Abstract
This paper is an analysis of the social interaction between drug sellers, their clients and local health care workers within a medical trial that introduced rapid diagnostic tests for malaria into private sector drug shops in Mukono District, Uganda. It locates the introduction of a new technology to test blood and a system of referral within the context of local concerns about the choice and evaluation of treatment; and the socially legitimated statuses, roles and hierarchies within the local health care system. Based on the multi-layered interpretation of 21 focus group discussions, we describe three key aspects of the trial central to local interpretation: openly testing blood, supervisory visits to drug shops and a new referral form. Each had the potential to shift drug shop vendors from outsider to insider of the formal health service. The responses of the different groups of participants reflect their situation within the health care system. The clients and patients welcomed the local availability of new diagnostic technology and the apparent involvement of the government in securing good quality health services for them from providers with often uncertain credentials. The drug shop vendors welcomed the authorization to openly test blood, enabling the demonstration of a new skill and newfound legitimacy as a health worker rather than simple drug seller. Formal sector health workers were less enthusiastic about the trial, raising concerns about professional hierarchies and the maintenance of a boundary around the formal health service to ensure the exclusion of those they considered untrained, unprofessional and untrustworthy personnel.
Highlights
Over the last 20 years, with the growth of private sector medicine across sub-Saharan Africa, debates about its benefits, potential and dangers have become commonplace among global and national health policy-makers (Basu, Andrews, Kishore, Panjabi, &Stuckler, 2012; Fraser & Druce, 2006; Hozumi et al, 2009)
Joining the project Within this context the project began its contact with drug shop vendors in Mukono, going to visit those registered with the local district health office
We have sought to examine the interface between the project, its constituents and the health care system by providing an analysis of the moment at which the local residents and health workers came into contact with the project’s material products and the subjects of its training and supervisory programme
Summary
Over the last 20 years, with the growth of private sector medicine across sub-Saharan Africa, debates about its benefits, potential and dangers have become commonplace among global and national health policy-makers (Basu, Andrews, Kishore, Panjabi, &Stuckler, 2012; Fraser & Druce, 2006; Hozumi et al, 2009). In the context of poorly funded and often fractured public health services, the notion of ‘harnessing’ informal bio-medical providers to improve access to medication at community level has become a attractive option (Arrow, Panosian, & Gelband, 2004; Basu et al, 2012; Forsberg, Montagu, & Sundewall, 2011; Fraser & Druce, 2006) Attempts to utilize this supply chain and improve access to treatment and quality of service provision have been made with varying success, most notably of late through the introduction of the Affordable Medicines Facility for malaria (Tougher et al, 2012). The literature suggests that interventions to make improvements to the services offered by these informal providers (even apparently simple technological innovations such as rapid diagnostic tests (RDTs) for malaria) will be made complex and have multiple effects as they are refracted through intricate social and institutional relationships
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