Improving quality of malaria treatment services: Assessing inequities in consumers' perceptions and providers' behaviour in Nigeria

Article (PDF Available)inInternational Journal for Equity in Health 9(1):22 · October 2010with61 Reads
DOI: 10.1186/1475-9276-9-22 · Source: PubMed
Abstract
Information about quality of malaria treatment services of different healthcare providers is needed to know how to improve the treatment of malaria since inappropriate service provision leads to increased burden of malaria. Hence, the study determined the technical and perceived quality of malaria treatment services of different types of providers in three urban and three rural areas in southeast Nigeria. Questionnaire was used to interview randomly selected healthcare providers about the technical quality of their malaria treatment services. Exit polls were used to obtain information about perceived quality from consumers. A socio-economic status (SES) index and comparison of data between urban and rural areas was used to examine socio-economic status and geographic differences in quality of services. The lowest technical quality of services was found from patent medicine dealers. Conversely, public and private hospitals as well as primary healthcare centres had the highest quality of services. Householders were least satisfied with quality of services of patent medicine dealers and pharmacy shops and were mostly satisfied with services rendered by public and private hospitals. The urbanites were more satisfied with the overall quality of services than the rural dwellers. These findings provide areas for interventions to equitably improve the quality of malaria treatment services, especially for patent medicine dealers and pharmacy shops, that are two of the most common providers of malaria treatment especially with the current change of first line drugs from the relatively inexpensive drugs to the expensive artemisinin-based combination therapy, so as to decrease inappropriate drug prescribing, use, costs and resistance to artemisinin-based combination therapy.

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Improving quality of malaria treatment services:
assessing inequities in consumersperceptions
and providersbehaviour in Nigeria
Obinna Onwujekwe
1,2*
, Eric Obikeze
1,2
, Benjamin Uzochukwu
1,2,3
, Ijeoma Okoronkwo
1,4
,
Ogochukwu C Onwujekwe
5
Abstract
Background: Information about quality of malaria treatment services of different healthcare providers is needed to
know how to improve the treatment of malaria since inappropriate service provision leads to increased burden of
malaria. Hence, the study determined the technical and perceived quality of malaria treatment services of different
types of providers in three urban and three rural areas in southeast Nigeria.
Methods: Questionnaire was used to interview randomly selected healthcare providers about the technical quality
of their malaria treatment services. Exit polls were used to obtain information about perceived quality from
consumers. A socio-economic status (SES) index and comparison of data between urban and rural areas was used
to examine socio-economic status and geographic differences in quality of services.
Results: The lowest technical quality of services was found from patent medicine dealers. Conversely, public and
private hospitals as well as primary healthcare centres had the highest quality of services. Householders were least
satisfied with quality of services of patent medicine dealers and pharmacy shops and were mostly satisfied with
services rendered by public and private hospitals. The urbanites were more satisfied with the overall quality of
services than the rural dwellers.
Conclusion: These findings provide areas for interventions to equitably improve the quality of malaria treatment
services, especially for patent medicine dealers and pharmacy shops, that are two of the most common providers
of malaria treatment especially with the current change of first line drugs from the relatively inexpensive drugs to
the expensive artemisinin-based combination therapy, so as to decrease inappropriate drug prescribing, use, costs
and resistance to artemisinin-based combination therapy.
Introduction
Malaria is a major public health problem in Nigeria and
its treatment is sought from a broad spectrum of public
and private healthcare providers [1,2]. The erosion of
the public health system, arising from mismanagement,
has contributed to the growth of the private sector and,
in particular, the rise in the informalprivate sector as
a source of treatment [1]. Patients often resort to the
unregulated private commercial sector, where treatment
maybeinappropriatebutatalowercost[1].The
informal private sector is now a major source of anti-
malarial drugs, but these providers, especially patent
medicine dealers (patent medicine vendors) generally
provide low quality services [3]. A study of treatment of
childhood malaria in Zambia found that, in most cases,
drugs were bought at pharmacies or local shops, but
these treatments were often inconsistent with national
treatment guidelines; for example, they may include
counterfeit drugs, drugs of poor quality, incorrect dosing
and irrational prescription practices [4]. Private sellers
such as patent medicine dealers often lack knowledge of
appropriate treatment and are influenced by advertising
and profit motives [5].
* Correspondence: onwujekwe@yahoo.co.uk
1
Department of Health Administration and Management, College of
Medicine, University of Nigeria, Enugu, Nigeria
Full list of author information is available at the end of the article
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Perceived and actual quality of care administered at all
levels of health care are major determinants of health
outcomes and consumers choice of treatment provider
[6,7]. In many places, health services from both public
and private providers are of questionable quality, with
long waiting times, inaccurate diagnosis, inappropriate
prescription and advice and frequent drug stock-outs.
The use of presumptive malaria diagnosis without
laboratory support, which is a common diagnostic pro-
cedure for malaria in Nigeria and in many sub-Saharan
Africa (SSA) countries in both public and private facil-
ities predisposes to poor quality of malaria diagnosis
and treatment. Case history has proven an unreliable
diagnostic method; in one instance it was found that
nurses had a 10% accuracy of malaria diagnosis using
case history compared to doctors with a higher level of
accuracy [8].
Information about quality differentials across providers
is needed to identify the loci for intervention, as poor
quality of healthcare services is a major contributor to
the high direct and indirect costs to patients [6,9]. Stu-
dies from a number of countries note that the technical
capacity of private clinics is perceived as inferior [1,8]. If
a patient is very ill, the public sector may be preferred
for its sophisticated equipment and wide range of staff
[10]. Patients may also perceive private providers to rely
excessivelyondiagnostictestsandchargeveryhigh
prices and they are skeptical about the motivation of
private providers, believing they are more interested in
generating income for themselves than in the welfare of
their patients [10,11].
Public treatment services are themselves frequently
inefficient, of poor quality, and underutilized and often
lack drugs and diagnostic facilities [1,12]. Inappropriate
prescription is common in these facilities [13], reducing
the quality of care, wasting resources and potentially
contributing to the spread of drug resistance [14]. The
poor quality of care at public facilities, crowds, long
waiting times and cursory consultations, was a key fac-
tor in the preference for private providers [6]. Other
studies looking at a broader range of diseases in Nigeria
found widespread inappropriate drug use, low quality of
treatment, and ineffective regulation [12,15-18].
There is paucity of documented evidence about actual
quality of malaria treatment provided by different pri-
vate and public providers. The exploration of providers
used and quality of malaria treatment services they pro-
vide is needed to identify and correct problems asso-
ciated with quality of malaria treatment services [7].
Also, there is paucity of knowledge especially within the
private sector, particularly whether the poor are more
likely to use some private providers that deliver poor
services [9]. Poor quality of services deter use of health
services, particularly by the poor [6]. Some researchers
showed that there were positive associations between
socio-economic status and health seeking from an
appropriate provider for fever [19].
This paper provides information on the differential
quality of perceived and providersstated quality of
malaria treatment services from a broad spectrum of
public and private providers. Hence, the paper assesses
the relative quality of malaria treatment services offered
by different types of healthcare providers. The paper
also shows whether there are socio-economic and geo-
graphic differences in quality of services rendered to dif-
ferent consumer groups as well as influences on
perceived quality of treatment. The information gener-
ated by this study will help design policy measures to
strengthen the treatment component of the malaria con-
trol strategy, especially with the use of the expensive
artemisinin-based combination therapy (ACT) as first-
line treatment for malaria.
Methods
Study design
It was a cross-sectional study. Data was collected using
provider interviews and exit polls through question-
naires. The study site was Anambra State, southeast
Nigeria. The state has a high malaria transmission rate
throughout the year. Six communities were chosen for
the study and each site area had a full complement of
providers. Awka, Nnewi and Onitsha were selected
based on being urban. Njikoka, Aguata and Ogbaru
were selected based on their being rural. The commu-
nities were randomly selected using two-stage sampling,
by first stratifying the communities according to
whether they have a public hospital and then randomly
selecting the sites from those that have public hospitals.
Provider interview
The sampling frame included the major types of private
and public providers that use bio-medical (orthodox)
drugs to treat patients and at all levels of care in public
and private facilities. Private providers were hospital-
spharmacy shops (PS), laboratories and patent medicine
dealers (PMDs). Laboratories were included because in
real practice, they actually provide malaria treatment
practices instead of just diagnostic services that they are
permitted to provide. Public providers were hospitals
and Primary healthcare centres (PHCs). The sample size
was determined by considerations of the range of provi-
ders and feasibility. There was listing of providers in the
study areas using their association registers. Snow ball
approach was used to reach the providers who were not
included in the association register. Proportionate allo-
cation was used to choose different numbers of provi-
ders from the urban and rural areas because the urban
areas have more population of respondents. A total of
50 public and private providers in each urban and 25 in
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Page 2 of 9
each rural area were selected, adding up to 225 provi-
ders The sample size and breakdown of providers was
determined based on their utilisation rate by consumers
using existing data [20]. The sampling of private provi-
ders was hence made with probability proportionate to
size. All public providers in each study area were
included in the study because they were not many.
A structured questionnaire was administered by
trained field workers to the heads or owners of selected
public and private providers/outlets. The providers were
drawn from PMDs, PHC centres, public and private
hospitals as well as laboratories. The employees running
the facilities were interviewed in the absence of the
owner or head. In the case of hospitals, the providers
that were interviewed were medical doctors, whilst they
were pharmacists and laboratory technicians in the case
of pharmacies and laboratories respectively. In the PHC
centres, either the head or the next highest available
ranked healthcare provider was interviewed. Finally, in
PMDs, the owners or the highest ranked assistant was
interviewed. Information was obtained from the provider
about how they diagnosed and treated malaria with arte-
misinin-based drugs, especially ACTs. The selected pro-
viders on the aggregate treated more than 85% of adult
malaria and more than 90% of childhood malaria [2].
Exit polls
In order to obtain accurate data, at least ten clients from
each of the providers were interviewed just after receiv-
ing treatment from each of the 225 providers, giving a
minimum sample size of 2,250 exit polls. However,
when the number of clients interviewed were aggregated
across the different groups of providers, the numbers
were 860 in PMDs, 273 in PHC centres, 195 in public
hospitals, 716 in private hospitals, 222 in pharmacy
shops and 38 in laboratories, which were adequate for
making statistical inferences because the computed
overall minimum sample size for respondents was
achieved. The respondents on immediate exit from the
providerspremises were asked whether or not the qual-
ity of services that they just received based on five attri-
butes of treatment were acceptable or not acceptable to
them. The acceptability was based on consumersself-
assessed perception of the quality of diagnosis and other
dimensions of quality. The dimensions were: Diagnosis;
Correct drug; Correct dosage; Instructions on how to
take the drugs; and Follow-up information on what to
do if they did not recover. Data was also collected on
specific diagnostic actions which included provision of
blood tests, taking case history, measuring of tempera-
ture, heart rate and respiratory rate. In case that the
provider did not undertake any specific diagnostic action
before prescribing treatment of dispensing drugs, this
was recorded as no diagnosis. Data was also collected
on the specific type of main healthcare provider
(doctors, nurses, medical assistants, pharmacists, com-
munity-health workers and PMDs that treated the
patients) Data was also collected household socio-
economic status (assessed through ownership of assets
and household expenditure).
Trained data collectors interviewed patients or their
carers (in case of children) that had just received treat-
ment for fever from each of the sampled providers using
a pre-tested semi-structured questionnaire (after the
providers had been interviewed). Inclusion criterion was
all patients who were accepted through diagnosis to
have symptoms of malaria and such patients were
referred to the data collector by the provider for inter-
view after treatment had been given. Those who did not
have malaria symptoms, and were not referred to the
data collector from the provider were excluded from the
exit poll. The first ten eligible respondents were selected
and interviewed as they exited the providersfacilities.
Ethical approval and Consent The study was approved
by the Ethics Committee, University of Nigeria.
Informed consent was obtained from the respondent
who read and agreed to be interviewed having accepted
the conditions.
Data Analysis
Provider behaviour
Tabulations were used to examine variables for stated
quality elicited from the various providers in the differ-
ent areas. The variables on providersstated quality
between the different types of providers were compared.
The variables were: method of diagnosis of malaria; and
provision of ACTs and other anti-malarial drugs. This
was based on the premise that appropriate treatment
consists of proper diagnosis and treatment with nation-
ally recommended drugs. Other variables that were
explored included the type of healthcare provider that
provided treatment, the actions taken for diagnosis
(blood tests, history taking, measurement of tempera-
ture, heart rate and respiratory rate).
Perceived quality
Tabulations were used to examine variables for per-
ceived quality elicited in the exit poll. These variables
were the consumersperceptions of the quality of diag-
nosis, drugs that were provided, specified dosage, fol-
low-up instructions and general information provided to
the patients. They were all measured as binary variables
(1 = acceptable and 0 = not acceptable).
Cross-tabulations and logistic multiple regression ana-
lyses were used to examine the statistical relationship of
independent variables with perceptions about the five
perceived quality attributes. In cross-tabulation the bin-
ary place of residence variable and SES quartiles were
tabulated against the five consumer perceived quality
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attributes respectively. The five different dependent vari-
ables were perceptions of the quality of diagnosis, drugs
given, specified dosage, follow-up instructions and gen-
eral information provided to the patients. Cross tabula-
tions were also used to analyze relationship of specific
diagnostic actions with different healthcare providers.
In logistic regression analysis, the independent vari-
ables were the place of residence (urban = 1; rural = 2),
age (years), sex (male, female) and maximum educa-
tional level of schooling that the respondent attained, as
wellasSESweight.Thebasevariableforeducational
status was no formaleducation. The dependent vari-
ables were the five consumer perceived quality attributes
that were described in the preceding paragraph. The sta-
tistical significance and the percentage of correct predic-
tions of the logistic models were examined. Statistical
significance of the independent variables was set at the
5% level.
Equity analysis
Equity analysis examined the relationship between geo-
graphic location and socio-economic status (SES) with
the key quality variables. A continuous asset-based
socio-economic status (SES) index [2] was generated
using principal components analysis (PCA) with infor-
mation from the householdsasset holdings together
with the householdsper capita weekly cost of food. The
assets considered were householdsownership of motor-
car, motorcycle, radio, refrigerator, television set and
bicycle. Weights for the SES index where derived using
the first principal component of the PCA. One SES
model was estimated for pooled data of urban and rural
areas so that households could be directly compared.
The SES index was disaggregated into quartiles ranging
from Quartile 1 (Q1) which was the most poor group
and Q4, the least poor group. The SES index was used
to examine whether there were systematic differences in
quality by SES. The ratio of the lowest SES to the high-
est SES was computed as the measure of inequity. A
binary variable was created to represent urban and rural
residence.
Definitions
Providersstated quality refers to the effectiveness of
care in producing achievable health gain. It reflects the
stated appropriateness and technical competence of ser-
vices provided.
Perceived quality refers to quality as assessed from
the patients perspective.
Results
General characteristics of the consumers
The majority of respondents were females, married peo-
ple and those mostly in their mid-thirties were the
majority of respondents (Table 1). The table also shows
that most of the respondents had some formal educa-
tion and spent an average of 11.5 years in school. Whilst
64.5% of visits to healthcare providers were by the
respondents, the rest were for other household members
including children.
General characteristics of the providers
Seven major providers of malaria treatment services
were accessed for the study: public hospitals, private
hospitals, PHC centres, pharmacy shops, maternity
homes, PMDs and laboratories. There were 137 PMDs,
4 mixed goods sellers, 22 PHC centres, 6 maternity
homes, 20 private hospitals, 3 other low level providers
such as community-health workers and itinerant drug
sellers, 8 laboratories, 11 pharmacy shops and 11 public
hospitals. Three other high level providers were inter-
viewed. It was found that 60.4% of the respondents were
the heads of the facilities and the rest were their repre-
sentatives. The average numbers of years of formal edu-
cation that PMDs, providers in public hospital,
pharmacy shops, laboratories, PHC centres and provi-
ders in private hospitals were 5.0 (SD 2.9), 19.2
(SD24.0), 15.0 (SD 4.8), 17.4 (SD 3.1), 15.0 (SD 2.6) and
19.5 (SD 4.9) respectively.
The average number of clients that the PMDs, public
hospitals, pharmacy shops, laboratories, PHC centres
and private hospitals were attended to in their last busi-
ness days prior to the interview were 12.2 (SD 10.2),
Table 1 Socio-economic and demographic characteristics of the respondents from the exit poll
Enugwu-
Ukwu
n = 246
Awka
n = 498
Ekwulobia
n = 294
Nnewi
n = 495
Onitsha
n = 498
Okpoko
n = 275
Urban
n = 1488
Rural
n = 818
Combined
n = 2306
Females:
n (%)
139(56.5) 271(54.4) 173(58.8) 303(61.2) 350(70.3) 201(73.0) 924(62.1) 514(62.8) 1437(62.3)
Age: mean (SD) 37.4 (13.37) 37.02
(13.17)
36.7
(11.61)
35.37
(9.45)
35.94
(10.93)
33.09
(7.31)
36.37
(11.56)
37.21
(12.98)
36.05
(12.05)
Attended school: n (%) 221(89.8) 462(92.8) 253(86.1) 485(98.0) 487(97.8) 250(90.9) 1434(96.4) 724(88.5) 2158(93.6)
No of years of
education:
mean (SD)
11.17 (9.10) 11.97 (4.20) 10.91
(3.88)
10.80
(3.59)
11.79 (3.4) 10.87
(3.47)
11.60 (4.68) 11.13 (5.68) 11.53 (3.39)
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19.1 (SD 6.9), 24.7 (SD 28.0), 14.1 (SD 15.4), 9.3 (SD
3.5) and 17.5 (SD 18.1) people respectively.
Diagnosis of malaria and provision of Artemisinin-based
drugs
History taking was used in the diagnosis in 2098
(90.4%), blood test in 155 (19.6%) and others in 14
(5.8%) of the cases (Table 2). However, most of the pro-
viders combined the different diagnostic methods. In a
number of cases, especially in public and private hospi-
tals, and laboratories, history taking was a major addi-
tional diagnostic method. The least use of blood tests
was in primary healthcare (PHC) centres, whilst blood
tests were most highly used in laboratories. However,
both public and private hospitals used blood tests in
42% of cases to diagnose malaria (Table 2). The chi-
square of association of different providers with all the
different diagnostic actions were statistically significant.
The differential provision of artemisinin-based drugs by
different providers is shown in Table 3. Artemisinin-
monotherapy (AMT) was more prescribed and procured
compared to artemisinin-based combination therapy
(ACT). However, higher proportions of ACTs were pre-
scribed in public hospitals, compared to private hospi-
tals and other providers (Table 3).
Consumers perceived quality of treatment services by types
of healthcare providers from exit poll
The quality of treatment from different providers dif-
fered depending on the indicator of quality assessed
(Table 4). As would be expected, the quality of labora-
tory diagnosis was perceived to be best in laboratories
followed by public and private hospitals, whilst the low-
est perceived diagnostic quality was in pharmacies. The
laboratories had the lowest perceived quality scores for
all other indicators. The public hospibtals, private hospi-
tals and PHC centres were generally the best perform-
ing. Patent medicine sellers had fairly acceptable levels
of quality on all the five indicators. In scoring the two
common and very important quality attributes, which
were (availability and quality of drugs), pharmacies clo-
sely followed by private hospitals ranked highest in both
attributes. The patent medicine dealers were ranked
lowest in both availability and quality of drugs.
SES and R/U differences in diagnosis
Table 5 shows that the two better-off SES had more
blood tests and more history of the illness when com-
pared with the two worse-off SES groups. The better-off
SES groups also had more of their temperature and
respiratory rates measured. However, more of the count-
ing of the pulse rate was with the most-poor SES group.
The urbanites in general also had better diagnosis on all
points than the rural dwellers.
SES and R/U differences in prescribers of treatment
Table 6 shows that more qualified health personnel such
as doctors and pharmacists prescribed treatment for the
better-off SES groups and for urbanites (p < 0.05). Con-
versely, patent medicine dealers prescribed more of the
treatment to worse-off SEs groups and to rural dwellers
(p < 0.05).
SES and R/U differences in perceived quality of services
The better-off SES groups perceived higher quality of
services compared to the worse-off SES groups (Table
7). This was especially in terms of quality of diagnosis,
drug given correct dosage of the drugs, instructions
about how to take the drugs and general health infor-
mation. The rural-urban differences in perceived quality
of treatment were mixed. There were no statistically sig-
nificant differences in diagnosis, drugs given and correct
dosage. However, whilst the urbanites perceived higher
quality of follow-up instructions about the treatment,
the rural dwellers perceived higher quality in general
health information given. The rural dwellers were gener-
ally more satisfied with the quality of services that they
received compared to the urbanites (Table 8).
Multiple regression analyses
Logistic regression analysis showed that perceived qual-
ity of diagnosis was positively and statistically signifi-
cantly related to place of residence (p < 0.01), and SES
(p < 0.01). It was however negatively and statistically
significantly related to whether the respondentshighest
Table 2 Method of diagnosis of malaria by different healthcare providers
Patent Medicine Dealer
n = 860
n (%)
PHC centre
n = 273
n (%)
Public Hospital
n = 195
n (%)
Pharmacy
n = 222
n (%)
Private hospital
n = 716
n (%)
Laboratory
n=38
n (%)
Chi-square (p-value)
Blood test 24 (2.79) 10 (3.7) 86(41.9) 2 (0.9) 297 (41.5) 31 (81.5) 621.8 (0.0001)
History 725(84.3) 271(99.3) 190(97.4) 203 (91.4) 664 (92.7) 29 (76.3) 87.7 (.0001)
Temperature 118(13.7) 230(84.2) 89(45.6) 46 (20.7) 465 (64.9) 3 (7.8) 696.5 (.0001)
Heart rate 68(7.9) 134(49.0) 72(36.9) 27(12.1) 346 (48.3) 1 (2.6) 430.5 (.0001)
Respiration 53(6.1) 116(42.5) 75(38.5) 10(4.5) 323 (45.1) 1 (2.6) 447.1 (.0001)
No diagnosis 119(13.8) 20(7.3) 4(2.1) 12 (5.4) 24 (3.4) 1 (2.6) 79.6 (.0001)
Others 36(4.1) 9(3.2) 16(8.2) 4(1.8) 67 (9.3) 0 (0) 33.6 (.0001)
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Table 3 Differential provision of artemisinin-based drugs by different healthcare providers
Patent Medicine Dealer
n = 860
n (%)
PHC centre
n = 273
n (%)
Public Hospital
n = 195
n (%)
Pharmacy
n = 222
n (%)
Private hospital
n = 716
n (%)
Laboratory
n=38
n (%)
Chi-square (p-value)
Drugs prescribed
AS monotherapy 43 (5.2) 6(2.2) 5 (2.6) 27(7.5) 84 (6.1) 2 (5.2) 45.2 (.0001)
ACT 5 (0.6) 1(0.4) 15(7.7) 7 (3.2) 10 (1.4) 0 (0) 56.4 (.0001)
Drugs procured
AS monotherapy 44 (5.2) 5(1.8) 16 (8.2) 26 (11.7) 76 (10.6) 0 (0) 58.3 (.0001)
ACT 8 (0.9) 0(0) 15 (7.7) 9 (4.1) 10 (1.4) 1 (2.6) 36.4 (.0001)
Table 4 Consumersperceived quality of treatment services offered by different healthcare providers from exit poll
Diagnosis (%) Drug given (%) Correct dosage (%) Instructions (%) Information (%)
Laboratory 100 41.6 47.2 44.4 19.4
Pharmacy 49.7 89.5 80.5 82.9 52.1
Patent Med Dealer 56.1 88.6 81.0 84.9 51.3
PHC centre 77.3 91.2 85.3 87.1 46.8
Private hospital 84.4 91.1 85.9 88.0 64.9
Public hospital 85.6 91.8 79.5 80.0 58.9
Chi-2 (p-value) 131.3 (p < .0001) 1.6 (p = .20) 43.7 (p < .0001) 61.1 (p < .0001) 75.3 (p < .0001)
Table 5 SES and Rural-Urban differences in methods of diagnosis of malaria
Blood tests History Temperature Heart rate Respiration n (%)
n (%) n (%) n (%) n (%)
SES
Q1 most poor 100 (18.3) 469 (85.9) 185 (33.9) 65 (11.9) 123 (22.5)
Q2 very poor 95 (17.4) 486 (89.2) 226 (41.5) 43 (7.9) 140 (25.7)
Q3 poor 110 (20.1) 515 (94.2) 261 (47.7) 36 (6.6 197 (36.0)
Q4 least poor 128 (23.5) 506 (92.8) 241 (44.2) 35 (6.4) 171 (31.4)
Equity (Q1:Q4) ratio 0.8 0.9 0.8 1.9 0.7
Chi-square(p-value) 7.4 (.061) 26.6 (< .0001) 23.3 (< .0001) 14.2 (.003) 28.6(< .0001)
R/U differences
Rural 203 (24.7) 757 (92.2) 331 (40.3) 213 (25.9) 171(20.8)
Urban 252 (16.8) 1340 (89.4) 624 (41.6) 447 (29.8) 419 (28.0)
Equity (R:U ratio 1.47 1.03 0.96 0.87 0.74
Chi-square(p-value) 21.1 (< 001) 4.8 (.028) 0.38 (.54) 3.9 (.048) 14.3 (< .001)
Table 6 Rural-Urban differences in specific provider that prescribed treatment of malaria
Doctor Nurse Medical assistant Pharmacist Community Health Worker Patent Medicine Dealer
Exit poll
Q1 most poor 134 72 18 22 12 189
Q2 very poor 140 86 15 37 23 165
Q3 poor 174 82 26 50 23 145
Q4 least poor 172 90 19 57 25 134
Equity (Q1:Q4) ratio 0.78 0.8 0.95 0.39 0.48 1.4
Chi-square(p-value)) 11.8 (.001) 2.0 (.16) .57 (.45) 18.9 (.001) 3.9 (.047) 17.0 (.001)
R/U differences
Rural 279 92 11 38 32 328
Urban 589 142 19 138 69 520
Equity (R:U ratio) 0.87 1.18 1.0 0.5 0.85 1.15
Chi-square(p-value) 6.5 (.011) 1.7 (.19) 0.02(.88) 15.9 (< .001) 0.63 (.42) 6.3 (.012)
Onwujekwe et al.International Journal for Equity in Health 2010, 9:22
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education level was primary school (p < 0.05), junior
secondary school (p < 0.05), senior secondary school (p
< 0.05) and university (p < 0.01). Place of residence (p <
0.01) and SES (p < 0.01) were the only variables that
were positively and statistically significantly related to
perceptions of quality of drug. SES (p < 0.01) was the
only variable that was statistically significantly related to
perceived quality dosage and follow-up instructions and
the relationship between the two sets of variables was
positive. Finally, perceived quality of general information
provided was positively and statistically significantly
relatedtoageoftherespondent(p<.05)andSES(p<
0.01). All five logistic regression models were statistically
significant (p < .01) and all predicted more than 70% of
the observations.
Discussion and Recommendations
The services from the highly used drug sellers, patent
medicine dealers (PMD) and pharmacy shops (PS) were
of lowest quality. These findings are similar to those of
other studies that show that medicine sellers offer a ser-
vice to patients that is widely used but generally of poor
quality [21]. Public hospitals, private hospitals and PHC
centres had the best levels of both perceived and techni-
cal quality of services, although not generally optimal in
all the quality indicators used in the study. A similar
study found mostly erroneous drug prescribing practices
among private shops, indicating the need for innovative
and effective approaches to achieve rational prescribing
practices [22].
As was found in this study and by other studies, a range
of problems had been identified with the quality of
malaria treatment, both in formal health facilities and by
more informal providers of care such as shopkeepers [1].
Some of these problems are related to diagnosis [1]. In
this study, less than half of public and private hospitals
used blood tests to diagnose malaria and the tests were
rarely used by patent medicine dealers that provide the
bulk of malaria treatment services. There were few inci-
dences of prescription of ACTs. One of the few previous
studies that examined the quality of treatment of health
providers found that patent medicine dealers provide low
quality services to their clients [8]. A small study in rural
Nigeria identified inappropriate dispensing of anti-malar-
ials by the majority of patent medicine dealers [23].
The study would have been enriched if qualitative
research methods such as focus groups discussions
(FGDs) and indepth interviews were used to further
explore issues of quality of treatment from both provi-
dersand consumersperspectives. This lack of both
FGDs and IDIs is a study limitation, which future stu-
dies in this research area should incorporate when col-
lecting data so that information on differential quality of
treatment will be more robust. Also a bias that could
have been introduced to the study was the fact that data
was collected from patients that were referred to the
Table 7 SES and Rural-Urban differences in perceived quality of treatment services by types of healthcare providers
Diagnosis n
n (%)
Drug Given
n (%)
Correct Dosage n
n (%)
Instructions
n (%)
Information
n (%)
SES
Q1 most poor 326 (59.7) 474 (86.8) 409 (75.1) 423 (77.5) 240 (44.0)
Q2 very poor 376 (68.9) 469 (85.9) 440 (80.7) 458 (83.4) 279 (51.2)
Q3 poor 421 (77.1) 511 (93.6) 482 (88.3) 494 (90.5) 360 (66.1)
Q4 least poor
Equity (Q1:Q4) ratio
405 (74.3)
0.8
494 (90.6)
0.95
461 (84.6)
0.9
480 (88.1)
0.9
329 (60.4)
0.7
Chi-square(p-value) 48.8 (< .001) 24.0 (.001) 38.6 (< .001) 44.6 (< .001) 65.7 (< .001)
R/U differences
Rural 581 (70.7) 733 (89.2) 666 (81.2) 677 (82.4) 508 (61.9)
Urban 1052 (70.3) 1340 (89.5) 1246 (83.2) 1295 (86.5) 783 (52.3)
Equity (R:U) ratio 1.01 1.00 0.98 0.95 1.18
Chi-square (p-value) 1.88 (.39) 1.9 (.40) 3.2 (.21) 8.6 (.013) 21.5 (< .001)
Table 8 R/U differences in general level of satisfaction with services
Very satisfactory
n (%)
Satisfactory
n (%)
Not satisfactory
n (%)
Do not know
n (%)
R/U differences
Rural 509 (62.0) 300 (36.0) 2 (0.01) 8 (1.0)
Urban 817 (56.0) 583 (40.0) 38 (3.0) 38 (3.0)
Equity (R:U) ratio 1.11 0.90 0 0.33
Chi-square (p-value) (.003) (.053) (.002) (.004)
Onwujekwe et al.International Journal for Equity in Health 2010, 9:22
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Page 7 of 9
data collector by the provider for interview after treat-
ment has been given. Hence, providers may have
referred only patients where they felt that they provided
good quality of treatment services.
There were inequities in the quality of malaria treat-
ment services because the better-off SES and urbanites
were treated by more qualified personnel, had better
diagnostic procedures and instructions from the provi-
ders compared to worse-off SES and rural dwellers.
This was buttressed by the results of logistic analysis
that showed a consistent positive association of SES
with all perceived quality attributes. However, in two of
the logistic models, rural residence was positively asso-
ciated with perceived quality of care. The rural dwellers
possibly perceived higher quality of treatment because
they may have lower quality expectations and so were
satisfied with the treatment that they received. Some
authors showed that poor people bear a disproportion-
ate burden of the disease and have poor health-seeking
behaviour, thus leading them to seek treatment from
low-levelproviders and avoid any from of laboratory-
based formal diagnosis [1,2,7,24-27], which consequently
increases the burden of the disease on them [28]. The
fact that the two better-off SES groups perceived higher
quality of treatment than the worse-off SES was not
surprising considering that they received higher quality
diagnosis and were treated more by more qualified
personnel.
The finding that people were least satisfied with the
services, especially diagnostic procedure and follow-up
information, at PMD and PS, the two most common
sources of treatment of malaria is an area for policy and
programme interventions especially with the current
change of first line drugs from the relatively inexpensive
chloroquine and SP to the expensive ACT so as to
decrease inappropriate drug prescribing, use, costs and
resistance to ACT.
The current change of first line drugs to expensive
ACT implies an urgent need to improve quality of
treatment in both public and private sectors. Given
that majority of low-level providers, especially patent
medicine dealers, are not trained health professionals,
the low quality of treatment found calls for interven-
tions to enhance accurate diagnosis at first attempt
and facilitate the use of appropriate drug by retailers
and to reduce overall treatment cost and possible inci-
dence of drug resistance [29]. Also, interventions are
needed to improve quality of follow-up information in
PMD, PS and PHC centres so as to decrease inap-
propriate drug prescribing, use, costs and resistance to
ACT. The interventions could include training, provid-
ing of job aides and closer supervision by malaria con-
trol managers.
Acknowledgements
The study was supported by a grant from the Gates Malaria Partnership,
London School of Hygiene and Tropical Medicine. We thank Laura Fierce for
her comments.
Author details
1
Department of Health Administration and Management, College of
Medicine, University of Nigeria, Enugu, Nigeria.
2
Health Policy Research
Group, Department of Pharmacology and Therapeutics, College of Medicine,
University of Nigeria, Enugu, Nigeria.
3
Department of Community Medicine,
College of Medicine, University of Nigeria, Enugu, Nigeria.
4
Department of
Nursing Sciences, College of Medicine, University of Nigeria, Enugu, Nigeria.
5
Department of Pharmacy, University of Nigeria Teaching Hospital, Ituku-
Ozalla, Enugu, Nigeria.
Authorscontributions
OO conceived the study, participated in the design and performed statistical
analysis. BU and EO participated in the design of the study and
coordination. IO and OCO participated in literature review and data
collection. OO drafted the manuscript. All authors read and approved the
final manuscript
Competing interests
The authors declare that they have no competing interests.
Received: 27 April 2010 Accepted: 11 October 2010
Published: 11 October 2010
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doi:10.1186/1475-9276-9-22
Cite this article as: Onwujekwe et al.: Improving quality of malaria
treatment services: assessing inequities in consumersperceptions and
providersbehaviour in Nigeria. International Journal for Equity in Health
2010 9:22.
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    • "es provided by health workers is needed to identify and correct problems associated with quality of malaria treatment services. Patients' perception of quality of care is critical to community settings; studies have shown that perceived and actual qualities of care are the determinants of health outcomes and consumer's choice of treatment provider. [10,12] Actual quality of care focuses merely on structural and process measures, relating to professionally defined standard of care, and refers to whether health care services adhere to these standards, while perceived quality of care relates to the views of patients, which are attracting more and more importance. [13] This study aimed at "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Though the fight against malaria continued to be on the increased, the disease still remains a major public health problem in many developing countries, especially in the rural areas. The extent of drug use and its effect is affected among other things by the pattern in which these drugs are prescribed by the health workers. Patients’ assessment of the quality of care depends on their ability to judge whether health care providers are adhering to the defined standard of care, hence it is necessary to assess the views of patients regarding the quality of care they received from the primary health care (PHC) centers. Aim: This study aimed at evaluating consumer’s perception of the quality of malaria treatment in PHC centers of Jos and environs. Materials and Methods: Nine PHC centers were selected by multi-stage random sampling, five from Jos North and four from Jos South Local Government Areas of Plateau State. Patients of both sexes within the age range of 18 years and above who visited the PHC centers for malaria treatment were considered eligible to participate in the survey, provided that they were able to understand and respond to the interview questions. A semi-structured interviewer questionnaire which was adapted from previous health survey studies was administered to all the 249 eligible participants. The data collected were analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0 software programmer. Results: The result showed that there were no consistently significant differences (P > 0.05) regarding patient satisfaction between male and female patients across selected items in the various domains, that is, irrespective of respondents’ sex, their perception of the quality of health services rendered by PHCs was similar. Conclusion: It was therefore concluded that there was similar satisfaction level between the male and the female, though some key health services were not readily available in the PHC; most services that were available were readily accessible.
    Full-text · Article · Jul 2015 · PLoS ONE
    • "Differential treatment seeking for malaria in South-East Nigeria has been reported through a number of household surveys3456. These studies have found that those from poorer households attend low level and informal providers, or may not seek treatment at all [4,7,8]. These low level providers have often been associated with substandard practices including poor counselling, incorrect dosing, misdiagnosis and the use of less effective drugs [9,10]. "
    [Show abstract] [Hide abstract] ABSTRACT: Ensuring equitable coverage of appropriate malaria treatment remains a high priority for the Nigerian government. This study examines the health seeking behaviour, patient-provider interaction and quality of care received by febrile patients of different socio-economic status (SES) groups. A total of 1642 febrile patients and caregivers exiting public health centres, pharmacies and patent medicine dealers were surveyed in Enugu state, South-East Nigeria to obtain information on treatment seeking behaviour, patient-provider interactions and treatment received. Socioeconomic status was estimated for each patient using exit survey data on household assets in combination with asset ownership data from the 2008 Nigeria Demographic and Health Survey. Among the poorest SES group, 29% sought treatment at public health centres, 13% at pharmacies and 58% at patent medicine dealers (p < 0.01). Very few of those in the richest SES group used public health centres (4%) instead choosing to go to pharmacies (44%) and patent medicine dealers (52%, p < 0.001). During consultations with a healthcare provider, the poorest compared to the richest were significantly more likely to discuss symptoms with the provider, be physically examined and rely on providers for diagnosis and treatment rather than request a specific medicine. Those from the poorest SES group were however, least likely to request or to receive an antimalarial (p < 0.001). The use of artemisinin combination therapy (ACT), the recommended treatment for uncomplicated malaria, was low across all SES groups. The quality of malaria treatment is sub-optimal for all febrile patients. Having greater interaction with the provider also did not translate to better quality care for the poor. The poor face a number of significant barriers to accessing quality treatment especially in relation to treatment seeking behaviour and type of treatment received. Strategies to address these inequities are fundamental to achieving universal coverage of effective malaria treatment and ensuring that the most vulnerable people are not left behind.
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    • "Data from customer exit surveys showed that customers seeking care for children purchased an average of 6.8 drugs, with 55% purchasing non-essential drugs to treat malaria, acute respiratory infections, and diarrhea, resulting in an average additional and unnecessary expense of USD 1.09 to 2.19 per illness episode [77]. Customers infrequently consulted PPMVs about illness diagnosis, and PPMVs reported that they infrequently asked their customers about their illness history or conducted examina- tions [62,64,70,75] . Observational data and client exit surveys indicated that discussions of illness history occurred in 19% to 32% of encounters [21,57], although nearly a quarter of PPMVs reported that they would ask to see the sick child if she was not present at the shop [75]. "
    [Show abstract] [Hide abstract] ABSTRACT: Interventions to reduce the burden of disease and mortality in sub-Saharan Africa increasingly recognize the important role that drug retailers play in delivering basic healthcare services. In Nigeria, owner-operated drug retail outlets, known as patent and proprietary medicine vendors (PPMVs), are a main source of medicines for acute conditions, but their practices are not well understood. Greater understanding of the role of PPMVs and the quality of care they provide is needed in order to inform ongoing national health initiatives that aim to incorporate PPMVs as a delivery mechanism. This paper reviews and synthesizes the existing published and grey literature on the characteristics, knowledge and practices of PPMVs in Nigeria. We searched published and grey literature using a number of electronic databases, supplemented with website searches of relevant international agencies. We included all studies providing outcome data on PPMVs in Nigeria, including non-experimental studies, and assessed the rigor of each study using the WHO-Johns Hopkins Rigor scale. We used narrative synthesis to evaluate the findings. We identified 50 articles for inclusion. These studies provided data on a wide range of PPMV outcomes: training; health knowledge; health practices, including drug stocking and dispensing, client interaction, and referral; compliance with regulatory guidelines; and the effects of interventions targeting PPMVs. In general, PPMVs have low health knowledge and poor health treatment practices. However, the literature focuses largely on services for adult malaria, and little is known about other health areas or services for children. This review highlights several concerns with the quality of the private drug retail sector in Nigeria, as well as gaps in the existing evidence base. Future research should adopt a more holistic view of the services provided by PPMV shops, and evaluate intervention strategies that may improve the services provided in this sector.
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