Improving Management of Childhood Malaria in Nigeria and Uganda by Improving Practices of Patent Medicine Vendors

This 66-page report, published by BASICS II (a global child survival project funded by the Office of Health and Nutrition of the Bureau for Global Health of the United States Agency for International Development or USAID), explores the design, implementation, and preliminary results of interventions carried out in Nigeria and Uganda to reach patent medicine vendors (PMVs) in an effort to foster child survival.

As detailed here, PMVs include individuals, owners, or attendants working in private shops that may legally sell over-the-counter drugs, yet generally they illegally sell prescription drugs, such as antibiotics, sedatives, etc. The authors explain that a number of studies from Sub-Saharan African (SSA) have shown that between 15% and 82% of the population choose to first consult these informal providers for advice about and assistance with treatment of childhood illnesses. It has also been found that a large percentage of the drugs provided or dosages given, or both, at these private shops are inappropriate.

In response, the Ministries of Health in Nigeria and Uganda, in collaboration with various partners, designed approaches to draw on PMVs for delivery of basic child survival strategies and products to those populations less served by the public sector. These two distinct exploratory models - both described as involving behaviour change communication (BCC), some of it highly participatory in nature - built on lessons from similar efforts in SSA and elsewhere to develop approaches suited to the present situations in Nigeria and Uganda.

Further details about these interventions are shared in the excerpt, below. In short, although the authors stress that results from the intervention to change PMV practices were generally excellent, further studies will be needed to determine the sustainability of the intervention. However, early results compare favourably with other strategies, showing increases of 2% to 73% (simple malaria) and 2% to 90% (complicated malaria) for recommending the correct medicine, and 0% to 68% and 2% to 47%, respectively, for recommending the correct dose. The intervention also achieved significant improvements in the difficult-to-influence areas of referral and recommending insecticide-treated nets (ITNs) for the prevention of malaria. The approach was developed to bridge the gap between knowledge and practice, and the evidence suggests that it worked.

Excerpts from the document follow:

"Numerous reports have presented evidence that the first action of a large percentage of caregivers seeking treatment or advice for childhood illnesses in SSA is to visit a nearby drug shop....The “informal” drug shops may be licensed, but even so, drugs outside the scope of the license are usually available. This is one of the key reasons that governments generally shun PMVs as a group. The Uganda national strategy for private providers summarizes well the government’s predicament. “National polices do not recognize informal private practitioners as partners in public health programs. Regulation prohibits unqualified providers from practicing and hence, indirectly discourages effort to include them in child health programs. Moreover, health authorities fear that involving unqualified practitioners could be perceived as formal recognition and encouragement for them to continue their sub-standard practices” (Republic of Uganda MOH [Ministry of Health], 2002b). Even for countries facing the issue head on, like Uganda, there are no easy answers. In addition, PMVs and governments often mistrust one another, a situation that may cause difficulties on those occasions when working to improve PMVs’ practices is permitted.

Having gained national-level consent for limited implementation of promising approaches, the Nigeria and Uganda interventions moved forward with support of local governments, communities, PMVs, and in Nigeria with support of PMV associations. Both interventions, using somewhat different strategies for behavior change, reported significant improvements in key practices related to management of simple malaria, particularly providing the correct drug in the correct dose for malaria to caregivers of children under five with fever. The negotiation approach in Uganda also showed promise in the difficult area of changing practices related to how PMVs deal with severe illness in children. Both interventions are, however, only recently implemented, and so evidence of sustainability of these approaches is lacking.

Of the two approaches, the Nigeria intervention has shown the greatest promise for broad implementation. To date, about 1,600 PMVs have been trained in 11 LGAs [Local Government Associations] in Abia State, serving a population of nearly two million. The Uganda intervention also has promise, but the dependence on government health workers may not be feasible. The untested idea of using PMVs as moderators and supervisors may help with scaling up and sustaining this intervention. The community played a large role in the Nigeria intervention, both as a partner in implementation and as the target of behavior change messages and activities.

Unfortunately, one of the key unanswered questions is the contribution that BCC activities, including mass media targeting caregivers, have on increasing appropriate and timely treatment of malaria in children. Educating the population on the correct actions and drugs certainly helps, but how much effort should be placed in those activities versus activities more directly targeting PMVs and their practices is an important gap in our knowledge. A related question is to what extent can PMVs be used for dissemination of information to communities. In this regard, a consumer survey in Abia several months after implementation of the PMVs' training and launch of the PPAMs [prepackaged antimalarial drugs] found that PMVs were the most common source of information (34%) about recently introduced PPAMs, with health workers the second most common (24%) and mass media third (18%). This indicates that PMVs represent a largely untapped resource for diffusion of health messages, particularly those that deal with treatment of childhood illnesses...

In sum, the Nigeria and Uganda interventions add to the collective experience of working with the informal private sector..."