Comparison of the capacity between public and private health facilities to manage under-five children with febrile illnesses in Uganda

About half of mortality in children under five years in sub-Saharan Africa is caused by malaria, pneumonia and diarrhoea [1]. UNICEF, WHO and partners are working in an increasing number of countries to support the integrated community case management (iCCM) strategy to train, supply and supervise front-line workers to treat children for both diarrhoea and pneumonia, as well as for malaria in malaria-affected countries, using oral rehydration solution (ORS), zinc, oral antibiotics, and artemisinin-based combination therapy (ACT) [2]. In low and middle income (LMIC) countries, current treatment levels are unacceptably low with only 39% of children receiving correct treatment for diarrhoea and 30% with suspected pneumonia receiving an antibiotic [2]. In addition, less than 20% of children with fever in sub-Saharan Africa receive a finger/heel stick for malaria testing [3].

Several public health interventions to improve management of childhood illnesses largely focus on the public health sector. However, almost 60% of parents with febrile children in Uganda first seek care in the private sector, especially at drug shops [4], yet they provide sub-standard care [5, 6]. Therefore, non-public health facilities such drug shops, private clinics and pharmacies, may have a low knowledge on the recommended guidelines compared to public facilities. Learning from the lessons experienced in the public sector roll out of integrated management of childhood illness (IMCI) [7, 8] and the iCCM at the community [9], we designed an a intervention to introduce iCCM among the private health providers (drug shops and private clinics). Prior to the implementation of the intervention, a baseline study was conducted to assess whether capacity and appropriateness in care of under -five children with febrile in the private and public sector differed. Therefore, this study aimed to compare the private and public facilities in terms of capacity and appropriateness of care for acute febrile illnesses among children below five years in order to explore ways of improving quality of care.

This study compared the private and public health facilities in terms of capacity to manage acute febrile illnesses among children aged 5 years and below. More than 95% in both sectors reported stocking Coartem, the first-line anti-malarial drug. However, just over half of the public facilities compared to 85% of the private facilities reported stocking quinine, the second-line anti-malarial drug, p < 0.01. Surprisingly, stocks of obsolete monotherapy anti-malarial drugs, such as chloroquine, were reported in both sectors, though more commonly in the private health facilities. About an equal proportion in both sectors reported stocking amoxicillin and this was over 90%, while more than a half reported stocking gentamycin. Stocks of ORS were almost universal in both sectors. However, only 20% of the private health facilities reported having stock cards compared to 98% in the public health facilities. Most commonly received training reported was for malaria, reported by more than a half in both sectors, followed by diarrhoea, with just over a third. However, receipt of training in management of pneumonia was the least mentioned with only 21% in the public health facilities and 12% in the private facilities. Regarding diagnostics, the private health facilities lacked functioning microscopes, however more than half reported having RDTs. Malaria treatment guidelines were significantly lacking in the private sector, p = 0.01. Knowledge about first-line management of uncomplicated malaria, pneumonia and diarrhoea was significantly better in the public facilities compared to the private ones.

Although stocks of artemether/lumefantrine (Coartem^®) in the two sectors were almost universal, the private sector tended be better stocked compared to the public health facilities. Quinine was also significantly better stocked in the private sector compared to the public facilities, p < 0.01. This implies that the public facilities had sub-optimal capacity compared to the private sector with regard to treating severe malaria. In addition, both sectors had stocks of obsolete monotherapy anti-malarials, such as chloroquine. This is contrary to the Uganda Clinical Guidelines/National anti-malarial drug policy recommendation to use ACT for malaria treatment [13]. This may be an indication of inappropriate case management in both sectors. This is similar to that reported in previous studies [14]. Just over three out five of the respondents in the public facility reported receiving training in malarial management compared to just over a half in the private sector. Slightly over a third of the respondents in both sectors received training in diarrhoea management, while training in pneumonia was the least reported. The public facilities where interventions are used usually implemented do not seem to be doing well in receiving training. Knowledge in the management of pneumonia was low with just 55% of the respondents being knowledgeable in the management of pneumonia and moderate (79%) for management of diarrhoea in the public facilities. Knowledge about management of acute febrile illnesses, particularly pneumonia and diarrhoea was poor, with majority of providers erroneously mentioning use of antibiotics in the management of diarrhoea contrary to recommendations [15]. Despite the existence of some differences between the sectors in terms of knowledge in managing acute febrile illnesses in children, the knowledge in the public facilities is sub-optimal, indicating that providers in both sectors need similar attention and efforts to improve case management. Unpublished work from the same study shows training in malaria management was a predictor for health workers in private sectors to refer very sick children. Malaria treatment and IMCI guidelines were not common in the private sector, compared to the public sector. This calls for health provider training and orientation in current policies and guidelines in both sectors to reinforce correct performance. Efforts should be put in place to stock the recommended drugs particularly in the public facilities, where patients are referred for appropriate care.

Regarding diagnostics, the private health facilities lacked functioning microscopes, however more than half reported having RDTs. Previous research has shown that only 34% of malaria patients received appropriate ACT treatment which was attributed to the practice of presumptive treatment and inadequate training on malaria management [16]. Efforts need to be put in place to increase availability of RDTs in the private sector in order to implement the recent decision by the Ugandan Ministry of Health to have all suspected malaria cases confirmed by microscopy or RDT in order to improve case management. The challenges that were reported by the public facilities in receiving referred children included: lack of money, no documentation of previous treatment given, wrong diagnosis and treatment and patients coming when very sick, while on the side of the private sector, these were: caretakers lacking money to take up the referral, patients not complying, lack of drugs at the referral facilities and losing the trust of their clients as referral is taken as a sign of failure. These findings are in line with previous studies [6, 17, 18]. There is need to strengthen both the private and public health sector in order to provide quality of services care for the under five children with febrile illnesses, including uninterrupted availability of commodities and regular supportive supervision (Table 4).

Both private and public health sectors have deficiencies in supplies, equipment and knowledge in appropriate case management of acute febrile illnesses. To significantly improve the capacity to handle acute febrile illness among children under five, training in proper case management, availability of supplies and diagnostics need to be addressed in both the private and public facilities.

Sustainable interventions at community level, private facilities and public facilities are critical in order to improve case management of common childhood febrile illnesses. In addition, there is need to study dispensing practices in both sectors.