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Abstract
Background Intervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system.
Methods A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention.
Findings Stakeholders initially expressed caution and fears about the intervention’s implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops.
Conclusion The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.
- child health
- health systems
- malaria
- qualitative study
- acute respiratory infection
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Footnotes
Contributors FEK, HW, SP and ZS designed and conceptualized the study. FEK, HW and ZS developed and refined the study tools. FEK and CM conducted interviews, discussed emerging issues and modified topic guides during data collection. FEK, CM and EWJ read the transcripts and developed initial codes. FEK and CM developed mutually agreed codes, themes and categories. FEK, CM, EWJ and ZS contributed to data analysis and interpretation. FEK wrote the first paper draft. FEK,MB and ZS revised the first draft. FEK, CM, EWJ, SP, HW, MB and ZS reviewed and contributed to writing the paper. All authors read and approved the final manuscript.
Funding The study was supported by WHO Alliance for Health Policy and Systems Research, Einhorn Family Foundation, Pehr Lagermans Family, Sweden, Swedish Science Council and Uppsala University. These organisations had no role in the design, implementation, interpretation or reporting of the findings.
Disclaimer The authors are staff members of the WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the WHO.
Competing interests None declared.
Ethics approval WHO Ethics Review Committee, Makerere University School of Public Health Higher Degrees and Research Ethics Committee (IRB00011353) and the Uganda National Council for Science and Technology (HS1385).
Provenance and peer review Not commissioned; externally peer reviewed.
Correction notice This article has been corrected since it first published. The wording in the open access statement has been corrected.