Developing innovative approaches to improve treatment provision for childhood infection in peri-urban settings: A pilot study in accredited drug shops

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Pneumonia, malaria and diarrhoea are major causes of death in African children under 5 years of age, yet if diagnosis and treatment are available the majority of these deaths can be prevented. Children with these diseases should be seen and treated within 24 hours of becoming ill but affordable diagnosis and treatment are often not available close to home. Patients who do seek help often do so from retailers who sell medicines but do not provide diagnosis. In these situations, many children with serious diseases either receive the wrong treatment or the severity of their illness goes unrecognised. A simple solution, called integrated Community Case Management (iCCM), has shown encouraging results in improving diagnosis and treatment of these diseases when it is used by community health workers (volunteers who provide health services) in rural areas.The iCCM strategy has not been tested in urban areas, but this is increasingly important because the population of African cities is expanding. Generally, this urban expansion is unplanned so living conditions and sanitation are poor, placing children at increased risk of disease. Providing better services through retail outlets is one possible way to ensure access to affordable basic health services. However, this is subject to some debate on whether retailers can provide health services of acceptable quality and price. We plan to conduct a study in order to develop a community-based mechanism to deliver iCCM services that is suitable for urban areas. The study will be conducted in unplanned urban areas surrounding the Ugandan city of Kampala This site was chosen because it has many features of rapidly expanding cities: low socioeconomic status, unplanned housing, poor sanitation, poor provision of clean water and limited access to health services. During the study, we shall consult with local stakeholders (local communities, drug shop vendors, health staff and national authorities) to explore which of two alternative strategies to improve access to health care in urban areas would be most feasible and acceptable to the local population and national health authorities. In these two strategies, either community health worker volunteers (CHWs) or drug shop vendors would be trained by the Ministry of Health to diagnose and treat three key childhood diseases: pneumonia, malaria and diarrhoea, and to refer patients with severe or unknown illness to local health centres. A key aim of the study is to identify the most suitable way to supervise and support community volunteers and drug shop vendors, how to integrate them into the local health system, and how to assure the quality of the services they provide. We shall also conduct a small pilot study in 10 drug shops to measure the accuracy of diagnosis and quality of service provided after training. Drug shop vendors will be asked to record details of patients they see, including the symptoms, diagnosis and what actions were taken. This will be backed up by other methods of assessment by health professionals to assess whether the drug vendor used the iCCM guidelines and prescribed drugs correctly. The research team will also observe what happens when a sick child is treated in a drug shop, and carry out interviews to learn what providers, patients and local leaders thought of the treatments received in trained drug shops, and to explore the benefits and costs of the new approach to patients and drug shop vendors. We shall also measure how much it costs the Ministry of Health to support this approach. The data collected will be used to inform the development of a new intervention strategy to improve access to treatment for children living in unplanned urban areas, which will be tested in future studies.