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Cycle 1

Principal Investigator:  Anthony Mbonye, Makerere University School of Public Health
NIH-Supported Collaborator: Philip LaRussa, Columbia University
Title of NIH Award: Enhancing Training, Research Capacity and Expertise in HIV Care (ENTREE)

1-54 Training

 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 proposed intervention aims to improve timely referral and uptake of referral advice of children that seek care from private facilities. The private sector in this project will include private clinics and registered drug shops. The project will be 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 is a follow up to address these factors with the aim to improve uptake of referral.

The primary objective is 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 are: 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 will be applied to test the intervention in Mukono District, Central Uganda. In the intervention arm, village health teams will sensitize communities on the importance of referral. Private outlets in both arms will be trained to diagnose, treat, and refer children. The proposed intervention will have three components: i) village health trainers (VHTs) will be trained to do community sensitization and initiate community discussions aimed at identifying community support mechanisms for financial hardship (to be community led and managed) ii) training and supervision of providers in the private sector to diagnose, treat and refer sick children, iii) regular meetings between the public and private providers (convened by the district health team) to discuss the referral system.

Public Health Impact:
The data generated from this study will contribute to an 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.

NIH Collaborator:
Dr. LaRussa has significant experience conducting research in low-income countries and in the United States. He is the the Principal Investigator of the NIH-funded International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) Clinical Research Center, and will provide oversight on project development, implementation and evaluation.

Summary of Recent Activities: 

During the third quarter of 2015, the research team trained village health teams (VHTs) in sensitizing communities about the importance of referral and saving money for referral. The objectives of the sensitization meetings were to: 1) introduce the intervention being implemented by the intervention drug shops and private clinics in their respective areas; 2) explain the new roles of the intervention drug shops, private clinics, and the VHTs in supporting the study; and 3) request VHTs to mobilize communities to take up the ICCM packages, educate on danger signs, follow-up sick children, and encourage caretakers to comply with referral advice by the providers. Support supervision was continued during this period and its objectives were to ascertain the preparedness of the private providers to implement the intervention, assess the performance and progress of the health providers in implementing the intervention, and address any gaps in services. Since mid-September, providers have been left on their own without supervision. Data from the initial three months has been entered and the research team has developed six draft manuscripts from the baseline data, with three in advanced stages. The target is to have these manuscripts finalized and submitted by December, 2015. Future plans include the continuation of data collection of patient consultations and referrals, finalizing manuscripts for submission to relevant journals, and convening meeting between the public and private sectors to discuss how to address referral.

Health Cycle 1 Recipients