Impact of pharmacy worker training and deployment on access to essential medicines for children under five in Malawi: a cluster quasi-experimental evaluation.

BACKGROUND: Poor access to essential medicines is common in many low- and middle-income countries, partly due to an insufficient and inadequately trained workforce to manage the medicines supply chain. We conducted a prospective impact evaluation of the training and deployment of pharmacy assistants (PAs) to rural health centers in Malawi. METHODS: A quasi-experimental design was used to compare access to medicines in two districts where newly trained PAs were deployed to health centers (intervention) and two districts with no trained PAs at health centers (comparison). A baseline household survey and two annual post-intervention household surveys were conducted. We studied children under five years with a history of fever, cough and difficulty in breathing, and diarrhea in the previous two weeks. We collected data on access to antimalarials, antibiotics and oral rehydration salts (ORS) during the childrens' symptomatic periods. We used difference-in-differences regression models to estimate the impact of PA training and deployment on access to medicines. RESULTS: We included 3974 children across the three rounds of annual surveys: 1840 (46%) in the districts with PAs deployed at health centers and 2096 (53%) in districts with no PAs deployed at health centers. Approximately 80% of children had a fever, nearly 30% had a cough, and 43% had diarrhea in the previous two weeks. In the first year of the program, the presence of a PA led to a significant 74% increase in the odds of access to any antimalarial, and a significant 49% increase in the odds of access to artemisinin combination therapies. This effect was restricted to the first year post-intervention. There was no effect of presence of a PA on access to antibiotics or ORS. CONCLUSION: The training and deployment of pharmacy assistants to rural health centers in Malawi increased access to antimalarial medications over the first year, but the effect was attenuated over the second year. Pharmacy assistants training and deployment demonstrated no impact on access to antibiotics for pneumonia or oral rehydration salts for diarrhea.

Assessment of the scope and practice of evaluation among medical donation programs.

BACKGROUND: Medical donation programs for drugs, other medical products, training and other supportive services can improve access to essential medicines in low- and middle-income countries (LMICs) and provide emergency and disaster relief. The scope and extent to which medical donation programs evaluate their impact on recipients and health systems is not well documented. METHODS: We conducted a survey of the member organizations of the Partnership for Quality Medical Donations (PQMD), a global alliance of non-profit and corporate organizations, to identify evaluations conducted in conjunction with donation programs. RESULTS: Twenty-five out of the 36 PQMD organizations that were members at the time of the survey participated in the study, for a response rate of 69 %. PQMD members provided information on 34 of their major medical donation programs. Half of the donation programs reported conducting trainings as a part of their donation program. Twenty-six (76 %) programs reported that they conduct routine monitoring of their donation programs. Less than 30 % of donation programs were evaluated for their impact on health. Lack of technical staff and lack of funding were reported as key barriers to conducting impact evaluations. CONCLUSIONS: Member organizations of PQMD provide a broad range of medical donations, targeting a wide range of public health issues and events. While some level of monitoring and evaluation was conducted in nearly 80 % of the donation programs, a program's impact was infrequently evaluated. Opportunities exist to develop consistent metrics for medical donation programs, develop a common framework for impact evaluations, and advocate for data collection and analysis plans that collect meaningful metrics.

Health-related quality of life and social support among women treated for abortion complications in western Uganda.

BACKGROUND: While the impact of abortion complications on clinical outcomes and healthcare costs has been reported, we found no reports of their impact on Health-Related Quality of Life (HRQoL), nor the role of social support in moderating such outcomes. In this study, we performed an assessment of the relationship between abortion complications, HRQoL and social support among women in Uganda. METHODS: We interviewed women who were discharged after treatment for abortion complications and, as a comparison, women visiting a regional referral hospital for routine obstetric care. We administered the EuroQol instrument and the Social Support Questionnaire Short-Form, and collected demographic and socioeconomic data. We performed descriptive analyses using t-tests, Wilcoxon rank-sum tests and chi-square tests, and multivariable linear regressions with interaction effects to examine the associations between abortion complications, EQ-5D utility scores and social support. RESULTS: Our study included 139 women (70 with abortion complications, and 69 receiving routine obstetric care). In four out of the 5 dimensions of the EQ-5D, a larger proportion of women with abortion complications reported "some or severe" problems than women receiving routine obstetric care (self-care: 42% v 24%, p=0.033; usual activities: 49% v 16%, p<0.001; pain/discomfort: 68% v 25%, p<0.001; and anxiety/depression: 60% v 22%, p<0.001). After adjusting for age, social support, wealth tertile, employment status, marital status, and HIV status, women with abortion complications had a 0.12 (95% CI: 0.07, 0.18, p < 0.001) lower mean EQ-5D utility score than those receiving routine obstetric care. An analysis of the modifying effect of social support showed that a one-unit higher average number of people providing social support was associated with larger mean difference in EQ-5D utility score when comparing the two groups, while a one unit higher average satisfaction score with social support was associated with smaller mean differences in EQ-5D utility score. CONCLUSIONS: Our study suggests that abortion complications are associated with diminished HRQoL and the magnitude of the association depends on social support. However, the mediating role of social support in a setting of social and legal proscriptions to induced abortion is complex.

Capacity building in environmental health research in India and Nepal.

The Fogarty International Training and Research Program in Environmental and Occupational Health at UC Berkeley concentrates on two major environmental health issues in the Indian subcontinent: arsenic in drinking water in West Bengal, India, and indoor air pollution in India and Nepal. Local trainees and researchers have had the opportunity to work on related research. Concerning arsenic in drinking water, projects included studies of skin lesions, pulmonary effects, reproductive outcomes, and child development, as well as mitigation approaches to reduce exposures. Activities in the indoor air pollution project have emphasized quantifying exposures to smoke from cooking and heating as well as their associations with tuberculosis and eye disease. Training has focused on developing skills necessary to address these problems. The training emphasizes in-country mentoring of trainees related to their research projects, and intensive short courses at partner institutions. The focus of capacity building in environmental health research in countries in economic and environmental transition should be on country-based research projects with embedded training efforts.

Impact of pharmacy worker training and deployment on access to essential medicines and health outcomes in Malawi: protocol for a cluster quasi-experimental evaluation.

BACKGROUND: Access to essential medicines is core to saving lives and improving health outcomes of people worldwide, particularly in the low- and middle-income countries. Having a trained pharmacy workforce to manage the supply chain and safely dispense medicines is critical to ensuring timely access to quality pharmaceuticals and improving child health outcomes. METHODS/DESIGN: This study measures the impact of an innovative pharmacy assistant training program in the low-income country of Malawi on access to medicines and health outcomes. We employ a cluster quasi-experimental design with pre-and post-samples and decision analytic modeling to examine access to and the use of medicines for malaria, pneumonia, and diarrhea for children less than 5 years of age. Two intervention districts, with newly trained and deployed pharmacy assistants, and two usual care comparison districts, matched on socio-economic, geographic, and health-care utilization indicators, were selected for the study. A baseline household survey was conducted in March 2014, prior to the deployment of pharmacy assistants to the intervention district health centers. Follow-up surveys are planned at 12- and 24-months post-deployment. In addition, interviews are planned with caregivers, and time-motion studies will be conducted with health-care providers at the health centers to estimate costs and resources use. DISCUSSION: This impact evaluation is designed to provide data on the effects of a novel pharmacy assistant program on pharmaceutical systems performance, and morbidity and mortality for the most common causes of death for children under five. The results of this study should contribute to policy decisions about whether and how to scale up the health systems strengthening workforce development program to have the greatest impact on the supply chain and health outcomes in Malawi.