Medicine sellers’ perspectives on their role in providing health care in North-West Cameroon: a qualitative study

R Hughes, CIR Chandler, L Mangham-Jefferies, W Mbacham

Health Policy and Planning 2012, 28: 636-646 | DOI: 10.1093/heapol/czs103


Background: Increasing recognition of the importance of medicine sellers in low-resource settings has emerged alongside assumptions that their motives and capacities primarily relate to profit maximization. This article suggests a need to reframe thinking about the role of medicine sellers in developing country health systems.

Methods: We used in-depth interviews to explore perceptions of medicine seller roles among a restricted random sample of 20 medicine sellers in North-West Cameroon. Interviews and analysis explored self-perception of their work/role, community perceptions, skills and knowledge, regulation, future plans, links with the formal health system and diversity among medicine sellers.

Results: Medicine sellers in our study were a varied, yet distinct group. They saw themselves as closely integrated in the social and medical landscapes of clients. Although some client interactions were described as simple sales, many respondents presented themselves as gatekeepers of medicines and knowledge, reflecting a conceptualization of the distinctness of medicines over other commodities. Acknowledgement of limits in knowledge and resources led to recognition of the need for formal healthcare providers and justified a restricted scope of practice and the need for referral. Motivation was derived from a desire for both financial and social capital combined with a proximity to medicines and repeated exposure to ill health. Legitimacy was perceived to be derived from: a historical mandate; informal and formal training and effective ‘community regulation’.

Conclusions: The distinct role that medicine sellers describe themselves as occupying in this study area can be characterized as provision of ‘first aid’, urgent, reactive and sometimes providing intermediate care prior to referral. Medicine sellers suggest that they do not aspire to be doctors and emphasize the complementary, rather than competitive, nature of their relationship with formal providers. We discuss the challenges and opportunities of characterizing medicine sellers as a distinctive group of ‘first aiders’ in this setting.

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Exploring health providers’ and community perceptions and experiences with malaria tests in south-east Nigeria: a critical step towards appropriate treatment

OP Ezeoke, NN Ezumah, C Chandler, LJ Mangham-Jefferies, OE Onwujekwe, V Wiseman, BS Uzochukwu

Malaria Journal 2012, 11:368 | DOI: 10.1186/1475-2875-11-368


Background: The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers’ perceptions and experiences with malaria tests in south east Nigeria.

Methods: The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty- six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area.

Results: Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test.

Conclusion: The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people’s attitude towards malaria test results.

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A systematic review of strategies to scale up delivery of insecticide-treated nets for malaria control

B Willey, L Smith Paintain, L Mangham, J Armstrong-Schellenberg

Bulletin of the World Health Organization 2012, 90:672-684E | DOI: 10.2471/BLT.11.094771


Objective: To synthesize findings from recent studies of strategies to deliver insecticide-treated nets (ITNs) at scale in malaria-endemic areas.

Methods: Databases were searched for studies published between January 2000 and December 2010 in which: subjects resided in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children aged < 5 years was evaluated; and the study design was an individual or cluster-randomized controlled design, nonrandomized, quasi-experimental, before-and-after, interrupted time series or cross-sectional without temporal or geographical controls. Papers describing qualitative studies, case studies, process evaluations and cost-effectiveness studies linked to an eligible paper were also included. Study quality was assessed using the Cochrane risk of bias checklist and GRADE criteria. Important influences on scaling up were identified and assessed across delivery strategies.

Findings: A total of 32 papers describing 20 African studies were reviewed. Many delivery strategies involved health sectors and retail outlets (partial subsidy), antenatal care clinics (full subsidy) and campaigns (full subsidy). Strategies achieving high ownership among households and use among children < 5 delivered ITNs free through campaigns. Costs were largely comparable across strategies; ITNs were the main cost. Cost-effectiveness estimates were most sensitive to the assumed net lifespan and leakage. Common barriers to delivery included cost, stock-outs and poor logistics. Common facilitators were staff training and supervision, cooperation across departments or ministries and stakeholder involvement.

Conclusion: There is a broad taxonomy of strategies for delivering ITNs at scale.

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A cost-effectiveness analysis of provider and community interventions to improve the treatment of uncomplicated malaria in Nigeria: study protocol for a randomized controlled trial

V Wiseman, O Ezeoke, E Nwala, LJ Mangham, B Cundill, J Enemuo, E Uchegbu, B Uzochukwu, O Onwujekwe

Trials 2012, 13:81 | DOI: 10.1186/1745-6215-13-81


Background: There is mounting evidence of poor adherence by health service personnel to clinical guidelines for malaria following a symptomatic diagnosis. In response to this, the World Health Organization (WHO) recommends that in all settings clinical suspicion of malaria should be confirmed by parasitological diagnosis using microscopy or Rapid Diagnostic Test (RDT). The Government of Nigeria plans to introduce RDTs in public health facilities over the coming year. In this context, we will evaluate the effectiveness and cost-effectiveness of two interventions designed to support the roll-out of RDTs and improve the rational use of ACTs. It is feared that without supporting interventions, non-adherence will remain a serious impediment to implementing malaria treatment guidelines.

Methods/design: A three-arm stratified cluster randomized trial is used to compare the effectiveness and cost-effectiveness of: (1) provider malaria training intervention versus expected standard practice in malaria diagnosis and treatment; (2) provider malaria training intervention plus school-based intervention versus expected standard practice; and (3) the combined provider plus school-based intervention versus provider intervention alone. RDTs will be introduced in all arms of the trial. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit primary health centers, pharmacies, and patent medicine dealers. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider and community knowledge. Costs will be estimated from both a societal and provider perspective using standard economic evaluation methodologies.

Trial registration: NCT01350752

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‘As a clinician, you are not managing lab results, you are managing the patient’: how enactment of malaria at health facilities in Cameroon compares with new WHO guidelines

CIR Chandler, L Mangham, AN Njei, O Achonduh, WF Mbacham, V Wiseman

Social Science and Medicine 2012, 74:1528-1535 | DOI: 10.1016/j.socscimed.2012.01.025


In response to widespread overuse of antimalarial drugs, the World Health Organisation changed guidelines in 2010 to restrict the use of antimalarials to parasitologically confirmed malaria cases. Malaria rapid diagnostic tests (RDTs) have been presented as a means to realize the new guidelines, and National Malaria Control Programmes, including that of Cameroon, are developing plans to introduce the tests to replace microscopy or clinical diagnosis at public health facilities across the country.

We aimed to understand how malaria tests and antimalarial drugs are currently used as part of social interactions between health workers and patients at public and mission health facilities in Yaoundé and Bamenda and surrounding districts in the Northwest region of Cameroon. In May to June 2010, we held 17 focus group discussions with 146 health workers involved in clinical care from 49 health facilities.

Clinicians enacted malaria as a ‘juggling’ exercise, involving attention to pathophysiology of the patient as well as their desires and medical reputations, utilising tests and medicines for their therapeutic effects as symbols in the process of care. Parasites were rarely mentioned in describing diagnostic decisions.

These enactments of malaria contrast with evidence-based guidelines emanating from WHO, which assume the parasite is the central driver of practice. If RDTs are to be taken up in practice, public health practitioners need to pay careful attention to the values and priorities of health workers and patients if they are to work with them to improve diagnosis and treatment of febrile illnesses.

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A cost-effectiveness analysis of provider interventions to improve health worker practice in providing treatment for uncomplicated malaria in Cameroon: study protocol for a cluster randomized trial

V Wiseman, LJ Mangham, B Cundill, OA Achonduh, AN Nji, AN Njei, C Chandler, W Mbacham

Trials 2012, 13:4  DOI: 10.1186/1745-6215-13-4


Background: Governments and donors all over Africa are searching for sustainable, affordable and cost-effective ways to improve the quality of malaria case management. Widespread deficiencies have been reported in the prescribing and counselling practices of health care providers treating febrile patients in both public and private health facilities. Cameroon is no exception with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials and the use of incorrect dosages. This study evaluates the effectiveness and cost-effectiveness of introducing two different provider training packages, alongside rapid diagnostic tests (RDTs), designed to equip providers with the knowledge and practical skills needed to effectively diagnose and treat febrile patients. The overall aim is to target antimalarial treatment better and to facilitate optimal use of malaria treatment guidelines.

Methods/Design: A 3-arm stratified, cluster randomized trial will be conducted to assess whether introducing RDTs with provider training (basic or enhanced) is more cost-effective than current practice without RDTs, and whether there is a difference in the cost effectiveness of the provider training interventions. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit public and mission health facilities. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider knowledge. Costs will be estimated from a societal and provider perspective using standard economic evaluation methodologies.

Trial Registration: NCT00981877

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Malaria prevalence and treatment of febrile patients at health facilities and medicine retailers in Cameroon

LJ Mangham, B Cundill, OA Achonduh, JN Ambebila, A Lele, TN Metoh, SN Ndive, IC Ndong, RL Nguela, AM Nji, B Orang-Ojong, J Pamen-Ngako, V Wiseman, WF Mbacham

Tropical Medicine and International Health 2012, 17(3):330-342 | DOI: 10.1111/j.1365-3156.2011.02918.x


Objective: To investigate the quality of malaria case management in Cameroon 5 years after the adoption of artemisinin-based combination therapy (ACT). Treatment patterns were examined in different types of facility, and the factors associated with being prescribed or receiving an ACT were investigated.

Methods: A cross-sectional cluster survey was conducted among individuals of all ages who left public and private health facilities and medicine retailers in Cameroon and who reported seeking treatment for a fever. Prevalence of malaria was determined by rapid diagnostic tests (RDTs) in consenting patients attending the facilities and medicine retailers.

Results: Among the patients, 73% were prescribed or received an antimalarial, and 51% were prescribed or received an ACT. Treatment provided to patients significantly differed by type of facility: 65% of patients at public facilities, 55% of patients at private facilities and 45% of patients at medicine retailers were prescribed or received an ACT (P = 0.023). The odds of a febrile patient being prescribed or receiving an ACT were significantly higher for patients who asked for an ACT (OR = 24.1, P < 0.001), were examined by the health worker (OR = 1.88, P = 0.021), had not previously sought an antimalarial for the illness (OR = 2.29, P = 0.001) and sought treatment at a public (OR = 3.55) or private facility (OR = 1.99, P = 0.003). Malaria was confirmed in 29% of patients and 70% of patients with a negative result were prescribed or received an antimalarial.

Conclusions: Malaria case management could be improved. Symptomatic diagnosis is inefficient because two-thirds of febrile patients do not have malaria. Government plans to extend malaria testing should promote rational use of ACT; though, the introduction of rapid diagnostic testing needs to be accompanied by updated clinical guidelines that provide clear guidance for the treatment of patients with negative test results.

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School-based intermittent screening and treatment of malaria in Kenya: cost analysis and framing of an economic evaluation

T Drake, G Okello, K Njagi, KE Halliday, MCH Jukes, L Mangham, S Brooker

Malaria Journal 2011, 10:273 | DOI: 10.1186/1475-2875-10-273


Background: The control of malaria in schools is receiving increasing attention, but there remains currently no consensus as to the optimal intervention strategy. This paper analyses the costs of intermittent screening and treatment (IST) of malaria in schools, implemented as part of a cluster-randomized controlled trial on the Kenyan coast.

Methods: Financial and economic costs were estimated using an ingredients approach whereby all resources required in the delivery of IST are quantified and valued. Sensitivity analysis was conducted to investigate how programme variation affects costs and to identify potential cost savings in the future implementation of IST.

Results: The estimated financial cost of IST per child screened is US$ 6.61 (economic cost US$ 6.24). Key contributors to cost were salary costs (36%) and malaria rapid diagnostic tests (RDT) (22%). Almost half (47%) of the intervention cost comprises redeployment of existing resources including health worker time and use of hospital vehicles. Sensitivity analysis identified changes to intervention delivery that can reduce programme costs by 40%, including use of alternative RDTs and removal of supervised treatment. Cost-effectiveness is also likely to be highly sensitive to the proportion of children found to be RDT-positive.

Conclusion: In the current context, school-based IST is a relatively expensive malaria intervention, but reducing the complexity of delivery can result in considerable savings in the cost of intervention.

Published: 20 September 2011

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Treatment of uncomplicated malaria at public health facilities and medicine retailers in south-eastern Nigeria

LJ Mangham, B Cundill, O Ezeoke, E Nwala, BSC Uzochukwu, V Wiseman, O Onwujekwe

Malaria Journal 2011, 10:155 | DOI: 10.1186/1475-2875-10-155


Background: At primary care facilities in Nigeria, national treatment guidelines state that malaria should be symptomatically diagnosed and treated with artemisinin-based combination therapy (ACT). Evidence from households and health care providers indicates that many patients do not receive the recommended treatment. This study sought to determine the extent of the problem by collecting data as patients and caregivers leave health facilities, and determine what influences the treatment received.

Methods: A cross-sectional cluster survey of 2,039 respondents exiting public health centres, pharmacies and patent medicine dealers was undertaken in urban and rural settings in Enugu State, south-eastern Nigeria.

Results: Although 79% of febrile patients received an anti-malarial, only 23% received an ACT. Many patients (38%) received sulphadoxine-pyrimethamine (SP). A further 13% of patients received an artemisinin-derivative as a monotherapy. An estimated 66% of ACT dispensed was in the correct dose. The odds of a patient receiving an ACT was highly associated with consumer demand (OR: 55.5, p < 0.001).

Conclusion: Few febrile patients attending public health facilities, pharmacies and patent medicine dealers received an ACT, and the use of artemisinin-monotherapy and less effective anti-malarials is concerning. The results emphasize the importance of addressing both demand and supply-side influences on malaria treatment and the need for interventions that target consumer preferences as well as seek to improve health service provision.

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Seasonal and geographic differences in treatment-seeking and household cost of febrile illness among children in Malawi

VL Ewing, DG Lalloo, KS Phiri, A Roco-Feltrer, LJ Mangham, MA SanJoaquin

Malaria Journal 2011, 10:32 | DOI: 10.1186/1475-2875-10-32


Background: Households in malaria endemic countries experience considerable costs in accessing formal health facilities because of childhood malaria. The Ministry of Health in Malawi has defined certain villages as hard-to-reach on the basis of either their distance from health facilities or inaccessibility. Some of these villages have been assigned a community health worker, responsible for referring febrile children to a health facility. Health facility utilization and household costs of attending a health facility were compared between individuals living near the district hospital and those in hard-to-reach villages.

Methods: Two cross-sectional household surveys were conducted in the Chikhwawa district of Malawi; one during each of the wet and dry seasons. Half the participating villages were located near the hospital, the others were in areas defined as hard-to-reach. Data were collected on attendance to formal health facilities and economic costs incurred due to recent childhood febrile illness.

Results: Those living in hard-to-reach villages were less likely to attend a formal health facility compared to those living near the hospital (Dry season: OR 0.35, 95%CI0.18-0.67; Wet season: OR 0.46, 95%CI0.27-0.80). Analyses including community health workers (CHW) as a source of formal health-care decreased the strength of this relationship, and suggested that consulting a CHW may reduce attendance at health facilities, even if indicated. Although those in hard-to-reach villages were still less likely to attend in both the dry (OR 0.53, 95%CI 0.25-1.11) and wet (OR 0.60, 95%CI 0.37-0.98) seasons. Household costs for those who attended a health facility were greater for those in HTR villages (Dry: USD5.24; Wet: USD5.60) than for those living near the district hospital (Dry: USD3.45; Wet: USD4.46).

Conclusion: Those living in hard-to-reach areas were less likely to attend a health facility for a childhood febrile event and experienced greater associated household costs. Consulting CHWs was infrequent, but appeared to reduce attendance at a health facility, even when indicated. Health service planners must consider geographic and financial barriers to accessing public health facilities in designing appropriate interventions.

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