title: Private pharmacy practice and regulation. A randomized trial in Lao P.D.R. Assessing the impact of educational intervention for improving management of malaria and other childhood illnesses in Kibaha District-Tanzania. Improving pneumonia case-management in Benin: a randomized trial of a multi-faceted intervention to support health worker adherence to Integrated Management of Childhood Illness guidelines Effectiveness of evidence-based medicine on knowledge, attitudes, and practices of family planning providers: a randomized experiment in Jordan A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria The Impact of Retail-Sector Delivery of Artemether–Lumefantrine on Malaria Treatment of Children under Five in Kenya: A Cluster Randomized Controlled Trial Introducing rapid diagnostic tests for malaria into registered drug shops in Uganda: lessons learned and policy implications The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: randomized controlled trial Impact of ministry of health interventions on private medicine retailer knowledge and practices on anti-malarial treatment in Kenya. Impact of an intervention to improve treatment-seeking behavior and prevent sexually transmitted diseases among Nigerian youths. [Adhesion of physicians to the national malaria policy: situation in Antananarivo (Madagascar), 5 years after the policy revision]. Post-training quality of syndromic management of sexually transmitted infections by chemists and druggists in Pokhara, Nepal: is it satisfactory? Private pharmacies in Hanoi, Vietnam: a randomized trial of a 2-year multi-component intervention on knowledge and stated practice regarding ARI, STD and antibiotic/steroid requests. Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand--a randomized controlled trial. The impact of face-to-face educational outreach on diarrhoea treatment in pharmacies. Improving private drug sellers' practices for managing common health problems in Nepal. A clinical training unit for diarrhoea and acute respiratory infections: an intervention for primary health care physicians in Mexico. Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam.
abstract: OBJECTIVES The objective of this study was to assess the effectiveness of government regulation of private pharmacy practice in a low-income country . METHODS The intervention comprised inspections of the pharmacies , information , and distribution of documents to drug sellers and sanctions . It was implemented at two different intensity levels , active and regular intervention . The methods used to assess the effect of the interventions were interviews with the district drug inspectors , drug sellers and customers , inspection of drug purchases , and indicator surveys of pharmacies . Indicators for pharmacy-specific quality as well as for dispensing quality were developed . RESULTS The main finding was one of strong overall improvements from initially low levels . The improvements were particularly marked by increases in the availability of essential material s for dispensing by 34 % and in order in the pharmacy by 19 % . Information given to customers increased from 35 % to 51 % and the mixing of different drugs in the same package went down from 17 % to 9 % . The pharmacies in the active intervention districts showed greater improvements for four of the six indicators , although statistically significant compared with the regular intervention districts only for the essential material s indicator . CONCLUSIONS It was concluded that the regulatory activities have probably been an important factor behind the service quality improvements . It appeared feasible as well as effective to regulate private pharmacy practice in this particular low-income setting OBJECTIVE The study was carried out to evaluate short term effects of one to one educational intervention approach , conducted with 40 drug sellers in order to improve the private sector 's practice s , compliance and performance in using the national treatment guidelines for malaria and other common childhood ( diarrhoea , acute respiratory tract infection-ARI ) illnesses in Kibaha district-Tanzania . METHODS The training took place one month after baseline data collection . Data collection was undertaken eight months after training and the effects of training was evaluated . The 40 drug stores were divided into 20 intervention and 20 control facilities . Trained  nurses  were used as clients who posed as caretakers of sick under-five children needing medication . The drug dispensers/sellers knowledge of anti-malarials and other drugs and their dispensing practice s was assessed . RESULTS The intervention seemed to have had a significant impact on knowledge pattern for prescribing and dispensing practice s of drug stores for some common childhood illnesses but not in other control drug stores/shops . About 90 % ( n=18 ) of shops prescribed to clients , the approved first-line anti-malarial drug for uncomplicated malaria ( sulfadoxine-pyrimethamine ) , as compared to only 55 % ( n=11 ) of the control shops . CONCLUSION Changing the private sectors ' knowledge , behaviour and practice s/performance may be a slow and difficult process . The intervention approach applied in this study seems to be feasible at district-level . This strategy can be applied in all districts of Tanzania with the aim of achieving significant improvements in knowledge , behaviour , compliance , improving performance and practice s of drug sellers in drug stores/shops . However , other alternative strategies are needed to influence drug sellers'/dispensers ' compliance and performance . Thus , the overall impact on performance and practice s in these facilities will remain at moderate level for quite sometime unless national policies , other programs and stakeholders are involved actively Background Pneumonia is a leading cause of death among children under five years of age . The Integrated Management of Childhood Illness strategy can improve the quality of care for pneumonia and other common illnesses in developing countries , but adherence to these guidelines could be improved . We evaluated an intervention in Benin to support health worker adherence to the guidelines after training , focusing on pneumonia case management . Methods We conducted a r and omized trial . After a health facility survey in 1999 to assess health care quality before Integrated Management of Childhood Illness training , health workers received training plus either study supports ( job aids , non-financial incentives and supervision of workers and supervisors ) or " usual " supports . Follow-up surveys were conducted in 2001 , 2002 and 2004 . Outcomes were indicators of health care quality for Integrated Management-defined pneumonia . Further analyses included a graphical pathway analysis and multivariable logistic regression modelling to identify factors influencing case-management quality . Results We observed 301 consultations of children with non-severe pneumonia that were performed by 128 health workers in 88 public and private health facilities . Although outcomes improved in both intervention and control groups , we found no statistically significant difference between groups . However , training proceeded slowly , and low- quality care from untrained health workers diluted intervention effects . Per- protocol analyses suggested that health workers with training plus study supports performed better than those with training plus usual supports ( 20.4 and 19.2 percentage-point improvements for recommended treatment [ p = 0.08 ] and " recommended or adequate " treatment [ p = 0.01 ] , respectively ) . Both groups tended to perform better than untrained health workers . Analyses of treatment errors revealed that incomplete assessment and difficulties processing clinical findings led to missed pneumonia diagnoses , and missed diagnoses led to inadequate treatment . Increased supervision frequency was associated with better care ( odds ratio for recommended treatment = 2.1 [ 95 % confidence interval : 1.1 - 3.9 ] per additional supervisory visit ) . Conclusion Integrated Management of Childhood Illness training was useful , but insufficient , to achieve high- quality pneumonia case management . Our study supports led to additional improvements , although large gaps in performance still remained . A simple graphical pathway analysis can identify specific , common errors that health workers make in the case-management process ; this information could be used to target quality improvement activities , such as supervision ( Clinical Trials.gov number NCT00510679 ) Background Provider misconceptions and biases about contraceptive methods are major barriers to family planning access for women in low- and middle-income countries , including Jordan .  Evidence -Based Medicine ( EBM ) programs aim to reduce biases and misconceptions by providing doctors with the most up-to- date scientific evidence on contraceptive methods . Methods We evaluate the effects of an EBM program  conducted in Jordan on private providers ’ knowledge , attitudes , and practice s. Family planning providers r and omly assigned to a treatment group were invited to attend a roundtable seminar on the injectable contraceptive Depot Medroxy Progesterone Acetate ( DMPA ) , and to receive two 15 min one-on-one educational visits that reinforce the messages from the seminar . Results There was low compliance with the EBM program . The study fails to detect an impact on providers ’ knowledge of DMPA ’s side effects or on reported clinical practice s. There is suggestive evidence of a positive impact on providers ’ attitudes toward and confidence in prescribing the contraceptive to their patients . There is also evidence of positive selection into program participation . Conclusions We conclude that EBM may not be effective as a st and -alone program targeting a family planning method with a high level of provider and consumer bias . Evidence of positive selection into program participation underscores the importance of r and omization to avoid overestimating the true effects of interventions .Trial registration AEA RCT Registry , AEA RCT R0000539 , Background Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking . The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria ( mRDTs ) in registered drug shops in Ug and a , with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy ( ACT ) in patients seeking treatment for fever in drug shops . Methods A cluster-r and omized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district , central Ug and a. Ten clusters were r and omly allocated to the intervention ( diagnostic confirmation of malaria by mRDT followed by ACT ) and ten clusters to the control arm ( presumptive treatment of fevers with ACT ) . Treatment decisions by providers were vali date d by microscopy on a reference blood slide collected at the time of consultation . The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as : malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate , and patients with no malaria parasites not given ACT . Findings A total of 15,517 eligible patients ( 8672 intervention and 6845 control ) received treatment for fever between January-December 2011 . The proportion of febrile patients who received appropriate ACT treatment was 72·9 % versus 33·7 % in the control arm ; a difference of 36·1 % ( 95 % CI : 21·3 – 50·9 ) , p<0·001 . The majority of patients with fever in the intervention arm accepted to purchase an mRDT ( 97·8 % ) , of whom 58·5 % tested mRDT-positive . Drug shop vendors adhered to the mRDT results , reducing over-treatment of malaria by 72·6 % ( 95 % CI : 46·7– 98·4 ) , p<0·001 ) compared to drug shop vendors using presumptive diagnosis ( control arm ) . Conclusion Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT . Trial Registration Clinical Trials.gov NCT01194557 In a cluster r and omized trial , Beth Kangwana and colleagues find that provision of subsidized packs of the malaria therapy artemether-lumefantrine to shops more than doubled the proportion of children with fever who received drugs promptly Background Malaria is a major public health problem in Ug and a and the current policy recommends introduction of rapid diagnostic tests for malaria ( RDTs ) to facilitate effective case management . However , provision of RDTs in drug shops potentially raises a new set of issues , such as adherence to RDTs results , management of severe illnesses , referral of patients , and relationship with caretakers . The main objective of the study was to examine the impact of introducing  RDTs in registered drug shops in Ug and a and document lessons and policy implication s for future scale-up of malaria control in the private health sector . Methods A cluster-r and omized trial introducing RDTs into registered drug shops was implemented in central Ug and a from October 2010 to July 2012 . An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops , the lessons learned and policy implication s. Results Introducing RDTs into drug shops was feasible . To scale-up this intervention however , drug shop practice s need to be regulated since the registration process was not clear , supervision was inadequate and record keeping was poor . Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome , but at evaluation this was not found to be a constraint . This presents an important lesson for introducing health management information system into drug shops . Involving stakeholders , especially the district health team , in the design was important for ownership and sustainability . The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions . Conclusion Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy . It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present , with the aim of reducing current massive overdiagnosis and overtreatment of malaria . Design Cluster r and omized trial of 24 clusters of shops . Setting Dangme West , a poor rural district of Ghana . Participants Shops and their clients , both adults and children . Interventions Providing rapid diagnostic tests with realistic training . Main outcome measures The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial .  Secondary outcomes were use of antibiotics and antipyretics , and safety . Results Of 4603 clients , 3424 ( 74.4 % ) tested negative by double-read research slides . The proportion of slide-negative clients who received any antimalarial was 590/1854 ( 32 % ) in the intervention arm and 1378/1570 ( 88 % ) in the control arm ( adjusted risk ratio 0.41 ( 95 % CI 0.29 to 0.58 ) , P<0.0001 ) . Treatment was in high agreement with rapid diagnostic test result . Of those who were slide-positive , 690/787 ( 87.8 % ) in the intervention arm and 347/392 ( 88.5 % ) in the control arm received an  artemisinin combination therapy  ( adjusted risk ratio 0.96 ( 0.84 to 1.09 ) ) . There was no evidence of antibiotics being substituted for antimalarials . Overall , 1954/2641 ( 74 % ) clients in the intervention arm and 539/1962 ( 27 % ) in the control arm received appropriate treatment ( adjusted risk ratio 2.39 ( 1.69 to 3.39 ) , P<0.0001 ) . No safety concerns were identified . Conclusions Most patients with fever in Africa present to the private sector . In this trial , providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria , did not reduce prescribing of antimalarials to true malaria cases , and appeared safe . Rapid diagnostic tests should be considered for the informal private drug retail sector . Registration Clinical trials.gov Background Sexually transmitted diseases ( STD ) are important co-factors in HIV transmission . We studied the impact of health worker training and STD syndrome packets ( containing recommended drugs , condoms , partner notification cards and information leaflets ) on the quality of STD case management in primary care clinics in rural South Africa . Methods A r and omized controlled trial of five matched pairs of clinics compared the  intervention with routine syndromic management . Outcomes were measured by simulated patients using st and ardized scripts , and included the proportion given recommended drugs ; correctly case managed ( given recommended drugs plus condoms and partner cards ) ; adequately counselled ; reporting good staff attitude ; and consulted in privacy . Results At baseline , the quality of STD case management was similarly poor in both groups . Only 36 and 46 % of simulated patients visiting intervention and control clinics , respectively , were given recommended drugs . After the intervention , intervention clinics provided better case management than controls : 88 versus 50 % ( P < 0.01 ) received recommended drugs ; 83 versus 12 % ( P < 0.005 ) were correctly case managed ; 68 versus 46 % ( P = 0.06 ) were adequately counselled ; 84 versus 58 % experienced good staff attitude ( P = 0.07 ) ; and 92 versus 86 % ( P = 0.4 ) were consulted privately . A syndrome packet cost US$ 1.50 ; the incremental cost was US$ 6.80 . The total intervention cost equalled 0.3 % of annual district health expenditure . Interpretation A simple and affordable health service intervention achieved substantial improvements in STD case management . Although this is a critical component of STD control and can reduce HIV transmission , community-level interventions to influence health-seeking behaviour are also needed Small-scale interventions on training medicine retailers on malaria treatment improve over-the-counter medicine use , but there is little evidence on effectiveness when scaled up . This study evaluated the impact of Ministry of Health ( MoH ) training programs on the knowledge and practice s of medicine retailers in three districts in Kenya . A cluster r and omized trial was planned across 10 administrative divisions . Findings indicated that 30.7 % ( 95 % confidence interval [ CI ] : 23.3 , 39.0 ) and 5.2 % ( 95 % CI : 2.1 , 10.3 ) of program and control retailers , respectively , sold MoH amodiaquine  with correct advice on use to surrogate clients ( OR = 8.8 ; 95 % CI : 2.9 , 26.9 ; P < 0.001 ) . Similarly , 61.8 % ( 95 % CI : 54.2 , 69.1 ) and 6.3 % ( 95 % CI : 2.7 , 12.1 ) of program and control retailers , respectively , reported correct knowledge on dosing with amodiaquine ( OR = 29.8 ; 95 % CI : 8.2 , 108.8 ) . Large-scale retailer training programs within the national malaria control framework led to significant improvements in retailers ' practice s across three districts BACKGROUND Interventions to treat STDs have been reported to reduce HIV incidence . Interventions to improve treatment-seeking for STDs may impact on the duration and prevalence of STDs . Nigeria has high rates of STDs and an increasing incidence of HIV . OBJECTIVE To evaluate the impact of an intervention on STD treatment-seeking behavior and STD prevalence among Nigerian youth . METHODS A r and omized controlled trial in 12 schools in Edo State was conducted to evaluate an intervention to improve STD treatment-seeking and STD treatment provision . The intervention , based on formative research , consisted of community participation , peer education , public lectures , health clubs in the schools , and training of STD treatment providers , including those with no formal training . A question naire measured outcomes before and 10 months into the intervention . The effect of the intervention among four r and omly selected intervention schools compared to eight r and omly selected control schools was assessed using logistic regression with Huber 's formula to account for school clusters . RESULTS One thous and eight hundred and ninety-six and 1858 youths 14 - 20 years of age were enrolled in the pre- and post-intervention surveys . Youths in the intervention schools , compared to control schools , reported statistically significant improvements in knowledge of STDs , condom use , partner awareness that the youth had an STD , and STD treatment-seeking behavior . Treatment by private physicians increased ( OR=2.1 , 95 % CI=1.1 - 4.0 ) , and treatment by patent medicine dealers or pharmacists decreased ( OR=0.44 , 95 % CI=0.22 - 0.88 ) . The reported prevalence of STD symptoms in the past 6 months was significantly reduced in the intervention compared to control schools ( OR=0.68 , 95 % CI=0.48 - 0.95 ) . CONCLUSION Significant improvements in treatment-seeking for STD symptoms can be effected among Nigerian youths . The prevalence of reported STD symptoms can be decreased by improving treatment-seeking for and awareness of STDs Our goal was to evaluate and analyze physicians ' adherence  to the national malaria policy in Antananarivo , 5 years after its revision . This prospect i ve descriptive study was conducted in public and private health centers in Antananarivo in 2010 , from May 1 to June 30 . Adhesion to the new policy included adoption of the rapid diagnostic test for malaria ( RDT ) and /or microscopy as diagnostic methods and prescription of artemisinin-based combination therapy ( ACT ) as first-line treatment for uncomplicated malaria . A question naire was used to collect data from 106 physicians . Their average age was 43.9 years ( range : 26 to 59 years ) . The male-female sex-ratio was 0.59 . Physicians trained in using RDTs were confident in this means of diagnosis ( p < 10(-4 ) ) . Prescription of ACT by physicians was associated with their participation in malaria training ( p = 0.02 ) . Only 2/3 of the physicians adhered to the current policy . Adherence increased with trust ( p < 10(-4 ) ) , availability of RDT ( p < 10(-5 ) ) , and training about the policy . Physician adhesion , training and confidence are essential to this policy and to changing physician behavior . Improvement of the health system is also needed OBJECTIVE Using simulated client and provider interview methods , this study assessed chemists and druggists ' post-training management quality of syndromic sexually transmitted infections focusing on the areas of privacy maintaining , encouraging , history taking , counseling , referral practice , partner notification , and drug prescribing and then compared the findings of two methods . DESIGN Forty-five pharmacies from a list of 75 in Pokhara , who collected sexually transmitted infections data during 1999 , were selected r and omly . First simulated client successfully presented either urethral or vaginal discharge syndrome at 37 pharmacies and recorded the events of whole encounter into an observation form within 20 minutes . Later 39 chemists and druggists were interviewed by a pre-tested semi-structured question naire . MAIN MEASURE Results were reported mainly by numbers and corresponding percentages . For comparative purpose , P values were also shown . RESULTS Overall , interview method revealed satisfactory knowledge of chemists and druggists for management of sexually transmitted infections except drug prescribing but their actual behaviors , revealed by simulated client method , indicated lower quality and differed significantly in the areas of encouraging , history taking , counseling , referral practice , and partner notification . Both methods indicated very poor qualities of drug prescribing . CONCLUSION Retained knowledge of chemists and druggists for syndromic management of sexually transmitted infections were not applied to simulated client in actual practice . They should not prescribe drugs for patients of sexually transmitted infections , except referring to the doctors/hospitals . Continuous monitoring and further motivations for them may improve syndromic management quality of sexually transmitted infections . Moreover , depending on the purpose of study , various methods should be applied simultaneously to reach a better conclusion OBJECTIVES To assess the effectiveness of a multi-component intervention on knowledge and reported practice amongst staff working in private pharmacies in Hanoi regarding four conditions : urethral discharge [ sexually transmitted diseases ( STD ) ] , acute respiratory infection ( ARI ) , and non-prescription requests for antibiotics and steroids . METHOD R and omized controlled trial with staff working in 22 matched pair intervention and control private pharmacies who were administered a semistructured question naire on the four conditions before and 4 months after the interventions . The interventions focused on the four conditions and were in sequence ( i ) regulations enforcement ; ( ii ) face-to-face education and ( iii ) peer influence . Outcome measures were knowledge and reported change in practice for correct management of tracer conditions . RESULTS The intervention/control-pairs ( 22 after drop-outs ) were analysed pre- and post-intervention using the Wilcoxon signed rank test . STD : More drug sellers stated they would ask about the health of the partner ( P = 0.03 ) and more said they would advise condom use ( P = 0.01 ) and partner notification ( P = 0.04 ) . ARI : More drug sellers stated they would ask questions regarding fever ( P = 0.01 ) , fewer would give antibiotics ( P = 0.02 ) and more would give traditional medicines ( P = 0.03 ) . Antibiotics request : Fewer said they would sell a few capsules of cefalexin  without a prescription ( P = 0.02 ) . Steroid requests : No statistical difference was seen in the numbers who said they would sell steroids without a prescription as numbers declined in both intervention and control groups ( P = 0.12 ) . CONCLUSION The three interventions in series over 17 months were effective in changing the knowledge and reported practice of drug sellers in Hanoi Private pharmacies are the first line of health care in many communities , commonly selling antibiotics in small doses and prescription-only drugs such as steroids without medical supervision . The aim was to study the effectiveness of a multi-faceted intervention on the dispensing practice s of drug sellers in Hanoi and Bangkok . The study was a r and omized , controlled trial with 68 Hanoi and 78 Bangkok pharmacies , r and omly selected and assigned for intervention and control . Behaviour was assessed by five simulated client visits per pharmacy per dispensing practice , at baseline and a month or more after each intervention . Three three-month interventions were implemented sequentially with four months in between : enforcement of regulations with local inspectors visiting to emphasize the importance of prescription-only medicine legislation ; education , performed face-to-face in Hanoi and by a large group in Bangkok ; and peer review , voluntary in Bangkok and compulsory in Hanoi . The intervention result ed in significant improvements in Hanoi , reducing the dispensing of illegal steroids ( 29 % vs. 62 % ) and low dose antibiotics ( 69 % vs. 90 % ) , sustained by means of the peer review ( 17 % vs. 57 % steroids and 71 % vs. 95 % antibiotics ) , and in fewer dispensers asking no questions and giving no advice ( 11 % vs. 30 % steroids and 51 % vs. 81 % antibiotics ) . The only significant improvement in Bangkok was the reduction in illegally dispensing steroids ( 25 % vs. 44 % ) after the regulatory intervention . In Bangkok , fewer of those in the group who volunteered for the peer review asked no questions and gave no advice for low-dose antibiotics requests after the peer review ( 58 % vs. 81 % ) . A multi-component intervention can have a profound effect in changing dispensers ' behaviour , but the effect is dependant on the context and the method of implementation . Possible reasons for differences are discussed Private pharmacies are an important source of health care in developing countries . A number of studies have documented deficiencies in treatment , but little has been done to improve practice s. We conducted two controlled trials to determine the efficacy of face-to-face educational outreach in improving communication and product sales for cases of diarrhoea in children in 194 private pharmacies in two developing countries . A training guide was developed to enable a national diarrhoea control programme to identify problems and their causes in pharmacies , using quantitative and qualitative research methods . The guide also facilitates the design , implementation , and evaluation of an educational intervention , which includes brief one-on-one meetings between diarrhoea programme educators and pharmacists/owners , followed by one small group training session with all counter attendants working in the pharmacies . We evaluated the short-term impact of this intervention using a before- and -after comparison group design in Kenya , and a r and omized controlled design in Indonesia , with the pharmacy as unit of analysis in both countries ( n = 107 pharmacies in Kenya ; n = 87 in Indonesia ) . Using trained surrogate patients posing as mothers of a child under five with diarrhoea , we measured sales of oral rehydration salts ( ORS ) ; sales of antidiarrhoeal agents ; and history-taking and advice to continue fluids and food .  We also measured knowledge about dehydration and drugs to treat diarrhoea among Kenyan pharmacy employees after training . Major discrepancies were found at baseline between reported and observed behaviour . For example , 66 % of pharmacy attendants in Kenya , and 53 % in Indonesia , reported selling ORS for the previous case of child diarrhoea , but in only 33 % and 5 % of surrogate patient visits was ORS actually sold for such cases . After training , there was a significant increase in knowledge about diarrhoea and its treatment among counter attendants in Kenya , where these changes were measured . Sales of ORS in intervention pharmacies increased by an average of 30 % in Kenya ( almost a two-fold increase ) and 21 % in Indonesia compared to controls ( p < 0.05 ) ; antidiarrhoeal sales declined by an average of 15 % in Kenya and 20 % in Indonesia compared to controls ( p < 0.05 ) . There was a trend toward increased communication in both countries , and in Kenya we observed significant increases in discussion of dehydration during pharmacy visits ( p < 0.05 ) . We conclude that face-to-face training of pharmacy attendants which targets deficits in knowledge and specific problem behaviours can result in significant short-term improvements in product sales and communication with customers . The positive effects and cost-effectiveness of such programmes need to be tested over a longer period for other health problems and in other countries BACKGROUND In most Asian countries , 50 - 90 % of pharmaceutical sales are made in private drug outlets , by personnel with some training in drugs but not for the treatment of common health problems . The objective of the study was to determine effects of focused training for private drug sellers to improve practice s in treating acute respiratory infections and diarrhoea in children , and anaemia in pregnancy in Nepal . METHODS R and omized controlled , four way nested design study incorporating four interventions for drug retailers in both hill and terai districts . One group received mailed printed educational material s followed by mailed feedback ; a second received small group training followed by feedback ; a third received small group training only ; and a fourth , the control group , received no intervention . Surrogate customer method was used to assess practice s. Outcomes were measured using multivariate linear regression . RESULTS A significant increase in the asking of key history questions , recommendation ( prescribing by drug retailers ) of cotrimoxazole , and advice-giving for pneumonia ; a significant increase in ORS recommendation , and advice giving for diarrhoea including the avoidance of antidiarrhoeals ; and a significant increase in asking key history questions and recommending appropriate products in pregnancy cases . CONCLUSIONS Training intervention as well as training followed by practice feedback was effective in improving the management of common illnesses and pregnancy by private drug sellers In Tlaxcala State , Mexico , we determined that 80 % of children who died from diarrhoea or acute respiratory infections ( ARI ) received medical care before death ; in more than 70 % of the cases this care was provided by a private physician . Several strategies have been developed to improve physicians ' primary health care practice s but private practitioners have only rarely been included . The objective of the present study was to evaluate the impact of in-service training on the case management of diarrhoea and ARI among under-5-year-olds provided by private and public primary physicians . The training consisted of a five-day course of in-service practice during which physicians diagnosed and treated sick children attending a centre and conducted clinical discussion s of cases under guidance . Each training course was limited to six physicians . Clinical performance was evaluated by observation before and after the courses . The evaluation of diarrhoea case management covered assessment of dehydration , hydration therapy , prescription of antimicrobial and other drugs  , advice on diet , and counselling for mothers ; that of ARI case management covered diagnosis , decisions on antimicrobial therapy , use of symptomatic drugs , and counselling for mothers . In general the performance of public physicians both before and after the intervention was better than that of private doctors . Most aspects of the case management of children with diarrhoea improved among both groups of physicians after the course ; the proportion of private physicians who had five or six correct elements out of six increased from 14 % to 37 % : for public physicians the corresponding increase was from 53 % to 73 % . In ARI case management , decisions taken on antimicrobial therapy and symptomatic drug use improved in both groups ; the proportion of private physicians with at least three correct elements out of four increased from 13 % to 42 % , while among public doctors the corresponding increase was from 43 % to 78 % . H and s-on training courses thus seemed to be effective in improving the practice of physicians in both the private and public sectors The objective of this study was to assess the effects of a multicomponent intervention on private pharmacy practice . From 641 private pharmacies in Hanoi , 68 pharmacies were r and omly selected and matched into 34 pairs . Each pair consisted of a control and an intervention pharmacy . Three interventions were applied sequentially : Regulatory enforcement , Education , and Peer influence . Four tracer conditions were selected : uncomplicated acute respiratory infection ( ARI ) , sexually transmitted disease ( STD ) , requesting the prescription-only drugs prednisolone , and a short course of cefalexin . Practice was assessed through the Simulated Client Method ( SCM ) . The intervention pharmacies improved significantly compared to the control pharmacies ( P < .05 ) in all tracer conditions . For ARI , antibiotic dispensing decreased ( P < .02 ) and questions regarding breathing increased ( P < .01 ) . For STD , advice to go to the doctor and dispensing the correct syndromic treatment increased ( P < .01 ) . Dispensing of prednisolone and cefalexin decreased ( P < .01 ) and prescription requests increased ( P < .01 ) . Our conclusion is that it is possible to improve private pharmacy practice with a multicomponent intervention
target: Authors ' conclusions Training probably improves quality of care ( i.e. adherence to recommended practice ) , regulation may improve quality of care , and we are uncertain about the effects of co‐ordination on quality of private for‐profit healthcare services in LMICs .
background: Background Governments use different approaches to ensure that private for‐profit healthcare services meet certain quality st and ards .
  Such government guidance , referred to as public stewardship , encompasses government policies , regulatory mechanisms , and implementation strategies for ensuring accountability in the delivery of services .
  However , the effectiveness of these strategies in low‐ and middle‐income countries ( LMICs ) have not been the subject of a systematic review .
  Objectives To assess the effects of public sector regulation , training , or co‐ordination of the private for‐profit health sector in low‐ and middle‐income countries .