Variation in the quality and out-of-pocket cost of treatment for childhood malaria, diarrhoea, and pneumonia: Community and facility based care in rural Uganda

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Abstract

Background

A key barrier to appropriate treatment for malaria, diarrhoea, and pneumonia (MDP) in children under 5 years of age in low income rural settings is the lack of access to quality health care. The WHO and UNICEF have therefore called for the scale-up of integrated community case management (iCCM) using community health workers (CHWs). The current study assessed access to treatment, out-of-pocket expenditure and the quality of treatment provided in the public and private sectors compared to national guidelines, using data collected in a large representative survey of caregivers of children in 205 villages with iCCM-trained CHWs in mid-Western Uganda.

Results

The prevalence of suspected malaria, diarrhoea and suspected pneumonia in the preceding two weeks in 6501 children in the study sample were 45%, 11% and 24% respectively. Twenty percent of children were first taken to a CHW, 56% to a health facility, 14% to other providers and no care was sought for 11%. The CHW was more likely to provide appropriate treatment compared to any other provider or to those not seeking care for children with MDP (RR 1.51, 95% CI 1.42–1.61, p<0.001). Seeking care from a CHW had the lowest cost outlay (median $0.00, IQR $0.00-$1.80), whilst seeking care to a private doctor or clinic the highest (median $2.80, IQR $1.20-$6.00). We modelled the expected increase in overall treatment coverage if children currently treated in the private sector or not seeking care were taken to the CHW instead. In this scenario, coverage of appropriate treatment for MDP could increase in total from the current rate of 47% up to 64%.

Conclusion

Scale-up of iCCM-trained CHW programmes is key to the provision of affordable, high quality treatment for sick children, and can thus significantly contribute to closing the gap in coverage of appropriate treatment.

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Most cited references 48

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Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals

Viroj Tangcharoensathien, Anne Mills, Toomas Palu (2015)

The Sustainable Development Goals (SDGs), to be committed to by Heads of State at the upcoming 2015 United Nations General Assembly, have set much higher and more ambitious health-related goals and targets than did the Millennium Development Goals (MDGs). The main challenge among MDG off-track countries is the failure to provide and sustain financial access to quality services by communities, especially the poor. Universal health coverage (UHC), one of the SDG health targets indispensable to achieving an improved level and distribution of health, requires a significant increase in government investment in strengthening primary healthcare - the close-to-client service which can result in equitable access. Given the trend of increased fiscal capacity in most developing countries, aiming at long-term progress toward UHC is feasible, if there is political commitment and if focused, effective policies are in place. Trends in high income countries, including an aging population which increases demand for health workers, continue to trigger international migration of health personnel from low and middle income countries. The inspirational SDGs must be matched with redoubled government efforts to strengthen health delivery systems, produce and retain more and relevant health workers, and progressively realize UHC.

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Community Case Management of Fever Due to Malaria and Pneumonia in Children Under Five in Zambia: A Cluster Randomized Controlled Trial

Kojo Yeboah-Antwi, Portipher Pilingana, William MacLeod … (2010)

Introduction Pneumonia and malaria are major causes of morbidity and mortality in children under five in sub-Saharan Africa [1],[2]. In many rural areas in developing countries, health facilities are not readily accessible to much of the population [3],[4], and the health needs of large numbers of sick children are met through the informal sector, including community health workers (CHWs), drug sellers, and traditional healers [5]. Since access to health facilities is limited and most children die at home [5], new and innovative approaches to reducing childhood mortality will require interventions implemented at the community level. The World Health Organization (WHO) and the United Nations Children Fund (UNICEF) now recommend that where malaria and pneumonia are major killers, their treatment should be integrated in community case management activities [6]. Many pneumonia deaths could be prevented through early, appropriate and low-cost community-based treatment [7],[8]. Training CHWs in the management of acute lower respiratory tract infections has been shown to be feasible and effective [9],[10]. Similarly, several studies have shown that CHWs can be trained to provide effective malaria case management at the community level [11],[12]. Following WHO recommendations, artemisinin-based combination therapy (ACT) has been introduced as the first line treatment for uncomplicated malaria in much of sub-Saharan Africa [13],[14]. The use of rapid diagnostic tests (RDTs) for guiding malaria treatment has been found to offer a practical solution to the challenge of malaria diagnostics in Africa [15],[16]. As a result, RDTs are increasingly being utilized to improve malaria case management and reduce unnecessary ACT use [17]. Because the overlap of symptoms between malaria and pneumonia in children makes differential diagnosis in the absence of diagnostic equipment difficult [18],[19], RDT use by CHWs presents a remarkable opportunity to improve the diagnosis of malaria and pneumonia at the community level. The use of RDTs by CHWs has been found to be potentially effective and feasible [20]–[23]. Although ACTs and RDTs are now available at health facilities in Zambia, they have not been fully deployed at the community level. Few studies have evaluated the integrated management of fever due to pneumonia and malaria by CHWs in children [24],[25], and the strategy of having CHWs dispense ACT has not been carefully evaluated. In addition, the potential benefit(s) of RDTs in improving malaria diagnosis before treatment with ACT by CHWs remain unknown. The objective of this study was, therefore, to assess the effectiveness and feasibility of using CHWs to manage pneumonia and malaria in children with the aid of RDTs per our protocol (Text S1). Methods We report here, using the Consort checklist (Text S2), a cluster randomized controlled trial that compared two models for community-based management of malaria and/or nonsevere pneumonia in children in rural Zambia. A cluster design was used instead of individual randomization because it was socially and culturally inappropriate for a CHW to give one patient treatment for nonsevere pneumonia and to refer the next patient to a health facility. Baseline and poststudy household surveys were conducted to assess changes in health-seeking behavior. Study Area and Participants The study was conducted in the Chikankata Mission Hospital catchment area, a geographic area with an estimated population of 70,000 [26] extending across parts of Siavonga and Mazabuka Districts in Zambia's Southern Province. The Siavonga area is predominantly plain and referred to as “the valley”; and the Mazabuka area is hilly and referred to as “the plateau.” Malaria, malnutrition, pneumonia, and diarrhea are the leading causes of morbidity and death in children under five [27],[28]. Transmission of malaria is hyperendemic and highest in the rainy season from November to April [29]. The study area has poor road networks and is served by the mission hospital and five official Zambian Ministry of Health rural health centers, of which only one has a full complement of staff (clinical officer, environmental health technician, and midwife). Most sick children are seen by CHWs who work in a fixed location called the community health post, which serves a number of villages. At the time of study initiation, CHWs did not use ACT, RDTs, or amoxicillin. Instead they would treat malaria with sulfadoxine-pyrimethamine and refer suspected pneumonia cases to the nearest health facility. They also routinely managed children presenting with diarrhea and dehydration with oral rehydration therapy. Two to eight health posts are situated within a health center catchment area. There was no formalized incentive package for the CHWs, but the Chikankata Mission Hospital provided occasional incentives (i.e., bicycles, umbrella, and stationery) when resources were available. Children aged between 6 mo and 5 y who presented to a CHW at a health post with fever and/or cough/difficult breathing/fast breathing were eligible for participation. Exclusion criteria included age below 6 mo or above 5 y, signs or symptoms of severe illness, or known sensitivity to the study medications. The Intervention Training All study CHWs had previously undergone 6 wk training before becoming community health workers. As part of the study, they participated in an additional 5-d training workshop using modifications of nationally developed training manuals. Members from both the Mazabuka and Siavonga District Health Management Teams (DHMT), study staff, and the principal investigator (KYA) led the training workshop. Training team members were experienced in training Integrated Management of Childhood Illness (IMCI) skills. The workshop had two main parts. In one part, which lasted 4 d, both intervention and control CHWs were trained, using the CHW training manual (Text S3), to classify and manage children with pneumonia and/or malaria, and to manage stocks of drugs and supplies. The training of the CHWs was highly interactive and included a variety of methods including lectures, discussion, role play, demonstrations, case studies, and supervised clinical practice at the hospital. The training emphasized community-based integrated management of febrile children including basic clinical history taking, physical examination skills, counseling of caregivers, and recognition of signs of severe illness requiring referral. A major focus was training CHWs in the use of simplified treatment algorithms developed to aid classification and treatment of malaria and pneumonia, with separate algorithms for the intervention and the control CHWs. Each algorithm had three sections; section A was used for children who presented with fever plus cough and/or shortness of breath (fast breathing, difficult breathing); section B for children who presented with cough and/or shortness of breath (fast breathing, difficult breathing) but without fever; and section C for children who had fever alone, without cough and/or shortness of breath. The identification of danger signs was an important focus of the training, to help ensure that the child, if in danger, was immediately referred to the nearest health center. The CHWs were also trained in the use of simple dosing guidelines based on weight, if available, or age for artemether-lumefantrine (AL). As part of this component of the training, both groups of CHWs were trained on how to manage the drug supplies, including proper documentation of patient complaints, their physical examination, and medications administered to the child. The second part of the workshop involved additional training for the intervention CHWs only. The CHW RDT training manual (Text S4) was used for this half-day session, which focused on performing and interpreting RDTs, with the aid of RDT interpretation guides. The proper interpretation of RDT results was emphasized, including how to react to both positive and negative results. As part of the RDT training, intervention CHWs were trained in infection control measures such as aseptic technique, proper disposal of hazardous biological waste, and avoidance of lancet injuries. The intervention CHWs also received supplemental training in amoxicillin dosing and documentation of RDT results. After completion of training, the instructors assessed the competency of all CHWs to count respiratory rate and follow treatment algorithms, and, for the intervention CHWs, the proper performance and interpretation of RDTs. One month after initial training, the training team completed a follow-up skills assessment to ensure that CHWs retained the necessary skills. All study CHWs completed an additional 2-d refresher course 6 mo after the initial training. Specialized data collectors were recruited and trained in study procedures, research ethics, informed consent protocols, and the use of data collection instruments. Patient management and follow-up Intervention CHWs performed RDTs on children with reported fever and counted the respiratory rate of children with cough and/or difficult/fast breathing using a respiratory timer. They classified children with positive RDT results and normal respiratory rate as malaria and treated with AL and an antipyretic (acetaminophen). Children with positive RDT results and high respiratory rate (≥50 breaths per minute in children 95%). 10.1371/journal.pmed.1000340.t003 Table 3 Presenting complaints and signs. Complaint or Sign Intervention (n = 1,017) Control (n = 2,108) RR (95% CI) Fever 94.7% 98.9% 0.45 (0.39–0.53) Fever with temperature ≥37.5°C 45.5% 50.8% 0.87 (0.78–0.96) Cough 67.8% 63.3% 1.15 (1.03–1.28) Difficult breathing 16.8% 6.9% 1.80 (1.60–2.02) Fast breathing by history 35.8% 10.2% 2.45 (2.24–2.68) Fast breathing based on respiratory rate counted by the community health worker 37.6% 9.7% 2.61 (2.31–2.85) Caregiver visited community health post on the same day as the first symptom onset 12.1% 10.1% 1.14 (0.98–1.33) RDT Results and Treatment for Malaria Of the 975 children in the intervention arm who presented with a history of fever and had RDTs performed, 27.8% had a positive RDT result. RDT positivity varied by geographical area and rural health center catchment area, and was higher in children seen at community health posts located in the “valley” (Table 4). Of the 975 children with reported fever, 460 had a measured temperature of ≥37.5°C. The proportion of children with a positive RDT in this subgroup was 28.5%; hence there was no difference in the RDT positivity rate whether the child had reported fever or had a measured temperature of ≥37.5°C. 10.1371/journal.pmed.1000340.t004 Table 4 Proportion of children with positive rapid diagnostic tests. Children n RDTs done n RDT positives Percent Positive All children 975 271 27.8 Children with temperature ≥37.5°C 460 131 28.5 Geographic Location Valley (Siavonga) 487 219 45.0 Plateau (Mazabuka) 488 52 10.7 Community Health Post Sianyoolo 239 88 36.8 Chaanga 248 131 52.8 Chikankata 66 1 1.5 Nameembo 88 6 6.8 Nadezwe 134 6 4.5 Chikombola 200 39 19.5 The proportion of children presenting with a history of fever that received AL in the intervention arm was 27.5% compared to 99.1% in the control arm (RR 0.23, 95% CI 0.14–0.38). Only three of the 704 children with negative RDT results were given AL by the CHW. Caregivers of five children with negative RDT results sought and received antimalarials from other sources after the CHW did not provide them. Early and Appropriate Treatment for Pneumonia Of the children classified as nonsevere pneumonia in the intervention arm, 78.8% sought treatment (consulted a CHW) within 24–48 h of onset of first symptom and 68.2% received early and appropriate treatment. In the control arm, 75.4% of children classified as nonsevere pneumonia sought treatment within 24–48 h of onset of first symptom and only 13.3% received early and appropriate treatment. While there was no significant difference between the two arms in the proportions of children who sought treatment within 24–48 h of onset of first symptom (RR 1.06, 95% CI 0.91–1.23), the difference in the proportions that received early and appropriate treatment for nonsevere pneumonia was significant (RR 5.32, 95% CI 2.19–8.94). Several factors, including age of the child, presenting complaints, maternal age and education, were examined either as promoters of or barriers to early and appropriate treatment. Children ≤11 mo tended to be less likely to receive early and appropriate treatment compared to older children (RR 0.84, 95% CI 0.69–1.02). Children of mothers with primary or secondary education tended to receive early and appropriate treatment compared to children of women without any education (RR 1.18, 95% CI 0.97–1.45). However, maternal age and type of presenting complaint did not influence the achievement of early and appropriate treatment. Treatment Failure There was no difference in the overall treatment failure rates among patients enrolled in the intervention (9.3%) and control (10.0%) arms (Table 5). Similarly, there was no significant difference between arms in treatment failure rate among children classified as having malaria (Table 6). However, children in the intervention group who were classified as having nonsevere pneumonia were significantly less likely to experience treatment failure (RR 0.44, 95% CI 0.21–0.92). The most common reasons for treatment failure in both arms were persistent fever and fast/difficult breathing at follow up. Hospitalization was also an important reason for treatment failure in the control arm (Table 7). Two patients in the intervention arm and one in the control arm died. The final outcomes of hospitalized patients were not determined nor were verbal autopsies performed to ascertain the cause of death. 10.1371/journal.pmed.1000340.t005 Table 5 Treatment failure for all patients. Variable Intervention Control RRa (95% CI) Treatment failure at day 5–7 95/1,017 (9.3%) 211/2,108 (10.0%) 0.68 (0.39–1.19) Persistent fever, fast/difficult breathing at follow-up 73/975 (7.5%) 159/2,052 (7.7%) 0.74 (0.42–1.29) Lower chest in-drawing at follow-up 1/973 (0.1%) 9/2,052 (0.4%) 0.17 (0.01–2.11) Received additional antibiotics 13/975 (1.3%) 25/2,054 (1.2%) 0.94(0.19–4.79) Received additional antimalarials 4/975 (0.4%) 8/2,054 (0.4%) 1.24 (0.41–3.57) Hospitalization 4/1,017 (0.4%) 14/2,108 (0.7%) 0.25 (0.04–1.50) Death 2/1,017 (0.2%) 1/2,108 (0%) — a Adjusted for baseline fast breathing and fever. 10.1371/journal.pmed.1000340.t006 Table 6 Treatment failure for patients classified as malaria. Variable Intervention Control RRa (95% CI) Treatment failure at day 5–7 20/272 (7.4%) 207/2,082 (9.9%) 0.68 (0.38–1.19) Persistent fever, fast/difficult breathing at follow up 17/255 (6.7%) 155/2,026 (7.7%) 0.86 (0.51–1.45) Lower chest in-drawing at follow-up 0/253 (0%) 9/2,026 (0.4%) Received additional antibiotics 2/255 (0.8%) 25/2,028 (1.2%) 0.58 (0.09–3.96) Received additional antimalarials 1/255 (0.4%) 8/2,025 (0.4%) — Hospitalization 0/272 (0%) 14/2,082 (0.7%) — Death 0/272 (0%) 1/2,082 (0%) — a Adjusted for baseline fever. 10.1371/journal.pmed.1000340.t007 Table 7 Treatment failure for patients classified as pneumonia. Variable Intervention Control RRa (95% CI) Treatment failure day 5–7 41/362 (11.3%) 41/203 (20.2%) 0.44 (0.21–0.93) Persistent fever, fast/difficult breathing at follow up 36/344 (10.5%) 32/193 (16.6%) 0.50 (0.22–1.17) Lower chest in-drawing on presentation at follow-up 0/344 (0%) 2/193 (1.0%) Received additional antibiotics 3/344 (0.9%) 1/193 (0.5%) 1.71 (0.18–16.2) Received additional antimalarials 1/344 (0.3%) 0/193 (0) Hospitalization 2/362 (0.6%) 7/203 (3.4%) 0.13 (0.02–0.75) Death 1/362 (0.3%) 0/203 (0%) a Adjusted for baseline fast breathing. Among children classified as having nonsevere pneumonia in the control arm, 14 (6.8%) were not referred by the CHWs as per standard of care and training. Of those who were referred to a health center, 22% did not comply with the referral. The major reason for noncompliance was that the caregiver did not believe the child's illness was serious enough to warrant referral, particularly when the child had been given treatment for malaria. Health-Seeking Practices During the household surveys, 439 and 441 women were interviewed in the baseline and postintervention surveys, respectively. Table 8 shows the changes in health-seeking practices that occurred between the beginning and end of the 1-y study period. There was a significant shift in where sick children sought care between the preintervention (baseline) and the postintervention surveys in both arms. In the postintervention survey, the proportion that sought care from CHWs increased while there was a corresponding decrease in the proportion that sought care at the rural health centers or resorted to home care. However, for children with fast/difficult breathing, the same shift only occurred in the intervention arm. The most common reasons for not seeking care with a CHW were unavailability of the CHW (45%), sickness perceived to be too severe for the CHW to handle (12%), and being nearer to the rural health center than to the community health post (10%). 10.1371/journal.pmed.1000340.t008 Table 8 Proportion of children seeking care for all illnesses and fast breathing during the baseline and poststudy household surveys. Source of care Intervention Baseline Intervention Poststudy Control Baseline Control Poststudy All illnesses ( n = 174) ( n = 190) ( n = 163) ( n = 203) Home 12.7% 2.6% 7.4% 4.9% CHW 47.1% 78.9% 50.9% 77.3% RHC/CMH 40.2% 18.5% 41.7% 17.8% Fast breathing ( n = 61) ( n = 66) ( n = 59) ( n = 34) Home 6.6% 3.0% 6.8% 8.8% CHW 50.8% 77.3% 54.2% 55.9% RHC/CMH 42.6% 19.7% 39.0% 35.3% CMH, Chikankata Mission Hospital; RHC, rural heath center. Discussion This study has demonstrated the feasibility and effectiveness of using CHWs to provide integrated management of pneumonia and malaria at the community level. Allowing CHWs to dispense amoxicillin to children with nonsevere pneumonia and AL for malaria after the use of RDTs resulted in a significant increase in the proportion of appropriately timed antibiotic treatments for nonsevere pneumonia and in a significant decrease in inappropriate use of antimalarials. Our study showed a 5-fold increase in the proportion of children with nonsevere pneumonia who received early and appropriate treatment when treated by CHWs in the community instead of the existing system of referral to health centers. This finding adds to the growing evidence of the important role of community-based workers in the management of pneumonia, which has been well documented in South East Asia, as described below, but to a much lesser extent in sub-Saharan Africa. A community-based pneumonia management program in Nepal using female community health volunteers resulted in almost 70% of Nepal's under-five population having access to pneumonia treatment and a reduction of under-five mortality by almost 50% [34]. In Pakistan, case management of acute lower respiratory infections by village level CHWs backed by local health center staff resulted in the reduction of pneumonia-specific and all-cause mortality in children under five [35]. A community-based intervention project in which village heath workers and traditional birth attendants were trained to give mass education about pneumonia and to recognize and treat childhood pneumonia with cotrimoxazole in India also resulted in significant reductions of pneumonia-specific and all-cause mortality [36]. An operational research evaluation project that used nonrandomized design in Senegal showed that CHWs can correctly classify acute respiratory infection and appropriately treat with cotrimoxazole [37]. We found that adequately trained and appropriately resourced CHWs can perform and interpret RDTs, and give treatment for malaria. This finding is consistent with a recent study in Cambodia [23]. Basing treatment on RDT results led to a 4-fold reduction in the use of AL in this study area; the reduction was as high as 10-fold in the dry months when malaria transmission was quite low. This finding has major implications for malaria treatment since the consequences of malaria overdiagnosis may include poor health outcome due to missed diagnosis of alternative causes of symptoms, exposure to unnecessary medication, wastage of essential medicines, and unnecessary expenditure at both the household and health system levels [38]–[40]. Msellam and colleagues in Zanzibar also found that RDT use was associated with lower prescription rates of antimalarials than symptom-based clinical diagnosis alone [41]. Overdiagnosis of malaria without laboratory support has been widely reported [42]–[45], and the findings of this study support the likelihood that RDT use could substantially reduce the inappropriate use of antimalarials if prescribers adhere to the RDT results. Adherence to the results of the RDTs was very high in this study. This suggests that CHWs are more willing to restrict the use of antimalarials to RDT positive patients [46],[47] than health workers, who frequently opt to treat RDT-negative patients [48]–[50]. However, one study has reported high adherence to RDT results when health workers prescribe AL [51]. In the present study, the refresher training after 6 mo, frequent review and assessment of performance of the CHWs at the RHCs, and a relatively high level of education (68% of the CHWs had secondary education) may have contributed to the high level of adherence to treatment guidelines, which were simple and easy to read and interpret (Figures 2 and 3). Lemma and colleagues in Ethiopia have also shown that the use of AL and RDTs by CHWs is not only feasible but has the potential of reducing malaria transmission and case burden for health facilities [52]. 10.1371/journal.pmed.1000340.g002 Figure 2 Treatment algorithm for Intervention Community Health Workers. 10.1371/journal.pmed.1000340.g003 Figure 3 Treatment algorithm for Control Community Health Workers. This study is, to our knowledge, the first randomized, controlled trial of the management of both malaria and pneumonia in children at the community level by CHWs using RDTs to differentiate between malaria and pneumonia. In a Care International community-integrated multiple disease management project in Siaya, Kenya, only the performance of CHWs in managing the multiple diseases was evaluated [25]. Degefie and colleagues have just reported the findings of an evaluation of a project using volunteers to provide treatment for childhood diarrhea, malaria, and pneumonia in a remote district in Ethiopia. The volunteers in this project did not use RDTs and the investigators used a pre–post study design [24]. With the use of RDTs in this study, less than 30% of children with a clinical diagnosis of nonsevere pneumonia were confirmed to also be infected with malaria, compared to almost 90% of the children in the control arm, in which malaria and nonsevere pneumonia diagnoses were syndromic. Without the use of RDTs, most children diagnosed with pneumonia will also be classified as having malaria and will receive antimalarial drugs [19]. Ansah and colleagues in Ghana showed that using RDTs led to a significant reduction in overprescription of antimalarials and better targeting of antibiotics [53]. Providing effective and safe oral treatment for the community-based treatment of malaria will substantially improve access to care for children in malaria-endemic areas and will undoubtedly save lives. However, because of the overlap in clinical presentation for malaria and pneumonia, providing CHWs with malaria-specific treatment (AL) but no effective antibiotics for treating pneumonia or a means to distinguish the two, will undoubtedly lead to pneumonia treatment delays. Failure to comply with referral because caregivers did not think that the child was very sick or has been presumptively treated for malaria was seen in the present study; this has been documented elsewhere [54],[55]. Providing CHWs with the means to treat malaria but not pneumonia increases the risk of treatment delay and progression to more severe disease for children with pneumonia. Our study has a number of strengths including the cluster randomized design, large sample size, accounting for clustering in analysis, additional training program and supervision of CHWs, use of a simple algorithm for diagnosis of the two diseases, and a 12-mo duration, which allowed for seasonal variation of childhood illnesses. A major limitation of this study was an imbalance in the number of individuals enrolled between the study arms. Since the CHW and child characteristics (including time to health care seeking) were similar in both arms, there is evidence that randomization was not compromised. Clusters were only matched in pairs according to the distance between the community health post and the health center. At the time the study was designed, there were no data available on the size of the catchment areas of the different community health posts. Since utilization of services and health-seeking practices are multifaceted and influenced by many factors [56], it is likely that cluster randomization could not address all of these factors, and hence the resulting imbalance. The fact that more CHWs in the control arm considered themselves as full-time workers and therefore available to see patients most of the day may also have contributed to the larger number of patients seen in the control arm. In favor of this interpretation was the finding that unavailability of CHWs was the most common reason for caregivers not using the services of CHWs. There were twice as many children classified with pneumonia in the intervention arm relative to the control arm. As confirmed by the presenting complaints and postintervention household surveys, caregivers who suspected that their children had pneumonia (due to complaints of fast/difficult breathing) preferentially brought them to the intervention CHWs because they knew that amoxicillin was available. Caregivers in the control arm who suspected that their children had pneumonia bypassed the CHW and went straight to the rural health center. The population of the intervention and control arms was found to be similar; thus the imbalance in the number and cases seen is most likely due to health-seeking practices in response to the intervention and potentially unequal distribution of the catchment population sizes between the two study arms. There was no indication of any significant “contamination” of control caregivers seeking care from intervention CHWs. Improving access to care for remote communities through the implementation of community case management of disease is an important new focus for global health policy. Community case management of pneumonia is an effective approach to reducing child deaths in countries faced with insufficient human resources for health [34],[57] and a feasible, effective strategy to complement facility-based management for areas that lack access to facilities [58]. In addition to optimizing the management of malaria and pneumonia, community case management should also integrate treatment of dehydration due to diarrheal disease with oral rehydration therapy, as was the practice in our study site in rural Zambia, and should also integrate the use of zinc. Future efforts should focus on the incorporation of life-saving interventions for severe disease at the community level including rectal artesunate for severe malaria [59] and amoxicillin for severe pneumonia [60]. With improved point-of-service technologies such as RDTs for malaria, the skills of CHWs can be substantially enhanced. The use of RDTs by CHWs is likely to receive the approval of community members since providers with diagnostic capacity are generally preferred [61]. This study adds to the growing evidence that integrating community case management of pneumonia and malaria is feasible, opening the door to evaluations of the treatment by CHWs of other major diseases of children. Much can be done at the community level to save the lives of children in sub-Saharan Africa [62]. Supporting Information Text S1 Protocol. (0.33 MB DOC) Click here for additional data file. Text S2 CONSORT checklist. (0.19 MB DOC) Click here for additional data file. Text S3 CHW training manual. (0.31 MB DOC) Click here for additional data file. Text S4 CHW RDT training manual. (1.93 MB DOC) Click here for additional data file.

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Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda.

Lewis Evans, Juliet Nabyonga-Orem, Peter Ogwang Ogwal … (2006)

There is currently considerable discussion between governments, international agencies, bilateral donors and advocacy groups on whether user fees levied at government health facilities in poor countries should be abolished. It is claimed that this would lead to greater access for the poor and reduce the risks of catastrophic health expenditures if all other factors remained constant, though other factors rarely remain constant in practice. Accordingly, it is important to understand what has actually happened when user fees have been abolished, and why. All fees at first level government health facilities in Uganda were removed in March 2001. This study explores the impact on health service utilization and catastrophic health expenditures using data from National Household Surveys undertaken in 1997, 2000 and 2003. Utilization increased for the non-poor, but at a lower rate than it had in the period immediately before fees were abolished. Utilization among the poor increased much more rapidly after the abolition of fees than beforehand. Unexpectedly, the incidence of catastrophic health expenditure among the poor did not fall. The most likely explanation is that frequent unavailability of drugs at government facilities after 2001 forced patients to purchase from private pharmacies. Informal payments to health workers may also have increased to offset the lost revenue from fees. Countries thinking of removing user charges should first examine what types of activities and inputs at the facility level are funded from the revenue collected by fees, and then develop mechanisms to ensure that these activities can be sustained subsequently.

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Author and article information

Contributors

Seyi Soremekun:

ORCID: http://orcid.org/0000-0002-5531-0220

Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draft

Frida Kasteng: Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing

Raghu Lingam: Role: ConceptualizationRole: SupervisionRole: Writing – review & editing

Anna Vassall: Role: SupervisionRole: Writing – review & editing

Edmound Kertho: Role: InvestigationRole: Project administration

Stella Settumba: Role: Investigation

Patrick L. Etou: Role: Data curationRole: InvestigationRole: Software

Agnes Nanyonjo: Role: InvestigationRole: Methodology

Guus ten Asbroek: Role: InvestigationRole: Methodology

Karin Kallander: Role: Funding acquisitionRole: InvestigationRole: MethodologyRole: Resources

Betty Kirkwood: Role: Funding acquisitionRole: SupervisionRole: Writing – review & editing

Luzia Helena Carvalho: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 26 November 2018

Publication date Collection: 2018

Volume: 13

Issue: 11

Electronic Location Identifier: e0200543

Affiliations

[1 ] Department of Population Health, London School of Hygiene and Tropical Medicine, London United Kingdom

[2 ] Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London United Kingdom

[3 ] Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

[4 ] Institute of Health and Society, Newcastle University, Newcastle, United Kingdom

[5 ] The Malaria Consortium, Kampala, Uganda

[6 ] National Perinatal Epidemiology and Statistics Unit, University of New South Wales, Sidney, Australia

[7 ] African Population Health Research Centre, Nairobi, Kenya

[8 ] Department of Global Health, Academic Medical Centre, Amsterdam, The Netherlands

[9 ] The Malaria Consortium, London, United Kingdom

Instituto Rene Rachou, BRAZIL

Author notes

Competing Interests: The authors have declared that no competing interests exist.

¶ inSCALE Study Group: Membership of the inSCALE study group is provided in the Acknowledgments

* E-mail: seyi.soremekun@ 123456lshtm.ac.uk

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Seyi Soremekun http://orcid.org/0000-0002-5531-0220

Article

Publisher ID: PONE-D-17-43248

DOI: 10.1371/journal.pone.0200543

PMC ID: 6261061

PubMed ID: 30475808

SO-VID: b5db6ce7-2f59-4233-be21-293ada7a435b

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 13 December 2017

Date accepted : 28 June 2018

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Figures: 1, Tables: 10, Pages: 24

Funding

Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;

Award ID: OPP1002407

Award Recipient : Karin Kallander

The study was funded by a Bill and Melinda Gates Foundation grant to the Malaria Consortium - number OPP1002407. Webpage: https://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/Grants/2009/10/OPP1002407. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability The full raw data set is ethically restricted, as it is potentially identifying. For this reason, while a partial data set is publicly available, the full data set is only available upon request. Please find the partial data set, as well as the application for the full data set, here: https://doi.org/10.17037/DATA.00000796. Interested researchers are encouraged to use the data request form listed on the repository to request to access data. Requests could also be e-mailed to the LSHTM data repository manager, Gareth Knight, at researchdatamanagement@ 123456lshtm.ac.uk , though the request form through the LSHTM repository is preferred.

Variation in the quality and out-of-pocket cost of treatment for childhood malaria, diarrhoea, and pneumonia: Community and facility based care in rural Uganda

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