Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Patent medicines vendors a resource for tuberculosis case detection. Presenting Author: Obi, I E, Co Author: Onwasigwe C. N. Department of Community Medicine, University of Nigeria Teaching Hospital (UNTH), P. M. B , Enugu, Nigeria.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 BACKGROUND  The Patent and Proprietary Medicine Vendor (PPMV) is a person without formal pharmacy training who sells orthodox pharmaceutical products on a retail basis for profit.  This does not make the PPMV a health care provider, but the PPMV enterprise is the primary source of orthodox drugs for both urban and rural populations in developing nations.  In a state in Nigeria there were 600 doctors, 3000 nurses, 200 pharmacists and 4000 PPMVs.  70 to 200 people visit patent medicine stores per day and 25% of customers see the PPMV as a source of advice and information about their illness.  A significant proportion of patients with tuberculosis would have first consulted these PPMVs.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Background  The effective medical strategy for tuberculosis control, remains case detection and Directly Observed Therapy Short course (DOTS)  A person with a cough of three weeks duration is a pulmonary tuberculosis case suspect.  The median delay between onset of cough and diagnosis of tuberculosis is 8 weeks.  Tuberculosis case detection even in areas served by DOTS has been constant at about 52 percent.  Providing basic information about the earliest symptoms of tuberculosis and directing suspects for diagnosis can increase coverage.  There is a need to educate communities and non-orthodox care providers of the importance of early and accurate diagnosis and treatment of tuberculosis.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Background  Failure to involve all care providers used by tuberculosis suspects and patients hamper case detection, delay proper diagnosis, cause inappropriate and incomplete treatment, increase drug resistance and place a increase financial burden on patients.  There is the challenge of involving private health-care providers in National Tuberculosis Programs  In Bangladesh, ‘village doctors’ a mixed informal health provider group trained to refer customers to tuberculosis diagnostic services and to institute DOTS in their community, made an input of 10% of all cases referred to the tuberculosis diagnosis and treatment service.  Training can lead to PPMVs contributing to tuberculosis control

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Background General Objective:  To determine the effect of training of PPMVs on referral to a tuberculosis diagnostic and treatment service. Specific Objectives: 1. To determine the referral input from PPMVs on new clients presenting with cough at tuberculosis diagnosis and treatment service centers. 2. To determine the effect of training on the knowledge of PPMVs of a suspect case of pulmonary tuberculosis. 3. To observe the post intervention referral input from PPMVs on new clients presenting with cough at a tuberculosis diagnosis and treatment service.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Methodology  A training intervention on PPMVs in Enugu North local government area (LGA), Nigeria, with PPMVs in Nkanu West another LGA, same state as control.  Six month study period from June to December  Data on the source of referral from 78 new clients with cough were collected from tuberculosis diagnosis and treatment services, in the study and control areas over a two month period.  Knowledge on recognition of a suspect case of pulmonary tuberculosis was assessed in 159 PPMVs in the study and control areas.  The study group was trained (by lecture and role play) on the recognition and referral of a suspect case of pulmonary tuberculosis and issued pre- written referral notes to facilitate referral to the tuberculosis diagnostic and treatment centre in the study area.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Methods  The control group received a health talk on recognition of a case of diarrhea, benefit and method of early rehydration with oral rehydration salt or salt sugar solution.  Information on the source of referral from 111 new clients with cough were collected from the same tuberculosis diagnosis and treatment service centers, over the next three month period.  knowledge of a suspect case of pulmonary tuberculosis was re- assessed among the PPMVs, after the three month period.  The referral input of new cases from different sources in both areas and any change in the knowledge of a suspect case of pulmonary tuberculosis among the PPMV were analyzed using SPSS version 11.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Results

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Fig 2: Referral source (new patients) study area DOTS service

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Fig 3: Referral Source (new patients) control area DOTS service.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Fig 4: Pre Test Performance in study group PPMVs

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Fig 5 : Pre Test performance in control group PPMVs

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Fig 6: Sputum smear result in Patients referred by the PPMVs to DOTS service in study area

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Discussion  All the patent and proprietary medicines vendors in this study had basic primary education. (Fig 1) Studies have reported same.  As in this study (Fig 5), others have shown that this level of education does not confer on the PPMVs correct knowledge about the common illnesses experienced by their customers, hence they cannot be classified as being of the formal health sector but of the informal.  PPMVs do not refer patients to DOTS centres. (Fig 3)

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Discussion  PPMVs knowledge of a suspect case of pulmonary tuberculosis improved with training. (Fig 4) Studies abound showing that training of PPMVs, drug dispensers or paramedical prescribers have resulted in improvements in their knowledge of disease conditions and the correct actions towards alleviating the symptoms of their clientele.  The PPMV can be engaged to refer tuberculosis suspects identified by simple symptoms to formal health services for proper diagnosis and treatment. (Fig 2)  As seen in this study also (Fig 5), training PPMVs could yield quality contribution to tuberculosis control.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Conclusion  A public private mix linked by referral between PPMVs and national tuberculosis programs, could be possible.

Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 Thank you