The study aimed at assessing the effect of COVID-19 on treatment of pediatric febrile illnesses by registered private drug sellers in East-Central Uganda. Four major themes namely: Treatment practices, Logistics, Living standards and collaboration between government and private sector arose from the study.
The lock down affected drug seller treatment of febrile children in that because many parents were not able to work and earn a living as it had been before lock down, it was not easy to afford even the most basic drugs like fever reducers. This forced drug sellers to refer febrile children to public health facilities which give out free drugs or in some instances, parents were forced to take incomplete doses of drugs since that is what they could afford. In more extreme cases, the drug sellers gave drugs on credit. This resulted into heavy losses on the side of drug sellers since parents were not in position to pay back. In fact, in some areas, the drug sellers abandoned the business since they could no longer break even.
“The lockdown brought too much poverty in that most parents would not even afford paracetamol. As such, the children were referred to health centers or we would give medicines on credit which made us make so many losses. There was also the problem of taking incomplete doses and this affected the treatment of children and some died because of poor treatment.” (Participant 3, FGD 2, Nursing assistants)
Most of the enrolled nurses intimated that an elevated temperature was the most prevalent symptom among children reporting to drug shops for medical treatment before and during the lock down period. They also mentioned that besides using the symptoms observed in children for differential diagnosis, they used malaria rapid diagnostic tests to differentiate whether the elevation in temperature was due to malaria or not. Where the mRDT turned negative but the child still had a high fever, the enrolled nurses referred such children to higher level health facilities such as health Centre IIIs , IVs or even the regional referral hospital.
“Just like my elder has mentioned, cases were more for malaria and so the knowledge you gave us of using malaria rapid diagnostic tests before treating any fever helped us a lot. When the children were badly off, we would refer them to a health center three or four whichever is nearer. In some instances, we would refer them to Iganga regional referral hospital.” (Participant 2, FGD 1, Enrolled nurses)
As far as the key informants were concerned, most of them felt that drug seller treatment practices were challenged by the fact that it was difficult to differentiate pneumonia arising from COVID-19 from the usual community pneumonia. This further complicated treatment because most patients were referred when it was too late and needed critical care. Whereas children showed mild symptoms, it is the adults who were most affected. Those adults whose immunity was low ended up in regional referral or even the national referral hospital.
“I think they[drug sellers] found a lot of challenges in differentiating the two[COVID-19 pneumonia from community pneumonia] and even in adults we got late referrals where we would find that people would be referred very late and when we would do a rapid test, they would be COVID-19 positive. In addition, we would find that for some of them, it would be too late for their management. So generally, there was a challenge of differentiating between COVID-19 pneumonia and the common pneumonia other than COVID-19” (Key informant, Luuka District)
Most of the nursing assistants in the focus groups said that during lock down, the number of patients decreased. This is because most of the patients could not access the drug shops for treatment because of restricted movements imposed by the Ugandan government. In addition, some patients needed follow up visits but because of the restricted movement, the follow up visits were not possible. As such, many clients were lost during the process which reduced the income of many drug sellers.
“For me, before COVID came, we used to have many patients. However, when COVID came, the numbers reduced. Customers would ask us to check on them but we lacked transport. Movement from one district to another was not easy. Generally COVID brought us a lot of worry and fear and there was a lot of poverty in our land that we could do nothing. Even the strength to do anything just failed us. We were not doing business, we could not buy new stock, we had no strength to dig and so it brought us a lot of difficulty.” (Participant 6, FGD1, Nursing assistants)
Majority of the enrolled nurses said that the logistics of getting drugs from the big pharmacies in larger towns to the rural drug shops were very complicated in that transport prices were doubled. The doubling of transport prices meant that the end users of these drugs in the rural areas also had to pay a lot more than the usual prices. This was complicated further by the fact that the motor bike riders had to pay bribes in order to get passed mounted road blocks on major high ways. These bribes also had to be factored in the final cost of the drugs which made them almost unaffordable by the rural folks.
“For us, we would send the boda boda [commercial motorcycle] to pick up the drugs. However, the cost of transport was so high resulting into a higher cost of drugs. From Kiyunga to Iganga used to be 4,000/- [approximately 1.2 United States dollars] but during lock down, we would pay 8,500/- [approximately 2.4 United States dollars]. Some boda boda would even ask you to give them more money to bribe the police along the way especially if the journey had to include crossing into another district.” (Participant 2, FGD 2, Enrolled nurses)
The key informants said that the lock down due to COVID-19 had complicated the issue of transport in general and logistics in particular. They said that many drug sellers were not able to move from one place to another to re-stock drugs that were in short supply because of government restrictions to movement. The drug sellers also found it difficult to access their work places if they stayed in localities far from where they worked.
“When COVID-19 came in- the first lockdown, movement was difficult. Some of the drug sellers could not open their drug shops. I can give an example of a drug seller who had a drug shop in Bwaise but stayed in Mpigi. It meant that he could not move from his place of residence [Mpigi] to his place of work [Bwaise] to open his drug shop.” (Key informant, NDA)
Drug sellers in the FGDs that were composed of nursing assistants said that the number of children during lock down decreased tremendously. This is because many parents feared that by taking their children to drug sellers, they would catch COVID-19. On the other hand, the drug sellers also feared that parents with sick children would bring COVID-19 to them. This lack of trust by either party meant that the number of children going to drug shops for treatment decreased sharply during lock down. This fear was augmented by the fact that at the onset of COVID-19, health workers in public health facilities were the ones receiving the most up-to-date training on how to handle affected patients. There was little or no training going on in private health facilities. On the contrary, few drug sellers said that there was no difference in the number of children seeking care from drug shops before and during lock down.
So, while the living standards of most drug sellers were affected by the decrease in the number of patients seeking treatment from drug shops leading to reduced income, a few drug sellers experienced no change.
“For me what I noticed, before the lock down we used to get a big number of children. However, during the lock down the numbers reduced. We got into a situation where people feared to come for treatment. We also feared because we wondered how we were going to treat a sickness whose signs we were not sure of. We also feared that we could also easily contract the sickness. So, I realized that the numbers reduced.” (Participant 8, FGD2, Nursing assistants)
“The numbers were similar to the earlier times [before lock down]. There was no significant change.” (Participant 1, FGD1, Nursing assistants)
Similar to what the nursing assistants experienced, most of the enrolled nurses in rural areas intimated that the number of children had reduced during lock down compared to the period before lock down. This is because during lock down, many people including parents of children less than five years experienced a reduction in income. As such, they opted for half and or incomplete doses for treatment of febrile illnesses which translated to inappropriate treatment.
Conversely, enrolled nurses in the more urban areas said that they experienced an increase in business. This is because while curfew which was intended to curtail the movement of people was more severe in the rural areas, it was a bit more relaxed in the urban areas. As a result, more children were treated in the urban areas during lock down leading to more income for drug sellers since parents would easily walk to the drug shops for treatment even passed curfew hours. This greatly improved the living conditions of drug sellers in the urban areas.
“In my area, the number of children reduced very much. This was because people had no money and there was a lot of poverty. Them because people did not have money, they would not finish the dose. The other challenge was that the caretakers were not keen to follow instructions and they would miss administering the medicine on time which affects the way the medicine works.” (Participant 3, FGD 2, Enrolled nurses)
“Now for me am in an urban area so when they put curfew at 7pm, I got many customers at that time. The urban area is not like the village since people come for treatment on their way from work. We tried to treat children as we had masks and the masks were still new. So for me the numbers did not reduce as I continued to treat malaria cases even during covid.” (Participant 2, FGD 1, Enrolled nurses)
The key informants said that prior to the commencement of lock downs, the number of febrile children seeking medical attention from drug sellers was high. As such, this made a lot of business sense for the drug sellers to keep their drug shops open. Moreover, prior to the lock downs, drug sellers had been trained on how to manage children with febrile illnesses in an integrated manner. The drug sellers had also been trained on how to use malaria diagnostic tests to rule out malaria, observe for diarrhea and bow to count the number of breaths per minute for a particular age group while assessing febrile children before administering antibiotics for pneumonia treatment. This triaging of patients before administering treatment improved the image of the drug sellers, increased income and ultimately improved the living standards of drug sellers in Luuka district before the lock downs.
“In relation to treatment of children below 5 years being treated before lockdown, it was easy for drug sellers. This is because they were knowledgeable about the treatment of different conditions of children especially those that cause high morbidity and mortality like malaria, pneumonia and diarrhea. Treatment was easy since the drug sellers had training in integrated management of childhood illnesses (IMCI). So prior/before the lockdown I imagine the numbers [of children seeking treatment] were high.” (Key informant, MoH)
Collaboration between government and private sector
Majority of drug sellers that were involved in the focus group discussions mentioned that during lock down, government did not offer any subsidies to support their businesses. Instead, government intensified the crackdown on drug shops which did not have up-to-date licenses as well as illegal drug shops. This greatly reduced the number of service providers at the time they were needed most. For those that were able to operate having fulfilled the statutory requirements, government did not provide any personal protective equipment which may have included gloves, masks, sanitizer and covid suits. This lack of collaboration between government and the private sector that manifested as a lack of support for private health facilities may have been partly to blame for deaths that would have otherwise been avoided.
“The government did not give us any help. Instead, they would come to close us because of license and yet, during lock down we were not working. Government does not want us. So, instead of helping us, they come to close our drug shops. During lock down, there was a lot of poverty among the communities and things were very expensive because of transport. The government really treated us badly.” (Participant 1, FGD2, Nursing assistants)
“No, we did not get any help from government. We were really affected because drugs became very expensive making the already bad situation even worse. Piriton prices went up, vitamin C went up and all other drugs. There was no assistance at all. You see, even free government masks did not get to our village.” (Participant 4, FGD 2, Enrolled nurses)
All the key informants alluded to the fact that the most COVID-19 services were a preserve of the government during the first and second lock down period. As such, most, if not all processes had to be dispensed through public health facilities. Covid sample collection was done by health workers in public health facilities after which the samples were taken to a central collection point in the district before they were dispatched off to the central processing lab. Many private health providers were not in sync with this system and as such, were excluded from most of the covid testing and denied a chance to offer early treatment. This lack of concerted effort between the public and private sector is what many have pointed out as what could have led to a higher than expected mortality.
“COVID-19 samples for PCR testing used to be sent using the hub system. In this process, we used to collect samples, put them at a certain hub and then transportation would start from there. So, because of that, private facilities were not involved since they are not directly linked to hubs. Also, private facilities did not have sample collection kits. Even when we received rapid test kits that were meant to be used only on symptomatic patients, we were given instructions that these test kits should not cross to the private sector.” (Key informant, Luuka District)