Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals in Jinja...

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Pharmaceutical Society of Uganda International Pharmaceutical Federation Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals Case Study of Jinja Municipality END OF PROJECT REPORT December 2012 Morris Okumu, Freddy Eric Kitutu, Bush Herbert Aguma, Asha Nabbale, Brian Sekayombya Pharmaceutical Society of Uganda

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This is a project that was carried out as a pilot in one of the municipalities in Uganda. The project aimed at enhancing the role of private community pharmacies in early Tuberculosis detection and Referral

Transcript of Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals in Jinja...

Pharmaceutical Society of Uganda International Pharmaceutical Federation

Strengthening Community Pharmacies Role in

Early Tuberculosis Case Detection and Referrals –

Case Study of Jinja Municipality

END OF PROJECT REPORT

December 2012

Morris Okumu, Freddy Eric Kitutu, Bush Herbert Aguma, Asha Nabbale, Brian Sekayombya

Pharmaceutical Society of Uganda

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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©Pharmaceutical Society of Uganda

Tufnell Drive Kamwokya,

P. O. Box 3774, Kampala, Uganda

www.psu.or.ug

Errors and omissions excepted

The views expressed in this report do not necessarily reflect those of International Pharmaceutical

Federation (FIP) or the Pharmaceutical Society of Uganda (PSU). They are the works of the authors who

carried out the activity on behalf of PSU with support from FIP. For further clarifications, queries and any

additional issue regarding this report please contact the authors and/or PSU using the e-mail:

[email protected]; [email protected] and phones +256414340385 and +256312266993.

Recommended citation:

Morris Okumu, Freddy Eric Kitutu, Bush Herbert Aguma, Asha Nabbale, and Brian Sekayombya; (2012);

Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals in Jinja

Municipality, Uganda – End of Project Report; Submitted to International Pharmacy federation by the

Pharmaceutical Society of Uganda.

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Table of Contents

LIST OF TABLES AND FIGURES ........................................................................................................... IV

LIST OF ABBREVIATIONS AND ACRONYMS .......................................................................................... V

ACKNOWLEDGEMENTS ...................................................................................................................... VI

EXECUTIVE SUMMARY ..................................................................................................................... VII

1. INTRODUCTION ....................................................................................................................... 1

2. BACKGROUND ......................................................................................................................... 1

2.1. BACKGROUND TO THE PROJECT ................................................................................................ 1

2.2. TB SITUATION IN THE COUNTRY ................................................................................................ 2

2.3. PROJECT OBJECTIVES, DESIGN AND APPROACH ......................................................................... 5

3. METHODOLOGY ...................................................................................................................... 6

3.1. ASSESSMENT DESIGN AND APPROACHES .................................................................................... 6

3.2. STUDY POPULATION .................................................................................................................. 6

3.3. TB PRESENTATION AND PREDISPOSING SIGNS AND SYMPTOMS .................................................. 7

3.4. DATA COLLECTION AND MANAGEMENT ..................................................................................... 7

3.5. ETHICAL CONSIDERATIONS ....................................................................................................... 8

3.6. LIMITATIONS ............................................................................................................................ 8

4. RESULTS ................................................................................................................................... 9

4.1. DEMOGRAPHIC CHARACTERISTICS OF THE PHARMACIES .......................................................... 9

4.2. PRACTICES IN MANAGEMENT OF PATIENTS WITH COUGH ....................................................... 11

4.3. KNOWLEDGE OF TB DIAGNOSIS AND TREATMENT AMONG HEALTH WORKERS ...................... 14

4.4. INFRASTRUCTURE/SYSTEM TO REFER AND FOLLOW-UP ......................................................... 17

5. DISCUSSIONS .......................................................................................................................... 19

5.1. PRIMARY CARE SERVICES AT PHARMACY LEVEL ..................................................................... 19

5.2. PRACTICE IN THE MANAGEMENT OF COUGH AT THE PHARMACIES .......................................... 21

5.3. KNOWLEDGE OF TB DIAGNOSIS AND TREATMENT AMONG HEALTH WORKERS ....................... 22

5.4. INFRASTRUCTURE/SYSTEM TO REFER AND FOLLOW UP ........................................................... 23

6. CONCLUSION AND RECOMMENDATIONS ........................................................................ 26

6.1. LEVEL OF ACHIEVEMENT OF THE PILOT PROJECT ................................................................... 26

6.2. SCALABILITY OF THE PROJECT ................................................................................................ 26

6.3. RECOMMENDATIONS ............................................................................................................... 27

ANNEX: STUDY TEAM ................................................................................................................. 28

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List of tables and figures

List of tables

Table 1: TB epidemiology in Uganda ............................................................................................................................. 3

Table 2: Type of pharmacy license .................................................................................................................................. 9

Table 3: Staffing norms in the assessed pharmacies ...................................................................................................... 9

Table 4: Level of nearest health facility ........................................................................................................................ 10

Table 5: Clientele load in the pharmacies per day ........................................................................................................ 10

Table 6: Key issues considered last time a patient with cough was managed ............................................................. 13

Table 7: Methods of transmission of TB reported ........................................................................................................ 14

Table 8: Presence of any agreement between the pharmacy and a health facility for referral ................................... 17

List of figures

Figure 1: Availability of different services in the pharmacies ....................................................................................... 11

Figure 2: Main actions taken in managing cough at the pharmacy ............................................................................. 11

Figure 3: Action taken by pharmacy when unable to manage cough .......................................................................... 12

Figure 4: Main medicines supplied in management of cough ...................................................................................... 12

Figure 5: Key penicillin used for cough .......................................................................................................................... 13

Figure 6: Steps taken to handle suspected TB .............................................................................................................. 14

Figure 7: Pre-referral Treatments given ....................................................................................................................... 15

Figure 8: Key pre-referral activities carried out ............................................................................................................ 15

Figure 9: Actions taken to confirmed TB cases in the pharmacy .................................................................................. 16

Figure 10: Reported signs and symptoms indicative of TB in the pharmacy ................................................................ 17

Figure 11: Record keeping and display of TB IEC materials in the pharmacies............................................................. 18

Figure 12: maintaining directory and procedures for referrals ..................................................................................... 18

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List of Abbreviations and Acronyms

BCC Behavioural Change Communications

DOTS Directly Observed Treatment Strategy

FDC’s Fixed Dose Combination

FIP International Pharmaceutical Federation

HIV Human Immuno-deficiency Virus

IEC Information Education Communication

MDR-TB Multi—Drug Resistant Tuberculosis

MoH Ministry of Health

NDA National Drug Authority

NTLP National Tuberculosis and Leprosy Control Program

OTC’s Over The Counter Medicines

PHC Primary Health Care

PSU Pharmaceutical Society of Uganda

RRH Regional Referral Hospital

TB Tuberculosis

UNCST Uganda National Council for Science and Technology

XDR-TB Extremely Drug-Resistant Tuberculosis

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Acknowledgements

We would like to thank the International Pharmaceutical Federation (FIP) for providing the

funding for this pilot project. We are particularly indebted to FIP colleagues Xuan Hao Chan and

Ying Chan who continuously worked with us from the inception phase to getting this milestone

accomplished. Secondly, we would like to appreciate the Council of Pharmaceutical Society of

Uganda (PSU) for the guidance and support towards this project. Our appreciations go to Yusuf

Kimbowa Sembatya and Samuel Acuti Opio who are former and current Secretaries respectively

for the endurance and support in this project. Together with the members of the Research

Committee, we have been able to meet tight deadlines and get work done under pressing

circumstances.

In a special way, we would like to thank Dr Francis E. Adatu, former Program Manager of the

National Tuberculosis and Leprosy Control Program (NTLP) of the Ministry of Health for the

guidance on policies, directions and technical understanding of TB situation in Uganda. Together

with Dr Samuel Kasozi the MDR-TB Coordinator at the NTLP, we were able to work through

and get the work within the policy confines.

Finally, we would like to thank in a special way the pharmacies we visited in Jinja for not only

allowing us access to their premises and valuable business information, but for the openness and

greater involvement in the study.

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Executive Summary

Background

The Pharmaceutical Society of Uganda (PSU) in July 2011 was awarded funding from the

International Pharmaceutical Federation for a pilot project for strengthening role of community

pharmacies in early Tuberculosis case detection and referral. This seed funding of US$ 10,000

awarded under the first round of the FIP challenge on TB, supported a pilot project in Jinja

municipality for a period of three months. The project was in response to rise is number of MDR-

TB cases world-over calling for an expanded role of pharmacists in control of antimicrobial

resistance. An end of project evaluation was carried out to assess the feasibility/scalability of the

interventions designed during the pilot.

Project design and evaluation approach

The project was designed as a pilot innovation to explore possible role of community pharmacies

in case detection, referral and treatment monitoring for TB with a geographic focus of Jinja

municipality. Jinja Municipality was chosen because of a high TB burden, strong public sector

TB management infrastructure, typical urban/rural mix of the population, and a relatively robust

community pharmacy system compared with other districts in Uganda. The project had entail

three months of intensive intervention using continuous quality improvement model to provide

basis for scale-up. The key project strategies were Capacity building and systems strengthening,

linkages and referral mechanisms development, Behavioural change, and partnerships. The

evaluation method involved a cross-sectional survey of 13 out of 14 targeted pharmacies in Jinja

municipality. The focus areas were cough management, TB diagnosis, case management, and

referral systems between the pharmacies.

Results and discussions

Characteristics of pharmacies: 53% of pharmacies reached were both wholesale and retail in

licensure and they had all in been in Jinja for over 5 years at time of evaluation. They are open for

over eight (8) hours each day. The average number of staff in these pharmacies was 3 with nurses

being the most predominant cadre of personnel by training and none had a pharmacy technician

employed with them. The staffing norms are well in line with the task-shifting approaches

practiced in the country arising from shortage of skilled manpower. The level of the nearest

public health facility to most of the pharmacies is the regional referral Hospital. The daily average

number of patients served in the retail section is about 93 patients while that for wholesale is

about 22 clients. On the overall, the level of availability of the services is much lower than it

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should be since the pharmacies are expected to provide emergency support to patients in need of

treatment and support before referral for the appropriate medical attention.

Management of cough practices: more than half of the pharmacies were able to take history, ask

about current medication and provide antibiotic treatment as part of management of cough. There

is a general improvement in the key areas of management of cough in the pharmacies at end-line.

When unable to manage cough, over 90% prefer to refer the patient to Jinja RRH in preference to

any other health facility. In management of cough, penicillin antibiotics are the most used

products and use of erythromycin reduced after period of exposure. The pharmacies appear to

have common approach to managing cough with the priority issues being type of cough, length of

cough and age of the patient.

Knowledge of TB Diagnosis and Treatment among Health Workers: There is a good

understanding of the key methods for transmission of TB. However, the respondents appear not to

clearly understand the role of the pre-disposing factors such as contact and underlying HIV

infection. The pharmacies provide supportive care and pre-referral support and treatment. They

are not mandated to treat TB cases within their settings. There appear to be a clear understanding

of requirements for effective referral of cases to another health facility, a central pillar of primary

health care. Majority of the respondents reported referring confirmed TB cases with appropriate

counselling of patient. While 50% noted that it is with anti-TB drugs, only 30% could clearly

differentiate that the treatment is divided into two phases (i.e. initial and continuation phase) and

that 4 drugs are given in the initial phase and 2 are given in the continuation phase. The

understanding of the signs and symptoms of TB infection is relatively fine with many of the

cardinal ones coming out clearly in over 80% of respondents.

Infrastructure/System to Refer and Follow-Up: None of the pharmacies had any formal linkage or

agreement with a facility for any form of referral. Informal linkages were reported but are mainly

for purpose of complimentary services and business competitiveness especially for congested

areas. This situation remained the same after the period of pilot intervention. Keeping of referrals

records improved slightly while all pharmacies exposed to the intervention were able to have and

at least display IEC materials.

Conclusion:

The key outputs demonstrated in the pilot phase included: The design of basic referral

infrastructure and system to improve linkage with the other TB diagnosis and treatment centres

within the municipality; Mapping of the key gaps and opportunities for effective TB case

detection within the pharmacies; and, development of Standard operating procedures and

algorithm for TB case detection within community pharmacies. The appreciation of risks of

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antimicrobial resistance in relation to TB improved among the pharmacies with more

understanding key risks factors. The basic ingredients for conducting the project were all

available in the pharmacies and in the environment.

Recommendations:

This project is scalable with a number of key recommendations that include:

a) The current guidelines on licensing of pharmacies as well as code of practice needs to be

revisited to allow pharmacies carry out more primary health care services including diagnosis

of common ailments.

b) Institute strong public-private partnerships in the management of TB that should involve role

of pharmacies especially in the TB DOTS programme. Pharmacies can then be accredited to

dispense medicines and refills for patients who do not need to go to hospitals.

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1. INTRODUCTION

In July 2011, the International Pharmaceutical Federation (FIP) awarded the Pharmaceutical

Society of Uganda (PSU) a seed funding to carry out a pilot project focussing on strengthening

the role of community pharmacies in early Tuberculosis case detection and referral. This project,

awarded under the first round of the FIP challenge on TB, was intended to strength the role of FIP

member organisations in TB diagnosis, referrals, treatment and prevention with major emphasis

on prevention of spread and emergence of multi-drug resistant TB (MDR-TB). After six months

of implementation, PSU carried out end of project evaluation in July 2012 to document lessons

learnt, project outputs and outcomes and provide basis for future activities. This report provides

the outcomes of the final evaluation for the project carried out in July 2012 and overall synthesis

of recommendations for future interventions and scale-up in Uganda.

2. BACKGROUND

2.1. Background to the project

The FIP challenge on TB to which this project is part of, focuses on expanding the role of

pharmacists in control of antimicrobial resistance. This project focuses on early identification of

TB suspects and referral activities for diagnosis. Early identification of TB suspects and referral is

anticipated to increase case detection, reduce delays in diagnosis and save costs of care. Early

diagnosis has been shown to contribute to improved treatment outcomes including prevention of

possible development of drug resistance to existing medicines occurring as a result of both

irrational use and mismanagement of the patient1. The main challenge is therefore to scale-up TB

care and control, while preventing acquired drug resistance, is to increase active and early case

detection so that transmission can be interrupted by rapid start of treatment for both drug-

susceptible and drug-resistant TB2. The rise is number of MDR-TB cases world-over has called

for a multi-faceted approach to all aspects of diagnosis, treatment, control and prevention beyond

the traditional healthcare setting.

2.1.1. Project design

This project is designed as a pilot innovation to explore possible role of community pharmacies in

case detection, referral and treatment monitoring for TB with a geographic focus of Jinja

municipality. Jinja Municipality was chosen because of a high TB burden, strong public sector

1 Joint Tuberculosis Committee of the British Thoracic Society (2000) Control and prevention of tuberculosis in the

United Kingdom: recommendations 2000. Thorax, 55, 887–901

2 L. P. Ormerod; Multidrug-resistant tuberculosis (MDR-TB): epidemiology, prevention and treatment, British Medical

Bulletin; 2012, Volume 73-74, Issue 1, 17-24

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TB management infrastructure, typical urban/rural mix of the population, and a relatively robust

community pharmacy system compared with other districts in Uganda3. The interventions for this

project shall act in greater synergy with all other interventions already in place in public and

private sector while focussing on the peculiarities of community pharmacies. The project had

entail three months of intensive intervention to provide basis for scale-up.

2.1.2. Project approach

This project used a continuous quality improvement model that looks at identifying gaps and

challenges in service delivery in the community pharmacies and initiating small but incremental

changes that will be monitored for outcomes. This involves improving capacity of community

pharmacies in case detection, linkages provision, and provide evidence for scalability of

pharmacy level TB control models. The key project strategies are Capacity building and systems

strengthening, linkages and referral mechanisms development, Behavioural change, and

partnerships. Selected pharmacies shall be provided with mentorship over the pilot period

followed up with a carefully structured case management approach.

2.1.3. Background to PSU

Founded in 1960 and governed by The Pharmacy and Drugs Act of 1970, the PSU is the national

professional organisation and governing body for pharmacy in Uganda. PSU is responsible for

ethical practice of pharmacy in Uganda. Governed by a twelve member council, PSU functions

through the Secretariat headed by a Secretary. The functions of the council are executed through

committees, of which the Research and Development Committee is responsible for this particular

pilot project.

2.2. TB situation in the country

2.2.1. TB epidemiology

With an estimated and highly growing population of 32.9 million people, Uganda is among the

TB high burden countries ranked 16th on the list of 22 high-burden countries in the world. The

TB control and prevention is exacerbated by the high burden of HIV infection with an estimated

38.7% of new TB patients being HIV positive. To date, further attempts to manage this problem

have been made in area of integrating TB and HIV infection and treatment as appropriate. The

summary of the epidemiology is shown in table 1.

3 Draft Profile of Jinja Municipality, accessed from

http://www.skelleftea.se/Skol%20och%20kulturkontoret/Innehallssidor/Bifogat/JINJA%20MUNICIPALITY%20PROFIL

E.pdf April 2012

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Table 1: TB epidemiology in Uganda4

Parameter 2011 2010

Male Female Total Male Female Total

Total disease burden 15,246 9,174 24,420 28,071 17,475 45,546

New cases 8,285 4,555 12,840 14,939 8,517 23,456

Relapses reported 379 173 552 926 366 1,291

Total defaulters 447 1331 580 910 299 1,209

Treatment failures 90 50 140 174 90 321

The national burden of TB continues to remain stable but there is a noted rise in treatment failures

and MDR-TB cases which is indicative of challenges with treatment adherence and possible

decline in effectiveness of strategies to prevent antimicrobial resistance. There is therefore a

greater need to develop strong policies and interventions that call for wider public and private

sector involvement if the country is to effectively meet global targets for TB control and

prevention.

2.2.2. TB control in Uganda

The country TB program is managed under the National TB and Leprosy Control Program

(NTLP) with significant support from development and bilateral partners. The NTLP which is the

national disease prevention organisation has continued to face challenges with continuity of

medicines. The resent increase in cases of insufficient supply of TB medicines in the country5

coupled with challenges in coordination of private sector players increases the risk of MDR-TB

and possible emergence of Extremely Drug-Resistant Tuberculosis (XDR-TB) if nothing is done.

The rise in case load cannot be exclusively associated with lack on medicines but also extends to

challenges with diagnostic capacity, poor patient adherence and possible community acquired

resistance through direct contact with the MDR-TB patients.

The emergence of MDR-TB is believed to be linked to poor adherence to prescribed TB

treatment, social barriers such as stigma, discrimination, poverty, poor DOT system and non

compliance to the guidelines from prescribers partly due to drug stock-outs in some facilities.

Particularly, many patients come to health facilities with advanced TB cases owing to them

seeking medical care in private health outlets such as clinics, drug shops and pharmacies.

Whereas these outlets provide options for primary health care services, their role in effectively

diagnosing and referring TB patients for treatment remains unabated. As such, country TB case

4 Source: National Tuberculosis and Leprosy Control Program (NTLP) cohort analysis reports

5 MoH Pharmacy Stock Status Reports for August 2011, October 2011, January 2012 and March 2012; Published

online by MoH at http://health.go.ug/mohweb/?page_id=388

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detection is affected and this could be linked to poor access to health care services, and a limited

number of skilled staff and diagnostic facilities.

The country has been able to adopt and implement the DOTS with varying level of success in the

different regions of the country. Whereas the DOTS appeared to have worked, dwindling

resources for contact tracing and follow-up has affected sustainability. Despite the ban on sale of

TB medicines in private pharmaceutical outlets, illegal quantities continue to find their way there

and this affects the national strategies for follow up. Also not all persons in need of TB treatment

are receiving it with vaccination coverage continuing to elude about 10% of newborn children.6

2.2.3. Evidence of feasibility of TB case detection in pharmacies

Referral of patients to clinical care centres including hospitals and other established health

facilities remain a key requirement for pharmacy practice and is well enshrined in the concept of

provision of pharmaceutical care. It has been shown that this referral is very feasible and can

work very for cases of suspected TB but if significant impact on case detection is to be achieved,

the roles of the pharmacists and expectations of the clients have to be clearly managed7. The key

challenges are in the way the community looks at the pharmacies and how the pharmacies are

positioning themselves to carry on the additional role. Community pharmacies are therefore prime

candidates for effective detection and referral of suspected cases of TB to centres for diagnosis.

Strengthening the community pharmacies role in early case detection could lead to formation of

public-private partnerships which can be used to provide a service that is liked by the patients

produces an increased rate of patient notification and there high rates of treatment success. This

uses the strength that pharmacies have where there places of first contact for many of patients

with cough8. Community pharmacies are generally privately owned and together with other drug

seller outlets is one of the commonest points of first contact care with the health system in many

low and middle income countries including Uganda. This situation therefore underscores their

role in the public-private partnership arrangement for delivery of primary health care services.

This form of arrangement has been demonstrated to provide results and improve health systems

outcomes when they are carefully and strategically utilised9.

6 Ministry of Health Uganda; Health Sector Strategic & Investment Plan 2010/11 – 2014/15;2010, Kampala, Uganda

7 Lönnroth K et al; Referring TB suspects from private pharmacies to the National Tuberculosis Programme:

experiences from two districts in Ho Chi Minh City, Vietnam; Int. J. of TB & Lung Disease 2003 Dec;7(12):1147-53

8 Mukund Uplekar; Involving private health care providers in delivery of TB care: global strategy; Journal of

Tuberculosis (2003): 83, 156-164 9Lambert ML, Delgado R, Michaux G, Vols A, Speybroeck N, Van der Stuyft P.; Collaboration between private

pharmacies and national tuberculosis programme: an intervention in Bolivia; Tropical Medicine and International Health. 2005 Mar;10(3):246-50

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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In Cambodia with a high burden of T.B, the National Centre for T.B and Leprosy Control (MOH)

developed a Public-Private Mix DOTS strategy and the Phase 1 of the strategy was to improve

referrals from private facilities to the public facilities and the results of the 1st phase showed that

pharmacies were an excellent location for identification of the undiagnosed cases.10

This and

other studies demonstrate the greater interest in enhancing the place of pharmacy services in the

provision and delivery of health care. It is important that more evidence is generated in areas of

capacity and quality of services of local pharmacies in providing TB early diagnosis and

prevention.

2.3. Project objectives, design and approach

2.3.1. Overall Project Goal

“To contribute to reduction of spread and incidence of multi-drug resistant tuberculosis in

Uganda through strengthening of community pharmacies involvement in early case detection and

effective referral and follow up”.

2.3.2. Project Objectives

The project and service delivery/development objectives to be addressed are to:

i) Conduct a baseline and needs assessment among community pharmacies;

ii) Design evidence based interventions to improve TB case detection, referral and follow up of

TB in community pharmacies;

iii) Implement the designed interventions to improve TB case detection, referral and follow up

of TB care among the community pharmacies

This report is a summative evaluation of the pilot project to understand possible bottlenecks and

opportunities for full scale-up of interventions within community pharmacies to address MDR-TB

challenges in Uganda.

10

Hara Mihalea and D’Arcy Richardson, (2009); Public-Private Mix Involving Pharmacies And Other Providers In TB Control -- A Cambodia Case Study; submitted to the United States Agency for International Development (USAID) by PATH under TB IQC Task Order 01

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3. METHODOLOGY

3.1. Assessment design and approaches

3.1.1. Design of overall project/assessment

The assessment used the before and after outcomes mapping approach in targeted community

pharmacies in Jinja municipality. The two assessments involved a cross-sectional study/review

using semi-structured questionnaire administered to the staffs working in the community

pharmacies. The questionnaire was structured in key thematic areas of knowledge and practices in

management of cough and tuberculosis; referral systems and mechanisms; and overall services

offering of the sampled pharmacies.

3.1.2. Exposure provided to the selected pharmacies

Out of the target pharmacies, five (5) were given a training and mentorship program on the key

aspects of TB diagnosis, treatment, prevention and referral systems. The exposure period lasted

up to six weeks after initial assessment.

3.2. Study population

3.2.1. Definition of study population

The primary review unit for the assessments were a community pharmacy. At each community

pharmacy a member authorized to handle medicines and provide health care to patients/clients

was chosen for the interview. This interviewee was either the Pharmacist, the pharmacy

technician, midwife, nurse or any other auxiliary staff.

3.2.2. Inclusion and exclusion criteria

The inclusion criteria for community pharmacies in the assessments included:

Being located in Jinja municipality,

Providing medicines and health services directly to the patients or clients (a retailer),

Having a minimum of retail operating license issued by NDA during the study period, and

Provision of consent to participate.

The inclusion criteria for respondents from the community pharmacy included:

Being employed by the community pharmacies selected to participate in the study,

Having authorisation to handle medicines and provide healthcare services, and

Consenting to participate in the study

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3.3. TB presentation and predisposing signs and symptoms

The central focus of the assessments was to look at how the pharmacy persons are able to identify

suspected TB cases and the capacity to effectively refer these patients for prompt diagnosis. This

therefore focussed around identifying the classical signs and symptoms of TB infection as well as

carrying differential diagnosis from all other conditions with similar presentations. The

pharmacies were compared before and after period of exposure to tailor-made training on TB case

management and effective referral systems.

3.3.1. Definition of suspected TB case11

A patient is suspected of having an infection of TB if he/she presents with the following signs and

symptoms:

Productive cough: prolonged cough of three or more weeks

Chest pain, and hemoptysis

Symptoms of low grade remittent fever, chills, night sweats, appetite loss, easy fatigue

Fever, chills and night sweats

Weight loss of greater than three kilograms over last one month

History of contact with a TB patient

Pharmacy workers are expected to identify these signs, understand drug treatment, and be able to

refer the patient for further investigations.

3.4. Data collection and management

3.4.1. Data collection process

Data was collected using a structured tool. The data collectors were trained on use of the tool as

well as principles of research ethics. The structured tool was the same tool used in the baseline

survey. The team were able to revise the tools before embarking on data collection.

The data collection exercise involved two teams over two days. Each pharmacy was coded and

given a unique identification number. The pharmacies were informed a week prior to the exercise

and contacts were made directly with the supervising pharmacists and directors. During the two

day data collection exercise, the teams planned to visit 14 pharmacies each time12

.

11

These definitions were adapted from the Uganda NTLP guidelines for TB diagnosis and treatment. They are well in

line with the recommended signs and symptoms as defined by the WHO STOP-TB Partnership

12 The target of 14 pharmacies was based on the number registered by NDA in Jinja municipality that met the

inclusion and exclusion criteria for the assessment

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3.4.2. Storage and cleaning of data

There were no identifiers collected, the community pharmacies were only identified by a one or

two digit code and only the study coordinator, the principal investigator and data collectors had

access to the definition of the codes.

3.4.3. Data analysis approach

The data was pre-coded, entered into Epi-Data and exported to SPPSS for cleaning and analysis.

The analysis of the data was carried out based on key thematic areas of demographics, knowledge

and practices in cough management, knowledge and practices of tuberculosis management and

control, systems to manage and refer suspected TB cases, and overall suitability of the pharmacy

for increased responsibility.

3.5. Ethical considerations

This assessment was approved and registered with the Uganda National Council of Science and

Technology (UNCST) before commencing. All pharmacies consented in writing to participating

in the assessment while all respondents were able to provide oral consent. No identifiers were

collected and the codes were excluded during analysis of data.

3.6. Limitations

This study has a number of limitations that includes the following:

Lack of generalizability: the findings from this study cannot be generalised to the whole

country but it only provides inferences to what could be a national situation

The study does not attempt to prove causation or direct linkage between cases of MDR-TB

and role of community pharmacies. It only describes their current situation in the study area

The outcomes of the evaluation are biased by the level of education of the respondents. Not

all the supervising pharmacists were respondents during the process of the data collection.

Respondents from some pharmacies claimed had no time for the full length of the

questionnaire.

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4. RESULTS

Below here are the results of the two assessments presented based on the key thematic areas of the

study namely: practice in management of cough; knowledge and practice of TB diagnosis and

treatment; referral system in place; and current services being offered by the assessed pharmacies.

4.1. Demographic characteristics of the pharmacies

4.1.1. Characteristics of pharmacies and respondents

Table 2: Type of pharmacy license

Generally, there was little difference in the

pharmacies license type with only one

changing to have additional wholesale

service. More than half of the pharmacies

provided both wholesale and retail services.

In the end-line survey, all respondents in the four pharmacies provided with the exposure after the

baseline attended the project workshop. The workshop was on the management of cough and TB

and was organized by PSU in Jinja. The mean length of stay of all the pharmacies interviewed

was 191 months in Jinja meaning averagely the pharmacies have been in place for 15 years.

4.1.2. Staffing norms of assessed Pharmacies

Table 3: Staffing norms in the assessed pharmacies

The average number of staff

in these pharmacies was 3

with the minimum number

being 2 and the maximum

being 5 members of staff.

Nurses are most commonly

found in the pharmacies with

generally no pharmacy

technicians.

The staffing norms are well in line with the task-shifting approaches practiced in the country

arising from shortage of skilled manpower. The existing non-pharmacy trained personnel were

not assessed for their level of competencies to handle medicines or if they had ever received the

mandatory training of pharmacy auxiliary staffs routinely organised by PSU.

Type Baseline End-line

Wholesale and retail 8 (61.5%) 7 (53.8%)

Retail only 5 (38.5%) 6 (46.2%)

Total 13 (100%) 13 (100%)

Type/cadre of staff

in pharmacy

Number of pharmacies

Total Mean Minimum Maximum

All health workers 11 3.27 2 5

Nurses 11 2.27 1 4

Midwives 10 0.00 0 0

Pharmacy technicians 10 0.00 0 0

Pharmacists 11 0.36 0 2

Nursing assistants 10 0.30 0 1

Others 10 0.10 0 2

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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4.1.3. Opening Times/hours of the pharmacies visited

On average all the pharmacies visited open for about 12.64 hours from Monday to Friday, then

11.73 hours on Saturday, and 9.5 hours on Sunday. There was no significant difference in opening

hours at baseline and at end-line of the project period that was a little

too short a period. This is important parameter for purpose of access to

prompt referral and presumptive diagnostic services to patients who

always prefer pharmaceutical outlets as first point of primary care.

4.1.4. Level of the nearest Health Facility

Table 4: Level of nearest health facility

The level of the nearest public health facility to

most of the pharmacies is the regional referral

Hospital. Most of the pharmacies (5 Pharmacies)

indicated that the nearest private health facility is

not at a level of a Health center II, III, IV, or even

a general Hospital. This is indicative of

challenges with the primary care system.

4.1.5. Time to the nearest health facility

Generally, most pharmacies are located within proximity of a known health facility with an

average of four minutes walk away. The preferred facilities were at least five to ten minutes away

for private and public respectively. On average, the pharmacies are within walkable distances

from facilities able to carry out prompt and effective TB diagnosis.

4.1.6. Number of patients served at the Pharmacy

When asked for their load of patients, the pharmacies noted a higher number coming for retail

than for wholesale with median numbers of 50 and 20 patients respectively. The retail clientele is

at least 2 ½ times higher than the wholesale one not considering total monetary value. The daily

average number of patients served in the retail section is about 93 patients while that for

wholesale is about 22 clients.

Table 5: Clientele load in the pharmacies per day

Clientele service type N Minimum Maximum Median Mean

Retail services 11 40 400 50 93

Wholesale services 7 0 50 20 22

Level of health facility Public Private

Regional Referral Hospital 11 0

General Hospital 0 1

Health Centre IV 0 1

Health Centre III 0 1

Health centre II 0 3

Other 0 5

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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4.1.7. Service available and offered at the pharmacy premises

More pharmacies indicated availability of different primary health care services although very

few were actually being offered to the patients who require them (Figure 1 below). On the overall,

the level of availability of the services is much lower than it should be since the pharmacies are

expected to provide emergency support to patients in need of treatment and support before referral

for the appropriate medical attention.

Figure 1: Availability of different services in the pharmacies

4.2. Practices in Management of Patients with Cough

4.2.1. Management of cough at the pharmacy

Figure 2: Main actions taken in managing cough at the pharmacy

0% 5% 10% 15% 20%

HIV rapid tests

Malaria rapid tests

Immunisation for children

Pregnancy tests

First aid

Wound dressing

Injectable contraception

0%

0%

8%

0%

8%

8%

0%

0%

11%

0%

10%

0%

20%

10%

End-line Baseline

0% 20% 40% 60% 80% 100%

Take history

Ask about current medication

Provide antibiotic treatment

Review treatment notes

Provide any medication

Refer difficult cases

Recommend non-drug therapy

Give out cough syrup

100%

38%

23%

15%

15%

15%

8%

8%

91%

64%

55%

18%

9%

27%

0%

18%

Number of pharmacies

Act

ion

s ta

ken

End line (N=11) Baseline (N=13)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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There is a general improvement in the key areas of management of cough in the pharmacies at

end-line. Referral and review of current antibiotics before giving further treatment increased

showing possibly better case management.

4.2.2. Options taken when unable to manage cough at the pharmacy

Figure 3: Action taken by pharmacy when unable to manage cough

The community pharmacies prefer to refer their patients with cough to Jinja RRH hospital more

than to any other facility. There was an increase in number of referrals to health centres while the

referrals to Jinja RRH decreased.

4.2.3. Medicines pharmacies supply to cough patients

When asked for which medicines they supply in management of cough at the pharmacy, a number

of key responses were provided as in figure 4.use of penicillin antibiotics is the highest overall

while use of Erythromycin reduced to by 75% indicating better understanding of the risks.

Figure 4: Main medicines supplied in management of cough

0% 50% 100%

Refer to Jinja RRH

Refer to any clinic

Refer to any hospital

Refer to any government health centre

Other action

92%

31%

31%

8%

8%

91%

9%

18%

27%

9%

Number of pharmacies

Act

ion

ta

ken

End line (N=11) Baseline (N=13)

0% 10% 20% 30% 40% 50% 60% 70%

Penicillin antibiotics

Erythromycin

Other antibacterials

Antipyretics

Cough preparations

Other remedies

52%

31%

23%

8%

23%

69%

52%

9%

9%

0%

41%

27%

Number of pharmacies

Med

icin

e su

pp

lied

End line (N=11) Baseline (N=13)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

13

Figure 5: Key penicillin used for cough

Amoxicillin and the Ampicillin with

Cloxacillin are the predominant

antibacterial products supplied for

management of cough. This could be

driven mainly by their cost as the

other products used are way too

expensive for the common population

in the municipality. Generally,

penicillin products are used more

than the macrolides group to which

erythromycin belongs. The extent to

which penicillins are supplied not

being very different in the baseline and end-line surveys. The drop in use of erythromycin from

30.8% to 9.1% is good in reducing the extent to which T.B infection may be masked.

4.2.4. Key factors taken into consideration while managing cough

The respondents were asked about the key factors they took into consideration the last time they

managed cough at the pharmacy. A range of responses were given as shown in table 6.

Table 6: Key issues considered last time a patient with cough was managed

Key issues for consideration

No. of pharmacies (%)

Baseline (N=13) End line (N=11)

Number Proportion Number Proportion

Type of cough 11 84.6% 9 81.9%

How long the cough has lasted 11 84.6% 9 81.9%

Age of patient 4 30.8% 4 36.4%

Possible allergies of patient 3 23.1% 0 0.0%

Current medications 3 23.1% 2 18.2%

Economic status of the patient 1 7.7% 1 9.1%

Other 4 30.8% 0 0.0%

None 1 7.7% 0 0.0%

There was no significant change in the key factors put into consideration when managing cough at

the pharmacies. Many of the pharmacies appear to have common approach to managing cough

with the priority issues being type of cough, length of cough and age of the patient.

0%

20%

40%

60%

80%

100% 92%

69%

31%

15%

91% 91%

9% 18%

Nu

mb

er

of

ph

arm

acie

s

Baseline (N=13) End line (N=11)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

14

4.3. Knowledge of TB Diagnosis and Treatment among Health Workers

The second key component of the assessments was to understand and compare the knowledge of

the health workers regarding diagnosis and treatment of TB at baseline and at end-line.

4.3.1. Understanding the epidemiology of TB

When asked about the ways in which people can contract TB in the general setting, the

respondents provided responses indicated in table 7.

Table 7: Methods of transmission of TB reported

Methods of transmission reported

No. of pharmacies (%)

Baseline (N=13) End line (N=11)

Number Proportion Number Proportion

Inhaling or ingesting droplets or aerosols from

infected person 10 76.9% 8 72.7%

Contact/touch with a TB infected person 6 46.2% 8 72.7%

Having HIV/AIDS infection 3 23.1% 1 9.1%

Sleeping in damp poorly ventilated rooms 1 7.7% 0 0%

Other 2 15.4% 1 9.1%

There is a good understanding of the key methods for transmission of TB. However, the

respondents appear not to clearly understand the role of the pre-disposing factors such as contact

and underlying HIV infection. There was no significant difference on the knowledge on the ways

in which one could contract tuberculosis between the two assessments.

4.3.2. Handling suspected TB cases

When asked for ways in which they

handle suspected TB patients in the

pharmacies, majority indicated that

they refer for diagnosis and care at

an appropriate facility (Figure 6).

Generally, many of the pharmacies

provide supportive care and pre-

referral support and treatment. They

are not mandated to treat TB cases

within their settings. They only

focus on referral as their key role.

Figure 6: Steps taken to handle suspected TB

0% 20% 40% 60% 80% 100%

Assess for danger signs

Take detailed history

Counsel as appropriate

Provide supportive treatment

Refer for full diagnosis/care

8%

15%

31%

8%

100%

22%

22%

11%

11%

89%

End line (N=9) Baseline (N=13)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

15

When asked for where they make their referrals, more than 95% of the facilities reported referring

to Jinja RRH due to both proximity and the possibility of quick diagnosis and turn-around time.

There was no significant difference between the baseline and end-line performance.

4.3.3. Referral of suspected TB cases

In carrying out the referral process, the different pharmacies were asked about which treatment

they (they would) provide to the suspected cases.

Figure 7: Pre-referral Treatments given

Generally, the pharmacies supply

patients with penicillin type of

antibacterial agents alongside a

cocktail of painkillers. There was

a drop in number of cases

receiving erythromycin as part of

referral treatment in the end-line

survey.

The other treatments given

include anti-depressants,

treatment of other underlying

illnesses and overall supportive therapy including the psycho-social support required.

The key activities carried out in the

referral process are indicated in figure

8. Generally, the pharmacies are keen

on providing counselling and

indicating a form of referral for the

patients.

The focus on these two areas showed

some marginal improvement in the

end-line survey as compared to

baseline. There appear to be a clear

understanding of requirements for

effective referral of cases to another

health facility, a central pillar of

primary health care.

Figure 8: Key pre-referral activities carried out

0% 10% 20% 30% 40% 50% 60% 70%

15% 8%

23%

8% 8% 15%

62%

13% 25%

13% 13% 13% 13%

38%

Baseline (N=13)

0 5 10

Counsel the patient

Write a referral note

Just send the patient away

Leave it to the patient to decide

Other

5

2

1

1

3

6

4

1

1

2

End line (N=11) Baseline (N=11)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

16

4.3.4. Managing confirmed TB cases in the pharmacy

On the other hand, majority of the respondents reported referring confirmed TB cases with

appropriate counselling of patient (Figure 9). Preference for referral improved almost two fold

after the intervention period. The other actions remain inconclusive and with little variation

among the pharmacies.

Figure 9: Actions taken to confirmed TB cases in the pharmacy

4.3.5. Knowledge of TB treatment in the clinical setting

The specific knowledge of TB treatment remains poor among the respondents. While 50% noted

that it is with anti-TB drugs, only 30% could clearly differentiate that the treatment is divided into

two phases (i.e. initial and continuation phase) and that 4 drugs are given in the initial phase and 2

are given in the continuation phase. The end-line survey observed s a slight increase in knowledge

on the specifics of the treatment such as the phases of treatment.

Knowledge about the specific treatment for TB remains wanting

among the respondents with Rifampicin and streptomycin are

the most commonly known medicines by over 65% of

respondents. There is limited appreciation of the different

formulations especially the Fixed Dose used for TB treatment.

There was no difference in the level knowledge on the

other/ancillary medicines administered with anti-TBs during the

management of TB.

0% 20% 40% 60% 80%

Assess for danger signs

Counsel as appropriate

Provide supportive treatment

Refer for follow-up elsewhere

Supply treatment in pharmacy

Send patient away

None

Other

15%

15%

15%

38%

8%

8%

8%

31%

0%

10%

0%

80%

10%

0%

0%

0%

End line (N=10) Baseline(N=13)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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4.3.6. Knowledge of signs and symptom of TB

When assessed for what would alert them of possibility of patient having TB infection, many of

the respondents (over 70%) noted that persistent cough for over two weeks and night sweats were

key signs as indicated in figure 10.

Figure 10: Reported signs and symptoms indicative of TB in the pharmacy

The understanding of the signs and symptoms of TB infection is relatively fine with many of the

cardinal ones coming out clearly. There was a marked improvement in the understanding of these

signs and symptoms in the end-line as compared to baseline survey.

4.4. Infrastructure/System to Refer and Follow-Up

4.4.1. Linkage with facilities for referral

None of the pharmacies had any formal linkage or agreement with a facility for any form of

referral. Informal linkages were reported but are mainly for purpose of complimentary services

and business competitiveness especially for congested areas. This situation remained the same

after the period of pilot intervention.

Table 8: Presence of any agreement between the pharmacy and a health facility for referral

Item N Frequency Percent

Agreement available 11 0 0

Agreement not available 11 11 100

0% 20% 40% 60% 80% 100%

Chest pain at coughing or breathing

Coughing

Persistent cough > two weeks

Coughing up blood (hemoptysis)

Night Sweats

Poor Appetite

Weight loss

Fatigue or Weakness

Trouble Breathing

Dizziness

Other

31%

31%

85%

8%

62%

31%

31%

15%

8%

8%

8%

0%

20%

80%

30%

70%

70%

60%

0%

0%

0%

20%

End line (N=10) Baseline (N=13)

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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4.4.2. Keeping records of referrals and IEC materials

Overall, the record keeping of the pharmacies in relation to referrals and display of IEC materials

for control of TB remains low. Keeping of records improved slightly while all pharmacies

exposed to the intervention were able to have and at least display IEC materials (Figure 11).

Figure 11: Record keeping and display of TB IEC materials in the pharmacies

Keep any records of

referred patients

Keep any records of

suspected TB cases

Keep any record for

confirmed TB cases

Pharmacy displayed

TB IEC materials

4.4.3. Maintaining directory and procedures for referrals

The pharmacies generally do not maintain directories of health facilities within the municipality

to allow for effective linkage (Figure 12). Only the pharmacies in the intervention arm developed

and put in place procedures for referral and reporting suspected and confirmed cases of TB. While

the pharmacies were all trained to follow-up clients, only 2 were able to do so at end-line.

Figure 12: maintaining directory and procedures for referrals

Maintained directory of

possible TB referral facilities

Had written procedures for

referral/reporting cases Follow up any referred cases

0%

20%

40%

60%

80%

100%

12 8

1 3

Yes No

0 2

13 8

Yes No

1 1

12 10

Yes No

0 3

13 8

Yes No

0%

20%

40%

60%

80%

100%

Baseline Endline

1 2

10 8

Yes No

Baseline Endline

0 2

12 9

Yes No

Baseline Endline

1 2

11 9

Yes No

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

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5. DISCUSSIONS

5.1. Primary care services at pharmacy level

Primary Health Care (PHC) as defined by the World Health Organization in 1978 is “essential

health care; based on practical, scientifically sound, and socially acceptable method and

technology; universally accessible to all in the community through their full participation; at an

affordable cost; and geared toward self-reliance and self-determination”.13

As a philosophy, PHC

is based on the overlap of mutuality, social justice and equality; while as a strategy it on

individual and community strengths (assets) and opportunities for change (needs); maximizes the

involvement of the community; includes all relevant sectors but avoids duplication of services;

and uses only health technologies that are accessible, acceptable, affordable and appropriate14

.

Pharmacy outlets in Uganda are by law designed to mainly offer dispensing of medicines (both

prescription only and over the counter medicines) as well as advisory services to patients and

other health care workers. Over the years, provision of emergency prescription services as well

disease prevention has been taken as acceptable although not fully prescribed in the existing

regulations within the country. Generally, these pharmacies are open for long hours from Monday

to Friday during the week and for at least three hours on Sundays making them suitable for

improving access to basic PHC services. This has not been matched with the level of services they

provide beyond being an outlet for supply medicines to patients yet they are within the reach of

many people within Jinja municipality.

5.1.1. Provision of complimentary primary care services

Generally community pharmacies remain as point of access to “Medication Therapy Experts” that

should in their course of work “integrate knowledge, skills and professional attitudes to

effectively contribute to improved quality of drug therapy through the provision of patient-centred

care and in collaboration with health care providers”15

. With increased drive for pharmacies to

move towards patient-centred care where a lot of time and emphasis is placed on the patient as

opposed to drugs/medicines, community pharmacy practice has not been demonstrated here.

Many of the pharmacies only note availability of essential PHC services but do not extend them.

13

Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978, jointly sponsored by the World Health Organization and the United Nations Children’s Fund. Geneva, World Health Organization, 1978 (Health for All Series No. 1)

14 WHO, 2008; The world health report 2008: primary health care now more than ever; Geneva, World Health

Organization, 2008.

15 Kennie-Kaulbach, N., Farrell, B., Ward, N., Johnston, S., Gubbels, A., Eguale, T. et al. (2012). Pharmacist provision

of primary health care: a modified Delphi validation of pharmacists' competencies. BMC Family Practice, 13, 27

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

20

To be able to qualify this preference, the pharmacies still need to be able to provide

complimentary services such as first aid and as well as rapid diagnostic testing. Community

pharmacies in Jinja haven’t leveraged their full capacities to be able to provide comprehensive

PHC complimentary to the other health systems that is driven by collection of nurses, doctors and

other paramedical staff. They report availability of many of these services but have not been able

to provide these services even within the confines of the regulations in Uganda. In order to be able

to support effective presumptive diagnosis and prompt referrals for TB, these pharmacies have to

look at expanding their basic services beyond the current norm of dispensing and patient advisory

roles and move towards strengthening additional services.

5.1.2. Gaps in and opportunities for delivery of TB diagnostic services

Primary health care needs to be delivered close to the people; thus, should rely on maximum use

of both lay and professional health care practitioners. While TB diagnosis is still requires a

laboratory with capacity to handle the technical issues desired, the need to have early and prompt

referral for suspected cases remain within one component of PHC: education for the identification

and prevention / control of prevailing health challenges16

. Community pharmacies and drug seller

outlets are considered the first contact point for majority of the population in Uganda accounting

for many more treatments than the conventional clinical care settings17

. With private sellers also

accounting for rise in MDR-TB as a result of unclear diagnosis of diseases, there are still a lot of

gaps in service delivery to control TB spread.

The pharmacies in Jinja municipality require additional skills and training to fully incorporate TB

suspected case detection as well as capacity to effectively refer them for prompt diagnosis. The

basic infrastructure for these services exists although not exploited. It is a regulatory requirement

for all pharmacies to maintain a directory of all services providers and this has hardly been

implemented in the country as a whole. As a result, the pharmacies prefer to refer patients directly

to Jinja RRH which is a tertiary referral institution despite availability of many other primary and

secondary care (first referral) facilities within the municipality. This is a mentality that it is in only

such facilities that specialized services such as TB care and management are found. These

pharmacies are well suited to provide an active linkage with other PHC facilities that should carry

out first contact care.

16

Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978, jointly sponsored by the World Health Organization and the United Nations Children’s Fund. Geneva, World Health Organization, 1978 (Health for All Series No. 1)

17 Management Sciences for Health (MSH), 2011; East African Drug Sellers’ Initiative (EADSI) Project Report

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

21

5.2. Practice in the Management of cough at the pharmacies

5.2.1. Effectiveness of cough management

Effective cough management requires a greater understanding of the classification and possible

causes of cough. While generally not agreed upon, the most fitting definition of cough is “a

forced expulsive manoeuvre, usually against a closed glottis and which is associated with a

characteristic sound”18

. Multiple algorithms have been applied in evaluation of cough and they

have all had different opinions and conclusions for adults19

. While these have all been used, the

evaluation of cough to ensure that TB suspicion diagnosis is made remains a critical issue

especially in resource constrained setting where uptake and effective utilisation of national

guidelines remains poor in the private sector. Critically, not all cough can be managed in similar

way further complicating medication and non-medication therapies in both adults and children20

.

There is significantly high number of patients who come to these pharmacies with cough and they

are at risk of being mismanaged without proper expertise. Over 80% of the pharmacies considered

in this evaluation were able to identify type and length of cough as critical factor in their

management. This together with age of patients ensures that correct choice of treatment option is

made to the patient. The pharmacies however complicate their management of cough with high

use of antibiotics (over 50% in many cases) and evidently more utilisation of medicines that can

mask symptoms of TB treatment. With this approach, all borderline patients and atypical patients

with possible TB can easily be missed out. However, at end-line with the minimum exposure

period, it was possible to demonstrate a decline in use of potent medicines that can mask TB as

well as better understanding of cough algorithm. Referral and review of current antibiotics before

giving further treatment improved at end-line showing possibly better case management yet still

the management of the cough many times is not standardized; it is subjective to who provides the

treatment and experience.

5.2.2. Cough management and TB

Generally, the pharmacies had greater awareness of the need to ensure TB is not missed out in

consideration for a patient with long history of coughing. Majority of the pharmacies considered

history taking for a patient as a key issue in determining the options to take in provision of

treatment and possible referral services at their level. While it is desirable for the pharmacies to

18

Widdicombe J, Fontana G.; Cough: what's in a name? European Respiratory Journal 2006; 2810–15.15

19 Morice A H, McGarvey L , and Pavord I; Recommendations for the management of cough in adults; Thorax, 2006

September; 61(Suppl 1): i1–i24

20 McGarvey L P; Which investigations are most useful in the diagnosis of chronic cough; Thorax, 2004 April;

59(4):342-6

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

22

make TB as a critical differential, the high expansion of workers within these units makes it hard

a target and task to achieve overnight.

The non-judicious use of erythromycin and possibly other macrolides pose a big threat to not only

prompt diagnosis of cough but as well the possibility of further exacerbating the MDR-TB crisis

in the country. This together with lack of clear understanding of the hierarchical need for

functional PHC services continues to hamper effective delivery of required healthcare in

reproducible manner outside conventional public sector system. This situation is very reversible

with putting in place of proper systems as well as providing a mechanism to routinely support the

pharmacy staff to improve in their practice. The difference in findings from the end-line

assessment was further evidence to this overall process.

A final area of critical consideration here is the poly-pharmacy and over-prescription of penicillin

class of antibacterial agents for many cases of cough. While this has provided remissions it

increases risk of development of antimicrobial resistance within the community pharmacy setting.

Amoxicillin and the Ampicillin with Cloxacillin are the predominant antibacterial products

supplied for management of cough and their choice is possibly driven mainly by their cost as the

other products used are way too expensive for the common populace. This still compounds the

key challenge of ensuring that right diagnosis is obtained for every case presenting to the

community pharmacies while working within the confines of national regulations.

5.3. Knowledge of TB diagnosis and treatment among Health Workers

5.3.1. Awareness about signs and symptoms

Awareness and appreciation of the signs and symptoms of any disease is a critical factor in

ensuring proper and prompt diagnosis and treatment of any presenting illness including TB. There

was an improvement in awareness of the key signs and symptoms that would alert one of a

possible TB suspect despite many of the respondents not having had any proper training on TB

management and referral of suspects. Most of the health workers from the pharmacies that were

involved in the study had knowledge on the transmission of TB from one individual to another

and an improvement on the information regarding signs and symptoms of TB and a significant

number able to tell a notifiable and a non notifiable disease. Notification of any TB infection is

considered critical in success of fight against MDR-TB as well as XDR-TB in resource

constrained settings like Uganda.

There was a reduction in the number of respondents that intimated that they supply antibiotics to

suspected TB cases with a big number of the respondents giving no therapy to suspected cases but

refer them to where they can be better managed. This together with the improved understanding

of need to carry out effective referral remains central in ensuring the community pharmacies and

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals – Case Study of Jinja Municipality

23

other medicines outlets are better positioned to handle the need to part of global response in fight

against antimicrobial resistance. If well planned, harmonised and trained in, the staff have

capacity to provide excellent referral systems that could speed up diagnosis and improve quality

of care. There is a correlation between the improvement in the knowledge and the number of

respondents that attended the pilot project training.

5.3.2. Understanding of TB care and treatment

Unlike many other infectious diseases, TB is a condition that if well managed (inclusive of patient

adherence issues) gets to full remission. Unfortunately, majority of TB cases in developing

countries like Uganda continues to be poorly handled at community practice level. The

Knowledge on the specific drugs used in the management of TB and how TB is managed in a

clinical setting improved in the after exposure to the intervention arm. The basic appreciation of

the overall TB care process in the country remains poor with not so many respondents able to

appreciate or remember the guidelines from NTLP/MoH. As such, the risk of misuse of TB

medicines remains much higher than estimated. The duration of treatment of TB was averagely

known and the different medicines that are not classified as Anti-TBs but administered during the

management of TB were somehow mentioned.

While stringent regulations exist for importation and sale of TB medicines, a number of

community pharmacies in Jinja had not just residual stocks21

. There were few respondents who

mentioned on the fixed dose combinations that are used in the management of TB while over 67%

knew about the single medicines that are incidentally stocked within their premises. Community

pharmacies continue to possibly reap significant benefits from selling these medicines in time of

scarcity; a situation which is evident within the national system22

. It is therefore important that the

national system for treatment of TB is considered using a more comprehensive approach that is

able to address both knowledge gaps and sustainable supply systems.

5.4. Infrastructure/System to refer and follow up

5.4.1. Requirements for effective referral:

Referral systems in both clinical and community systems do not work in isolation but as a

network. There are certain essential elements to optimize the referral system’s operational

effectiveness and outcomes and they include Referral Network, Coordinating Agency, A Focal

Person at each agency/organization, A Directory of Resources, A standardized referral forms, A

21

Okumu M, et al, 2012; Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals – Case Study of Jinja Municipality: Baseline Report; Pharmaceutical Society of Uganda

22 MoH Pharmacy Stock Status Reports for August 2011, October 2011, January 2012 and March 2012; Published

online by MoH at http://health.go.ug/mohweb/?page_id=388

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feedback loop to track referrals, and Documentation of referrals.23,24

While there is some slim

direction, the current infrastructures in the community pharmacies are adequate for effective

referral if fully expanded and utilised. Community pharmacies have been unable to have basic

records in place and where available, they normally represent less than 5% of actual performance

outside sales information. A lot of tailoring to suit the changing dynamics of the population and

service sector remains critical in ensuring the community pharmacies keep relevant to fight

against TB drug resistance.

In consideration, referral is not necessarily between lower and higher level of the health system

but as well between health facilities of the same classification with an aim of achieving overall

goal of health system25

. Referral is considered to be a set of activities undertaken by a healthcare

provider or facility in response to its inability to provide the quality or type of intervention

suitable for the need of the patient. While many of the pharmacies indicated having to do

referrals, the formal structures for this were not there before the pilot in Jinja. This project clearly

demonstrates that effective referrals is actually feasible between public and private (including for

profit) facilities in provision of PHC services.

5.4.2. Pharmacy operations and referrals

To meet the requirements above, pharmacies need to maintain adequate records, understand the

need to refer and know who to refer to. In addition, the referral centres should be those that are

accessible to the patient and have the required expertise to diagnose and treat TB. With some

marginal improvement in record keeping, there is a greater opportunity to utilise these records

more to improve delivery of services at community pharmacy level. However the pharmacies are

still not in position to exploit their capacity to carry out effective referral services in an

environment where profitability greatly outweighs the need for linkages.

There are over twenty (20) facilities within Jinja that have capacity to diagnose and treat TB and

are accredited by NTLP; however the awareness by the respondents of these facilities is low, as

indicated by the centre to which the referrals were made. Over the exposure period, the number of

pharmacies who were able to know and appreciate the other centres that can offer the required TB

services increased. Capacitating these pharmacies appropriately would most probably lead to

better care and advice to suspected TB patients. There is need to further address gaps in record

keeping, maintenance of directories of health facilities as well as other key challenges.

23

DSWD and UNDP Philippines, 2010; A Referral System for Care and Support Services for Persons Living with HIV and their Families in the Community

24 Family Health International (FHI), 2005; Establishing Referral Networks for Comprehensive HIV Care in Low-

Resource Settings; Arlington, VA

25 World Health Organization, 2006; The world health report 2006: working together for health, Geneva

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5.4.3. Legal framework for pharmacies

Pharmacies in Uganda are supervised by pharmacies, who in Uganda are not licensed prescribers

for Prescription Only Medicines (POM) thus decisions to treat in a pharmacy are limited to OTCs

and support services such as first aid. In addition Pharmacies are not authorised to provide

diagnostic services except if they open up a laboratory with an additional license independent of

that of the pharmacy for this particular purpose. Pharmaceutical care goes beyond provision of a

medicine and by extension there is need to include other complimentary services to improve

quality of services. With such limitations, provision of pharmaceutical care is still limited yet the

opportunities to do so exist within the network of pharmacies.

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6. CONCLUSION AND RECOMMENDATIONS

6.1. Level of Achievement of the pilot project

Looking at the overall project implementation and key outcomes, the following key outputs were

demonstrated in the pilot phase:

i) The design of basic referral infrastructure and system to improve linkage with the other TB

diagnosis and treatment centres within the municipality. This was a clear initiation of the

basic structure for linkages and referrals.

ii) Mapping of the key gaps and opportunities for effective TB case detection within the

pharmacies was carried out. This provides benchmark for getting full-scale project

iii) Standard operating procedures and algorithm for TB case detection within community

pharmacies to support referrals were developed and rolled out.

Based on utilisation of the outputs, the appreciation of risks of antimicrobial resistance in relation

to TB improved among the pharmacies with more understanding key risks factors. The exposed

pharmacies were able to strengthen their internal record keeping and management of cough. The

process of referral improved marginally.

6.2. Scalability of the project

The basic ingredients for conducting the project were all available in the pharmacies and in the

environment considering the three critical elements of technical and organisational capacity,

financial viability and environmental suitability.

6.2.1. Technical and organisational requirements

The principal implementer of the project, PSU had the necessary technical persons to carry out

the activity and within the pharmacies, there were human resources available were adequate to

meet the scope of the project. The pharmacy staffs were provided with orientation and mentorship

in the area of TB prevention, diagnosis, control and treatment.

6.2.2. Environment issues/relevance to the stakeholders

The concept of use of community pharmacies (and other medicines outlet) as alternative to

provision of PHC service having been tried in Uganda and received great support from the

principal consumers of the services the clients, the project was piloted using the same concept

having the client in mind. While the policy limitations/barriers do exist use of pharmacies to carry

out simple presumptive diagnosis using clearly defined algorithm can support the call for

effective reduction in the incidence of delayed diagnosis of TB.

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6.3. Recommendations

Based on the pilot period, the following key recommendations are being made to scale-up the

interventions beyond the current geographical region.

6.3.1. Policy level recommendations

c) The current guidelines on licensing of pharmacies as well as code of practice needs to be

revisited to allow pharmacies carry out more primary health care services including diagnosis

of common ailments.

d) Institute strong public-private partnerships in the management of TB that should involve role

of pharmacies especially in the TB DOTS programme. Pharmacies can then be accredited to

dispense medicines and refills for patients who do not need to go to hospitals.

6.3.2. Recommendations for further research

a) Attitudes of the population on receiving part of their TB care in the private pharmacies

b) Impact of availability of single TB medicines on growth of MDR-TB in Uganda

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ANNEX: STUDY TEAM

Project Lead/ Principal Investigator

1. Mr. Morris Okumu

Deputy Project Lead/ Co-Principal Investigator

1. Mr. Kitutu Freddy Eric

Project Coordinator

1. Mr. Aguma Bush Herbert

Core Project Team Members

1. Asha Nabbale,

2. Brian Sekayombya

3. Bush Herbert Aguma

4. Freddy Eric Kitutu

5. Morris Okumu

Data Collection

Name Designation, Institution

1. Mr. Brian Arinitwe Pharmacist, Kawolo Hospital

2. Mr. Peter Niwagaba Pharmacist, Kambuga Hospital

3. Ms. Murungi Marion Intern Pharmacist, Mulago Hospital

4. Mr. Katwesigye Rogers Intern Pharmacist, Mulago Hospital

Data Management and Reporting

1. Mr Morris Okumu

2. Mr. Freddy Eric Kitutu

3. Mr. Brian Denis Sekayombya