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Shopping for health care

Nurses and researchers tell us how micro-franchising works

Nurses running Child and Family Welfare Shop outlets in villages and a slum, the Executive Director of the enterprise and TDR researchers take the real measure of micro-franchised healthcare. Is it sustainable? Is it the solution for health care in Africa, or just a welcome small addition?

According to the WHO’s World Health Report 2006, Africa carries 24% of the global burden of disease but has only 3% of health workers and less than 1% of world health expenditure. ‘The exodus of skilled professionals’ – who leave for better prospects in richer countries – “in the midst of so much unmet health need places Africa at the epicentre of the global health workforce crisis’ says the report.

It estimates that in sub-Saharan countries the health workforce needs to increase by ‘almost 140%’ to meet basic needs. This amounts to a shortfall of over 800 000 doctors, nurses and midwives.

So with the public sector failing so miserably, can the private sector step in? One’s first reaction would be ‘of course not!’ – the problem is amongst the poorest people on Earth, and poor consumers are not going to be able to pay; where the private sector health does have a hold in Africa, it is in offering expensive hospital treatments to rich clients in the cities.

But – the situation is not quite so obvious. When last year RealHealthNews was visiting a small slum in Nairobi, to meet local women working as voluntary (and unpaid) health workers, two things struck us: first, although poor, all the women wanted was recognition, like a badge or some symbol of their role, so they could gain respect in the community; and second, the slum was full of economic life. The tiniest things were being traded for pennies – like the little girl of seven years old, with a stall outside her hut, at which she sat with a single cabbage and a knife, cutting a slice for the occasional customer.

Another factor in the local ‘economy’ – i.e. the factors driving exchange of labour or goods amongst the poorest – is the tendency to mistrust free gifts; greater trust and value is placed on something for which people pay, however small the payment.

Even health – or the hope of it - is sold, with chemists selling drugs, of whatever quality and in whatever amount the patient can afford, traditional healers and others making a living on the ‘health market’.

So what does this have to do with providing real health? It means that if the price or the return (like respect and the badge) are right, it is possible for real accredited health work to be paid for, even in a Nairobi slum.

So this year RealHealthNews returned, to a different slum – Nairobi’s biggest, Kibera – and to two villages in rural areas on the slopes of Mt Kenya, to see on the ground how a private-enterprise project for health care for the poorest, Child and Family Welfare Shops, a project of The HealthSTORE Foundation - founded by New Zealander Scott Hillstrom - was working.

CFW shopkeepers have no salary, and must make a living from the health services, advice and products they sell. On the face of it this could lead to malpractice and overselling – as happens in some private pharmacies - but they are trained, and are carefully monitored from the centre – and by government – to ensure their work and products are high quality. The best survive by establishing a reputation for good, trustworthy and reliable service in the community.

They must buy their stock at subsidized prices from the centre in Nairobi. We interviewed CFWshops Kenya country director, Liza Kimbo, on the principles in our last issue (RealHealthNews 7, pp 6-9). That was fascinating, but here we go one step further. We talk to real CFW shopkeepers in the slums and villages of Kenya, and to CFWshops’ Executive Director, businesswoman Esther Njuguna, in Nairobi.

And we talk to Athuman Chiguso, who is doing a research project with Franco Pagnoni of the UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases (TDR), to investigate CFWshops’ impact on the supply and use of antimalarials in the community.

Each shopkeeper we met – all women – has a different story and motivation.

Regina Nyaga, in Kiorugari Village in Kirinyaga District, is a young trained nurse. She decided not to follow many of her colleagues abroad but to stay near her family and help her people. She aims to make her shop pay enough to equal the salary she’d get as a nurse at a government clinic, as well as pay her community health worker, Daniel Kamanga.

>RHN: So how do you like working in this village?

RN: We enjoy helping the people here. You are giving them the drugs that they really appreciate, and they come and you show you that they have got well. And you feel good also, treating them, because they have confidence in you.

>RHN: So what sort of conditions can you treat here? What kind of patients do you get?

RN: This is a rice growing area, and there is a lot of stagnant water for the rice fields, so many people here come with malaria. And we treat them. Others come with abdominal pains, and when they are tested most of them have got worms, and we treat them. The main conditions that we see are upper respiratory tract infections, malaria and abdominal pains.

>RHN: What ages of people do you get coming with malaria? Are they mostly children or all ages?

RN: Malaria? All ages, children and adults. Especially at this time when we are giving random diagnostic tests. Many of them come and when we test some of them are negative and others positive.

We treat the positive ones with artemether-lumefantrine [Coartem], which is doing very well. They take it for three days and then they can come for review if they don’t feel any improvement. But we don’t see them coming back, they get well in three days.

RN: Before we came they were really suffering here, because they had no nets for prevention, and in the rice fields are very near their homes. So they were really suffering. They were just buying drugs from the chemist. So they were exposed to more drugs than they should have had… most of them really became serious.

>RHN: What sort of drugs can you get at the chemist?

RN: From the chemist you can get SP [sulfadoxine-pyrimethamine] and even cotecxin-amodiaquine [a Chinese artemisinin combination therapy]. They get all the drugs from the chemist. They just say which complaints they have and the chemist sells to them.

>RHN: Why wasn’t that a solution to the problem?

RN: Even if they are treated it could be that patient did not have malaria alone, [or at all], and then when she gets home and there is no prevention and the malaria attacks again. So they keep on taking the drugs and repeating the dose – the malaria parasites regrowing in their bodies, which was a big problem. And the more you get the attacks the more complications you have.

>RHN: And are you able to earn enough to make a living for yourself here?

RN: Yes. Actually I do. All my salary comes from here.

>RHN: Are you happy with what you are earning?

RN: I’m happy but I’m hoping for more.

>RHN: So you want it to be even more successful.

RN: Yes. That’s why I’m working hard, to earn more.

>RHN: Some people, some nurses particularly, like to go to a city or even go abroad. Why do you stay here?

RN: I prefer it here because it’s where my family is. I want to be with them. To care for them with the little that I get.

>RHN: You are not alone here – you have Daniel Kamanga here as your community health worker. You’re the expert, and he’s your helper.

RN: Yes. He was in the shop before. They started with the soaps and they could keep the drugs. But this time they have drugs that a nurse should handle, that’s why I am here. But he can do most of it.

>RHN: So what drugs can you handle now that he could not?

RN: Diazepam for people who come here convulsing [from malaria or epilepsy], the injectables, and antibiotics.

>RHN: You know that the World Health Organisation estimates that Africa needs nearly a million more health workers because there are very few who stay in the villages. So you’re a special person. Africa needs a million more people like you. Do you think this is a way of keeping people? If they get a good salary from working in the village and they get the benefit and the pleasure of their patients. Is this a way forward for Africa?

RN: I hope so. If only they are able to make their lives comfortable, because if you get a low salary then you are not able to meet your requirements, and you will not enjoy it. But if the places that you are working in are improved, and we get a good salary and we are able to help… Our training is to be able to help people and we are able to help them wherever we are, that’s our profession.

>RHN: For you what is a good salary? Would you like to earn as much as a teacher? Or more? How much would you like to earn?

RN: I think I would like to earn the same as the other nurses in the government clinics earn.

>RHN: Are you earning that much yet?

RN: Not yet. Not yet.

>RHN: When do you think you might be able achieve that? In a year?

RN: Every month I’m hoping to.

RN: What makes it grow is if the economy is better. Because our patients get their money from the rice. If it fails then they will not have money and the economy, the society goes down.

>RHN: What do you earn from mostly?

RN: The testing. We just charge them a few coins. We charge 20 shillings for the testing, and because we fill in forms and do other investigations, and check their blood pressure, in total we charge them 40 shillings: 20 for consultation and then 20 for the testing.

>RHN: And how much do people around here earn per day, typically?

RN: They earn 120, 150 shillings a day.

>RHN: So it’s one-third to a quarter of a day’s work. It’s affordable.

RN: It’s affordable if there is labour. When there is work.

>RHN: How many patients do you get per day?

RN: 18 to 20 a day.

>RHN: And you as a nurse when you see somebody seriously sick you can send him or her to the district hospital.

RN: Yes, I refer them. That’s where they go.

>RHN: What’s the transport from here? There’s no bus.

RN: There are bicycles.

>RHN: Bicycles. You can’t send a very sick person on a bicycle.

RN: There are bicycles and then there are the carts. Donkey carts.

>RHN: So they can go on a donkey cart.

RN: Yes. If a person is very sick. Or you call from Kabibi, you just call by phone and an ambulance will come. And then they charge you for the trip.

Jeane Mjiru, in Mjiwa Clinic in Ena Market, is a retired nurse, who has come back to her village, as do many retirees. She wanted to continue to care for her people, so to run a CFW Shop gave her that chance. She has a small pension, and income from the shop is a supplement.

>RHN: Jeane, may I ask about the patients who come here? Are they the ones that have a little bit more money?

JN: It depends, because sometimes they are referred here to get their medicines when they are not available in the government institutions. Or there are some who prefer to come here rather than going to the government clinic. It depends which.

>RHN: So the government services sometimes have interruptions in supply of drugs.

JN: Yes, sometimes they finish up their stocks before they get their next order. So they can write a prescription for a patient and the patient goes to the chemist, or comes here for the drugs.

>RHN: Are your supplies are guaranteed?

JN: Yes, most of the time we have the drugs.

>RHN: What illnesses do you treat?

JN: We see many illnesses, like upper respiratory tract infection, malaria, pneumonia, cuts, wounds, conjunctivitis. We do antenatal care and family planning. There are many cases that we can help here.

>RHN: You told me that for malaria you see more adults than children. Why do you think that would be?

JN: I think through the giving of the bed nets. The children are more protected than the adults. That’s what I think.

>RHN: Do you think that the children sleep under nets more than the adults?

JN: I think so. They protect their children more than themselves. We have been issuing free nets to the children and pregnant mothers. So they would think those nets are only for the children.

>RHN: How many patients do you get a day?

JN: Usually we attend to 10-20 per day.

>RHN: You’re competing with other clinics in the neighbourhood, like the government clinic, or the chemists. How do you try to make your services better, so they come to you?

JN: By talking to the clients, giving them health education. And our rates are cheaper than the other clinics.

>RHN: One of the things that is supposed to happen with these clinics is that you, the nurse, and your community health worker if you have one, are supposed to be able to earn enough from the business to make an income. Does that work here?

JN: Sometimes yes, sometimes no. Because if you see few patients…. Or it could be enough. It depends.

>RHN: You are a retired government nurse. Do you get a pension?

JN: Yes.

>RHN: So the income you get from this shop is a supplement, it’s an addition.

JN: Yes.

Dora Nyanja, in Kibera next to Nairobi, holds a masters degree in public health, is a midwife, is married to an advocate, has three young children, and yet works 12-14 hours a day in her shop in the slum. She doesn’t make a living from her work, but sees her work as a calling, enjoys competing with other clinics and shops, has made strong friendships there and believes she’s saving lives.

DN: I came to Kibera because I wanted to work with CFWshops. They insisted that you come to the marginalized areas, and Kibera was one of them. Actually it posed a big challenge because I didn’t know how I was going to be accepted into the community, owing to the fact that I was from elsewhere. Here I was just thinking I could provide healthcare to the people.

I didn’t know how it was going to be taken, but just before I opened – about six months before I opened – I managed to work with CFW on a project here, at that time I started interacting with the people here and I saw it could actually work.

Kibera is very big. You have about 13 villages. This is just one of the villages that we have in Kibera, called Soweto Kianda. The first challenge came in trying to get premises to put up a clinic because in one place there are no bathroom facilities; in another there’s no running water; in another there’s no power. But eventually I found this one.

>RHN: Are you able to make an income here?

DN: The more clients you see, the higher the likelihood that you will make a profit - then I am able to pay my staff and I am able to pay rent and also to replenish my stock.

But at the end of the day I don’t have much left for me, maybe just for transport, because I live about 20 kilometres from here. I have to come in the morning and go back in the evening, that is if I can go back - because like last night I had to spend here because there was a fracas in the village.

>RHN: So you don’t pay yourself a salary, or very little?

DN: It’s little.

>RHN: So you can survive? You’ve got other sources of income?

DN: I wouldn’t say other sources of income because I look at my profession at times as a calling.

>RHN: But you have to feed yourself?

DN: Fortunately for me, I have a spouse who is very caring and I told him, my heart is in Kibera and that is where I want to go. I want to serve people there.

Because if we all run away, if I decided to go to the big hospitals where they know they know about taking care of themselves – they live in fairly good hygienic places, the sanitary conditions here are very poor - if we all go the big hospitals, who is going to serve these people right here?

By the time these people come to the national hospitals or the other hospitals, they have already been mismanaged in the village. So one of us has to give way and go and serve the people right there, and so I said, let me come and see.

For everything that you do, God always has a better plan for you in future. And so I decided, let me come and see what God has in store here.

>RHN: So how long have you been here?

DN: A year and a half.

>RHN: How do you feel now, after a year and a half?

DN: I feel appreciated by the community because they come and they support the business. You know that healthcare is a bit tricky because on one end you want to give quality, but at a price that they can afford. So sometimes they can’t pay the whole bill - I also incur a lot of debts here. I have to give a lot of credit.

But at the end of the day I am at least able to pay the rent and I’m able to pay my assistant and I have something, just a little, to keep me moving. And as I keep on saying, I have a very supportive spouse.

>RHN: And what kind of people do you see? What kind of cases?

DN: I see an average of 60 patients in a day. Mostly, when it is cold like this, we see a lot of upper respiratory tract infections and chest infections.

And one of the major ailments is malaria. Malaria is a major issue here.

>RHN: But isn’t that imported, from outside Kibera?

DN: That is what the government has been saying, that the malaria that we have in Nairobi is imported. But Kibera is a special kind of region. You can see there are no sewers and the sanitary conditions are poor. I would say we are in a fairly good building here. If I could take you to some of my patients that I treat, their places mud-walled and thin; you can actually see through. You can see garbage all over and those are very good places for breeding mosquitoes.

>RHN: And you can see sewage in the streets.

DN: Yes. And then we also have diarrhoea and vomiting in both children and adults, which is a very common ailment here because of the hygienic conditions.

That is why when I go to the community I tell them, if you cannot afford fuel to boil your water, you have an alternative – you have Water Guard [a water cleansing agent].

>RHN: How about the competition? You told me you are beginning to get more clients than they are. So what is special about what you offer, I mean why are they coming here rather than to them?

DN: One thing, there is no queue here, and I would say there is no queue because they know the timings. Another thing, they know that they are going to get somebody who is ready to listen to them; my personal relationship with them I would say is good.

>RHN: So this is a very, very personal thing?

DN: Yes. And they also have credit facilities. I tell them that I buy these drugs and I expect you to pay a subsidised fee so that I can also replenish my stock.

>RHN: And they pay you back?

DN: They do pay. Okay, you’ll get a few crooks here and there who will move from one clinic to the other, but the genuine ones will always pay even if they do not have money on that day, they will pay some other time.

>RHN: And you’ve got a particular personal commitment to it and the support of your husband. But do you think this model would work for someone who really wants to make a living out of this?

DN: Somebody who really wants to make a living [here] will not. It will not work for them. This has to come out of your hand because compared to the hours that we put in – I work a minimum of ten to twelve hours in a day - somebody who works for about ten hours should be able to make, like if I look at my colleagues who are working in the UK and America, who are trained to the same level, I know they are making millions of dollars. Unlike what I am making here.

>RHN: Or maybe millions of shillings, not millions of dollars.

DN: Yes, millions of shillings. They are making millions of shillings unlike me who am here, but at the end of the day I have job satisfaction. I have served my community and they appreciate what I have done and I feel I’ve really given a service to the people.

>RHN: In your village and the neighbourhood around, how many health facilities are competing with one another, would you say?

DN: Now that is another challenge here. We have many drug stores here, which are unregistered.

>RHN: Which are private?

DN: And unregistered. But when we talk of health facilities, we have one major one that is run by the Centers for Disease Control – CDC – and their service is absolutely free, especially for malaria and diarrhoeal diseases. Absolutely free, they don’t pay anything. It’s about 200 metres from here.

I would say, when I look at it, that is my major competitor. But again, much as people are poor in this community, not everybody wants free things. They have more confidence if you tell them, you will pay so much.

>RHN: Do you think so? That’s interesting.

DN: Because I think they put question marks on the free things, especially when they don’t get well. But if they get well they are comfortable, and they say that is good enough.

>RHN: An important matter is sustainability. CFWshops aim to be sustainable in the community, as you were explaining. Do you think the CDC clinic will be sustainable?

DN: No, it’s not sustainable. What is happening with CDC down there, it was just a clinic like any other, and then CDC decided to come in and assist. So the model of CDC is such that the manager of that clinic is paid a salary and then some drugs come.

>RHN: So it will last as long as the help lasts.

DN: But then what happens here, at the fees we charge, people are able to come. What has sustained this outlet here? They come because they know that the health worker is trained, because again much as this community is poor, they also look at those kinds of issues.

They know that this is a trained health worker, this is a health worker who is humble and down-to-earth, who can take care of us, and this is a health care worker who is not hungry for money. She charges something that we can be able to afford.

At times they are not able to pay it back at that point, but they know, within a week I will have earned my salary. You’ve charged me 200 shillings, I don’t have 200 now, I have 100 shillings, can I pay tomorrow, can I pay it on another day, and that kind of flexibility works very well with them.

>RHN: So you’ve established a relationship with these people.

DN: And that is the core of the business here.

DN: Like I have a neighbour here who I found here who runs a pharmacy and he’s been here for quite a long time and the community trusts them because they live here, they come from here. But the other day we had an inspection…

>RHN: By whom?

DN: By some health officials and some police officers…

>RHN: From the government?

DN: Yes, asking for licences. And fortunately it was only my clinic that was open; the doors were open, so the community is able to know, ah, that’s a genuine one. They could see that those other ones don’t have licences yet they are operating.

>RHN: So your neighbour, he hid when the inspectors came.

DN: Yes. That is what happened.

DN: So somehow the community comes to learn of them and they know. But change does not come overnight and it does not come within a day; it takes time.

>RHN: How unusual do you think you are? I mean do you think there are many people like you? Africa, they say, needs nearly a million health workers. Do you think there are a million men or women like you who are prepared to work on these terms?

DN: Most of us are hungry for money. We want to make money quickly but it takes time to identify who can do what and it also takes a special heart.

>RHN: What does your husband do?

DN: He’s an advocate.

>RHN: An advocate? So he’s well paid.

DN: Well I wouldn’t say he’s well paid. We just try to leave within our means. We get our basic needs and we say, that’s it.

>RHN: Do you think you’re saving lives?

DN: I think I do, I think I do.

Esther Njuguna is the Executive Director of CFWshops in Nairobi.

She ran her family’s business for eight years distributing agricultural chemicals and veterinary drugs for multinationals. So how did she end up for a health organization like CFWshops?

EN: Well, the strategic direction now is towards business, more and more away from NGOs, so that’s how I ended up here as Director.

>RHN: What are the challenges for CFWshops from the centre, from Nairobi?

EN: At the moment our biggest restriction is the government requirement that any of the nurses that run any of the clinics must have ten years experience. Now there are not many nurses available with ten years experience. So we do find that limiting.

Most Kenyans retire back home to their rural areas, so we tend to capture the retired nurses - which is excellent for them because they are retiring but they retire with a small business on the side.

And we have realised that we need to help them the shopkeepers a bit more to generate an income from their outlets. One thing to do of course is to equip them to provide more services. Dora who you met for example is qualified midwife, so we’re looking at what can she do as a midwife - but of course it must be within the Ministry of Health guidelines for her.

We’re doing that with several of our other nurses, making it possible to be able to provide immunisation services from their outlets, for example, or prenatal and post-natal services.

>RHN: I understand you have 65 shops at present – what fraction would you say are really profitable, with the franchisee making a living?

EN: At the moment I would say 50%. One of the challenges that our franchisees meet is simply the income level of the communities that they are operating in. Many of our nurses will actually provide services free of charge because the members of the community are not able to pay for the consultation fees. And some of the community members are also not even able to pay for the medication.

So some of our franchisees give medication on credit. They’ve come up with arrangements with the community for that, but some of them are struggling to stay afloat.

But as long as the products that we are selling to people are priced correctly, so they are affordable to them, then they are willing to spend that little income that they have on our products. Because of the confidence that they have, that they are getting quality products, they are willing to spend.

>RHN: I’ve heard many times that people actually like to pay a little bit and not just get something free, because they feel that there’s some value in it.

EN: Yes. People are sceptical when something is offered to them for free; sometimes they think, is it expired, is it being dumped here? So people do want to pay for something then they know for sure they are getting some value for money. And our products are so priced that they can actually be able to afford them.

>RHN: If you take the 50% that are succeeding, how would you characterise those? Are they in richer communities or are the franchisees particularly clever at business?

EN: I would say the success factors of our franchisees are two. One is the location. Some of them just happen to be at the right location. And the second is the personality of the franchisees – they command respect within the community. So we find that those are the two reasons that tend to make some of them very successful.

>RHN: By ‘location’ do you mean the ‘micro-location’ so to speak, whether they are on a crossroad or whatever it might be?

EN: Yes, the micro-location. The successful ones are probably at a crossroads, they’re at a shopping centre, where there’s a market, where there’s heavier traffic.

>RHN: You know what they say in England about the secret of success for small shops in communities – location, location, location!

EN: Yes, it’s location for ours as well.

>RHN: Another issue that struck me in Kibera, when I was talking to Dora, is the variety of outlets there are. You’re not just competing with the national health system for example, there are donors coming in. There’s a CDC clinic quite close to Dora’s outlet in Kibera. There are the faith-based outlets, there are the small traders who are trying to make a living for themselves selling drugs and there are faith healers and all sorts of people.

There’s actually a lot of ‘healthcare’, some better and some worse, that the customer has to choose between. So how do you make CFWshops special from the customer’s point of view?

EN: What counts are the quality of the service that they get from our nurses; the confidence that they have in the quality of products that we have on offer; and the consistency of our work.

>RHN: So that confidence builds up in the community over time, over experience of the product and the care.

EN: Yes. With regard to the government clinics especially, it’s the queuing – you can spend a whole day waiting to see the doctor. We don’t have those kinds of problems.

>RHN: Can CFWshops do anything about antiretroviral distribution?

EN: Up to now we’ve not been doing anything specific with HIV/AIDS, but definitely we are now going into it. We’re about to get into a programme with USAID, to tackle the issues of HIV/AIDS and the treatment of opportunistic diseases and the availability of antiretrovirals through our clinics.

USAID are coming with the funding for everything - the drugs, everything that goes into ensuring that we’re able to treat HIV/AIDS in our patients.

>RHN: Do you have plans to expand?

EN: Within the next five years, we’re aiming to have 250 clinics. We could do more – the need is great. But because of our logistical support to the franchisees, at the moment we can only begin by increasing the density of our outlets in the areas where we currently have shops. Then we will move outwards in concentric rings around that.

We give a lot of support to our franchisees: we have health services officers and outlet performance officers who visit them weekly, and we have our logistics officers who supply the drugs to them - so because of that, we have to manage our growth in order not compromise that kind of technical support.

CFWshops have been going since 1999. It has taken a long time to grow. And you have to understand that even as we grow, we have natural attrition. Some clinics we will start and they will never take off and we have to shut them, or we have to relocate them to new sites. But we are currently rolling out at about 20 to 30 new clinics every year.

>RHN: What about public health messages? Can your shops deliver those?

EN: Yes indeed. That’s part of our franchisees’ work, to conduct outreach within the community, to pass on public health messages. They look at it this way: they’re educating the community to change – behaviour change. But on the other hand they are also getting themselves known by the community. So when the community have ailments or they fall ill, they know where to go. So it works both ways – they’re passing on the public health messages but they’re also marketing their outlets at the same time.

RealHealthNews also spoke to researchers investigating the effectiveness of CFWshops, at least against one key disease – malaria: Athuman Chiguso in Kenya and Franco Pagnoni in Geneva.

>RHN: Athuman Chiguso, you’re working with the UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases (TDR) to research the impact of CFWshops. Can you tell us what you’re doing?

AC: We are studying access to the first line anti-malaria drug artemether/lumefantrine [Novartis’ Coartem] in nine CFW clinics in three districts of Kenya – two with seasonal malaria and one where it is endemic.

We are looking to see whether first line anti-malarials are available in communities; then to see if people are complying with the treatment; and to see if there is any adverse reaction to the drugs .

>RHN: Is there a compliance issue?

AC: Well the regime is six doses over three days, compared to the previous [single dose] regime of sulfadoxine-pyrimethamine.

The first dose you take immediately having met the nurse, and the second dose after eight hours. Then the second day you need to take one in the morning and then another dose in the evening, and then continue for the next two days.

The regime relies on the patient. The nurse has to give education correctly at the desk. She or he must tell the patient that they will be feeling OK after the second dose, but ask them to please continue through the treatment. Then the nurse must tell them that if they have any fever, if any time they get an adverse reaction, they must please report back to the clinic.

So far patients have been complying with the treatment and they appear to be happy about the drug they are taking. There have just been two small reactions in six months.

One of the things we want to see is can micro-franchising [the CFWshops model] be an opportunity to access first line anti-malarials? And is it a benefit to both the community and the franchisee? In other words, is it sustainable?

RealHealthNews also spoke to Franco Pagnoni, at TDR HQ in Geneva:

FP: We are measuring if this is a feasible way of distributing Coartem – if the distribution system works, if drugs are available; and then of course the main outcome measure of the project is whether the population likes it, whether this way of making Coartem available increases the proportion of children that is treated promptly and correctly with Coartem.

We are comparing a baseline, before the CFWshops began distributing Coartem, with a point after about a year later. The baseline study was done in late 2006.

The indicator is the proportion of children treated. For example, if without Coartem at the CFWshops maybe 50% of children got Coartem within 24 hrs and took it as prescribed, probably through government clinics; and maybe after a year of having Coartem available at the CFWshops we found this proportion had increased to 70%, we’d be seeing a positive benefit of 20%.

The CFWshops first give a rapid diagnostic test, to see if you have parasites or not, and they don’t give Coartem to those who don’t have parasites; and when the give Coartem they give the blister packs that TDR has developed, with the full course, together with information and instructions.

Compliance goes together with access – we want the treatment to be correct, so we want mothers to comply with the correct schedule, and CFW shopkeepers have to give the appropriate instructions – e.g. no to prescribe it for severe malaria (that needs treatment at the hospital). So we are evaluating all these parameters: access but with quality, quality of prescription from the side of the shopkeeper and administration from the mother.

What the mothers do at home of course we don’t know. We can’t follow every patient. But compliance will be measured through random structured interviews, and inspection of the blister packs, at home.

The ‘after’ survey will be done before or after the coming Presidential election in Kenya, in November 2007 or January 2008. Publication will be maybe six months later.


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CFWshops (a project of The HealthSTORE Foundation)


HealthSTORE founder Scott Hillstrom


WHO World Health Report 2006, on the world health staffing crisis


The UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases (TDR) – implementation research


WHO guidelines on malaria diagnosis and treatment


Procurement of Coartem through WHO – pdf file 100 KB


Cotecxin artemisinin combination therapy marketed by Holley-Cotec of Beijing, reportedly available in some private outlets in Kenya







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