Understanding health system linkages: Formative research to develop strategies to support quality improvement in treatment in the private sector

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Prompt antibiotic therapy for an infected patient can make the difference between cure and death or long-term disability. Unfortunately, all around the world, some infections are becoming resistant to the antibiotic medicines used to treat them. This could lead to a future scenario in which illnesses last longer, deaths increase, and the cost of treatment rises. Under this scenario, the greatest impacts are likely to be felt in low-income countries where infectious diseases are most common and many families lack financial security. Antibiotic resistance is now considered to be one of the biggest threats to global health. The World Health Organization has called for urgent action, research and investment to counter this threat, through the development of new antimicrobial drugs and through more responsible use of existing drugs. In September 2016, global leaders met at the UN General Assembly - only the fourth time in the history of the UN that a health topic was discussed at the General Assembly - to call for concerted action by every national government to limit the development and spread of drug resistance.Poor prescription practices by health workers, such as overuse of drugs, sale of partial doses, or non-adherence by patients to the full treatment course, all create situations which are conducive to the selection and spread of resistant mutations. Health workers and pharmacists can help tackle resistance by only dispensing antibiotic drugs when they are truly needed; and by prescribing the right drug in the right quantities to treat the illness. Improving the use of antibiotic medicines thus ultimately involves guiding the treatment decisions made by health workers and patients to discourage indiscriminate use. Therefore, if effective intervention strategies are to be developed, better knowledge and understanding of the factors that influence the prescribing practices of health workers will be essential.The private sector plays an important role in provision of health care in many African countries, with many patients seeking care from private clinics and drug shops, and cannot be overlooked in strategies to control misuse of antibiotics. Neither can treatment practices and standards be addressed by focusing on one sector in isolation. The private sector interacts with, and is shaped by the organisation and performance of the public sector, demand from patients and regulatory controls. Poor practices in one sector can easily undermine or disincentivize behavioural change in another. Yet regulation of the private sector is an acknowledged weakness of the health system in many low income countries. The proposed research aims to address this challenge. We shall investigate the situations, norms, experiences, and motivations that affect health care practices in private clinics and drug shops in rural Uganda, including the influence of interactions between private providers, government health workers and public health officials, in order to generate improved understandings of how the health system can more effectively control treatment practices, and improve the quality of care that patients receive from private providers. We intend to use the knowledge and insights gained from this research to develop a comprehensive intervention strategy to improve patient care and combat irresponsible use of antibiotics in private clinics and drug shops in Uganda. This intervention strategy will be tested in future studies. We hope that our findings will also be of value to Ministries of Health and national governments in other low-income countries, and can be used to help inform the development of national plans to counter the threat of antimicrobial resistance.