Coverage, Adherence and Costs of Intermittent Preventive Treatment of Malaria in Children Employing Different Delivery Strategies in Jasikan, Ghana

BACKGROUND: Intermittent preventive treatment of malaria in children (IPTc) involves the administration of a course of anti-malarial drugs at specified time intervals to children at risk of malaria regardless of whether or not they are known to be infected. IPTc provides a high level of protection against uncomplicated and severe malaria, with monthly sulphadoxine-pyrimethamine plus amodiaquine (SP&AQ) and sulphadoxine-pyrimethamine plus piperaquine being the most efficacious regimens. A key challenge is the identification of a cost-effective delivery strategy. METHODS: A community randomized trial was undertaken in Jasikan district, Ghana to assess IPTc effectiveness and costs using SP&AQ delivered in three different ways. Twelve villages were randomly selected to receive IPTc from village health workers (VHWs) or facility-based nurses working at health centres' outpatient departments (OPD) or EPI outreach clinics. Children aged 3 to 59 months-old received one IPT course (three doses) in May, June, September and October. Effectiveness was measured in terms of children covered and adherent to a course and delivery costs were calculated in financial and economic terms using an ingredient approach from the provider perspective. RESULTS: The economic cost per child receiving at least the first dose of all 4 courses was US$4.58 when IPTc was delivered by VHWs, US$4.93 by OPD nurses and US$5.65 by EPI nurses. The unit economic cost of receiving all 3 doses of all 4 courses was US$7.56 and US$8.51 when IPTc was delivered by VHWs or facility-based nurses respectively. The main cost driver for the VHW delivery was supervision, reflecting resources used for travelling to more remote communities rather than more intense supervision, and for OPD and EPI delivery, it was the opportunity cost of the time spent by nurses in dispensing IPTc. CONCLUSIONS: VHWs achieve higher IPTc coverage and adherence at lower costs than facility-based nurses in Jasikan district, Ghana. TRIAL REGISTRATION: ClinicalTrials.gov NCT00119132

Retail sector distribution chains for malaria treatment in the developing world: a review of the literature

BACKGROUND: In many low-income countries, the retail sector plays an important role in the treatment of malaria and is increasingly being considered as a channel for improving medicine availability. Retailers are the last link in a distribution chain and their supply sources are likely to have an important influence on the availability, quality and price of malaria treatment. This article presents the findings of a systematic literature review on the retail sector distribution chain for malaria treatment in low and middle-income countries. METHODS: Publication databases were searched using key terms relevant to the distribution chain serving all types of anti-malarial retailers. Organizations involved in malaria treatment and distribution chain related activities were contacted to identify unpublished studies. RESULTS: A total of 32 references distributed across 12 developing countries were identified. The distribution chain had a pyramid shape with numerous suppliers at the bottom and fewer at the top. The chain supplying rural and less-formal outlets was made of more levels than that serving urban and more formal outlets. Wholesale markets tended to be relatively concentrated, especially at the top of the chain where few importers accounted for most of the anti-malarial volumes sold. Wholesale price mark-ups varied across chain levels, ranging from 27% to 99% at the top of the chain, 8% at intermediate level (one study only) and 2% to 67% at the level supplying retailers directly. Retail mark-ups tended to be higher, and varied across outlet types, ranging from 3% to 566% in pharmacies, 29% to 669% in drug shops and 100% to 233% in general shops. Information on pricing determinants was very limited. CONCLUSIONS: Evidence on the distribution chain for retail sector malaria treatment was mainly descriptive and lacked representative data on a national scale. These are important limitations in the advent of the Affordable Medicine Facility for Malaria, which aims to increase consumer access to artemisinin-based combination therapy (ACT), through a subsidy introduced at the top of the distribution chain. This review calls for rigorous distribution chain analysis, notably on the factors that influence ACT availability and prices in order to contribute to efforts towards improved access to effective malaria treatment

Improving access to health care for malaria in Africa: a review of literature on what attracts patients

BACKGROUND: Increasing access to health care services is considered central to improving the health of populations. Existing reviews to understand factors affecting access to health care have focused on attributes of patients and their communities that act as 'barriers' to access, such as education level, financial and cultural factors. This review addresses the need to learn about provider characteristics that encourage patients to attend their health services. METHODS: This literature review aims to describe research that has identified characteristics that clients are looking for in the providers they approach for their health care needs, specifically for malaria in Africa. Keywords of 'malaria' and 'treatment seek*' or 'health seek*' and 'Africa' were searched for in the following databases: Web of Science, IBSS and Medline. Reviews of each paper were undertaken by two members of the team. Factors attracting patients according to each paper were listed and the strength of evidence was assessed by evaluating the methods used and the richness of descriptions of findings. RESULTS: A total of 97 papers fulfilled the inclusion criteria and were included in the review. The review of these papers identified several characteristics that were reported to attract patients to providers of all types, including lower cost of services, close proximity to patients, positive manner of providers, medicines that patients believe will cure them, and timeliness of services. Additional categories of factors were noted to attract patients to either higher or lower-level providers. The strength of evidence reviewed varied, with limitations observed in the use of methods utilizing pre-defined questions and the uncritical use of concepts such as 'quality', 'costs' and 'access'. Although most papers (90%) were published since the year 2000, most categories of attributes had been described in earlier papers. CONCLUSION: This paper argues that improving access to services requires attention to factors that will attract patients, and recommends that public services are improved in the specific aspects identified in this review. It also argues that research into access should expand its lens to consider provider characteristics more broadly, especially using methods that enable open responses. Access must be reconceptualized beyond the notion of barriers to consider attributes of attraction if patients are to receive quality care quickly

The optimum pH for the derivative spectrophotometric determination of co-trimoxazole in binary mixtures

Background: Although the experimental assessment of co-trimoxazole by use of derivative spectrophotmetry underscores the usefulness of this method due to its relative simplicity with which it can be carried out over the official United States Pharmacopoeia (USP), high pressure liquid chromatography (hplc) methods for this drug, suitable optimum conditions ought to be refined for its universal acceptability. Objective: The objective of the present work was to obtain the optimum pH level for the UV assessment of co-trimoxazole. Methods: The aqueous solutions of the individual drugs and their binary mixtures were buffered with Sodium Acetate-Acetic Acid buffer in the pH ranges 2-7 and scanned on zero order and on first-order derivative at the wave length between 200- 300nm Results: At the same drug solution concentrations, spectral shifts occurred with change in pH, especially between the wavelengths 200 and 240nm, only seeming to converge from approximate wavelength 260nm onwards. Absorbance fluctuations were also observed at the same drug concentrations in the pH range 2 to 3.5 and 5 to 7 when the solutions were scanned, even at the wavelength where the spectra seem to converge. However there were no absorbance differences between pH 4 and 5. Conclusion: The UV spectrophotometric method is dependent on the optimum pH and this has been found to range from 4 to 5. Key words: hypsochromic shift, auxochromes, sulphamethoxazole, trimethoprim, spectroscopy, pH, UV, pyridines African Health Sciences 2002; 2(3): 114-11

Community pharmaceutical care: an 8-month critical review of two pharmacies in Kampala

Background: The concept of pharmaceutical care is neither well developed nor adequately documented in Uganda. Objectives: This study is therefore an attempt to identify and quantify the various service components of community pharmacy practice in Kampala, Uganda's capital city. Setting: Two pharmacies operating retail outlets were chosen out of about 110 in Kampala. The city itself is fairly small with a rather congested population. It is Uganda's economic hub with the greatest number of private sector health facilities and pharmacy outlets. Methods: This study involved an 8-month observation period at the two pharmacies, combined with a data collection form to record demographic characteristics of respondents and parameters such as self-medication, pharmacy initiated therapy, prescription filling, patient/non-patient clients and treatment received. Results: 567 observations were made. Missing data for parameters studied were omitted during analysis, thus yielding different totals for the various sets of variables. Just less than half of 564 respondents (44.3%), were females compared to males (55.7%). The study found that clients over the age of 12 years seeking pharmaceutical services were 8-fold (93.1%) more likely to be the very patients compared to children (OR = 8.3; 95% CI, 3.7-18.7). Slightly ove r thirty percent of respondents (32.3%) were third party patients. About fifteen percent (14.7%) of respondents came to fill prescriptions, 28.8% to receive pharmacy-initiated therapy and 56.5% came for self-medication with all drugs including antibiotics at 22.4%. Most clients (75.2%) received treatment.The availability of a drug at the pharmacy was found to be a significant predictor of whether treatment was received, with the client age acting as a confounding variable (OR = 59.7; 95% CI 25.9-137.6). African Health Sciences 2003 3(2); 87-9

The cardiotonic effect of the crude ethanolic extract of Nerium oleander in the isolated guinea pig hearts

Cardiovascular diseases are increasingly becoming one of the leading diseases causing morbidity and mortality in Uganda. Ethnographic evidence suggests that these diseases are often first managed by indigenous and related herbs before patients are referred for allopathic forms of management. One such herb of interest is Nerium oleander. Therefore the crude ethanolic extracts of the dried leaves of this herb were tested against the following parameters in the isolated guinea pig hearts: force of contraction, heart rate and cardiac flow. The extracts brought about dose-dependent increases in all these parameters from their baseline readings. Compared with graded doses of digoxin the effects closely mirrored the activities in a dose dependent manner. At the mechanism of action level, it would appear the extract works in the same as digoxin since their dose-contraction-reponse curves are parallel. This finding would tend to provide a strong rationale for the herb's traditional use in cardiovascular illness

Introducing rapid diagnostic tests for malaria into drug shops in Uganda: design and implementation of a cluster randomized trial.

BACKGROUND: An intervention was designed to introduce rapid diagnostics tests for malaria (mRDTs) into registered drug shops in Uganda to encourage rational and appropriate treatment of malaria with artemisinin-based combination therapy (ACT). We conducted participatory training of drug shop vendors and implemented supporting interventions to orientate local communities (patients) and the public sector (health facility staff and district officials) to the behavioral changes in diagnosis, treatment and referral being introduced in drug shops. The intervention was designed to be evaluated through a cluster randomized trial. In this paper, we present detailed design, implementation and evaluation experiences in order to help inform future studies of a complex nature. METHODS: Three preparatory studies (formative, baseline and willingness-to-pay) were conducted to explore perceptions on diagnosis and treatment of malaria at drug shops, and affordable prices for mRDTs and ACTs in order to inform the design of the intervention and implementation modalities. The intervention required careful design with the intention to be acceptable, sustainable and effective. Critical components of intervention were: community sensitization and creating awareness, training of drug shop vendors to diagnose malaria with mRDTs, treat and refer customers to formal health facilities, giving pre-referral rectal artesunate and improved record-keeping. The primary outcome was the proportion of patients receiving appropriately-targeted treatment with ACT, evaluated against microscopy on a research blood slide. RESULTS: Introducing mRDTs in drug shops may seem simple, but our experience of intervention design, conduct and evaluation showed this to be a complex process requiring multiple interventions and evaluation components drawing from a combination of epidemiological, social science and health economics methodologies. The trial was conducted in phases sequenced such that each benefited from the other. CONCLUSIONS: The main challenges in designing this trial were maintaining a balance between a robust intervention to support effective behaviour change and introducing practices that would be sustainable in a real-life situation in tropical Africa; as well as achieving a detailed evaluation without inadvertently influencing prescribing behaviour. TRIAL REGISTRATION: NCT01194557 registered with ClinicalTrials.gov 2 September 2010

Home treatment of 'malaria' in children in rural Gambia is uncommon.

Home treatment with antimalarials is a common practice in many countries, and may save lives by ensuring that more malaria cases receive prompt treatment. Through retrospective surveys we found that home treatment of young children with antimalarials was uncommon in rural Gambia. Few families kept medicines in the home in case of illness, 28% kept paracetamol and only 8% kept chloroquine. Less than 10% of cases of childhood 'malaria' had been treated with chloroquine at home, and 69% of those giving home medication did not know the correct dosage for a child. The most common course of treatment was the use of paracetamol and/or tepid sponging to reduce fever, before the child was taken to a government health facility. Treating a child with antimalarials at home was more costly than other forms of treatment. The low cost associated with the use of health services for children and the limited availability of antimalarials outside major towns contribute to the high use of government health services. This shows that that home treatment cannot be assumed to be the predominant mode of malaria treatment throughout Africa, and highlights the need for country-specific policies based on accurate local knowledge of treatment practices in both rural and urban areas