PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER) HEALTH
Cycle 1 

Project Overview

Uganda’s under-five mortality is high, currently estimated at 90/1000 live births. Poor referral of sick children that seek care from the private sector is one of the contributory factors. The intervention conducted under this project aimed to improve timely referral and uptake of referral advice of children that seek care from private facilities. The private sector in this project included private clinics and registered drug shops. The project was implemented in Mukono District, central Uganda. This region was selected because a recent concluded trial in the district showed that drug shop vendors (DSVs) adhere to diagnostic test results, treat appropriately and refer sick children, although uptake of referral is poor. The main reasons attributed to the observed poor referral were negative attitude towards referral forms from drugs shops by the health workers at referral facilities, perceptions of poor quality of care at referral facilities and costs involved (Hutchinson. 2012).

This project was a follow up to address these factors with the aim to improve uptake of referral. The primary objective of the project was to assess the effect of strengthening the referral system on timely uptake of referral of sick children who seek care in the private sector. The secondary objectives were (1) to assess appropriate case management for malaria, pneumonia, and diarrhea; (2) to explore factors which influence the referral or non-referral of sick children from the private sector; and (3) to assess the cost effectiveness of uptake of referral of sick children who seek care in the private sector. A cluster randomized design was applied to test the intervention. In the intervention arm, village health teams sensitized communities on the importance of referral. Private outlets in both arms were trained to diagnose, treat, and refer children. The intervention had three components: (1) training of village health trainers (VHTs) to do community sensitization and initiate community discussions aimed at identifying community support mechanisms for financial hardship (to be community led and managed); (2) training and supervision of providers in the private sector to diagnose, treat, and refer sick children, and (3) regular meetings between the public and private providers (convened by the district health team) to discuss the referral system. The data generated from this study contributed to a better understanding of factors of importance for strengthening the referral system, including optimal training required, supervision activities, community participation, and the costs involved. The lessons learned are likely to inform programming at a national and district level to improve referral of children from the private sector.

Final Summary of Project Activities

A sample of study clusters implemented the intervention with ten randomly allocated to the intervention and ten to the control arm. The primary outcome was the proportion of sick children referred from the private sector were seen at higher level facilities:

• Intervention Arm: Community awareness on referral and training private providers using RDTs/ICCM to treat and refer sick children; supervision and regular meetings between the private and public sector.
• Control Arm: No community awareness on referral (trained private providers using RDTs/ICCM to treat and refer sick children).
  The primary outcomes were: An increase in appropriate case management for malaria, pneumonia, and diarrhea among children in the private sector; and improved cost-effectiveness of timely and uptake of referral of sick children. The Secondary outcomes were: The increase in the proportion of sick children seeking care and receiving prompt treatment at private outlets within 24 hours of onset of symptoms; the decrease in time between consultations at private outlets and uptake of referral at health facilities (referral facilities); and understanding the factors which influence the referral or non-referral of sick children from the private sector.