Making retail medicine outlets a catalyst for malaria case management  in Ghana

The retail medicine outlet is one of the turfs that may decide how fast Ghana can move from the ranks of the 11 malaria-burdened countries to the malaria elimination stage.

Current global data from the World Health Organisation (WHO) paints a gloomy picture of Ghana’s malaria control efforts.

Approximately 70 per cent of the world’s malaria burden is said to be concentrated in just 11 countries including Ghana. The rest of the countries are Burkina Faso, Cameroon, Democratic Republic of the Congo, Mali, Mozambique, Niger, Nigeria, Uganda, United Republic of Tanzania and India.

Pharmacies and over-the-counter (OTC) drug facilities provide the channels for accessing malaria treatment but it appears some of these facilities are difficult terrains for controlling the disease.

These drug outlets occupy a very strategic position in bringing basic health care to the door steps of many households and local communities because of various reasons such as accessibility, affordability, and convenience.

At the beginning of this year, health authorities and their partners regularly promoted an interesting advert encouraging the public to access malaria care in the right way.

Early in the morning, upon tuning in to one of the popular Accra-based FM stations, one can easily relate to the conversations playing out in the advert urging people to adopt positive behavior and visit the hospital to test and first confirm that they have malaria before following up with the right treatment at the hospital. It also reminded people to make use of treated bed nets to prevent an attack from the disease.

Self-diagnosis and self-medication were strongly prohibited in the advert, regardless of the symptoms presenting as malaria and this provided useful public information. However it appeared this advert had a missing link in the chain of events to be followed.

Local drug facilities provide a strong linkage and are, more or less, leading the charge in dispensing malaria care at the very basic level.

Generally, quite a large section of the public access health services at these facilities and not at the hospitals or clinics, where the advert was actually pointing people to get basic malaria treatment.

Drug facilities are part of people’s lives because they help them to get first-aid or simple health care and therefore in dispensing malaria care, their actions, be it positive or negative, directly impact upon malaria case management.

These outlets could provide one of the litmus tests for how effectively cases are treated, while poor services or inappropriate malaria care provided by them may just be the Achilles heel in dealing with the disease effectively.

A matter of convenience

Household behaviour and community health services play a big role in effectively treating malaria cases.

Kasoa is one of the fastest growing communities in the Central region. Its proximity to Accra and strategic location along the Ghana-Cote d’Ivoire route may be among reasons why this town is bursting at it seams and becoming densely populated. It is also located along the highway to Ghana’s oil-rich Western region.

Construction work and structures are springing up all over Kasoa and it is fast becoming a commercial hub for small businesses. Almost all banks in the country are opening branches in this town, pharmacies and OTC medicine outlets are also all over the place.

Madam Ama Nyarku is a businesswoman who lives around the Walantu area in Kasoa, she has four children. A few metres away from her house are two OTC drug facilities, the Emmanuel Adom Bonney and Theresa Owusu medicine outlets, both quite close to each other.

A 10 minutes’ walk from where Madam Nyarku lives is the Kasoa Polyclinic of the Ghana Health Service, situated along the main Kasoa-Cape Coast road. Along this same lane are several drug and health facilities such as Bedita Pharmaceuticals, Eklesia Pharmacy, Nhyira Pharmacy and Justub, a private clinic. These health care facilities are an enclave, where people living around can easily access services and treatment.

Explaining what she does when she feels she has malaria, Madam Nyarku says her first choice for treatment among these health facilities is the pharmacy.

Adding that when she feels the illness is a serious one and complicated by other health conditions which she thinks may not be malaria, she then goes to the hospital.

For her, visiting the hospital to treat malaria may require other tests such as blood test and urine test, before drugs are prescribed and all these could go as high as GH¢100.

“If you go to the hospital, you will by all means go through procedure.. … you will not be given drugs immediately,” she said.

She says by skipping a visit to the hospital, she may only have to spend about GH¢20 to get some artemisinin-based combination therapy (ACTs) antimalarial.

She goes on to describe the way she manages her children to keep malaria away. According to her, although these drugs are meant for treatment, she has adopted a habit of at least, once in a while, dosing her young children with antimalarial syrup to prevent rather than to treat malaria because she does not want to wait for an attack first before treating them.

She feels the drugs can serve for both treatment and prevention, although evidence does not support this.

Kafui Gbeve is a housewife who lives at Nungua in the Greater Accra region, in a less densely populated community.

In June this year, she noticed her last child aged eight years was running a temperature and also coughing. She did not allow him to go to school and followed up with a call to her relative, a nurse who works at the LEKMA Hospital in Nungua.

She told the nurse exactly what was wrong with her little boy and after being instructed what to do, Madam Gbeve went to the drug outlet, a few houses away, to buy some drugs including an antimalarial which she administered to the child without any confirmatory test for the presence of malaria.

While speaking to, she showed the leftover pack of the yellowish looking Shal’Artem, an ACT branded artemether lumefantrine she had bought at the facility, in addition to paracetamol and a cough mixture.

She says apart from the time she would have wasted in seeking treatment at the hospital, the cost would have been much more than she spent at the drug facility.

“If you go to the hospital, you would return in the evening,” she added.

These antimalarials are available in different brands and prices, enabling everyone to make their choices based on the size of their pocket, although prices differ from one facility to the other for the same drug. Coartem is the most expensive brand selling between GH¢44 and GH¢45 and Lonart goes for GH¢16. Other drugs are low priced such as Sahtem at GH¢6 and others far below this, making malaria treatment at the community level very affordable as compared to going to the hospital for the same treatment, especially if it is just to treat an uncomplicated case of malaria.

What is convenient plays a major role in accessing malaria care. Clients arriving at a local drug facility are convenience shoppers looking for services that are cheap, affordable and less cumbersome when compared to visiting the hospital or clinic.

It is also very comfortable for people to discuss medical issues at these drug facilities, seek advice and sample treatment options instead of going through the usual top-down approach when seeking medical services at the hospital, where some medical professionals sometimes impose treatment on clients who may already be  intimidated by their surroundings.

Grassroot care

Medicine outlets operating within local communities are pivotal in providing universal health coverage (UHC) and are strongly positioned to support Ghana’s efforts in delivering primary health care (PHC).

The WHO in a document on UHC, released in January this year, defines UHC to mean that all individuals and communities receive the health services they need without suffering financial hardship. It explains that PHC is the most efficient and cost effective way to achieve UHC around the world and goes on to describe PHC as an approach to health and wellbeing centred on the needs and circumstances of individuals, families and communities.

It notes that PHC should systematically address the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviours) through evidence-informed public policies and actions across all sectors. Adding that, it must empower individuals, families, and communities to optimise their health. According to the document,  people and communities must also become co-developers of health and social services through their participation as self-carers and care-givers.

In the light of these, the role of individuals, households and medicine outlets within the local community settings is crucial to ensuring that malaria is conquered right from the household to the community level as part of the agenda for Ghana’s UHC programme.

Drug outlets are the grass root health facilities providing basic services to majority of Ghanaians. These outlets are in business and managed by the private sector but they are also providing public services.

Some limited training have been directed at some of these facilities by the health authorities, but sustained attention and more investments would have to be deployed to empower them to provide quality services to households and local communities.

Research and tailor-made interventions directed at drug facilities are also needed to enable them assist in proper and quality case management of common diseases such as malaria.

A few years ago, the WHO launched the T3 (Test Treat Track) Strategy urging malaria-endemic countries, donors and the global malaria community to scale up diagnostic testing, treatment and surveillance for the disease.

The key policy message was that every suspected malaria case should be tested. Every confirmed case should also be treated with a quality-assured antimalarial medicine, and the disease should be tracked through a timely and accurate surveillance system.

The WHO made it clear that because misdiagnosis could bring in significant morbidity and mortality, high-quality malaria diagnosis is important in all settings, including the local drug facility level.

It therefore recommended prompt malaria diagnosis either by microscopy or malaria rapid diagnostic tests (RDTs) for all suspected malaria cases before treatment.

The arguments supporting the T3 Strategy is that diagnostic testing improves the overall management of patients with febrile or feverish illnesses, and may also help to reduce the emergence and spread of drug resistance by reserving antimalarials for those who actually have malaria.

Ghana is part of the global community and is implementing the T3 Strategy and over the past few years, efforts have been made to push the test, treat and track policy.

For instance, malaria diagnostic refresher training has been provided for some laboratory professionals across the country to help provide quality testing for all suspected cases of malaria.

Additionally, some OTC medicine sellers and others working at pharmacies have been sensitised on the need to test before treating as part of the services provided.

These are laudable efforts by health authorities, led by the Ghana Health Service and its agency the National Malaria Control Programme (NMCP).

Despite these actions, the desire to seek treatment at home, and the behavior of providers are still not the best and are a major challenge in providing quality malaria care.

Arguably, care providers at these drug outlets have their own challenges to deal with. They are business people. They have to combine health services, customer satisfaction and profit-making at the same time, when serving clients.

They have to decide whether to sink resources in purchasing RDTs kits, even if people do not want to test.  They have to decide whether to dispense antimalarial drugs based on mere clinical suspicion, which seems to be the more practical thing to do, because if they insist on testing before giving out drugs, which is not free, a client would just move away to another facility. And drug outlets are all over the place and very close to each other.

The Dilemma

Can care providers at these outlets who are often busy, find the time to educate their clients by promoting the test before treatment policy as a component of services they provide?

More importantly can they spend extra time to dig deeper to see if the feverish conditions are linked to malaria or to another disease?

Are they aware that some critical examination or more probing is needed before giving out antimalarial drugs and that many clients who present with febrile conditions are not cases meant for a “quick fix” service?

What if a test result from the RDTs kit proves that the fever a client presents with is not malaria? This is a tough question, especially for operators of OTC drug outlets, who may not have trained staffs that are aware that there are several health conditions that manifest with a fever such as upper respiratory infections, hepatitis, pneumonia, tuberculosis, urinary tract infections, typhoid and meningitis.

Various questions and other situations have led to some outlets not stocking RDT kits, for very practical reasons.

During a visit to the Kingdom OTC facility at the Ashaiman Municipal market in the Greater Accra region, Juliet Nkansah, the attendant had said they no longer stock these RDT kits because it always produces a negative test result, even when everything points to the fact that the client is experiencing symptoms of malaria.

A follow up visit to the VicMag Pharmacy also located near the Ashaiman market, to further dig for information on these kits, showed that although this facility had the RDT kits, they also confirmed that results from the kits were almost always negative, even when all symptoms pointed to a case of malaria.

These reports about negative test results from the kits have some merit because the situation has been globally discussed and subjected to investigations and more research may be going on.

A report, under the title “Malaria Rapid Diagnostic Test Performance” released a couple of years ago by the Global Malaria Programme of the WHO explains that some findings from false negative RDT results are more likely to “be due to the procurement and use of poor-quality RDTs or use of the wrong comparator for the diagnostic test, such as poor-quality microscopy for cross-checking negative RDT results.

It adds that poor transport and storage conditions for RDTs, with sustained exposure to high temperature, can affect their diagnostic performance”.

The report further explains that more rarely, operator errors, the product, supply chain, host and parasite factors can also lead to false negative RDT results and therefore investigations are needed in such cases.

According to the Global Malaria Programme, thousands of febrile children with negative RDT results have been followed up in several studies, which showed no malaria-related deaths or hospitalizations.

It therefore says that treatment of individuals with negative RDT results promotes drug resistance, wastes resources and can delay diagnosis of non-malaria causes of fever.

It adds that investigation should be carried out to determine the quality of the RDTs and the competence of the operator, among others.

Negative test results are not the only contentious issues facing malaria care providers at retail drug outlets. During an interaction at the Deccon Pharmacy located at the Spintex junction along the Nungua-Ashaiman road, the attendant had explained that although they have the tests kits available, some people do not want to be tested since they are convinced they have malaria and just want to buy drugs without bothering to test first.

She had added that if testing is made free it may help since some people cannot pay for both the drugs and the tests.

Another facility, Pucon, located along the Kasoa-Nyanyano road in the Central region, sells OTC drugs. During a visit to this facility it came out that they had the antimalarials but no RDTs kits and this had nothing to do with lack of supplies.

The attendant had explained that they usually conduct presumptive treatment because once a client describes the symptoms it is easy to conclude it is an attack of malaria, adding that they only test occasionally when people request for it.

Other facilities visited in Kasoa showed they had no problems with supplies. What is however common is that testing for the presence of malaria before treatment is not top of the agenda, unless a client specifically makes the request to be tested.

Some drug outlets are however doing very well such as the PharmaTrust pharmacy, located along the main Kasoa-Cape Coast road in an imposing building. Right on its premises it provides both laboratory diagnosis and RDTs services and each is priced at GH¢10. It was therefore not a surprise that upon visiting this facility and explaining the presence of some symptoms, the attendant had asked that a test be conducted for confirmation of malaria before treatment.

There are cost variations for conducting RDTs from facility to facility. Some drug outlets charge as low as GH¢5 and others between GH¢8 and GH¢10. This makes a case for free or subsidized testing because quite a number of people are unable to pay for the tests and drugs.

At the Theresa Owusu OTC medicine outlet, although they had the kits to test, at the time of visiting, however, the attendant had explained that the person who could conduct the tests was not present, raising a question of skills training in managing malaria at the community level.

Issues of time constraints, cost, convenience, household behavior, the ubiquitous presence of retail medicine outlets and the kind of services provided within communities are some key determinants in providing quality malaria case management.

The drug outlets are no doubt very useful in providing care at the grass root because they are more like convenience shops where one can get medications anytime, anywhere and any day.

However, a number of them have become very tough terrains to promote effective treatment of malaria cases. The NMCP may need to adopt new strategies to significantly scale-up effective implementation of the T3 strategy at every level of care including the local drug facility level.

Possibly testing should be subsidised or provided for free for a period of time to promote and entrench the habit of testing before treatment.

With just a few month to meet the 2020 national objectives of providing parasitological diagnosis for all suspected malaria cases and prompt and effective treatment for 100 per cent of all confirmed malaria cases, health officials in the country may have to channel more efforts and resources into household and community malaria care.

Also, it is important that all stakeholders at the community level, are sensitised that after testing, all non-malaria cases appearing like malaria should be referred to a higher health facility.

There is the need for a new and tough approach to the national response in managing malaria at the grassroots to promote quality and effective care.

By Eunice Menka

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