9), and patients with comorbidities were more likely to develop an ADR than those without (aOR 7.4, 95% CI 4.4–12.3).

Conclusion

The burden of ADRs is high among women and in patients from urban settings and those with comorbidities. Such risk factors need to be considered in order to optimise therapy. Close monitoring of ADRs is key in implementation of the malaria treatment policy.

Electronic supplementary material

The online version of this article (10.1007/s40264-018-0659-x) contains supplementary material, which is available to authorized users.

Global variation in bacterial strains that cause tuberculosis disease: a systematic review and meta-analysis

BACKGROUND

The host, microbial, and environmental factors that contribute to variation in tuberculosis (TB) disease are incompletely understood. Accumulating evidence suggests that one driver of geographic variation in TB disease is the local ecology of mycobacterial genotypes or strains, and there is a need for a comprehensive and systematic synthesis of these data. The objectives of this study were to (1) map the global distribution of genotypes that cause TB disease and (2) examine whether any epidemiologically relevant clinical characteristics were associated with those genotypes.

METHODS

We performed a systematic review of PubMed and Scopus to create a comprehensive dataset of human TB molecular epidemiology studies that used representative sampling techniques. The methods were developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We extracted and synthesized data from studies that reported prevalence of bacterial genotypes and from studies that reported clinical characteristics associated with those genotypes.

RESULTS

The results of this study are twofold. First, we identified 206 studies for inclusion in the study, representing over 200,000 bacterial isolates collected over 27 years in 85 countries. We mapped the genotypes and found that, consistent with previously published maps, Euro-American lineage 4 and East Asian lineage 2 strains are widespread, and West African lineages 5 and 6 strains are geographically restricted. Second, 30 studies also reported transmission chains and 4 reported treatment failure associated with genotypes. We performed a meta-analysis and found substantial heterogeneity across studies. However, based on the data available, we found that lineage 2 strains may be associated with increased risk of transmission chains, while lineages 5 and 6 strains may be associated with reduced risk, compared with lineage 4 strains.

CONCLUSIONS

This study provides the most comprehensive systematic analysis of the evidence for diversity in bacterial strains that cause TB disease. The results show both geographic and epidemiological differences between strains, which could inform our understanding of the global burden of TB. Our findings also highlight the challenges of collecting the clinical data required to inform TB diagnosis and treatment. We urge future national TB programs and research efforts to prioritize and reinforce clinical data collection in study designs and results dissemination.

Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys

Background

Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011.

Methods

We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests.

Results

Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components.

Conclusions

The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.

Private sector drug shops frequently dispense parenteral anti-malarials in a rural region of Western Uganda

BACKGROUND

Malaria is a leading cause of paediatric morbidity and mortality in Uganda. More than half of febrile children in rural areas initially seek care at private clinics and drug shops. These shops are generally unregulated and the quality of clinical care is variable, with the potential for misdiagnosis and the development of drug resistance. There is thus an urgent need to identify rural drug shops and coordinate their malaria treatment efforts with those of the public sector. The objective of the study was to identify all drug shops in the Bugoye sub-county of Western Uganda and assess their anti-malarial dispensing practices.

METHODS

This study is a cross-sectional survey of drug shops in a rural sub-county of Western Uganda. In the first phase, shop locations, licensing and shopkeeper's qualifications, and supply and pricing of anti-malarials were characterized. In the second phase, the proportion of anti-malarials dispensed by private drug shops was compared to public health facilities.

RESULTS

A total of 48 drug shops were identified. Only one drug shop (1 of 48, 2%) was licensed with the sub-county's records office. The drug shops stocked a variety of anti-malarials, including first-line therapies and less effective agents (e.g., sulfadoxine/pyrimethamine). Almost all drug shops (45 of 48, 94%) provided parenteral anti-malarials. Of the 3900 individuals who received anti-malarials during the study, 2080 (53.3%) purchased anti-malarials through the private sector compared to 1820 (46.7%) who obtained anti-malarials through the public sector. Drug shops were the primary source of parenteral anti-malarials. Inadequate dosing of anti-malarials was more common in drug shops.

CONCLUSIONS

Drug shops are major sources of parenteral anti-malarials, which should be reserved for cases of severe malaria. Strengthening malaria case management and incorporating drug shops in future interventions is necessary to optimize malaria control efforts in the sub-county, and in similarly endemic regions.

Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda

Background

Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda.

Methods

Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013.

Results

Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients’ finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification.

Conclusion

Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3343-z) contains supplementary material, which is available to authorized users.