Radha, a young mother in a remote village of Nepal’s Sankhuwasabha district, walks one hour to the marketplace. It is 11 am and Radha is tired and sweaty after carrying her sick baby, who has had a fever for two days, on her back. She stops at the first drug shop she comes to – the nearest health post is another 10 minutes’ walk. The drug dispenser is a certified health assistant. The drug seller examines the baby, dispenses an antibiotic, and tells Radha to come back if the fever does not go away.
When asked why she stopped at the drug shop, given that the health post was only a few minutes further, Radha said, “It is too early for Sunday! The health post doesn’t open until mid-day on Sundays. And when they are open, they either don’t have the medicines or they offer tablets, which are not easy for small children to take. If they prescribe syrup, we have to come to the drug shop to buy it anyway, so there is no point going there.”
As in many developing countries, services for sick young infants and children are often provided by private drug shops in Nepal. According to the 2011 Nepal Demographic and Health Survey (NDHS), 78 percent of caretakers sought care when a child had symptoms of acute respiratory infection and, of those, most went to private providers (this was the case both in rural and urban areas).
Past studies in Nepal reveal that parents of sick children generally prefer the private sector because they see these providers to be offering better quality,[1] more flexible facility hours, and more reliable availability of staff at the time of visit. The Saving Newborn Lives (SNL) program in Nepal, in close partnership with the Ministry of Health Child Health Division, conducted a study on the management of sick young infants by non-physicians in the private sector.
The study included 60 private drug outlets and 24 government facilities in 6 districts. Almost all of the private drug shops were providing care to children of all ages. The credentials of health workers were generally comparable between the public and private sectors. The opening hours and availability of health workers were considerably greater in medicine shops compared to public clinics. A variety of antibiotics were reported to be used; some private practitioners also used injectable steroids to treat young infants, a potentially harmful practice.
As a result of this study, the Child Health Division formed a committee to develop a strategy for engagement with the private sector for the management of sick children. This initial study, though helpful in offering insights on what’s going on in this sector, was neither representative nor large enough to determine rates or proportions for various aspects of quality of care and cannot serve as a basis for comparison for future tracking of progress. A large representative survey would provide a more definitive picture and could serve as a baseline against which to track change. SNL has been engaging with USAID to plan a nationally representative survey to assess the care of PSBI among young infants in the private sector by non-physician providers in medicine shops and this study is expected to be completed by mid-2017.
Meanwhile, it is important for the maternal-newborn health community in Nepal to work with the government and advocate for a pragmatic approach to the registration process of drug shops, especially in remote locations where the public must resort to drug shops regardless of whether they are registered. It is equally important to ensure that adequate monitoring mechanisms are in place for such private drug shops to help ensure quality care.
Anjana KC is the program manager, technical & quality assurance, for Save the Children’s Saving Newborn Lives program in Nepal.
[1] Quality of private sector services is largely unknown and only about half of private drug shops are registered under the government’s Department of Drug Administration. Many unregistered shops are opened by health assistants, with the same credentials as public providers. The government acknowledges the need to engage with the private sector to provide services for children but has yet to take concrete steps.