Presentation by Anthony Mbonye Principal Investigator, ACT Consortium study in Uganda Ministry of Health

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2. Improving malaria diagnosis & treatment
in the private health sector in Uganda
Anthony Mbonye (MB ChB, PhD)
Director of Health Services -Ministry of Health, Uganda
& Associate Professor, School of Public Health, Makerere University
Answering key questions on malaria drug delivery 2

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Malaria diagnosis in Uganda
 Rapid diagnostic tests (RDTs) were introduced in public health facilities
in Uganda in 2010
 Up to 80% of malaria cases are treated in the private sector
 Two-arm trial to compare feasibility and impact of using RDTs vs current
practice (presumptive treatment of fever) in 65 registered drug shops
 Improved targeting of ACTs as primary endpoint:
Impact and cost-effectiveness of the intervention on proportion of patients
receiving appropriate ACT treatment [with microscopy as gold standard]

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What is a registered drug shop?
• Registered with Ministry of Health (National
Drug Authority), licensed to sell Class C drugs,
including antimalarials, but not antibiotics or
injections
• Most located in or around trading centres
(rural and built-up areas)
• Typically comprise 1-2 rooms with 1-2 staff
• Most have appearance of pharmacies, with
drugs displayed on shelves or in glass cabinets
• Drug shop vendors smartly dressed, some with
white coats
• Subject to periodic inspection by District
Assistant Drug Inspector

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Intervention Design and Outcomes

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What did the intervention include?
RDT training
based on WHO
generic RDT
training materials

7. Answering key questions on malaria drug delivery 7

8. Trial findings:
Adherence to RDTs and targeting of ACTs
Answering key questions on malaria drug delivery 8

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Improved targeting of ACTs
Control group RDT group
Use of RDTs in drug shops: significant increase in proportion of ACT treatment
decisions that were consistent with “true” malaria status [microscopy], p<0.001
33% appropriate 75% appropriatevs.

11. Qualitative Evaluation
Answering key questions on malaria drug delivery 11
Aim: To understand more about the processes involved
with the introduction of RDTs at drug shops

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Support for RDTs in drug shops
Research participants were broadly supportive of the introduction of RDTs
into drug shops:
• Community members liked RDTs because they allow
them to “know the truth about their illness” and stated
that they sought out drug shop vendors who could test
for malaria and recommended drug shops who carried
out RDTs to other community members.
• Drug shop vendors reported that they liked to use RDTs
and that the availability of RDTs in their shops increases
the number of clients, their profitability, their status and
diagnostic skills.
• Government health-workers were generally in favour of
drug shops using RDTs - as long as vendors were well
trained, properly supervised and their practice was
limited by knowing when to refer patients who they
were unable to manage.
its not that we studied
much but the patients
themselves know that
we are real health
workers, they no longer
know us as people only
selling drugs. Now they
know that we also test
what.. even blood.
So for us we no longer
accept to have our
children given treatment
before having their blood
taken off, because I see
now that it is very cheap

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Effect on reputation of shops
……there are those
(project supervisors)
who usually come here
now. If they come and
they do not disturb him
and they do not close
his drug shop, we also
get encouraged to
remain supporting that
facility
The businesses are up to date and have life in them. You can’t spend a
day without working. Even he (the patient) who hadn’t come for testing
gets to know that this health provider knows what he is doing - even if
he had come with another ailment. After he develops trust in the DSV he
brings his children and they get tested and you treat them. Whenever he
gets any ailment, he comes, because he has confidence in you.
They [patients] see that
we are really health
workers. This has a way
it puts life in us and we
feel big, ehhe [yes] and
you see yourself
becoming big.
• Patients were pleased diagnosis was available in drug shops,
and felt reassured by the training and supervision of providers
with otherwise uncertain credentials
• Vendors welcomed the opportunity to demonstrate a new skill
and a status more akin to a qualified health worker
• Together, the views of drug shop vendors revealed that the
intervention had a profound effect on how drug shops were
perceived and used.
• Highlights the need to consider wider effects of RDT training
interventions in the private sector

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Conclusions
Summary findings
 RDTs are likely to be popular in the private
retail sector
 Clients are willing to buy RDTs at subsidised
prices, and trained drug shop vendors can
use RDTs and comply with results
 RDT training in drug shops can improve
targeting of ACTs to malaria patients, and
reduce overuse of these drugs
 Training to perform tests can also change the
reputation of drug shops
 RDTs are likely to be financially viable for
drug shops: profit from enhanced
reputation, increased clientele and sale of
other medicine to RDT-negative clients
 Referral from shops is uncommon and faces
multiple challenges
Issues for consideration by program
managers
 It is feasible to collaborate with the private
retail sector to improve malaria treatment
 There may be multiple benefits to drug shop
vendors in being part of an RDT training
programme
 Visible government involvement may help
promote compliance with guidelines
 RDTs could increase popularity of drug
shops and affect where patients seek care
 RDT use may give a false impression of
vendors’ other skills, and could expose
patients to less desirable practices.
 RDTs should only be introduced within
broader accreditation programmes aiming
to improve standard of care in private retail
sector. Effective regulation by authorities is
also needed

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What has since taken place
 National dissemination meeting of results in Kampala, Sept 2015
 The study results were discussed at an international meeting, on
introducing RDTs in the private health sector, in Entebbe, Oct 2015
 Two meetings have been held involving the Uganda National Drug
Authority that registers and regulates drug shops to discuss RDTs in
the private sector
 A road map has made drawn to draft a guideline for introducing RDTs
in the private sector
 Draft guidelines have been discussed in the Technical Working Group,
Ministry of Health

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The Policy Environment
 Changing epidemiology of malaria: prevalence reduced from 42% to 9%.
Some areas like Kampala have less than 1%. Thus increasing need for
testing before treating malaria
 Discussions with Ministry of Finance to increase funding for malaria
control (for ACTs & IRS) in highly endemic districts of North and Eastern
Uganda
 Application to Global Fund to purchase RDTs for the community level
 A results-based financing strategy could help introduce RDTs in the private
sector

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Acknowledgments
Principal Investigators
Anthony Mbonye, Ministry of Health, Uganda
Siân Clarke, LSHTM, UK
Pascal Magnussen, University of Copenhagen, Denmark
Research Team in London
Kristian Hansen Sham Lal
Eleanor Hutchinson Clare Chandler
Bonnie Cundill Caroline Lynch
Field Team in Uganda
Field co-ordinator: Stephen Kalake
Microscopists: Francis Adome, Betty Nabette, Annette Enzaru
Social scientists: Miriam Kayendeke, James Kizito, Christine Nabirye,
Jonathan Ngobi, Josephine Nabukeera

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Please send
questions & comments to
#actdiagnosis
@ACTconsortium
debora.miranda@lshtm.ac.uk