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PURPOSE: Improving access to malaria treatment in rural remote areas remains a major challenge facing innovative strategies, such as Accredited Drug Dispensing Outlets (ADDOs) and Community Health Workers (CHWs) programs in Tanzania. This study tested the effectiveness of a financial benefit approach to motivate CHWs to improve prompt access to malaria treatment. PATIENTS AND METHODS: We applied a quasi-experimental study design in rural-remote areas in Kilosa district, Tanzania. Febrile children in selected intervention areas were provided access to malaria diagnostic and treatment at a minimal fee to CHWs and compared with non-intervention areas. We measured impact using difference in differences (DID) analysis. RESULTS: At baseline, 870 children <5 years of age were recruited and 1,127 in post-intervention. The DID in prompt access to malaria diagnostics and treatment was 28.0% in favor of intervention. A net pre and post decrease (DID=24.1%) in seeking care from public facilities was observed, signifying decrease in workload. Incidentally, knowledge on malaria treatment increased in intervention area (DID 11%-21%). CONCLUSION: Using the financial benefit approach, CHWs were able to significantly improve prompt access to malaria diagnostics and treatment in rural remote areas. Scaling up of the strategy might speed up the pace toward achieving national target of accurate diagnosis and appropriate treatment by 80% in 2020.

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BACKGROUND: Studies indicate that antibiotics are sold against regulation and without prescription in private drugstores in rural Tanzania. The objective of the study was to explore and describe antibiotics sale and dispensing practices and link it to drugseller knowledge and perceptions of antibiotics and antibiotic resistance. METHODS: Exit customers of private drugstores in eight districts were interviewed about the drugstore encounter and drugs bought. Drugsellers filled in a questionnaire with closed- and open-ended questions about antibiotics and resistance. Data were analyzed using mixed quantitative and qualitative methods. RESULTS: Of 350 interviewed exit customers, 24% had bought antibiotics. Thirty percent had seen a health worker before coming and almost all of these had a prescription. Antibiotics were dispensed mainly for cough, stomachache, genital complaints and diarrhea but not for malaria or headache. Dispensed drugs were assessed as relevant for the symptoms or disease presented in 83% of all cases and 51% for antibiotics specifically. Non-prescribed drugs were assessed as more relevant than the prescribed. The knowledge level of the drugseller was ranked as high or very high by 75% of the respondents. Seventy-five drugsellers from three districts participated. Seventy-nine percent stated that diseases caused by bacteria can be treated with antibiotics but 24% of these also said that antibiotics can be used for treating viral disease. Most (85%) said that STI can be treated with antibiotics while 1% said the same about headache, 4% general weakness and 3% 'all diseases'. Seventy-two percent had heard of antibiotic resistance. When describing what an antibiotic is, the respondents used six different kinds of keywords. Descriptions of what antibiotic resistance is and how it occurs were quite rational from a biomedical point of view with some exceptions. They gave rise to five categories and one theme: Perceiving antibiotic resistance based on practical experience. CONCLUSIONS: The drugsellers have considerable "practical knowledge" of antibiotics and a perception of antibiotic resistance based on practical experience. In the process of upgrading private drugstores and formalizing the sale of antibiotics from these outlets in resource-constrained settings, their "practical knowledge" as well as their perceptions must be taken into account in order to attain rational dispensing practices.

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OBJECTIVE: To explore views on pharmacy practice in Africa as perceived by pharmacists from several African countries. METHOD AND SETTING: Data was collected using pre-tested semi-structured interview guides. A total of 15 pharmacists from nine African countries were interviewed. The analysis used a phenomenographic approach where categorisation with regard to differences in expressed perceptions of the pharmacist's role was made. MAIN OUTCOME: Perceptions on pharmacy practice in Africa as expressed by pharmacists from nine African countries. RESULTS: Four qualitatively different ways of perceiving the pharmacist's role were identified and sorted into subcategories under the two main categories A and B as follows A. Pharmaceutical information provider with the sub-categories: A1. The satisfied dispenser, and A2. The dissatisfied dispenser; and B. Health care provider, with the sub-categories: B1. The health care team member, and B2. The lifesaver. In category A, the pharmacist is described foremost as a provider of pharmaceuticals and information with a distinction being made with regard to whether the interviewees expressed dissatisfaction with their situation or not. In category B, the pharmacist was described as a provider of health care and two different approaches to this were found. CONCLUSION: The study describes different ways of perceiving the role of the pharmacist in nine African countries. It offers an insight into the situation of the African pharmacist that can be used as a starting point for further discussion and research on the development of pharmacy practice and for the creation and implementation of national Good Pharmacy Practice (GPP) guidelines.

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Following the difficult economic situation various countries introduced health sector reforms, including user charges to finance the system. The assessment of user costs for maternity services in Tanzania was part of a larger study, which covered inputs, outputs and efficiency of services. The study was carried out from October 1997 to January 1998 in Mtwara urban and rural district in South Tanzania. One hundred and seven women attending a quarter of government health facilities were randomly selected and interviewed. Twenty one key informants were also interviewed and service procedures observed. Users of maternity services pay mainly for admission, drugs, other supplies and travel costs. Travel costs represent about half of these financial costs. The average total costs vary between US$11.60 for antenatal consultation and US$135.40 for caesarean section at the hospital. Unofficial payments are not included in the calculation. The amounts vary and payment is irregular. We therefore conclude that time costs are constantly higher than financial costs. High direct payments and the fear of unofficial costs are acute barriers to the use of maternity services. User costs can substantially be reduced by the re-organisation of service delivery especially at antenatal consultation.

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