The private sector has tremendous potential as part of an approach to reduce child mortality by ensuring greater public access to child health-related medicines.

However, because the private sector provides services in a relatively uncontrolled environment, when compared with the public sector, care and medicine quality can be compromised. Poor practices may at times result from lack of knowledge. The economic incentives that drive the private sector may also conflict with appropriate and adequate care and treatment.

Increasingly, organizations and governments are recognizing the potential of the private sector for reducing child mortality and are designing (usually small-scale) interventions using providers in the private sector to increase access to pharmaceuticals.

As the first step in developing a strategy to enhance access to and appropriate use of medicines for child health through the private sector, the RPM Plus Program conducted a systematic literature review. This review documents the results from a broad array of interventions in the private sector—primarily in medicine outlets—used either singly or in combination.

RPM Plus identified these interventions as potentially contributing to greater access to medicines—

• Prepackaged medicines
  
  Using prepackaged medicines in some circumstances can be an effective mechanism to improve the quality of medicines for the treatment for childhood malaria and pneumonia and can also increase patient adherence and rational use of medicines.
  
  
• Short duration, one-on-one information sharing ("detailing"), peer-to-peer, or vendor-to-vendor type training, and behavioral change interventions
  
  Evidence shows that short duration (usually less than 20 minutes direct contact time) training interventions, such as one-on-one information sharing or "detailing," can contribute to improved prescribing and dispensing of appropriate medicines for childhood illness in the private sector.
  
  
• Short duration interventions to create community demand
  
  Indications are that interventions to create community demand may be effective only in combination with other interventions. The relative effectiveness of neighbor-to-neighbor interventions, interactive group discussions between shopkeepers and community members, and short duration shop visits by community members should be compared to identify which method produces the greatest coverage and adherence.
  
  
• Oversight and regulation through intermediaries
  
  Evidence suggests that enforcement interventions can improve access to and rational use of appropriate medicines for childhood illness in the private sector; for example, regulation and enforcement are essential in reducing the inappropriate use of antibiotics for childhood pneumonia. However, regulatory agencies are finding it increasingly difficult, if not impossible, to oversee and regulate the rapidly increasing numbers of private-sector pharmacies and retail drugstores.
  
  
• Franchising and accreditation
  
  Both franchising and accreditation share the premise that quality control, standardization of inputs and practices, and strong management and regulatory oversight can, in combination, lead to increased access to quality pharmaceuticals. Though evidence is insufficient now, preliminary findings indicate that these private-sector mechanisms can improve the availability of essential pharmaceuticals. Evaluations are expected to show that these interventions are effective, and efforts will be made to adapt them for use on a larger scale.
  
  
• Contracting
  
  Contracting the delivery of health services between governments or agencies and nongovernmental organizations or private for-profit providers can be a suitable way to improve access to medicines for childhood illness in the private sector. When governments contract out health services, the contract deliverables can include effective treatment of childhood malaria, pneumonia, and diarrheal disease, as well as vitamin A and zinc supplementation.
  
  
• Incentives
  
  Some evidence indicates that incentives can be used to promote and shape appropriate behavior of health service providers and clients. Incentives can be combined with other types of interventions and in-service contracting situations, where the use of incentives toward effective performance can be written into the contract. Likewise, targeted subsidies to the poor, such as voucher schemes or direct cash grants, are types of incentives that still need to be evaluated and, if shown to work, replicated widely.

Based on our systematic review of previous private sector work, RPM Plus developed a strategy for interventions in the private sector. A child health component has been integrated into the Accredited Drug Dispensing Outlet (ADDO) program in Tanzania. The ADDO program, which is administered by the Tanzanian Food and Drugs Authority (TFDA), created retail medicine outlets, called Duka La Dawa Muhimu (Swahili for “essential drug shop”) that must adhere to standards related to product and service quality to achieve and maintain government accreditation.

The child health intervention package seeks to maintain and improve the quality of care provided by the ADDOs with a particular focus on child health. The package [PDF - 349 KB] includes a module for the ADDO training and mechanisms to strengthen community demand creation, oversight, regulation and monitoring and evaluation. One part of the community mobilization strategy is to get community leaders, district officials and radio journalists together to produce radio spots that will encourage better illness prevention and care seeking practices for children when they are ill focusing on malaria, diarrheal diseases and acute respiratory infections. Two radio workshops have been held resulting in 17 radio spots and one song.

RPM Plus has been working in partnership with the Basic Support for the Institutionalizing Child Survival (BASICS) project on the design and implementation of this package. The child health private sector interventions will be incorporated into the Ministry of Health rollout plan for the ADDOs. To date, more than 1,373 dispensers in
four regions have been trained to deliver child health services.

In 2006, complementary assessments were conducted and results served as a basis to develop and integrate the child health component within the ADDO program. Improving Child Health through the ADDO Program: Baseline Survey from Five Districts in Tanzania presents quantitative findings and recommendations based on ADDO dispenser interviews, record reviews, simulated client scenarios and a household survey. Findings highlight the knowledge and practices of ADDO dispensers, availability of key medicines and practices and beliefs of caretakers regarding treatment of sick children. Improving Child Health through the ADDO Program presents qualitative findings and recommendations based on formative research.

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