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      Private sector drug shops frequently dispense parenteral anti-malarials in a rural region of Western Uganda

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          Abstract

          Background

          Malaria is a leading cause of paediatric morbidity and mortality in Uganda. More than half of febrile children in rural areas initially seek care at private clinics and drug shops. These shops are generally unregulated and the quality of clinical care is variable, with the potential for misdiagnosis and the development of drug resistance. There is thus an urgent need to identify rural drug shops and coordinate their malaria treatment efforts with those of the public sector. The objective of the study was to identify all drug shops in the Bugoye sub-county of Western Uganda and assess their anti-malarial dispensing practices.

          Methods

          This study is a cross-sectional survey of drug shops in a rural sub-county of Western Uganda. In the first phase, shop locations, licensing and shopkeeper’s qualifications, and supply and pricing of anti-malarials were characterized. In the second phase, the proportion of anti-malarials dispensed by private drug shops was compared to public health facilities.

          Results

          A total of 48 drug shops were identified. Only one drug shop (1 of 48, 2%) was licensed with the sub-county’s records office. The drug shops stocked a variety of anti-malarials, including first-line therapies and less effective agents (e.g., sulfadoxine/pyrimethamine). Almost all drug shops (45 of 48, 94%) provided parenteral anti-malarials. Of the 3900 individuals who received anti-malarials during the study, 2080 (53.3%) purchased anti-malarials through the private sector compared to 1820 (46.7%) who obtained anti-malarials through the public sector. Drug shops were the primary source of parenteral anti-malarials. Inadequate dosing of anti-malarials was more common in drug shops.

          Conclusions

          Drug shops are major sources of parenteral anti-malarials, which should be reserved for cases of severe malaria. Strengthening malaria case management and incorporating drug shops in future interventions is necessary to optimize malaria control efforts in the sub-county, and in similarly endemic regions.

          Electronic supplementary material

          The online version of this article (10.1186/s12936-018-2454-7) contains supplementary material, which is available to authorized users.

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          Most cited references 22

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          What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review

          Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.
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            What can be done about the private health sector in low-income countries?

            A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.
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              Utilization of public or private health care providers by febrile children after user fee removal in Uganda

              Background Despite investments in providing free government health services in Uganda, many caretakers still seek treatment from the drug shops/private clinics. The study aimed to assess determinants for use of government facilities or drug shops/private clinics for febrile illnesses in children under five. Methods Structured questionnaires were administered to caretakers in 1078 randomly selected households in the Iganga – Mayuge Demographic Surveillance site. Those with children who had had fever in the previous two weeks and who had sought care from outside the home were interviewed on presenting symptoms and why they chose the provider they went to. Symptoms children presented with and reasons for seeking care from government facilities were compared with those of drug shops/private clinics. Results Of those who sought care outside the home, 62.7% (286/456) had first gone to drug shops/private clinics and 33.1% (151/456) first went to government facilities. Predictors of having gone to government facilities with a febrile child were child presenting with vomiting (OR 2.07; 95% CI 1.10 – 3.89) and perceiving that the health providers were qualified (OR 10.32; 95% CI 5.84 – 18.26) or experienced (OR 1.93; 95% CI 1.07 – 3.48). Those who took the febrile child to drug shops/private clinics did so because they were going there to get first aid (OR 0.20; 95% CI 0.08 – 0.52). Conclusion Private providers offer 'first aid' to caretakers with febrile children. Government financial assistance to health care providers should not stop at government facilities. Multi-faceted interventions in the private sector and implementation of community case management of febrile children through community medicine distributors could increase the proportion of children who access quality care promptly.
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                Author and article information

                Contributors
                510.284.7002 , ltwang@ucsd.edu
                Journal
                Malar J
                Malar. J
                Malaria Journal
                BioMed Central (London )
                1475-2875
                22 August 2018
                22 August 2018
                2018
                : 17
                Affiliations
                [1 ]ISNI 0000 0001 2107 4242, GRID grid.266100.3, School of Medicine, , University of California San Diego, ; 9500 Gilman Drive, La Jolla, CA 92093 USA
                [2 ]GRID grid.415705.2, Bugoye Level III Health Centre, , Uganda Ministry of Health, ; Bugoye, Kasese District, Western Region Uganda
                [3 ]ISNI 0000000122483208, GRID grid.10698.36, Department of Geography, , University of North Carolina at Chapel Hill, ; Campus Box 3220, Chapel Hill, NC 27599 USA
                [4 ]ISNI 0000000122483208, GRID grid.10698.36, Division of General Medicine & Clinical Epidemiology, , University of North Carolina at Chapel Hill, ; 5039 Old Clinic Building, CB 7110, Chapel Hill, 27599 USA
                [5 ]ISNI 0000 0001 0232 6272, GRID grid.33440.30, Department of Community Health, , Mbarara University of Science & Technology, ; P.O. Box 1410, Mbarara, Uganda
                [6 ]ISNI 000000041936877X, GRID grid.5386.8, Department of Emergency Medicine, , Weill Cornell Medical College, ; 525 East 68th Street, New York, NY 10065 USA
                [7 ]ISNI 0000000122483208, GRID grid.10698.36, Division of Infectious Diseases, , University of North Carolina at Chapel Hill, ; 130 Mason Farm Road, Chapel Hill, NC 27599 USA
                Article
                2454
                10.1186/s12936-018-2454-7
                6106765
                30134987
                © The Author(s) 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000002, National Institutes of Health;
                Award ID: T32 AI007151
                Award ID: K23 MH111409
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100007911, University of California, San Diego;
                Award ID: Global Health Academic Concentration
                Award Recipient :
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                © The Author(s) 2018

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