Private sector drug retailers and malaria control in Kenya

In many areas where malaria is endemic, people will buy drugs first from a local seller and treat themselves at home. Almost all home-based treatments are undertaken on a 'trial and error' basis.

Many different brand names of anti-malarial and anti-pyretic (fever reducing) drugs are available as over-the-counter (OTC) medications. Customers buy these medications with little understanding of which to use, or how to use them. Since many malaria deaths happen in the first 48 hours, it will be difficult to change the current high burden of severe disease and deaths due to malaria unless early home-care practices are improved.

Between 1998 and 2002, the Kenya Medical Research Institute working with the Ministry of Health (MOH), developed, ran and evaluated a programme to train private drug retailers. The programme targeted a rural area in Kilifi district with a population of 70000, training 473 shopkeepers from 282 general retail outlets in 2-4 day workshops. District and community-based MOH personnel ran training and monitoring activities for retailers, alongside a wide-scale public information programme. In 1999, the recommended drug for malaria was changed from chloroquine to sulphadoxine-pyrimethamine (SP), and the training was adapted accordingly.

Comparisons were made using household survey data on fever treatment for children under five years before and after the programme was introduced. Drug retailers, communities, health workers and other MOH personnel responded positively towards the programme. The important changes between 1998 and 2001 were:

• More children with fever were given anti-malarial drugs as a first step, increasing from 29 per cent to 47 per cent.
• More children were given the right dose, increasing from seven per cent to 32 per cent after one year and to 65 per cent in 2001.
• More mothers chose paracetamol as a single anti-pyretic drug (nine to 58 per cent).
• Fewer mothers gave several different aspirin-containing anti-pyretic drugs at the same time (31 to three per cent), therefore reducing the danger of an overdose or poisoning.

Challenges include:

• 20 per cent of outlets trained in the first year closed, or all trained retailers left the outlet. To respond to this problem a selection process based on community perceptions of long-term stability and reliability, geographic coverage and availability of stock, and improved sustainability was introduced.
• Health benefits can only be achieved if OTC drugs are of adequate quality. Drug quality needs to be monitored, and results communicated to the public.
• The behaviour changes targeted are not simple. Adequate teaching skills and effective monitoring are important, and are achievable within a MOH district health team.

Training private drug retailers can improve early treatment of malaria at home. As well as giving important health benefits, improvements could support over-stretched public health resources, reduce household economic costs and potentially play a role in reducing the rate of development of drug resistance for OTC anti-malarial medications.

Vicki Marsh and Wilfred Mutemi
Kenya Medical Research Institute
PO Box 230
Kilifi
Kenya

vmarsh@kilifi.mimcom.net

See also
'Changing home treatment of childhood fevers by training shop keepers in rural Kenya', Tropical Medicine and International Health 4 (5): 383-38, by V.M. Marsh, W.M. Mutemi, J. Muturi, A. Haaland, W. Watkins, G. Otieno, and K. Marsh, 1999

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