Patent medicines vendors
a resource for tuberculosis case
detection.
Presenting Author: Obi, I E,
Co Author: Onwasigwe C. N.
Department of Community Medicine, University of Nigeria
Teaching Hospital (UNTH), P. M. B. 01129, Enugu, Nigeria.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
BACKGROUND

The Patent and Proprietary Medicine Vendor (PPMV) is a person
without formal pharmacy training who sells orthodox pharmaceutical
products on a retail basis for profit.

This does not make the PPMV a health care provider, but the PPMV
enterprise is the primary source of orthodox drugs for both urban and
rural populations in developing nations.

In a state in Nigeria there were 600 doctors, 3000 nurses, 200
pharmacists and 4000 PPMVs.

70 to 200 people visit patent medicine stores per day and 25% of
customers see the PPMV as a source of advice and information
about their illness.

A significant proportion of patients with tuberculosis would have first
consulted these PPMVs.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Background

The effective medical strategy for tuberculosis control, remains case
detection and Directly Observed Therapy Short course (DOTS)

A person with a cough of three weeks duration is a pulmonary tuberculosis
case suspect.

The median delay between onset of cough and diagnosis of tuberculosis is 8
weeks.

Tuberculosis case detection even in areas served by DOTS has been
constant at about 52 percent.

Providing basic information about the earliest symptoms of tuberculosis and
directing suspects for diagnosis can increase coverage.

There is a need to educate communities and non-orthodox care providers of
the importance of early and accurate diagnosis and treatment of
tuberculosis.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Background

Failure to involve all care providers used by tuberculosis suspects
and patients hamper case detection, delay proper diagnosis, cause
inappropriate and incomplete treatment, increase drug resistance
and place a increase financial burden on patients.

There is the challenge of involving private health-care providers in
National Tuberculosis Programs

In Bangladesh, ‘village doctors’ a mixed informal health provider
group trained to refer customers to tuberculosis diagnostic services
and to institute DOTS in their community, made an input of 10% of all
cases referred to the tuberculosis diagnosis and treatment service.

Training can lead to PPMVs contributing to tuberculosis control
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Background
General Objective:
 To determine the effect of training of PPMVs on referral to a
tuberculosis diagnostic and treatment service.
Specific Objectives:
1. To determine the referral input from PPMVs on new clients
presenting with cough at tuberculosis diagnosis and treatment
service centers.
2. To determine the effect of training on the knowledge of PPMVs
of a suspect case of pulmonary tuberculosis.
3. To observe the post intervention referral input from PPMVs on
new clients presenting with cough at a tuberculosis diagnosis
and treatment service.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Methodology

A training intervention on PPMVs in Enugu North local government area
(LGA), Nigeria, with PPMVs in Nkanu West another LGA, same state as
control.

Six month study period from June to December 2007.

Data on the source of referral from 78 new clients with cough were collected
from tuberculosis diagnosis and treatment services, in the study and control
areas over a two month period.

Knowledge on recognition of a suspect case of pulmonary tuberculosis was
assessed in 159 PPMVs in the study and control areas.

The study group was trained (by lecture and role play) on the recognition
and referral of a suspect case of pulmonary tuberculosis and issued prewritten referral notes to facilitate referral to the tuberculosis diagnostic and
treatment centre in the study area.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Methods

The control group received a health talk on recognition of a case of
diarrhea, benefit and method of early rehydration with oral
rehydration salt or salt sugar solution.

Information on the source of referral from 111 new clients with cough
were collected from the same tuberculosis diagnosis and treatment
service centers, over the next three month period.

knowledge of a suspect case of pulmonary tuberculosis was reassessed among the PPMVs, after the three month period.

The referral input of new cases from different sources in both areas
and any change in the knowledge of a suspect case of pulmonary
tuberculosis among the PPMV were analyzed using SPSS version 11.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Results
Fig 1: Educational status of Patent and Proprietary Medicines
vendors
47
50
41
40
Number
24
30
10
13
12 12
20
0
0
0
None
Primary
Secondary
Educational status
Study group
Post
Secondary
Control group
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Percentage
Fig 2: Referral source (new patients) study area DOTS service
80
70
60
50
40
30
20
10
0
75
65.9
15.6 17.6
8.2
0
Government
Hospital
Private
Hospital
PPMV
4.7 1.2
4.7 7.1
Mission
Hospital
Self Referral
referral source
Pre intervention
Post intervention
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Fig 3: Referral Source (new patients) control area DOTS
service.
70
64.3
Percentage
60
50
48.3
41.4
40
30
21.4
14.3
20
6.9
10
0
0
0
3.4
0
Government
Hospital
Private
Hospital
PPMV
Mission
Hospital
Referral Source
Pre intervention
Post intervention
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Self Referral
Fig 4: Pre Test Performance in study group
PPMVs
77.7
80
70
60
50.8
49.2
50
Percentage 40
30
22.3
20
10
0
Post Intervention
Pre intervention
Correct
Incorrect
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Fig 5 : Pre Test performance in control group
PPMVs
54
52
54
52
50
48
46
Percentage 48
46
44
42
Pre Intervention
Correct
Post Intervention
Incorrect
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Fig 6: Sputum smear result in Patients referred by the PPMVs to
DOTS service in study area
29%
71%
Positive
Negative
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Discussion

All the patent and proprietary medicines vendors in this
study had basic primary education. (Fig 1) Studies have
reported same.

As in this study (Fig 5), others have shown that this level of
education does not confer on the PPMVs correct
knowledge about the common illnesses experienced by
their customers, hence they cannot be classified as being
of the formal health sector but of the informal.

PPMVs do not refer patients to DOTS centres. (Fig 3)
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Discussion

PPMVs knowledge of a suspect case of pulmonary tuberculosis
improved with training. (Fig 4) Studies abound showing that training
of PPMVs, drug dispensers or paramedical prescribers have resulted
in improvements in their knowledge of disease conditions and the
correct actions towards alleviating the symptoms of their clientele.

The PPMV can be engaged to refer tuberculosis suspects identified
by simple symptoms to formal health services for proper diagnosis
and treatment. (Fig 2)

As seen in this study also (Fig 5), training PPMVs could yield quality
contribution to tuberculosis control.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Conclusion

A public private mix linked by referral between
PPMVs and national tuberculosis programs,
could be possible.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009
Thank you
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)
Accra - Ghana, 10th - 12th March 2009