About half of over five million annual global deaths of children under five years old occur in sub-Saharan Africa [1
]. In Uganda, despite some progress, the under-five mortality stands at 46 deaths per 1000 live births. This is above the Sustainable Development Goal (SDG) target 3–25 deaths per 1000 live births [1
]. Like other resource-limited settings, the main causes of deaths among children in Uganda are pneumonia, malaria, diarrheal diseases, and neonatal conditions. These conditions are preventable and reversible if timely appropriate treatment is instituted [4
]. Evidence-based low cost interventions to mitigate child deaths offered at community level and primary level health facilities have been described, including preventive interventions and curative interventions, such as antibiotics for pneumonia, zinc therapy and oral rehydration salts (ORS) for diarrhea, early identification of danger signs and referral of newborns for appropriate treatment, prompt diagnosis and treatment of malaria with artemisinin-based combination therapies [8
]. These interventions can be offered by public and private lower level health facilities, and a recent modelling study at community level demonstrated that they could reduce child mortality significantly [13
Private health facilities offer an important service, filling the gaps in healthcare delivery in Uganda, with over 50% of sick children being first treated by primary level private health facilities [14
]. In low-income countries (LIC), especially in semi-urban and rural areas, private health facilities range from unregistered small drug shops, to registered clinics manned by mid-level health workers, and often only a few have the basic prerequisites to provide good quality health care [15
]. Kruk et al. in their study on variation in quality of primary-care in seven African countries including Uganda showed that private facilities performed better than public facilities [18
]. On the other hand, a study done in rural Uganda showed no difference in the quality of care for sick newborns in private practice compared to public facilities [19
]. Healthcare is said to be of good quality if it increases the likelihood of desired health outcomes and is consistent with current professional knowledge [20
]. Many lower-level private health facilities in rural Uganda are unregistered, often operated by inadequately trained health providers and may not be regulated by the Ministry of Health (MoH) [21
The Integrated Management of Childhood Illnesses (IMCI) is a strategy that can be used to deliver interventions for common childhood conditions, improving health worker skills and reducing mortality among children less than five years of age [24
]. Managing several conditions in an integrated manner saves time and ensures all conditions are treated without missing or delaying treatment [28
]. In Uganda, IMCI was implemented nationally in 1995, and had been rolled out throughout the country by 2003. It was adapted as a pre-service course for health workers, including nurse assistants, and eventually modules for community IMCI and IMCI for private practitioners were introduced [29
We assessed the appropriateness of care for common infections in under-five year old children with emphasis on pneumonia, malaria, diarrhea, and young infants with possible serious bacterial infections (PSBI) by healthcare workers at low-level private health facilities (LLPHF) in Mbarara District in Western Uganda. We also explored the perceptions of policymakers and healthcare providers on the quality of care provided. We used Integrated Management of Childhood Illnesses (IMCI) guidelines [30
] as the reference standard. Appropriateness of care is a measure of the technical quality of healthcare. Together with the assessment of the range of services offered, counselling quality, and promotion of continuity of care, they comprise the process domain of the Donabedian framework for quality of healthcare [31
We visited 120 private clinics, 110 of which fulfilled the enrolment criteria, and observed 777 medical consultations, an average of seven consultations per health facility. Over 70% of the consultations took place in facilities at the level of HCII or below. Only 10% of the consultations took place in facilities headed by medical doctors. The median age of the health workers who carried out the consultations was 27 years (IQR 24, 33) and median period in service was 3.4 years (IQR 2.0, 9.6). The characteristics of the health facilities in which the study took place and health workers are shown in Table 2
The majority of the consultations were carried out by health workers who had not had any refresher training in IMCI nor other stand-alone refresher trainings in the management of common childhood illnesses in the past 6 years as shown in Figure 2
The mean age of the children was 24 months (SD 16.0). Fever was present in 549 (71%), cough in 469 (60%), while 146 (19%) children had danger signs. The clinical presentation of the children is shown in Figure 3
while their demographic characteristics, as well as those of their caretakers are in Table 3
Most of the caretakers were peasants with a median monthly income of Uganda shillings 100,000 (IQR 30,000, 300,000), approximately 27 USD and 47% had attained at most primary school education.
3.1. Management of the Sick Children by the Health Workers
The management was said to be appropriate if all identification, classification, and treatments were done correctly. As shown in Table 4
, the clinical conditions were correctly identified in the majority of the consultations but wrongly treated. Among the 18 children deemed to have possible serious bacterial infections, only one was identified by the health workers as such. All conditions were inappropriately managed in over 80% of the consultations.
3.2. Factors Associated with Child Receiving Appropriate Care
shows the regression analysis for factors associated with appropriate care. Several factors including caretaker age >25 years, rural location of the health facility, and clinical conditions that the child presented with were associated with the appropriateness of care at univariable analysis. However, after controlling for interaction and adjusting for confounding in the multivariable analysis, only the presenting clinical condition was associated with appropriateness of care received. The care was less likely to be appropriate for children with diarrhea (OR 0.29, 95% CI: 0.11–0.76, p
= 0.012), as well as those able to feed orally (OR 0.07, 95% CI: 0.03–0.13, p
< 0.001). The care was likely to be appropriate among more severely ill children with danger signs including those who were vomiting everything (OR 10.1, 95% CI: 4.41–22.1, p
< 0.001), had seizures (OR 7.54, 95% CI: 2.97–19.1, p
< 0.001), or were lethargic or had impaired consciousness (OR 4.42, 95% CI: 1.03–19.1, p
3.3. Perspectives of Policymakers and Health Workers on Quality of Care Offered by LLPHF
During the same period, we carried out individual interviews with 30 healthcare workers and 13 policymakers to find out what they thought about the care given by LLPHFs. The main finding was health care being inappropriate. This is described in four subcategories and these results complement the quantitative results that show high level of inappropriate health care.
Referral of patients with severe conditions may not be timely
Inadequate infrastructure exacerbates inappropriate healthcare provision
The care is not patient centered but rather is driven by desire to make money or please the caretaker
Existing guidelines are not followed, leading to mismanagement patients
3.4. Referral of Patients with Severe Conditions May Not Be Timely
Participants confirmed that LLPHF mainly handle children with uncomplicated illnesses and should refer the severe cases, however some facilities delay referrals and in the long run mismanage such patients.
“Most of the low-level private clinics treat minor conditions, like simple coughs, malaria, pneumonias, they should not manage serious illnesses, as these should be referred to higher levels. The challenge is some facilities wait and only refer the child in very late stages.”
(Male policymaker, DHO)
“Here we mostly handle outpatient clients and a few in patients especially when conditions don’t require us to refer. To give examples we handle simple malaria, we handle respiratory infections including pneumonia because our facility is categorized as health center III.”
(Male nurse, rural clinic)
3.5. Inadequate Infrastructure Exacerbate Inappropriate Healthcare Provision
Most of the LLPHF have minimum infrastructure and inadequately trained staff. Many do not have proper laboratories and rarely carry out investigations, which often make the provision of appropriate care difficult.
“It is expensive paying an enrolled nurse….so they prefer to hire nursing aids, who you can pay little money. You find expired reagents and untrained lab personnel simply picked because they are relatives to the owner of the clinic. The fridges are not functional, instead, they just put water in the bucket and put reagents and they refer to that as a fridge. So how do you expect to find a correct result….?”
(Female policymaker from DHO)
“Most of us don’t carry out investigations so when the patients come with cough you give septrin (Cotrimoxazole), amoxicillin, plus Panadol (paracetamol) if the fever persists that is when the child may be taken for testing somewhere…..”
(Female nurse, rural clinic)
The care is not patient-centered but is rather driven by the desire to make money or please the caretaker. Often patients do not receive appropriate care because they are given unnecessary medications even for simple illnesses. This is said to be driven by the desire to make money and in some instances the unprofessional behaviors stem from the urge to satisfy the caretaker instead of the condition of the child.
“People want money; some may provide unnecessary treatment to make the treatment list very big and then get more money. I witnessed that behavior several times in one of the clinics I previously worked for.”
(Male clinical officer, rural clinic)
“There is irrational use of antibiotics in private clinics partly because it is always difficult to explain to the mother that the child’s simple cough does not need an antibiotic…. Sometimes you give that higher antibiotic to impress the mother but of course knowing that you are not doing the right thing. Unfortunately the children somehow have been mismanaged, the facilities have learnt the fact that if you don’t inject you don’t get the money.”
(Male doctor, urban clinic)
3.6. Existing Guidelines Are Not Followed, Leading to Mismanagement of Patients
Participants noted that even if national guidelines for managing childhood illnesses exist, they are not utilized by all LLPHF. This is either because the health workers at the LLPHF often do not have access to the guidelines, they do not know about their existence, and have not been trained on their use, or they just do not bother to follow these guidelines. In the long run, there is mismanagement of children and misuse of medicines.
“We sometimes attend conferences where they elaborate the new clinical guidelines that come up. Some of us follow the guidelines but many others do not. When they see someone has a fever, has a complication they start off by pumping the drugs.”
(Male doctor, urban clinic)
“When we are assessing these children we use the knowledge we acquired from school but we have not been given any guidelines to use; that is the challenge.”
(Male clinical officer, rural clinic)
Some other participants, however, intimated that the services varied from clinic to clinic and that because of competition, the LLPHF endeavor to provide fair services, otherwise they lose their clientele.
“The services are fair….if the child is taken to the facility and is not well managed in the next one day will be moved to the next health facility for better services….we are in town and they can easily get to a number of facilities around.”
(Male doctor, urban clinic).
We assessed appropriateness of care and associated factors for children aged ˂5 years presenting with pneumonia, malaria, diarrhea, or possible serious infections at LLPHF in Mbarara, and explored how the policymakers and healthcare providers perceived the quality of care provided. We found that majority of children presenting with these common childhood infections were not managed appropriately. While pneumonia, diarrhea, and malaria were diagnosed correctly in most of the consultations, often the given treatment was wrong. Almost all infants with a possible serious bacterial infection were wrongly diagnosed and treated. Children who had danger signs, especially vomiting everything, seizures, and lethargy or impaired consciousness were more likely to receive appropriate medical care, while those who were able to feed orally were more likely to receive inappropriate care. The qualitative results complemented the quantitative results and showed that policymakers and the health workers perceived the healthcare provided by LLPHF as inappropriate because guidelines were not being followed and the care was often driven by the desire to make money or please the caretaker than the clinical needs of the patient.
While pneumonia, diarrhea, and malaria were identified correctly according to IMCI guidelines, the wrong treatment was often administered either by giving unnecessary medications, the wrong medicine, or omitting important medications, which translated into inappropriate care of the conditions. This is contrary to the standards set by the WHO in 2018, which require that all sick infants, children with cough, diarrhea, or fever are thoroughly assessed, classified, and given correct medications for the condition [43
]. Inappropriate care for these common childhood infections has been described by other researchers in Uganda and other LMICs. Mbonye et al. in their research among private clinics and drug shops found that children with normal respiratory rates received unnecessary antibiotics for pneumonia [44
], while Kjaergaad et al. found inappropriate prescription rate of antibiotics for viral upper respiratory tract infections of 23–68% in Uganda and other countries across the globe [45
]. Other studies carried out in private and public health facilities in Uganda and other African countries found that 7–24% children testing positive for malaria never received the correct malaria medicine [46
]. In a study from Nigeria, over 85% of children with watery diarrhea were given unnecessary antibiotics, while in a study from Ethiopia, the assessment, as well as treatment of children for cough, fever, and diarrhea in clinics was of poor quality [48
]. In our study, it is probable that the health workers were able to diagnose the conditions using the knowledge they had from their professional training since the presentation of the conditions remains the same. On the other hand, treatment of diseases is updated often as better tools become available and new evidence emerges, necessitating policy change. If the dissemination of new policies is not carried out in tandem with their introduction and refresher training, the health workers may continue giving the old treatments because they have not acquired the new knowledge. In addition, even if the new knowledge is passed on, it would take some time for people to change the behavior they are used to. This therefore necessitates supportive supervision or a closer follow up by the policy implementation team at the district. The LLPHF are often left out in refresher training and in addition often do not have access to current treatment guidelines [15
]. The fact that young infants with possible serious bacterial infections were wrongly diagnosed and consequently inappropriately treated could be explained by the limited knowledge of diseases affecting young infants, an area needing specialists, yet the health workers at LLPHF are mostly of a lower cadre. A community inquiry carried out in the same region and central Uganda as well as Mali also identified mismanagement as cause of deaths among newborns [53
]. A recent research policy working paper by the World Bank highlighted the lack of clinical knowledge as a major barrier to quality care provided by health facilities in 10 African countries including Uganda [54
Children without danger signs were more likely to receive inappropriate medical care while those with danger signs were more likely to receive appropriate care. Most patients who present to these LLPHF have mild illness, however they are administered with medication that should be reserved for severe cases. They, for example, do not need antibiotics for a mild cough, nor need injections for nonsevere pneumonia or uncomplicated malaria. They are able to swallow and should be given oral medications where necessary, not injections. For children with danger signs, this may be justifiable thus the treatment will be appropriate. This injudicious prescription of medications in private practice has been described by other researchers, for example, in Uganda and in India [52
]. Possible explanation to this phenomenon includes lack of knowledge among the providers in LLPHF, lack of clinical guidelines, or a drive for financial incentives. Indeed, in our study, the policymakers perceived the care as driven by financial incentives, wanting to please care takers rather than the patient needs, and failure for providers to follow clinical guidelines. This phenomenon of unprofessionalism has been observed by other researchers in other areas [55
]. A study done in Kenyan hospitals demonstrated that availability of clinical guidelines was associated with appropriate prescription of antimicrobials [57
]. While this Kenyan study was carried out in public hospitals, it can still be extrapolated to LLPHF that offer mainly outpatient care.
As a limitation to this study, observing health workers perform could have introduced the Hawthorne effect. This refers to a tendency of people to modify their behavior when being observed. In this instance, the healthcare workers would act more carefully and perform better than they usually do. This effect was minimized by the health workers being observed on more than one child. This increased rapport between them and the RAs, thus enabling the healthcare workers to become comfortable and act normal. Another limitation was that we did not collect data on the quality of the refresher training that the HCW received. This could have probably helped us to understand why refresher training did not result in better performance. The mixed concurrent multi-level design allowed data collection using different methods and thus strengthened the validity of the study while interviewing a wide range of participants at different levels facilitated getting views of the policymakers, as well as care providers.