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

对感染的患者进行及时的抗生素治疗可以决定治愈还是死亡或长期残疾。不幸的是，在世界各地，一些感染正在对用于治疗它们的抗生素药物产生抗药性。这可能导致未来的情况，即疾病持续更长时间，死亡人数增加，治疗成本上升。在这种情况下，低收入国家可能感受到最大的影响，这些国家传染病最常见，许多家庭缺乏经济保障。抗生素耐药性现在被认为是对全球健康的最大威胁之一。世界卫生组织呼吁采取紧急行动、进行研究和投资，通过开发新的抗微生物药物和更负责任地使用现有药物来应对这一威胁。2016年9月，全球领导人在联合国大会上开会-这是联合国历史上第四次在联合国大会上讨论卫生议题-呼吁各国政府采取一致行动，限制耐药性的发展和传播。卫生工作者不良的处方做法，如过度使用药物、销售部分剂量或患者不坚持完整疗程，都会造成有利于选择和传播耐药性突变的情况。卫生工作者和药剂师可以通过只在真正需要时才分发抗生素药物，以及通过开出正确数量的正确药物来治疗疾病，来帮助解决耐药性问题。因此，改进抗生素药物的使用最终涉及指导卫生工作者和患者作出的治疗决定，以阻止不分青红皂白地使用。因此，如果要制定有效的干预战略，更好地了解和了解影响卫生工作者处方做法的因素将是至关重要的。私营部门在许多非洲国家提供卫生保健方面发挥着重要作用，许多患者从私人诊所和药店寻求护理，在控制滥用抗生素的战略中不能忽视这一点。治疗做法和标准也不能通过孤立地侧重于一个部门来解决。私营部门与公共部门的组织和业绩、患者的需求和监管控制相互作用，并受其影响。一个部门的不良做法很容易破坏或阻碍另一个部门的行为改变。然而，在许多低收入国家，对私营部门的监管是卫生系统的一个公认弱点。拟议的研究旨在应对这一挑战。我们将调查影响乌干达农村私人诊所和药店医疗保健做法的情况、规范、经验和动机，包括私人提供者、政府卫生工作者和公共卫生官员之间互动的影响，以便更好地了解卫生系统如何更有效地控制治疗做法，并提高患者从私人提供者那里获得的护理质量。我们打算利用从这项研究中获得的知识和见解来制定一项全面的干预战略，以改善患者护理，并打击乌干达私人诊所和药店不负责任地使用抗生素。这一干预策略将在未来的研究中得到检验。我们希望我们的发现也将对其他低收入国家的卫生部和国家政府有价值，并可用于帮助制定应对抗菌素耐药性威胁的国家计划。

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.