Impact of pharmacy worker training and deployment on access to essential medicines for children under five in Malawi: a cluster quasi-experimental evaluation

Abstract

BackgroundPoor access to essential medicines is common in many low- and middle-income countries, partly due to an insufficient and inadequately trained workforce to manage the medicines supply chain. We conducted a prospective impact evaluation of the training and deployment of pharmacy assistants (PAs) to rural health centers in Malawi.MethodsA quasi-experimental design was used to compare access to medicines in two districts where newly trained PAs were deployed to health centers (intervention) and two districts with no trained PAs at health centers (comparison). A baseline household survey and two annual post-intervention household surveys were conducted. We studied children under five years with a history of fever, cough and difficulty in breathing, and diarrhea in the previous two weeks. We collected data on access to antimalarials, antibiotics and oral rehydration salts (ORS) during the childrens’ symptomatic periods. We used difference-in-differences regression models to estimate the impact of PA training and deployment on access to medicines.ResultsWe included 3974 children across the three rounds of annual surveys: 1840 (46%) in the districts with PAs deployed at health centers and 2096 (53%) in districts with no PAs deployed at health centers. Approximately 80% of children had a fever, nearly 30% had a cough, and 43% had diarrhea in the previous two weeks. In the first year of the program, the presence of a PA led to a significant 74% increase in the odds of access to any antimalarial, and a significant 49% increase in the odds of access to artemisinin combination therapies. This effect was restricted to the first year post-intervention. There was no effect of presence of a PA on access to antibiotics or ORS.ConclusionThe training and deployment of pharmacy assistants to rural health centers in Malawi increased access to antimalarial medications over the first year, but the effect was attenuated over the second year. Pharmacy assistants training and deployment demonstrated no impact on access to antibiotics for pneumonia or oral rehydration salts for diarrhea.

Improving antibiotic use through behaviour change: a systematic review of interventions evaluated in low- and middle-income countries

“…The interventions targeting antibiotic prescribing included: antibiotic prescription forms; face-to-face educational seminars or distribution of educational material; training workshops; and implementation of guidelines or antibiotic stewardship programmes either targeting at physicians, other prescribers such as nurses, medical officers or community health workers or pharmacy personnel. The other main outcome indicators were antibiotic use ( Ngoh and Shepherd, 1997 ; Santa-Ana-Tellez et al , 2013 ) and antibiotic dispensing ( Tumwikirize et al , 2004 ; Chalker et al , 2005 ; Babigumira et al , 2017 ). For studies focusing on antibiotic use, the target groups included patients, the community and pharmacy staff, and the behaviour change interventions implemented included education and restriction.…”

“…Further, few evaluations measured the impact of behaviour change interventions over >12 months. While the majority of the studies had a short follow-up period (for example, Podiphak, 1993; Meyer 2001; Liang, 2014 ; Yang, 2014; Babigumira, 2017 ; Hoa, 2017; Wei, 2017; Zhang, 2018 ), some did consider the importance of longer-term benefit assessment by having an evaluation period of 18 months after the intervention (Gutierrez et al , 1994; Pérez-Cuevas et al , 1996). Some also recognized the importance of the benefits of program continuation beyond the project period for the yield of long-term benefit (Bexell, 1996; Chandy, 2014).…”

The availability, prices and affordability of essential medicines in Malawi: A cross-sectional study

“…It is certainly not a coincidence that these four most affordable antibiotics are also the ones which are most available in all sectors (except for the very poor availability of the syrups in the public sector). As mentioned above, ciprofloxacin was much more widely available than warranted by the provisions of the Malawi Essential Medicines List [40, 41].…”

The effect of mobile phone text message reminders on health workers’ adherence to case management guidelines for malaria and other diseases in Malawi: lessons from qualitative data from a cluster-randomized trial

“…All HWs in the intervention arm providing outpatient care, as well as HWs dispensing drugs and, therefore, tasked with patient counselling about medication administration and adherence, were targeted to receive SMS reminders twice a day for 6 months. In Malawi, drug dispensers are lower-level cadre HWs, in many cases with minimal training; in some cases, patient attendants, ground labourers and security guards with on-the-job training play the role of drug dispensers [18].…”