SEVERAL EPIDEMIOLOGIC STUDIES HAVE demonstrated a link between sexually transmitted diseases (STDs) and human immune deficiency virus (HIV).1,2 A study in Mwanza, Tanzania, indicated that improved STD management at public heath facilities can reduce the incidence of HIV.3 Since then, donors, on whom many sub-Saharan countries depend for healthcare delivery, have emphasized STD management in the public sector. However, in Mwanza, 70% of men experiencing a symptomatic STD sought care in the public health sector, whereas the remainder sought traditional treatment or obtained treatment from other sources.4 Additionally, the cure rate for all STDs was more than 81% at the health centers. This scenario may not pertain to other parts of sub-Saharan Africa.
In Ghana and Cameroon, for example, 75% and 50%, respectively, of men with an STD sought treatment elsewhere before reporting to a health center.6,7 In Rakai district, Uganda, less then 20% of adults with symptoms suggestive of STDs sought treatment at government clinics.8 The choice of healthcare provider depends on the perceived quality of care, opportunity costs, and availability of medication.9 STD management by private providers tends to be of poor quality,10–12 resulting in prolonged infectiousness with consequent increased risk of acquiring and transmitting HIV.13 In nonindustrialized countries, the population’s ability to assess technical quality of healthcare providers is reportedly limited whereby they may emphasize quality factors of providers such as interpersonal skills and comfort without regard for technical factors.14
Difficulties related to the private sector relate mainly to their aim to optimize profit at the expense of best practice models of care, their inability to address preventive services, and their poor integration with government services.15 The ideal situation would, therefore, be provision of health care by the public sector in tandem with strict enforcement of regulatory mechanisms for the private sector. This is unlikely to be achieved because international health policies tend to reduce the range and availability of public health services,16 potentially increasing the role of private providers in healthcare provision. Furthermore, most developing countries lack the human and financial capacity for enforcement of regulatory policies.15
Management of STDs at public facilities may be poor, even when staff members are sufficiently trained and drugs and other consumables are adequately stocked and supplied.17 The government of Uganda has displayed a keen interest in developing the private sector through reform of the healthcare system.18 Within this context, we carried out a study in Uganda regarding the feasibility and acceptability of social marketing of prepackaged treatment for men with urethral discharge (MUD).19
We give a report of the management of urethral discharge in the private-for-profit formal (clinics) and informal (drug shops) sector and their patients’ compliance with treatment. The aim of the study was to enable policymakers to formulate appropriate interventions for improving STD control through these providers.
The Ugandan healthcare system suffered extensively during 20 years of civil unrest, exemplified by brain drain and chaos.20 As a result of perceived high cost and absence of medication at the health centers, the majority of the population resorted to self-medication whereby the health centers constituted the last source of treatment if all else had failed.21,22 Private provision of health care increased with the decline of public health services during the period of political chaos.23 In recent years, there has been steady improvement in the quality of services at public health facilities, medical supplies are usually available, and cost sharing has been abolished.
Antibiotics, or prescription drugs, may legally be prescribed only by registered medical practitioners, dentists, and veterinary surgeons. Legally sanctioned prescribers and registered pharmacists, staff members of a hospital dispensary, or similar institutions, can dispense drugs. Any person registered with or enrolled under the Nurses, Midwives and Nursing Assistant Act can dispense but not prescribe.
Drug shops are only entitled to sell nonprescription drugs such as analgesics and cough mixtures and should be run by a person with an appropriate qualification (relevant pharmaceutical, medical, veterinary, nursing, or other paramedical field approved by the National Drug Authority).24 In practice, many drug shops sell antibiotics and therefore operate as the first point of entry into the health sector.25 Legally, private clinics should be operated by medical doctors, but in practice, other types of health workers sometimes run them. The only legal commercial outlets for prescription drugs, the pharmacies, are all located in towns, considerably limiting access because 90% of the population resides in rural areas.
The data on management of MUD were collected during the period September through December 1998. The study was conducted in 5 districts: 2 divisions of Kampala and the districts of Jinja, Luweero, Masaka, and Mbarara. Each district was subdivided into 5 clusters consisting of a concentration of healthcare delivery sites, both from the formal and informal private health sector, and each cluster was visited once a week. All owners of the drug shops and private clinics within the clusters were requested to refer men with urethral discharge for interview 1 to 3 weeks after initiation of treatment. Of 177 facilities that were approached, 129 agreed to participate. A contact slip giving the date and place of interview was completed in duplicate by private clinic or drug shop staff when the patients consulted the facility for treatment. One contact slip would be given to the patient while the interview team collected the copies. All men referred were interviewed apart from in Mbarara, where the interviewers were overwhelmed and could only take a select few. Verbal consent of the subjects was obtained before each interview. The study was cleared by the Science and Ethics Committee of the Uganda Virus Research Institute.
Enrollment criteria were the presence of at least 1 symptom of urethral discharge, ie, painful urination or urethral discharge, a minimum and maximum period of 1 week and 3 weeks, respectively, between the initiation of treatment and the time of the interview, and having sought treatment at a drug shop or private clinic.
All interviews were conducted by trained interviewers using a piloted precoded structured questionnaire. The aim of the questionnaire was to elicit health-seeking behavior, the quality of management of urethral discharge, treatment outcome and patients’ behavior in respect to STD management, and their perception of quality of treatment received. Questions regarding treatment outcome related only to symptoms of urethral discharge during the last treatment episode. The responses were compared between clients of private clinics and drug shops.
When records were present and the treatment provided to the study subjects was recorded by facility staff, this information was used. However, because many facilities did not keep records of treatments given to patients, this information was obtained from the respondents themselves, if they remembered. Questions concerning the treatment related only to the use of injections, tablets, or capsules and if tablets, the number of tablets taken. One tablet to be taken on the spot followed by 2 tablets daily for 1 week was considered to be the treatment recommended by the National Guidelines (ciprofloxacin plus doxycycline) even if they could not name the tablets. If they followed some other regimen or did not recognize that one, then it was assumed that they did not follow National Guidelines. In many cases, respondents were not able to describe their treatment accurately enough for us to make a decision about it.
Health-seeking behavior was measured by time between the onset of symptoms and initiation of treatment. Literacy was taken as an indicator of educational level.
The quality of management of urethral discharge was determined by several factors: 1) if the treatment used was in accordance with the National Guidelines; and 2) the number of properly managed patients (treatment according to the National Guidelines, told to refer their partner and to use condoms or abstain from sex during treatment).
Treatment outcome was based on symptoms of urethral discharge; cure was defined as complete disappearance of urethral discharge symptoms at the time of interview. Information on treatment outcome was self-reported and was not confirmed by laboratory testing. Patients’ behavior was measured by actual referral of the partner, the reported use of condoms or sexual abstention during treatment, and completion of treatment. Patients’ perception of quality of treatment was ascertained by questioning whether they would recommend their treatment to a friend.
All data were analyzed using EpiInfo version 6.04b according to 2 strata: drug shops and private clinics as source of treatment. Differences between proportions were calculated using the chi-squared test and statistical significance was determined at 5%.
A total of 405 men who sought treatment for urethral discharge at drug shops (141) and at private clinics (264) were interviewed. Twenty-nine percent (116) concurrently suffered from genital ulcer disease (GUD). The median age of the interviewees was 28.5 years (range, 16–79 years).
The time between onset of symptoms and seeking treatment is displayed in Figure 1. Overall 77% sought treatment within 1 week of initiation of symptoms. For 11% of the interviewees, treatment was sought after more than 3 weeks (median, 60 days; range, 24–380 days). The median duration between onset of symptoms and seeking treatment was 4 days for private clinic interviewees (range, 1–366 days) versus 5 for drug shop interviewees (range, 1–390 days) (statistically nonsignificant difference).
Quality of Management of Urethral Discharge
Treatment regimens were recorded for 121 patients (30% of all patients), 41 from drug shops and 80 from private clinics. For 284 patients, the treatment received was unknown. Overall, 31% (126 of 405) received treatment with just a single antibiotic, and this was more common among drug shop patients than clinic recruits (44% vs. 25%; P = 0.04). Twenty-five patients (8 drug shop and 17 private clinic patients) had GUD in addition to urethral discharge. Of those, 12 received benzathine penicillin as recommended by the National Guidelines. Of all interviewees, 9% (35 of 405) had received treatment in line with the National Guidelines (Table 1). This was significantly higher for drug shop clients than private clinic patients: (14% vs. 6%; P = 0.01). Overall, only 7% (28 of 405) were properly managed, and this was lower among clients seen at the private clinics than at drug shops (5% vs. 11%; P = 0.01).
The overall reported cure rate was 47% (190 of 405). This was significantly higher among private clinic patients than drug shop clients (52 vs. 38%; P = 0.006). The cure rate was significantly higher for patients who sought treatment within 1 week of initiation of symptoms than patients who waited longer: 53% (165 of 310) versus 26% (25 of 95) (P <0.001). Of the patients whose treatment regimen was recorded, the cure rate was 24% (9 of 38) for those whose regime consisted of a single antibiotic versus 57% (47 of 83) for those consisting of 2 or more antibiotics (P = 0.002). For those who were treated in line with the National Guidelines, the cure rate was 66% (23 of 35) compared with 45% (167 of 370) for those receiving another treatment (P = 0.02).
Overall, 54% (220 of 405) reported having informed their partner to go for treatment. Significantly more married patients informed their partner to go for treatment than unmarried patients: 65% (154 of 239) versus 40% (66 of 166) (P <0.001). The main reason given for not referring a partner was “no steady partner” (47%). Other reasons included: the partner living too far away (16%), not knowing that she required treatment too (11%), and fear of blame (10%). Of all interviewees, 38% (155 of 405) reported that their partner went for treatment. This was significantly more among married patients than unmarried patients: 54% (129 of 239) versus 17% (29 of 166) (P <0.001).
Overall, condom use during treatment was 18% (72 of 405). Significantly more private clinic patients reported the use of condoms during treatment than drug shop patients: 22% (58 of 262) versus 10%. Of the interviewees reporting not having used a condom during treatment, 77% (258 of 333) claimed to have had no sex during treatment.
Overall, 18% (72 of 405) of patients were illiterate. This was higher among drug shop clients than clinic patients (23% vs. 15%; P = 0.03). In total, 9% (35 of 405) took treatment recommended by a friend, and this was significantly more common among drug shop clients (19%) compared with private clinic patients (3%). Eighty-seven percent (352 of 405) of all interviewees completed the recommended treatment course: 90% of private clinic patients versus 81% of drug shop clients. Overall, 7% (29 of 405) of patients halted the treatment course prematurely because of lack of funds. This was more common among drug shop clients (12%) than private clinic patients (5%).
The median price per treatment was 6000 Ush (US $4.6) (range, 400–50,000 Ush). This was 4000 Ush (range, 400–40,000) at drug shops, which was significantly lower than the median price of 6450 Ush (range, 4500–50,000 Ush) at private clinics (Kruskal-Wallis, P <0.001). Of the 53 patients who did not complete treatment, the main reasons were: insufficient money (55%), symptoms had disappeared (23%), and forgot (17%).
Patients’ Perception of Quality of Treatment
Less than half of the interviewees reported complete cure. However, of those who were not cured, 56% (121 of 215) would recommend their treatment to their friends if they suffered the same condition. Eighty-one percent of these interviewees would recommend the treatment because it “reduces symptoms,” 17% because it reduces the pain, and 2% because of its price.
This article highlights the poor practices of STD management in the Ugandan private-for-profit formal and informal health sectors, represented by private clinics and drug shops, respectively. Because we had no control over who was referred and who was not, patient selection in this evaluation may have been biased because healthcare providers tended to refer those who they felt would be cured. Consequently, the cure rate obtained in this study may be an overestimation. However, patients would have been referred before they started treatment so the care providers could not have known accurately who would be cured and who would not. Relying on self-reported disappearance of symptoms without laboratory confirmation may also inflate cure rates. Dallabetta et al.26 found in Malawi that of 238 men treated for urethritis and having no symptoms at follow up, 9% still had gonorrhea and 22% had nongonococcal urethritis.
Patients’ health-seeking behavior was similar to the results of Moses et al.27 in Nairobi, Kenya. We failed, however, to ascertain the reason for delayed health-seeking among the 23% of interviewees who sought treatment 1 week or more after recognition of symptoms. This warrants further research. In this study, reported cure rate was positively associated with presenting for treatment within 1 week of symptom recognition, which is similar to findings from the Ivory Coast.28 Delay in care seeking by patients with STDs is of concern because the observed reduction in HIV incidence during the Mwanza trial was considered to result from a reduced duration of STDs in men.29 These findings stress the importance of ongoing education of the public on STD symptom recognition and appropriate and timely health-seeking behavior.
Only 9% of patients were treated according to National Guidelines, but this was significantly more for patients recruited at drug shops than patients treated at private clinics. This may be the result of the free flow of drugs, staff, and medical knowledge between the public and informal health sector as reported by Adome et al.25 A baseline assessment of STD management by the public sector in Uganda in 1996 found that only 14% of patients with GUD or urethral discharge syndrome were properly managed according to the National Guidelines.30 This figure is similar to the 11% of MUD who were properly managed at drug shops but is significantly higher than the rate at private clinics (5%). A cross-sectional survey of public healthcare providers in 1998 concluded that 21% of patients with STDs were treated in accordance with National Guidelines, whereas 28% were informed to abstain from sex or use condoms while on treatment and were counseled on partner referral.31
Higher cure rates were associated with being treated in accordance with the National Guidelines, having sought treatment within 1 week on initiation of symptoms, and treatment consisting of more than 1 antibiotic. The principal etiologies of urethral discharge to be targeted according to World Health Organization recommendations are Neisseria gonorrhoeae and Chlamydia trachomatis, either alone or in combination, so the use of 2 appropriate antibiotics to cover these pathogens for treatment is recommended.7 It is therefore worrying to note that 31% of the treatment regimens consisted of a single antibiotic, especially because the reported cure rate of such patients was only 24%.
Two thirds of patients were advised to refer their partner for treatment and to use condoms while being on treatment. This was significantly more common at private clinics than at drug shops. This is probably related to the direct contact between the healthcare provider and the patient because a study conducted in Rwanda32 indicated that improved counseling of patients with STDs increased partner referral. Hence, a major opportunity to counsel the patient, especially for those who only buy antibiotics without disclosing its purpose, is missed. Such patients will most likely consult a drug shop because significantly more drug shop clients than private clinic patients self-medicated with a treatment recommended by a friend.
Married men were significantly more likely to inform their partners to go for treatment than unmarried men. There is therefore a need for innovative strategies to reach occasional sexual partners.32 Less than one fifth of the interviewees reported using condoms during treatment, the majority preferring to abstain from sex during that period. The preference of Ugandans for abstinence rather than using condoms has been reported previously.33
The fact that 56% of the MUD would recommend the treatment to others even though they have not been cured is worrying. This action seems to be related to their interpretation of cure, which is often simply “reduction of symptoms” or “disappearance of pain.” In this respect, counseling of the patient regarding completion of treatment is indispensable. An additional aid may be prepackaged treatment for STDs. In a trial in Uganda, patients who used such treatment were significantly more likely to complete the recommended treatment course than patients treated along conventional methods.19 Respective cure rates were 84% and 47%.
In this assessment, we present a bleak picture of STD management at the private-for-profit sector in Uganda, especially at drug shops. However, our data suggest that drug shops play an important role as healthcare providers for the poorer people: more drug shop clients were unable to complete their treatment as a result of a lack of money despite paying considerably less than at private clinics. Drug shop patients were also significantly more illiterate than private clinic patients.
Reinforcing the government’s regulatory capacity in tandem with technical upgrading of the public and formal private sector is considered a long-term strategy for potentially minimizing the informal sector’s role in healthcare provision.14 In the short-term, concurrent provision of training and prepackaged treatment for STD management to private and public practitioners may considerably aid in improving treatment outcomes for patients.19,34 At public facilities, support supervision should be intensified,31 and patient compliance with treatment could be greatly enhanced with the use of single-dose treatments that are now affordable.35 The recent abolition of official cost sharing at public health facilities may stimulate care-seeking at such facilities, as reported from Uganda36 and South Africa.37
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