Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda.

BACKGROUND: Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops. METHODS: Drug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever 'appropriately treated of malaria with ACT' was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers. FINDINGS: The introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results. CONCLUSION: mRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.

A new strategy and its effect on adherence to intermittent preventive treatment of malaria in pregnancy in Uganda.

BACKGROUND: Few women in Uganda access intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). Previous studies have shown that high costs, frequent stock-out of drugs, supplies and poor quality of care are the greatest hindrance for women to access health services. In order to increase adherence to IPTp, we conceptualised an intervention that offset delivery care costs through providing a mama kit, created awareness on health benefits of IPTp and built trust between the provider and the client. METHODS: The new strategy was conceived along four constructs namely: 1) creating awareness by training midwives to explain the benefits of SP and the importance of adhering to the two doses of SP as IPTp to all pregnant women who attended ANC and consented to the study. Midwives were trained for two days in customer care and to provide a friendly environment. The pregnant women were also informed of the benefits of attending ANC and delivering at health facilities. 2) Each woman was promised a mama kit during ANC; 3) trust was built by showing the mama kit to each woman and branding it with her name; 4) keeping the promise by providing the mama kit when women came to deliver. The strategy to increase adherence to two doses of SP and encourage women to deliver at health facilities was implemented at two health facilities in Mukono district (Kawolo hospital and Mukono health centre IV). The inclusion criteria were women who: i) consented to the study and ii) were in the second trimester of pregnancy. All pregnant women in the second trimester (4-6 months gestation) who attended ANC and consented to participate in the study were informed of the benefits of SP, the importance of delivering at health facilities, were advised to attend the scheduled visits, promised a mama kit and ensured the kit was available at delivery. The primary outcome was the proportion of pregnant women adhering to a two dose SP regimen. RESULTS: A total of 2,276 women received the first dose of SP and 1,656 (72.8%) came back for the second dose. 1,069 women were involved in the evaluation (384 had participated in the intervention while 685 had not). The main reasons that enabled those who participated in the intervention to adhere to the two doses of IPTp and deliver at the study facilities were: an explanation provided on the benefits of IPTp and delivering at health facilities (25.1%), availability of a mama kit at delivery (24.6%), kind midwives (19.8%) and fearing complications of pregnancy (8.5%). Overall, 78.0% of these women reported that they were influenced to adhere to IPTp by the intervention. In a multivariable regression, nearby facility, P = 0. 007, promising a mama kit, P = 0.002, kind midwives, P = 0.0001 and husbands' encouragement, P = 0.0001 were the significant factors influencing adherence to IPTp with SP. CONCLUSION: The new strategy was a good incentive for women to attend scheduled ANC visits, adhere to IPTp and deliver at the study facilities. Policy implications include the urgent need for developing a motivation package based on the Health-Trust Model to increase access and adherence to IPTp.

Injected with controversy: sales and administration of injectable contraceptives in drug shops in Uganda.

CONTEXT: Informal drug shops are the first line of health care in many poor countries. In Uganda, these facilities commonly sell and administer the injectable contraceptive depot medroxyprogesterone acetate (DMPA), even though they are prohibited by law from selling any injectable drugs. It is important to understand drug shop operators' current practices and their potential to provide DMPA to hard-to-reach populations. METHODS: Between November 2007 and January 2008, 157 drug shops were identified in three rural districts of Uganda, and the operators of the 124 facilities that sold DMPA were surveyed. Data were analyzed with descriptive methods. RESULTS: Only 35% of operators reported that the facility in which they worked was a licensed drug shop and another 9% reported that the facility was a private clinic; all claimed to have some nursing, midwifery, or other health or medical qualification. Ninety-six percent administered DMPA in the shop. Operators gave a mean of 10 injections (including three of DMPA) per week. Forty-three percent of those who administered DMPA reported disposing of used syringes in sharps containers; in the previous 12 months, 24% had had a needle-stick injury and 17% had had a patient with an injection-related abscess. Eleven percent said they had ever reused a disposable syringe. Overall, contraceptive knowledge was low, and attitudes toward family planning reflected common traditional biases. CONCLUSION: Provision of DMPA is common in rural drug shops, but needs to be made safer. Absent stronger regulation and accreditation, drug shop operators can be trained as community-based providers to help meet the extensive unmet demand for family planning in rural areas.

Intermittent preventive treatment of malaria in pregnancy: a community-based delivery system and its effect on parasitemia, anemia and low birth weight in Uganda.

OBJECTIVE: The main objective of the study was to assess the impact of a community-based delivery system of intermittent preventive treatment (IPT) for malaria in pregnancy with sulfadoxine-pyrimethamine (SP) on access, parasitemia, anemia and low birth weight as primary outcome measures. METHODS: A study was designed to test the community-based delivery system of IPT through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilizers (APMs), and to compare these with IPT at health units in an area of high malaria transmission - Mukono District, Uganda. RESULTS: Two thousand seven hundred and eighty-five pregnant women participated in the study. The majority of the women (92.4%) at the community-based approaches received their first dose of IPT during their second trimester compared to 76.1% at health units (p<0.0001). At both health units and the community-based approaches, IPT increased mean hemoglobin by 6.7% (p<0.0001) for all parities and by 10.2% among primigravidae. IPT reduced the prevalence of severe anemia from 5.7% to 3.1% (p<0.04). The prevalence of parasitemia was reduced from 24.5% to 16.1% (p<0.001), and parasite density reduced significantly (p<0.02) after the first dose and remained stable with the second dose. Overall the proportion of low birth weight was 6.3% (8.3% at health units versus 6.0% at the community-based approaches, p<0.03) highlighting the importance of access and adherence to IPT. This intervention was acceptable to 89.6% of the women at the community-based approaches intending to use IPT in the future, while 48.1% of them had recommended it to other women. CONCLUSIONS: The community-based approaches increased access and adherence to IPT with an effect on anemia, severe anemia, parasitemia and low birth weight. However the reduced effect of IPT on parasitemia points to drug resistance with SP and this requires further evaluation; research into the identification of other more efficacious drugs for malaria prevention in pregnancy is also required.

A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda.

Community delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) is one potential option that could mitigate malaria in pregnancy. However, there is concern that this approach may lead to complacency among women with low access to essential care at health units. A non-randomised community trial assessed a new delivery system of IPTp through traditional birth attendants, drug shop vendors, community reproductive health workers and adolescent peer mobilisers (the intervention) compared with IPTp at health units (control). The study enrolled a total of 2081 pregnant women with the new approaches. Data on care-seeking practices before and after the intervention were collected. The majority of women with the new approaches accessed IPTp in the second trimester and adhered to two doses of sulfadoxine/pyrimethamine (SP) (1404/2081; 67.5%). Antenatal care (four recommended visits) increased from 3.4% (27/805) to 56.8% (558/983) (P<0.001). The proportion of women delivering at health units increased from 34.3% (276/805) to 41.5% (434/1045) (P=0.02), whilst the proportion of women seeking care for malaria at health units increased from 16.7% (128/767) to 36.0% (146/405) (P<0.001). Similarly, use of insecticide-treated nets increased from 7.7% (160/2081) to 22.4% (236/1055) (P<0.001). In conclusion, the community-based system was effective in delivering IPTp, whilst women still accessed and benefited from essential care at health units.

Intermittent preventive treatment of malaria in pregnancy: the effect of new delivery approaches on access and compliance rates in Uganda.

OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer intermittent preventive treatment (IPT) with sulfadoxine-pyremethamine to pregnant women, and reach those most at risk of malaria and increase access and compliance to it. METHODS: The study was designed to assess new approaches of delivering IPT through these groups and compare it with IPT at health units. The primary outcome measures were: the proportion of adolescents and primigravidae accessed; gestational age at recruitment and the proportion of women who completed two doses of sulfadoxine-pyremethamine. RESULTS: Two thousand seven hundred and eighty-five pregnant women (78% of those in the study area) participated. With new approaches, 92.4% of the women received IPT during the second trimester as recommended by the policy, vs. 76.1% at health units, P < 0.0001. Of the women who received two doses of sulfadoxine-pyremethamine, 39.9% were at health units (control) vs. 67.5% through new approaches (P < 0.0001). Women using the new approaches also accessed IPT early: the mean gestational age when receiving the first dose of sulfadoxine-pyremethamine was 21.0 weeks vs. 23.1 weeks at health units (P < 0.0001). However, the health units were used by a higher proportion of primigravidae (23.6% vs. 20.0%, P < 0.04), and this was also the case for adolescents (28.4% vs. 25.0%, P < 0.03). This intervention was acceptable with 89.1% of the women at the new approaches intending to use IPT in future. CONCLUSIONS: The new approaches increased access to and compliance with IPT. We recommend a review of the policy to allow the provision of IPT through the new approaches.

Intermittent preventive treatment of malaria in pregnancy: evaluation of a new delivery approach and the policy implications for malaria control in Uganda.

The impact of intermittent preventive treatment (IPT) on malaria in pregnancy is well known. In countries where this policy is implemented, poor access and low compliance to this intervention has been widely reported. A study was designed to assess a new approach to deliver IPT to pregnant women through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilisers (APMs); and compared this approach with IPT at health units. We evaluated this approach to assess user perceptions, its acceptability and sustainability. Results show that the new approach increased access and compliance to IPT. Mean gestational age at first dose of IPT was 21.0 weeks with the community approaches versus 23.1 weeks at health units, P>0.0001. Health units accessed a high proportion of adolescents, 28.4%, versus 25.0% at the new approaches, P<0.03; most primigravidae, 23.6%, versus 20.0% at the new approaches, P<0.04. The proportion of women who received two doses of SP was 67.5.2% with the new approaches versus 39.9% at health units, P<0.0001. The new approach was associated with a three-fold increase in use of ITNs from 8.8% at baseline to 23.4%. The factors that most influenced acceptability and use of IPT were trusted and easy accessible resource persons, their ability to make home visits especially with CRHWs and APMs; the support of spouses. Another factor was the high awareness on dangers of malaria in pregnancy and the benefits of IPT created by the resource persons. The women perceived better health using the first dose of sulphadoxine-pyremethamine (SP) and this compelled them to go for the second dose. IPT with this approach was highly acceptable with 89.1% of women at the new approaches intending to use it for the next pregnancy, while 48.0% of them had recommended it to other women. We suggest a review of the current policy on malaria prevention in pregnancy to allow provision of IPT through community structures that are feasible, practical and acceptable.

Risk factors associated with maternal deaths in health units in Uganda

This study was conducted to assess the magnitude of maternal deaths in health units in Uganda; and the risk factors associated with such death. A retrospective study of maternal deaths in 20 hospitals and 54 randomly selected health centres was conducted in 12 randomly selected districts of Uganda. The reference period for documenting maternal deaths was September 1992 to September 1993. The International Classification of Diseases 10 was used to define a maternal death. Data on maternal deaths and associated risk factors risk factors was obtained from admission and patient case notes.SPSS/PC statistical package was used to carry out advanced statistical analysis. Long linear analysis was used to rank risk factors for maternal mortality ratio of 557 per 100;000 live births. Three hundred and sixty (86.1) mothers died within one hour of admissio. The risk factors identifed were inadequate antibiotic supply; intravenous drug fluids and blood for transfusion in health units; non-use of family planning; use of traditional medicine; mothers aged 15-19 and 30-50 years. Others included those who had a history of two or more abortions and stillbirths; parity of five and above; and living within a distance of more than 10km to the nearest health unit. We conclude that the focus on the risk factors for maternal deaths have policy implications