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What influences availability of medicines for the community management of childhood illnesses in central Uganda? Implications for scaling up the integrated community case management programme

  • James Bagonza1Email author,
  • Elizeus Rutebemberwa1,
  • Tim Eckmanns2 and
  • Elizabeth Ekirapa-Kiracho1
BMC Public Health201515:1180

https://doi.org/10.1186/s12889-015-2525-4

Received: 20 June 2015

Accepted: 18 November 2015

Published: 25 November 2015

Abstract

Background

The integrated Community Case Management (iCCM) of childhood illnesses strategy has been adopted world over to reduce child related ill health and mortality. Community Health workers (CHWs) who implement this strategy need a regular supply of drugs to effectively treat children under 5 years with malaria, pneumonia and diarrhea. In this paper, we report the prevalence and factors influencing availability of medicines for managing malaria, pneumonia and diarrhea in communities in central Uganda.

Methods

A cross sectional study was conducted among 303 CHWs in Wakiso district in central Uganda. Eligible CHWs from two randomly selected Health Sub Districts (HSDs) were interviewed. Questionnaires, check lists, record reviews were used to collect information on CHW background characteristics, CHW’s prescription behaviors, health system support factors and availability of iCCM drugs. Multivariable logistic regression analysis was done to assess factors associated with availability of iCCM drugs.

Results

Out of 300 CHWs, 239 (79.9 %) were females and mean age was 42.1 (standard deviation =11.1 years). The prevalence of iCCM drug availability was 8.3 % and 33 respondents (11 %) had no drugs at all. Factors associated with iCCM drug availability were; being supervised within the last month (adjusted OR = 3.70, 95 % CI 1.22–11.24), appropriate drug prescriptions (adjusted OR = 3.71, 95 % CI 1.38–9.96), regular submission of drug reports (adjusted OR = 4.02, 95 % CI 1.62–10.10) and having a respiratory timer as a diagnostic tool (adjusted OR =3.11, 95 % CI 1.08–9.00).

Conclusions

The low medicine stocks for the community management of childhood illnesses calls for strengthening of CHW supervision, medicine prescription and reporting, and increasing availability of functional diagnostic tools.

Keywords

Drug Availability Childhood Illnesses Community health workers Uganda

Background

Although progress has been made in reducing under five mortality in Sub Saharan Africa [1, 2], it is still a huge challenge. The rate of decrease of under-five mortality in Uganda from 1990 (160 per1000 live births) to 2006 (137 per 1000 live births) and now 90 per 1000 live births was good, but insufficient to achieve the Millennium Development Goal of 56 per 1000 live births by 2015 [3, 4]. Three quarters of the under five deaths are still due to a handful of causes such as malaria, pneumonia, diarrhea and newborn conditions [5, 6]. Therefore, interventions that promote appropriate treatment of childhood pneumonia, diarrhoea and malaria will lead to major reductions in under five mortality. The integrated Community Case Management (iCCM) of common childhood illnesses (malaria, pneumonia and diarrhea) has been widely adopted as a means to reduce childhood morbidity and mortality by increasing access to essential child health services [7, 8]. Under the iCCM strategy, Community Health Workers (CHWs) are trained to diagnose and treat sick children with malaria, pneumonia and diarrhea in communities. To this end, they are provided with pre-packed medicines which include amoxicillin for treating non severe pneumonia, Artemisinin Combination Therapy (ACT) for uncomplicated malaria, Oral Rehydration Salts (ORS) and zinc for diarrhea. All patients are screened for the three diseases and treatment is administered basing on the results of the examination and diagnostic testing that includes: malaria rapid diagnostic tests, disease history and respiratory rates. This approach can result in a 70 % reduction in mortality from pneumonia in children under age five, and reduce overall malaria mortality by 53 % [9, 10]. Therefore, effective community case management calls for an uninterrupted supply of medicines and equipment necessary to promote early identification and correct treatment of childhood diseases [1113].

Child health programs often suffer shortages of key products, which suggest that supply chain factors may be adversely affecting outcomes of those programs [1417]. Poor supply chain management, including limited or none existent stock control and forecasting, means that even though drugs may be available centrally, there can be frequent stock-outs at community level. Indeed supply chain management systems for national health systems coupled with prescriber’s training, experience, use of guidelines and drug utilization rates, often impact on the availability of medicines [1820].

Since CHWs are the first level of contact between community and the health care system, stock-outs of essential medicines for treating common childhood illnesses may lead to delayed access to care thereby increasing child mortality [2123]. Although literature on the assessment of drug availability in the formal health sector is widely available [2426], medicine availability for community case management programmes for childhood malaria, pneumonia and diarrhea has not been fully documented in Uganda. Secondly, many studies addressing barriers of access to essential drugs in developing countries have mainly focused on the supply chain management systems and not on the prescribers’ perspectives and health system support factors such as training and supervision [14, 16, 27]. Given the paucity of data on the availability of drugs among CHWs, the objectives of this study were to document the prevalence and factors influencing availability of iCCM drugs in central Uganda.

Methods

Study setting

This study was conducted in Wakiso district. Wakiso lies in the central region of Uganda about 12 km from Kampala, the capital city of Uganda. Wakiso has a population of 1,260,900 [4] and the top five major causes of morbidity in the district are malaria, respiratory tract infections, intestinal worms, skin diseases and diarrhea [4]. Malaria is endemic in the area and the under-five mortality rate for the region is 128/1000 live births [4]. The district is divided into seven Health Sub Districts (HSDs). A HSD is the functional zone of the district health system responsible for the delivery of maternal and child health services, health promotion messages as well as treatment of infectious diseases such as malaria. Within the HSD are peripheral health facilities which supervise CHW’s activities. Community Health workers are provided with pre-packed medicines which include; amoxicillin, Artemisinin-based Combination Therapy (ACT), Oral Rehydration Salts (ORS) and zinc. Amoxicillin is pre packed in two dose/strength formulations: 125 mg (red pack) for children aged 2 months to 12 months and 250 mg (green pack) for children from 12 months to 5 years. Likewise ACTs (Coartem*) is pre packed in two dose formulations: 20/120 mg pack of 6 tablets (yellow pack) for children aged 2 months to 3 years and the 20/120 mg pack of 12 tablets for children between 3 and 5 years. Each CHW takes care of about 25 to 30 households.

Study design

This was a cross sectional study that employed quantitative methods of data collection and the outcome of interest was drug availability for the iCCM programme. Eligible respondents were CHWs who had been recruited on the iCCM programme for more than six months by the time of the study in Wakiso district and gave informed consent to participate in the study. CHWs who were not available in the district during the study period were excluded.

Sample size calculation and sampling procedure

The sample size formula by Kish Leslie [28] was used to calculate the required number of CHWs to participate in the study. A sample size of 305 CHWs was calculated based on the following assumptions: a two sided test with a precision of 5 %, and an estimated prevalence of drug availability of 33 % [29]. The seven HSDs in Wakiso were stratified into rural (4 HSDs) and peri-urban (3 HSDs) and two were selected randomly taking one from the rural HSDs and one from the peri-urban HSDs. On average each HSD had about 180 CHWs managing sick children under the iCCM programme. In each Sub County or town council within the selected HSDs, we contacted the health facility managers or health workers responsible for CHWs activities to obtain lists of CHWs responsible for iCCM programme. We located the eligible CHWs in their homes through their supervisors and local council/village leaders.

Data collection and drug availability

A physical drug count of the four iCCM drugs (ACTs, Amoxicillin, ORS and Zinc) was done on the day of the interview using data extraction sheets and check lists. Pretested semi structured questionnaires were administered to collect information on factors affecting drug availability. This tool captured socio-demographic information: individual, health system support factors that may affect drug availability. A retrospective records review of the iCCM patient registers for the previous 6 months was done to collect data on CHW’s drug prescription behaviors. Specifically we looked at the diagnoses and drugs prescribed by CHWs for each patient seen in the last 6 months to determine whether the prescriptions were appropriate basing on the iCCM treatment guidelines.

A CHW was classified as having drugs when all the four iCCM drugs were present on the day of the survey. Where a CHW only had some or none of the four iCCM drugs, this was classified as no availability of iCCM drugs. In addition, information on individual drug availabilities and total stock-outs of all the four drugs (absence of any drug) was captured.

Data collection tools were pretested and data was collected by five trained research assistants who were supervised by the principal investigator. Data collection tools were translated into the local language (Luganda) and back translated by other people without prior knowledge of the instrument.

Data analysis

Data were double entered in Epi-Info software version 3.3.2 of 2005 and analyzed using STATA 10 (STATA Corp, College Station, TX, USA). Community health worker’s background characteristics and drug availability were summarized descriptively. Drug availability was dichotomized as “YES” if all the four iCCM drugs were available and “No” if only some or none of the drugs were present. Relationships between CHWs background characteristics, health system support factors and drug availability were assessed using odds ratios. A p value of less than 0.05 was taken to represent a statistically significant association. All variables with a p-value of less than 0.2 [30] at univariate analysis as well as variables known to predict medicine availability from literature such as prescriber’s education level, sex, occupation and time since last training on dispensing drugs [31, 32] were used in multivariable regression analysis. However, before conducting multivariable analysis, the existence of multicolinearlity was investigated using the correlation coefficients between each pair of the independent variables. Correlated variables (correlation coefficient value greater than 0.5 with a p-value less or equal to 0.05) were excluded from the logistic regression analysis model. A binary logistic regression analysis with a backward elimination method was done to determine independent factors associated with availability of iCCM drugs. Conclusions were drawn based on the adjusted odds ratios with their corresponding 95 % confidence intervals. Interactions among the independent variables were not statistically significant. In order to determine how well the model fit the data, Pearson chi-squared test (p > 0.05) was used to determine the goodness of fit of the model.

Ethical considerations

Ethical approval to conduct this study was got from Uganda National Council of Science and Technology, Makerere University School of Public Health Higher Degrees Research and Ethics Committee, and Wakiso district health authorities. Written informed consent was obtained from the study participants. Data accruing from the study was kept securely locked at all times and no personal identifiers were used or recorded on any tools used for data collection.

Results

Of the 303 study participants, only 300 (99.0 %) were included in our analysis. Data from three respondents (1.0 %) were excluded from further analysis on account of having incompletely filled data collection tools. Table 1 shows background characteristics of respondents. Majority 79.7 % of the respondents were females and the mean age was 42.1 years (standard deviation 11.1 years). More than half, 65 % had secondary education as the highest level of education attained while only 14.3 % were in formal employment.
Table 1

Background characteristics of respondents

Variable

Respondents (N = 300)

n (%)

Sex

Male

61 (20.3)

 

Female

239 (79.7)

Age

20–29 years

28 (9.3)

 

30–39 years

85 (28.3)

 

40–49 years

100 (33.3)

 

50–50 years

77 (25.6)

 

>60 years

10 (3.3)

Education

None/primary

68 (22.7)

 

Secondary

195 (65.0)

 

Tertiary

37 (12.3)

Religion

Catholic

78 (26.0)

 

Protestant

121 (40.3)

 

Moslem

56 (18.6)

 

Others

45 (15.3)

Marital status

Never married

21 (7.0)

 

Married

173 (57.7)

 

Separated

60 (20.0)

 

Divorced

46 (15.5)

Occupation

Unemployed

63 (21.0)

 

Formal employment

43 (14.3)

 

Self-employment

175 (58.3)

 

Others

19 (6.3)

Availability of iCCM drugs

Table 2 describes availability of iCCM drugs among CHWs. Only 25 respondents (8.3 %) had all the four iCCM medicines while 33 respondents (11 %) had no drugs at all. ACTs/Coartem*-20/120 mg (6 tablet pack) a drug used to treat malaria was the least available (at 3.3 %) of all the iCCM medicines. Amoxicillin was the most prevalent drug at 79 % for the 250 mg dose strength (green pack) and 64.7 % for the 125 mg dose strength (red pack).
Table 2

Availability of iCCM drugs among CHWs

Variable

Availability of iCCM drugs (N = 300, %)

Number of iCCMDrugs

 

 All the four iCCM drugs

25 (8.3)

 Only three of the iCCM drugs

69 (23.0)

 Only two of the iCCM drugs

107 (35.7)

 One of the iCCM drugs

66 (22.0)

 No iCCM drug at all

33 (11.0)

Type of iCCM drugs

 

 ACTs 20/120 mg 6 tablets pack (yellow)

10 (3.3)

 ACTs 20/120 mg 12 tablets pack (blue)

106 (35.3)

 Amoxicillin 125 mg pack (red)

194 (64.7)

 Amoxicillin 250 mg pack (green)

237 (79.0)

 Zinc 20 mg

79 (26.3)

 Oral Rehydration Salts (ORS)

140 (46.7)

Factors associated with availability of iCCM drugs among CHWs

Table 3 describes associations between health system factors and availability of iCCM drugs at unadjusted analysis. Community health workers who were regularly submitting monthly reports were more likely to have all the four iCCM drugs (OR = 3.48 95 % CI 1.62–9.52) compared to those who were not submitting reports. Community Health workers who had more than 90 % of their prescriptions done appropriately were more likely to have all the iCCM drugs (OR = 3.32 95 % CI 1.33–8.32). Time since last training in dispensing iCCM drugs, supervision from health workers and not having diagnostic equipment (respiratory timer) were not associated with availability of iCCM medicines at crude analysis.
Table 3

Association between Health system factors and drug availability among CHWs

Variable

Drug availability (N = 300)

OR (95 % CI)

P values

 

Yes (n, %)

No (n, %)

  

Ever treating children above 5 years

    

 Yes

2 (11.1)

16 (88.9)

1.00

 

 No

23 (8.2)

259 (91.8)

0.71 (0.15–3.29)

0.660

Ever supplied drugs to care givers who have not brought sick children

    

 Yes

1 (5.6)

18 (94.4)

1.00

 

 No

24 (8.5)

257 (91.5)

1.68 (0.15–9.99)

0.829

Training on dispensing drugs

    

 Within 6 months

1 (4.0)

24 96.0)

1.00

 

 6 to 12 month

1 (4.4)

22 (95.6)

1.09 (0.06–19.07)

0.953

 More 12 months

23 (9.1)

229 (90.9)

2.41 (0.31–18.77)

0.386

Having a respiratory timer

    

 No

6 (4.7)

121 (95.3)

1.00

 

 Yes

19 (9.9)

154 (90.1)

2.48 (0.93–7.69)

0.056

Supervision

    

 No

19 (7.3)

240 (92.7)

1.00

 

 Yes

6 (14.6)

35 (85.4)

2.16 (0.71–5.88)

0.179

Monthly reporting

    

 No

9 (4.2)

182 (95.8)

1.00

 

 Yes

16 (14.7)

93 (85.3)

3.48 (1.62–9.52)

0.011

Appropriateness of prescriptions

    

 Less than 90 %

7 (4.3)

155 (95.7)

1.00

 

 More than 90 %

18 (13.0)

120 (86.9)

3.32 (1.33–8.32)

0.006

Table 4 shows results of the multivariable analysis of independent factors associated with iCCM drug availability. When factors were fitted in a logistic regression model for multivariable analysis, 99.5 % (n = 298) of respondents were retained in the analysis. Factors that were found to be independently associated with drug availability were: being supervised within the last one month (adjusted OR = 3.70,95 % CI (1.22–11.24), having more than 90 % of prescriptions appropriately done (adjusted OR = 3.71, 95 % CI 1.38–9.96), regular submission of monthly drug reports (adjusted OR = 4.02, 95 % CI, 1.62–10.10), Having a functional respiratory timer as a diagnostic tool (adjusted OR =3.11,95 % CI, 1.08–9.00). In the multivariable model, we adjusted for sex, prescriber’s education level, occupation and time since the last training in dispensing drugs.
Table 4

Factors affecting iCCM drug availability among CHWs

Variable

Crude OR (95 % CI)

Adjusted OR (95 % CI)

P value

Appropriateness of prescriptions

   

 Less than 90 %

1.00

1.00

 

 More than 90 %

3.32 (1.33–8.32)

3.71 (1.38–9.96)

0.009

Having respiratory timers

   

 No

1.00

1.00

 

 Yes

2.48 (0.93–7.69)

3.11 (1.08–9.00)

0.036

Monthly reporting

   

 No

1.00

1.00

 

 Yes

3.48 (1.62–9.52)

4.02 (1.62–10.10)

0.003

Supervision by Health workers in previous month

   

 No

1.00

1.00

 

 Yes

2.16 ( 0.71–5.88)

3.70 (1.22–11.24)

0.021

Discussion

Main findings

Overall, this survey showed low availability of drugs necessary to manage common childhood illnesses at community level in central Uganda. Less than 10 % of the CHWs had all the four iCCM drugs for treating malaria, pneumonia and diarrhea at the time of the survey. Availability of iCCM drugs among CHWs was mainly associated with timely submission of monthly drug reports, supervision by health workers, and appropriateness of prescriptions by CHWs, and having diagnostic tools especially respiratory timers.

Implications for community care

Our results imply that over 90 % of the CHWs could not effectively treat all the childhood conditions targeted under the iCCM policy on the day of the survey. This could negatively impact on the strategy of using CHWs to increase timely treatment of childhood conditions so as to reduce childhood morbidity. In the management of childhood illnesses, both dose strengths of ACTs (Coartem*) are important because children require different dosages on the basis of age and weight, and substitution of doses may compromise the quality of care. The low concurrent availability of the age specific packs of ACTs (Coartem*) may lead to ineffective treatment of malaria and this subsequently promotes irrational drug use by CHWs. Irrational use of medicines can result in incomplete recovery, development of resistance and adverse medicine reactions. For CHWs who provide curative treatment, the continuous supply of drugs is an essential part of their effectiveness and thus replenishment of drug supplies is necessary to maintain the provision curative services in communities [33]. Intermittent drug supplies often lead to great declines in care seeking for CHW services. When CHWs do not have drugs, community members are often aware of the stock-outs and seek care elsewhere [34, 35]. In addition, drug availability is an important component of CHW motivation [21] and indeed, lack of drugs has been shown to decrease their morale and the community’s perception of their effectiveness [29].

Lack of diagnostic equipment may promote presumptive treatment of pneumonia leading to over prescription of amoxicillin. Correct use of respiratory timers not only improves diagnosis and treatment of pneumonia but also leads to rational use of amoxicillin by CHWs [36, 37]. A large number of the children who die from pneumonia do so as a result of inappropriate treatment due to misdiagnosis of symptoms. First level health facility workers and CHWs diagnose pneumonia, primarily through counting respiratory rates of children with cough or difficulties in breathing. However, counting respiratory rates is often challenging and even for highly trained health workers, misclassifications are common. Pneumonia is often misdiagnosed as malaria by CHWs and caregivers in resource poor settings until it develops into a severe stage. Studies show that many developing countries still face significant challenges in the provision of effective health care, diagnosis and treatment of pneumonia [38, 39]. Diagnostic support aids for pneumonia are expected to contribute to improved, more accurate diagnosis and classification of pneumonia.

Community health workers are supposed to ensure that the right information regarding drug consumption and stock at hand is collected and made available to right people who make informed decisions on the resupply of drugs. Regular submission of drug reports enables program coordinators to quantify drug needs based on utilization. This may improve supply reliability and supply chain performance. In addition, it allows identification of drug supply chain bottlenecks that may affect programme implementation. When community level drug needs are not carefully considered and estimated in quantifications and procurements, CHWs are likely to suffer the most from shortages and expiries since they are at the end of the supply chain [17, 40].

Supervisors of CHWs are supposed to provide ongoing support, identify best practices, challenges, provide feedback in a constructive way, in addition to suggesting coping mechanisms. Additionally, they are supposed to review CHW registers and cross check the drug inventory to ensure that drugs are replenished regularly. Through such interactions with CHWs, supervisors are supposed to reinforce CHW’s competencies in case management, drug use and record keeping.

Implications for research

Although low medicine stock-outs for treating childhood conditions have been reported previously [16, 41], concurrent stock-outs of the age specific packs for ACTs and amoxicillin deserves serious attention as this precludes any form of treatment for malaria and pneumonia. When the age and weight specific drugs are absent, CHWs tend to improvise treatments by dividing larger pack sizes for lower age categories and combining smaller packs for older children [42, 43]. Although this still enables dispensing, it may compromise patient’s adherence and treatment outcomes [44]. Indeed several studies undertaken under the routine conditions of child care have reported high levels of non-adherence [45, 46]. Nevertheless, the possible negative effects of the stock-outs of the age-specific packs on patient’s adherence need further investigation.

Whereas regular submission of drug reports may increase drug availability as demonstrated in this study and other studies in Malawi, Ethiopia and Rwanda [47], the quality of such reports in terms of completeness, accuracy and timeliness should be examined. These attributes of data quality affect the usefulness of such reports for decision making regarding the supply chain for iCCM drugs. One of the challenges that may lead to delays in reporting could be lack of transport to deliver reports to health facilities and communication breakdowns between CHWs and their supervisors. As such, innovative ways to improve communication between CHWs and the formal health system may enhance CHW’s performance. Although supervision is key to CHW’s performance [48], CHW supervision continues to be reported as one of the weakest links in community health programs [49, 50]. Thus it may be worthwhile to investigate key bottlenecks in supervising CHWs so that they are addressed.

Strengths and limitations

There are some limitations in the data that are worth noting. In this study, drug availability was determined by the presence of iCCM drugs with CHWs on the day of the survey. Day of visit results do not show if iCCM drugs have been in stock continuously, nor whether supply levels are too low or too high to avoid future stock-outs. Missing data or incomplete filling of patient care registers could have affected how the appropriateness of drug prescriptions was assessed. Since this was a cross sectional study, we cannot infer causality. We only we report factors associated with drug availability other than determinants of drug availability. However, this study provides useful information on the availability of iCCM drugs and the associated factors. Understanding and identifying solutions to address drug constraints for the community case management of childhood diseases may yield substantial improvements in programme’s effectiveness, scale up, and impact in reducing child mortality.

Conclusion

Medicine availability is a challenge for the iCCM program in central Uganda. Under the iCCM program, CHWs are required to submit monthly drugs reports indicating stock levels before receiving new drug stocks. Innovative ways of improving supervision, reporting, prescribing and availability of diagnostic tools may increase availability of iCCM medicines. Improving availability of iCCM drugs among CHWs is vital if iCCM is going to be successful at treating childhood illness, and ultimately, reducing child mortality.

Declarations

Acknowledgments

We acknowledge the support of the Ugandan Ministry of Health, African Field Epidemiology Network (AFENET), Makerere University School of Public Health, Wakiso District Health Authorities, Data collectors and individuals who participated in the survey. We are grateful to the African Program for Advanced Research and Epidemiological Training (APARET) for funding this survey.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Health Policy Planning and Management, Makerere University College of Health Sciences, School of Public Health
(2)
Robert Koch Institute

References

  1. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 2011;378(9797):1139–65.View ArticlePubMedGoogle Scholar
  2. Cohen RL, Alfonso YN, Adam T, Kuruvilla S, Schweitzer J, Bishai D. Country progress towards the Millennium Development Goals: adjusting for socioeconomic factors reveals greater progress and new challenges. Glob Health. 2014;10(1):67.View ArticleGoogle Scholar
  3. Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet. 2010;375(9730):1988–2008.View ArticlePubMedGoogle Scholar
  4. UBOS. Uganda Demographic Health Survey 2011 preliminary report. Calverton: UBOS and ICF Macro, Kampala; 2012.Google Scholar
  5. Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet (London, England). 2015;385(9966):430–40.View ArticleGoogle Scholar
  6. Wiens MO, Gan H, Barigye C, Zhou G, Kumbakumba E, Kabakyenga J, et al. A cohort study of morbidity, mortality and health seeking behavior following rural health center visits by children under 12 in southwestern Uganda. PLoS ONE. 2015;10(1):e0118055.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Tiono AB, Kaboré Y, Traoré A, Convelbo N, Pagnoni F, Sirima SB. Implementation of Home based management of malaria in children reduces the work load for peripheral health facilities in a rural district of Burkina Faso. Malar J. 2008;7:201.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Marsh DR, Gilroy KE, Van de Weerdt R, Wansi E, Qazi S. Community case management of pneumonia: at a tipping point? Bull World Health Organ. 2008;86(5):381–9.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Chinbuah MA, Kager PA, Abbey M, Gyapong M, Awini E, Nonvignon J, et al. Impact of community management of fever (using antimalarials with or without antibiotics) on childhood mortality: a cluster-randomized controlled trial in Ghana. Am J Trop Med Hyg. 2012;87(5 Suppl):11–20.View ArticlePubMedPubMed CentralGoogle Scholar
  10. de Sousa A, Tiedje KE, Recht J, Bjelic I, Hamer DH. Community case management of childhood illnesses: policy and implementation in Countdown to 2015 countries. Bull World Health Organ. 2012;90(3):183–90.View ArticlePubMedGoogle Scholar
  11. Dawson P, Pradhan Y, Houston R, Karki S, Poudel D, Hodgins S. From research to national expansion: 20 years’ experience of community-based management of childhood pneumonia in Nepal. Bull World Health Organ. 2008;86(5):339–43.View ArticlePubMedPubMed CentralGoogle Scholar
  12. Awor P, Miller J, Peterson S. Systematic literature review of integrated community case management and the private sector in Africa: Relevant experiences and potential next steps. J Glob Health. 2014;4(2):020414.Google Scholar
  13. Miller NP, Amouzou A, Tafesse M, Hazel E, Legesse H, Degefie T, et al. Integrated Community Case Management of Childhood Illness in Ethiopia: Implementation Strength and Quality of Care. Am J Trop Med Hyg. 2014;91(2):424-34.Google Scholar
  14. Lufesi N, Andrew M, Aursnes I. Deficient supplies of drugs for life threatening diseases in an African community. BMC Health Serv Res. 2007;7(1):86.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Robertson J, Forte G, Trapsida JM, Hill S. What essential medicines for children are on the shelf? Bull World Health Organ. 2009;87(3):231–7.View ArticlePubMedPubMed CentralGoogle Scholar
  16. Chandani Y, Noel M, Pomeroy A, Andersson S, Pahl MK, Williams T. Factors affecting availability of essential medicines among community health workers in Ethiopia, Malawi, and Rwanda: solving the last mile puzzle. AmJTrop Med Hyg. 2012;87(5 Suppl):120–6.View ArticleGoogle Scholar
  17. Oliver K, Young M, Oliphant N, Diaz T, Kim J. Review of systematic challenges to the scale-up of integrated community case management: Emerging lessons & recommendations from the catalytic initiative (CI/IHSS). New York: United Nations Children’s Fund (UNICEF); 2012.Google Scholar
  18. Prasad B, Muraleedharan V. Community Health Workers: a review of concepts, practice and policy concerns, A review as part of ongoing research of International Consortium for Research on Equitable Health Systems (CREHS). 2007.Google Scholar
  19. Uzochukwu BS, Onwujekwe OE, Akpala CO. Effect of the Bamako-Initiative drug revolving fund on availability and rational use of essential drugs in primary health care facilities in south-east Nigeria. Health Policy Plan. 2002;17(4):378–83.View ArticlePubMedGoogle Scholar
  20. Zurovac D, Tibenderana J, Nankabirwa J, Ssekitooleko J, Njogu J, Rwakimari J, et al. Malaria case-management under artemether-lumefantrine treatment policy in Uganda. Malar J. 2008;7(1):1–10.View ArticleGoogle Scholar
  21. Banek K, Nankabirwa J, Maiteki-Sebuguzi C, DiLiberto D, Taaka L, Chandler CI, et al: Community case management of malaria: exploring support, capacity and motivation of community medicine distributors in Uganda. Health Policy Plan. 2015;30(4):451-61.Google Scholar
  22. Strachan C, Wharton–Smith A, Sinyangwe C, Mubiru D, Ssekitooleko J, Meier J, et al. Integrated community case management of malaria, pneumonia and diarrhoea across three african countries: a qualitative study exploring lessons learnt and implications for further scale up. J Glob Health. 2014;4(2):020404.Google Scholar
  23. Abbey M, Bartholomew LK, Nonvignon J, Chinbuah MA, Pappoe M, Gyapong M, et al. Factors related to retention of community health workers in a trial on community-based management of fever in children under 5 years in the Dangme West District of Ghana. Intl Health. 2014;6(2):99-105.Google Scholar
  24. Fang Y, Wagner AK, Yang S, Jiang M, Zhang F, Ross-Degnan D. Access to affordable medicines after health reform: evidence from two cross-sectional surveys in Shaanxi Province, western China. Lancet Glob Health. 2013;1(4):e227–37.View ArticlePubMedGoogle Scholar
  25. Wang X, Fang Y, Yang S, Jiang M, Yan K, Wu L, et al. Access to paediatric essential medicines: a survey of prices, availability, affordability and price components in Shaanxi Province. China PloS one. 2014;9(3):e90365.View ArticlePubMedGoogle Scholar
  26. Bazargani YT, Ewen M, de Boer A, Leufkens HG, Mantel-Teeuwisse AK. Essential Medicines Are More Available than Other Medicines around the Globe. PLoS ONE. 2014;9(2):e87576.View ArticlePubMedPubMed CentralGoogle Scholar
  27. Jitta J, Reynolds Whyte S, Nshakira N. The availability of drugs: what does it mean in Ugandan primary care. Health Policy. 2003;65(2):167–79.View ArticlePubMedGoogle Scholar
  28. Kish L. Survey Sampling. New York: John Wiley and Son ,inc; 1965.Google Scholar
  29. Stekelenburg J, Kyanamina SS, Wolffers I. Poor performance of community health workers in Kalabo District. Zambia Health Policy. 2003;65(2):109–18.View ArticlePubMedGoogle Scholar
  30. Alam K, Tasneem S, Oliveras E. Performance of Female Volunteer Community Health Workers in Dhaka’s Urban Slums A Case–control Study. 2011.Google Scholar
  31. Bhattacharyya K, Winch P. Community health worker incentives and disincentives. Virginia: USAID- BASICS II 2001.Google Scholar
  32. Ande O, Oladepo O, Brieger WR. Comparison of knowledge on diarrheal disease management between two types of community‐based distributors in Oyo State. Nigeria Health Educ Res. 2004;19(1):110.View ArticlePubMedGoogle Scholar
  33. Bagonza J, Kibira S, Rutebemberwa E. Performance of community health workers managing malaria, pneumonia and diarrhoea under the community case management programme in central Uganda: a cross sectional study. Malar J. 2014;13(1):367.View ArticlePubMedPubMed CentralGoogle Scholar
  34. Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res. 2008;8:247.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Rutebemberwa E, Nsabagasani X, Pariyo G, Tomson G, Peterson S, Kallander K. Use of drugs, perceived drug efficacy and preferred providers for febrile children: implications for home management of fever. Malar J. 2009;8(1):131.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Mukanga D, Babirye R, Peterson S, Pariyo GW, Ojiambo G, Tibenderana JK, et al. Can lay community health workers be trained to use diagnostics to distinguish and treat malaria and pneumonia in children? Lessons from rural Uganda. Trop Med Int Health. 2011;16(10):1234–42.View ArticlePubMedGoogle Scholar
  37. Hamer DH, Brooks ET, Semrau K, Pilingana P, MacLeod WB, Siazeele K, et al. Quality and safety of integrated community case management of malaria using rapid diagnostic tests and pneumonia by community health workers. Pathog Glob Health. 2012;106(1):32–9.View ArticlePubMedPubMed CentralGoogle Scholar
  38. Kallander K, Tomson G, Nsabagasani X, Sabiiti JN, Pariyo G, Peterson S. Can community health workers and caretakers recognise pneumonia in children? Experiences from Western Uganda. Trans R Soc Trop Med Hyg. 2006;100(10):956–63.View ArticlePubMedGoogle Scholar
  39. Graham SM, English M, Hazir T, Enarson P, Duke T. Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings. Bull World Health Organ. 2008;86(5):349–55.View ArticlePubMedPubMed CentralGoogle Scholar
  40. Chandani Y, Andersson S, Heaton A, Noel M, Shieshia M, Mwirotsi A, et al. Making products available among community health workers: Evidence for improving community health supply chains from Ethiopia, Malawi, and Rwanda. J Glob Health. 2014;4(2):020405.View ArticlePubMedPubMed CentralGoogle Scholar
  41. Sudoi RK, Githinji S, Nyandigisi A, Muturi A, Snow RW, Zurovac D. The magnitude and trend of artemether-lumefantrine stock-outs at public health facilities in Kenya. Malar J. 2012;11:37.View ArticlePubMedPubMed CentralGoogle Scholar
  42. Fogg C, Bajunirwe F, Piola P, Biraro S, Checchi F, Kiguli J, et al. Adherence to a six-dose regimen of artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Uganda. AmJTrop Med Hyg. 2004;71(5):525–30.Google Scholar
  43. Bell DJ, Wootton D, Mukaka M, Montgomery J, Kayange N, Chimpeni P, et al. Measurement of adherence, drug concentrations and the effectiveness of artemether-lumefantrine, chlorproguanil-dapsone or sulphadoxine-pyrimethamine in the treatment of uncomplicated malaria in Malawi. Malar J. 2009;8:204.View ArticlePubMedPubMed CentralGoogle Scholar
  44. Piola P, Fogg C, Bajunirwe F, Biraro S, Grandesso F, Ruzagira E, et al. Supervised versus unsupervised intake of six-dose artemether-lumefantrine for treatment of acute, uncomplicated Plasmodium falciparum malaria in Mbarara, Uganda: a randomised trial. Lancet. 2005;365(9469):1467–73.View ArticlePubMedGoogle Scholar
  45. Gerstl S, Dunkley S, Mukhtar A, Baker S, Maikere J. Successful introduction of artesunate combination therapy is not enough to fight malaria: results from an adherence study in Sierra Leone. Trans R Soc Trop Med Hyg. 2010;104(5):328–35.View ArticlePubMedGoogle Scholar
  46. Lawford H, Zurovac D, O’Reilly L, Hoibak S, Cowley A, Munga S, et al. Adherence to prescribed artemisinin-based combination therapy in Garissa and Bunyala districts. Kenya Malar J. 2011;10:281.View ArticlePubMedGoogle Scholar
  47. Chandani Y, Andersson S, Heaton A, Noel M, Shieshia M, Mwirotsi A, et al. Making products available among community health workers: Evidence for improving community health supply chains from Ethiopia, Malawi, and Rwanda. J Glob Health. 2014;4(2):120–6.Google Scholar
  48. Stekelenburg J, Kyanamina SS, Wolffers I. Poor performance of community health workers in Kalabo District, Zambia. Health Policy. 2003;65(2):109–18.View ArticlePubMedGoogle Scholar
  49. Perez F, Ba H, Dastagire SG, Altmann M. The role of community health workers in improving child health programmes in Mali. BMC Int Health Hum Rights. 2009;9(1):28.View ArticlePubMedPubMed CentralGoogle Scholar
  50. Bosch‐Capblanch X, Garner P. Primary health care supervision in developing countries. Tropical Med Int Health. 2008;13(3):369–83.View ArticleGoogle Scholar

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© Bagonza et al. 2015

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