In Bangladesh, there is a lack of knowledge about the large body of informal sector practitioners, who are the major providers of health care to the poor, especially in rural areas, knowledge which is essential for designing a need-based, pro-poor health system. This paper addresses this gap by presenting descriptive data on their professional background including knowledge and practices on common illnesses and conditions from a nationwide, population-based health-care provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers in the health care scenario of Bangladesh. Community health workers (CHWs) comprised about 7% of the providers. The TBAs/traditional healers had <5 years of schooling on average compared with 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and CHWs (average 8 years). Their main routes of entry into the profession were apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to a few months from semi-formal, unregulated private institutions. Their professional knowledge base was not at a level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs (e.g. use of antibiotics) than the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize the importance of the informal providers for the health care of the poor. Consequently, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system until constraints on the supply of qualified and motivated health care providers into the system can be alleviated.
BACKGROUND: Neonatal mortality accounts for a high proportion of deaths in children under the age of 5 years in Bangladesh. Therefore the project for advancing the health of newborns and mothers (Projahnmo) implemented a community-based intervention package through government and non-government organisation infrastructures to reduce neonatal mortality. METHODS: In Sylhet district, 24 clusters (with a population of about 20 000 each) were randomly assigned in equal numbers to one of two intervention arms or to the comparison arm. Because of the study design, masking was not feasible. All married women of reproductive age (15-49 years) were eligible to participate. In the home-care arm, female community health workers (one per 4000 population) identified pregnant women, made two antenatal home visits to promote birth and newborn-care preparedness, made postnatal home visits to assess newborns on the first, third, and seventh days of birth, and referred or treated sick neonates. In the community-care arm, birth and newborn-care preparedness and careseeking from qualified providers were promoted solely through group sessions held by female and male community mobilisers. The primary outcome was reduction in neonatal mortality. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number 00198705. FINDINGS: The number of clusters per arm was eight. The number of participants was 36059, 40159, and 37598 in the home-care, community-care, and comparison arms, respectively, with 14 769, 16 325, and 15 350 livebirths, respectively. In the last 6 months of the 30-month intervention, neonatal mortality rates were 29.2 per 1000, 45.2 per 1000, and 43.5 per 1000 in the home-care, community-care, and comparison arms, respectively. Neonatal mortality was reduced in the home-care arm by 34% (adjusted relative risk 0.66; 95% CI 0.47-0.93) during the last 6 months versus that in the comparison arm. No mortality reduction was noted in the community-care arm (0.95; 0.69-1.31). INTERPRETATION: A home-care strategy to promote an integrated package of preventive and curative newborn care is effective in reducing neonatal mortality in communities with a weak health system, low health-care use, and high neonatal mortality.
Most programs to reduce maternity deaths focus on hospital performance and general obstetric protocols. In communities where most mothers deliver at home, such strategies will not reduce avoidable deaths. The key concept in the actual intervention is to regard deliveries in poor rural communities as a trauma and to merge midwives and traditional birth attendants (TBAs) with an already existing and successful rural trauma rescue system. A total of 256 Cambodian careproviders, 41 health center midwives and paramedics, plus surgical teams at local hospitals were trained over a 2 year period. After completing the training program, the participants themselves rated their skills, confidence, and quality of team work by Visual Analog Scale measurement. The results demonstrate significant improvement, both for the TBAs and the certified midwives. The intervention results so far indicate that delivery life support training to rural careproviders increases their capacity to cope with emergency obstetric cases.
OBJECTIVE: The study was carried out to evaluate short term effects of one to one educational intervention approach, conducted with 40 drug sellers in order to improve the private sector's practices, compliance and performance in using the national treatment guidelines for malaria and other common childhood (diarrhoea, acute respiratory tract infection-ARI) illnesses in Kibaha district-Tanzania.
METHODS: The training took place one month after baseline data collection. Data collection was undertaken eight months after training and the effects of training was evaluated. The 40 drug stores were divided into 20 intervention and 20 control facilities. Trained nurses were used as clients who posed as caretakers of sick under-five children needing medication. The drug dispensers/sellers knowledge of anti-malarials and other drugs and their dispensing practices was assessed.
RESULTS: The intervention seemed to have had a significant impact on knowledge pattern for prescribing and dispensing practices of drug stores for some common childhood illnesses but not in other control drug stores/shops. About 90% (n=18) of shops prescribed to clients, the approved first-line anti-malarial drug for uncomplicated malaria (sulfadoxine-pyrimethamine), as compared to only 55% (n=11) of the control shops.
CONCLUSION: Changing the private sectors' knowledge, behaviour and practices/performance may be a slow and difficult process. The intervention approach applied in this study seems to be feasible at district-level. This strategy can be applied in all districts of Tanzania with the aim of achieving significant improvements in knowledge, behaviour, compliance, improving performance and practices of drug sellers in drug stores/shops. However, other alternative strategies are needed to influence drug sellers'/dispensers' compliance and performance. Thus, the overall impact on performance and practices in these facilities will remain at moderate level for quite sometime unless national policies, other programs and stakeholders are involved actively.
Rural populations disproportionately lack access to improved water supplies. We evaluated a novel scheme that employed community-based sales agents to disseminate the Safe Water System (SWS)--a household-level water chlorination and safe storage intervention--in rural Madagascar. Respondents from 242 households in 4 villages were interviewed; all used surface water for drinking water. Respondents from 239 households (99%) had heard of Sûr'Eau, the SWS disinfectant; 226 (95%) reported having ever used Sûr'Eau, and 166 (73%) reported current use. Current Sûr'Eau use was confirmed in 54% of households. Community sales agents effectively motivated their neighbors to adopt a new health behavior that prevents diarrhea. Future work should focus on strategies for sustaining SWS use, factors that motivate community-based sales agents to promote SWS, and the feasibility of scaling up this approach.
BACKGROUND: Global malaria control strategies highlight the need to increase early uptake of effective antimalarials for childhood fevers in endemic settings, based on a presumptive diagnosis of malaria in this age group. Many control programmes identify private medicine sellers as important targets to promote effective early treatment, based on reported widespread inadequate childhood fever treatment practices involving the retail sector. Data on adult use of over-the-counter (OTC) medicines is limited. This study aimed to assess childhood and adult patterns of OTC medicine use to inform national medicine retailer programmes in Kenya and other similar settings.
METHODS: Large-scale cluster randomized surveys of treatment seeking practices and malaria parasite prevalence were conducted for recent fevers in children under five years and recent acute illnesses in adults in three districts in Kenya with differing malaria endemicity.
RESULTS: A total of 12, 445 households were visited and data collected on recent illnesses in 11, 505 children and 19, 914 adults. OTC medicines were the most popular first response to fever in children with fever (47.0%; 95% CI 45.5, 48.5) and adults with acute illnesses (56.8%; 95% CI 55.2, 58.3). 36.9% (95% CI 34.7, 39.2) adults and 22.7% (95% CI 20.9, 24.6) children using OTC medicines purchased antimalarials, with similar proportions in low and high endemicity districts. 1.9% (95% CI 0.8, 4.2) adults and 12.1% (95% CI 16.3,34.2) children used multidose antimalarials appropriately. Although the majority of children and adults sought no further treatment, self-referral to a health facility within 72 hours of illness onset was the commonest pattern amongst those seeking further help.
CONCLUSION: In these surveys, OTC medicines were popular first treatments for fever in children or acute illnesses in adults. The proportions using OTC antimalarials were similar in areas of high and low malaria endemicity. In all districts, adults were more likely to self-treat with OTC antimalarial medicines than febrile children were to receive them, and less likely to use them in recommended ways. Government health centres were the most common second resort for treatment and were often used within 72 hours. In view of these practices, more research is needed to assess the impact on the popularity of private medicine sellers of strengthened public sector policies on access to malaria treatment and insecticide-treated bed nets. Improved targeting of OTC antimalarials to high risk groups, better communication strategies regarding adult as well as children's dosages, and facilitating more rapid referral to trained health workers where needed are important challenges to private medicine seller programmes.
Medicine sellers are widely used for fever and malaria treatment in sub-Saharan Africa, but concerns surround the appropriateness of drugs and information provided. Because there is increasing interest in improving their services, we reviewed the literature on their characteristics and interventions to improve their malaria-related practices. Sixteen interventions were identified, involving a mixture of training/capacity building, demand generation, quality assurance, and creating an enabling environment. Although evidence is insufficient to prove which approaches are superior, tentative conclusions were possible. Interventions increased rates of appropriate treatment, and medicine sellers were willing to participate. Features of successful interventions included a comprehensive situation analysis of the legal and market environment; buy-in from medicine sellers, community members and government; use of a combination of approaches; and maintenance of training and supervision. Interventions must be adapted to include artemisinin-based combination therapies, and their sustainability and potential to operate at a national level should be further explored.
We conducted a randomized, controlled, three-armed trial to assess whether training in syndromic management, with provision of packets, could improve the quality of STD services provided among non-formal care providers. The quality of STD case management service, observed by "incognito patients" in both intervention groups, improved substantially compared to the control group (p < 0.05). The training-and-packets group performed better in service delivery, HIV-testing referral, and condom provision when compared to the training-only group (all p < 0.05). The training-and-packets group also retained more knowledge and practiced more skillfully at six months post-intervention when compared to the training-only group (p < 0.05). Exit interviews of clients suggested that 81% of providers in the intervention groups offered advice on condom use when compared to none of those in the control group (p < 0.001). Syndromic management training and free syndrome packets for non-formal providers had a positive impact on the quality of STD care among the trained providers.
