Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals in Jinja Municipality, Uganda - End of Project Report

Pharmaceutical Society of Uganda International Pharmaceutical Federation
Strengthening Community Pharmacies Role in

Early Tuberculosis Case Detection and Referrals
Case Study of Jinja Municipality

END OF PROJECT REPORT
December 2012
Morris Okumu, Freddy Eric Kitutu, Bush Herbert Aguma, Asha Nabbale, Brian Sekayombya
Pharmaceutical Society of Uganda

Strengthening Community Pharmacies Role in Early TB Case Detection and Referrals Case Study of Jinja Municipality
ii

Pharmaceutical Society of Uganda
Tufnell Drive Kamwokya,
P. O. Box 3774, Kampala, Uganda
www.psu.or.ug

Errors and omissions excepted
The views expressed in this report do not necessarily reflect those of International Pharmaceutical
Federation (FIP) or the Pharmaceutical Society of Uganda (PSU). They are the works of the authors who
carried out the activity on behalf of PSU with support from FIP. For further clarifications, queries and any
additional issue regarding this report please contact the authors and/or PSU using the e-mail:
morriokum@yahoo.com; psupc@infocom.co.ug and phones +256414340385 and +256312266993.

Recommended citation:
Morris Okumu, Freddy Eric Kitutu, Bush Herbert Aguma, Asha Nabbale, and Brian Sekayombya; (2012);
Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals in Jinja
Municipality, Uganda End of Project Report; Submitted to International Pharmacy federation by the
Pharmaceutical Society of Uganda.
iii

Table of Contents
LIST OF TABLES AND FIGURES ........................................................................................................... IV
LIST OF ABBREVIATIONS AND ACRONYMS .......................................................................................... V
ACKNOWLEDGEMENTS ...................................................................................................................... VI
EXECUTIVE SUMMARY ..................................................................................................................... VII
1. INTRODUCTION ....................................................................................................................... 1
2. BACKGROUND ......................................................................................................................... 1
2.1. BACKGROUND TO THE PROJECT ................................................................................................ 1
2.2. TB SITUATION IN THE COUNTRY ................................................................................................ 2
2.3. PROJECT OBJECTIVES, DESIGN AND APPROACH ......................................................................... 5
3. METHODOLOGY ...................................................................................................................... 6
3.1. ASSESSMENT DESIGN AND APPROACHES .................................................................................... 6
3.2. STUDY POPULATION .................................................................................................................. 6
3.3. TB PRESENTATION AND PREDISPOSING SIGNS AND SYMPTOMS .................................................. 7
3.4. DATA COLLECTION AND MANAGEMENT ..................................................................................... 7
3.5. ETHICAL CONSIDERATIONS ....................................................................................................... 8
3.6. LIMITATIONS ............................................................................................................................ 8
4. RESULTS ................................................................................................................................... 9
4.1. DEMOGRAPHIC CHARACTERISTICS OF THE PHARMACIES .......................................................... 9
4.2. PRACTICES IN MANAGEMENT OF PATIENTS WITH COUGH ....................................................... 11
4.3. KNOWLEDGE OF TB DIAGNOSIS AND TREATMENT AMONG HEALTH WORKERS ...................... 14
4.4. INFRASTRUCTURE/SYSTEM TO REFER AND FOLLOW-UP ......................................................... 17
5. DISCUSSIONS .......................................................................................................................... 19
5.1. PRIMARY CARE SERVICES AT PHARMACY LEVEL ..................................................................... 19
5.2. PRACTICE IN THE MANAGEMENT OF COUGH AT THE PHARMACIES .......................................... 21
5.3. KNOWLEDGE OF TB DIAGNOSIS AND TREATMENT AMONG HEALTH WORKERS ....................... 22
5.4. INFRASTRUCTURE/SYSTEM TO REFER AND FOLLOW UP ........................................................... 23
6. CONCLUSION AND RECOMMENDATIONS ........................................................................ 26
6.1. LEVEL OF ACHIEVEMENT OF THE PILOT PROJECT ................................................................... 26
6.2. SCALABILITY OF THE PROJECT ................................................................................................ 26
6.3. RECOMMENDATIONS ............................................................................................................... 27
ANNEX: STUDY TEAM ................................................................................................................. 28

iv

List of tables and figures
List of tables
Table 1: TB epidemiology in Uganda ............................................................................................................................. 3
Table 2: Type of pharmacy license .................................................................................................................................. 9
Table 3: Staffing norms in the assessed pharmacies ...................................................................................................... 9
Table 4: Level of nearest health facility ........................................................................................................................ 10
Table 5: Clientele load in the pharmacies per day ........................................................................................................ 10
Table 6: Key issues considered last time a patient with cough was managed ............................................................. 13
Table 7: Methods of transmission of TB reported ........................................................................................................ 14
Table 8: Presence of any agreement between the pharmacy and a health facility for referral ................................... 17

List of figures
Figure 1: Availability of different services in the pharmacies ....................................................................................... 11
Figure 2: Main actions taken in managing cough at the pharmacy ............................................................................. 11
Figure 3: Action taken by pharmacy when unable to manage cough .......................................................................... 12
Figure 4: Main medicines supplied in management of cough ...................................................................................... 12
Figure 5: Key penicillin used for cough .......................................................................................................................... 13
Figure 6: Steps taken to handle suspected TB .............................................................................................................. 14
Figure 7: Pre-referral Treatments given ....................................................................................................................... 15
Figure 8: Key pre-referral activities carried out ............................................................................................................ 15
Figure 9: Actions taken to confirmed TB cases in the pharmacy .................................................................................. 16
Figure 10: Reported signs and symptoms indicative of TB in the pharmacy ................................................................ 17
Figure 11: Record keeping and display of TB IEC materials in the pharmacies............................................................. 18
Figure 12: maintaining directory and procedures for referrals ..................................................................................... 18

v

List of Abbreviations and Acronyms
BCC Behavioural Change Communications
DOTS Directly Observed Treatment Strategy
FDCs Fixed Dose Combination
FIP International Pharmaceutical Federation
HIV Human Immuno-deficiency Virus
IEC Information Education Communication
MDR-TB MultiDrug Resistant Tuberculosis
MoH Ministry of Health
NDA National Drug Authority
NTLP National Tuberculosis and Leprosy Control Program
OTCs Over The Counter Medicines
PHC Primary Health Care
PSU Pharmaceutical Society of Uganda
RRH Regional Referral Hospital
TB Tuberculosis
UNCST Uganda National Council for Science and Technology
XDR-TB Extremely Drug-Resistant Tuberculosis

vi

Acknowledgements
We would like to thank the International Pharmaceutical Federation (FIP) for providing the
funding for this pilot project. We are particularly indebted to FIP colleagues Xuan Hao Chan and
Ying Chan who continuously worked with us from the inception phase to getting this milestone
accomplished. Secondly, we would like to appreciate the Council of Pharmaceutical Society of
Uganda (PSU) for the guidance and support towards this project. Our appreciations go to Yusuf
Kimbowa Sembatya and Samuel Acuti Opio who are former and current Secretaries respectively
for the endurance and support in this project. Together with the members of the Research
Committee, we have been able to meet tight deadlines and get work done under pressing
circumstances.
In a special way, we would like to thank Dr Francis E. Adatu, former Program Manager of the
National Tuberculosis and Leprosy Control Program (NTLP) of the Ministry of Health for the
guidance on policies, directions and technical understanding of TB situation in Uganda. Together
with Dr Samuel Kasozi the MDR-TB Coordinator at the NTLP, we were able to work through
and get the work within the policy confines.
Finally, we would like to thank in a special way the pharmacies we visited in Jinja for not only
allowing us access to their premises and valuable business information, but for the openness and
greater involvement in the study.

vii

Executive Summary
Background
The Pharmaceutical Society of Uganda (PSU) in July 2011 was awarded funding from the
International Pharmaceutical Federation for a pilot project for strengthening role of community
pharmacies in early Tuberculosis case detection and referral. This seed funding of US$ 10,000
awarded under the first round of the FIP challenge on TB, supported a pilot project in Jinja
municipality for a period of three months. The project was in response to rise is number of MDR-
TB cases world-over calling for an expanded role of pharmacists in control of antimicrobial
resistance. An end of project evaluation was carried out to assess the feasibility/scalability of the
interventions designed during the pilot.
Project design and evaluation approach
The project was designed as a pilot innovation to explore possible role of community pharmacies
in case detection, referral and treatment monitoring for TB with a geographic focus of Jinja
municipality. Jinja Municipality was chosen because of a high TB burden, strong public sector
TB management infrastructure, typical urban/rural mix of the population, and a relatively robust
community pharmacy system compared with other districts in Uganda. The project had entail
three months of intensive intervention using continuous quality improvement model to provide
basis for scale-up. The key project strategies were Capacity building and systems strengthening,
linkages and referral mechanisms development, Behavioural change, and partnerships. The
evaluation method involved a cross-sectional survey of 13 out of 14 targeted pharmacies in Jinja
municipality. The focus areas were cough management, TB diagnosis, case management, and
referral systems between the pharmacies.
Results and discussions
Characteristics of pharmacies: 53% of pharmacies reached were both wholesale and retail in
licensure and they had all in been in Jinja for over 5 years at time of evaluation. They are open for
over eight (8) hours each day. The average number of staff in these pharmacies was 3 with nurses
being the most predominant cadre of personnel by training and none had a pharmacy technician
employed with them. The staffing norms are well in line with the task-shifting approaches
practiced in the country arising from shortage of skilled manpower. The level of the nearest
public health facility to most of the pharmacies is the regional referral Hospital. The daily average
number of patients served in the retail section is about 93 patients while that for wholesale is
about 22 clients. On the overall, the level of availability of the services is much lower than it
viii

should be since the pharmacies are expected to provide emergency support to patients in need of
treatment and support before referral for the appropriate medical attention.
Management of cough practices: more than half of the pharmacies were able to take history, ask
about current medication and provide antibiotic treatment as part of management of cough. There
is a general improvement in the key areas of management of cough in the pharmacies at end-line.
When unable to manage cough, over 90% prefer to refer the patient to Jinja RRH in preference to
any other health facility. In management of cough, penicillin antibiotics are the most used
products and use of erythromycin reduced after period of exposure. The pharmacies appear to
have common approach to managing cough with the priority issues being type of cough, length of
cough and age of the patient.
Knowledge of TB Diagnosis and Treatment among Health Workers: There is a good
understanding of the key methods for transmission of TB. However, the respondents appear not to
clearly understand the role of the pre-disposing factors such as contact and underlying HIV
infection. The pharmacies provide supportive care and pre-referral support and treatment. They
are not mandated to treat TB cases within their settings. There appear to be a clear understanding
of requirements for effective referral of cases to another health facility, a central pillar of primary
health care. Majority of the respondents reported referring confirmed TB cases with appropriate
counselling of patient. While 50% noted that it is with anti-TB drugs, only 30% could clearly
differentiate that the treatment is divided into two phases (i.e. initial and continuation phase) and
that 4 drugs are given in the initial phase and 2 are given in the continuation phase. The
understanding of the signs and symptoms of TB infection is relatively fine with many of the
cardinal ones coming out clearly in over 80% of respondents.
Infrastructure/System to Refer and Follow-Up: None of the pharmacies had any formal linkage or
agreement with a facility for any form of referral. Informal linkages were reported but are mainly
for purpose of complimentary services and business competitiveness especially for congested
areas. This situation remained the same after the period of pilot intervention. Keeping of referrals
records improved slightly while all pharmacies exposed to the intervention were able to have and
at least display IEC materials.
Conclusion:
The key outputs demonstrated in the pilot phase included: The design of basic referral
infrastructure and system to improve linkage with the other TB diagnosis and treatment centres
within the municipality; Mapping of the key gaps and opportunities for effective TB case
detection within the pharmacies; and, development of Standard operating procedures and
algorithm for TB case detection within community pharmacies. The appreciation of risks of
ix

antimicrobial resistance in relation to TB improved among the pharmacies with more
understanding key risks factors. The basic ingredients for conducting the project were all
available in the pharmacies and in the environment.
Recommendations:
This project is scalable with a number of key recommendations that include:
a) The current guidelines on licensing of pharmacies as well as code of practice needs to be
revisited to allow pharmacies carry out more primary health care services including diagnosis
of common ailments.
b) Institute strong public-private partnerships in the management of TB that should involve role
of pharmacies especially in the TB DOTS programme. Pharmacies can then be accredited to
dispense medicines and refills for patients who do not need to go to hospitals.

1

1. INTRODUCTION
In July 2011, the International Pharmaceutical Federation (FIP) awarded the Pharmaceutical
Society of Uganda (PSU) a seed funding to carry out a pilot project focussing on strengthening
the role of community pharmacies in early Tuberculosis case detection and referral. This project,
awarded under the first round of the FIP challenge on TB, was intended to strength the role of FIP
member organisations in TB diagnosis, referrals, treatment and prevention with major emphasis
on prevention of spread and emergence of multi-drug resistant TB (MDR-TB). After six months
of implementation, PSU carried out end of project evaluation in July 2012 to document lessons
learnt, project outputs and outcomes and provide basis for future activities. This report provides
the outcomes of the final evaluation for the project carried out in July 2012 and overall synthesis
of recommendations for future interventions and scale-up in Uganda.
2. BACKGROUND
2.1. Background to the project
The FIP challenge on TB to which this project is part of, focuses on expanding the role of
pharmacists in control of antimicrobial resistance. This project focuses on early identification of
TB suspects and referral activities for diagnosis. Early identification of TB suspects and referral is
anticipated to increase case detection, reduce delays in diagnosis and save costs of care. Early
diagnosis has been shown to contribute to improved treatment outcomes including prevention of
possible development of drug resistance to existing medicines occurring as a result of both
irrational use and mismanagement of the patient
1
. The main challenge is therefore to scale-up TB
care and control, while preventing acquired drug resistance, is to increase active and early case
detection so that transmission can be interrupted by rapid start of treatment for both drug-
susceptible and drug-resistant TB
2
. The rise is number of MDR-TB cases world-over has called
for a multi-faceted approach to all aspects of diagnosis, treatment, control and prevention beyond
the traditional healthcare setting.
2.1.1. Project design
This project is designed as a pilot innovation to explore possible role of community pharmacies in
case detection, referral and treatment monitoring for TB with a geographic focus of Jinja
municipality. Jinja Municipality was chosen because of a high TB burden, strong public sector

1
Joint Tuberculosis Committee of the British Thoracic Society (2000) Control and prevention of tuberculosis in the
United Kingdom: recommendations 2000. Thorax, 55, 887901
2
L. P. Ormerod; Multidrug-resistant tuberculosis (MDR-TB): epidemiology, prevention and treatment, British Medical
Bulletin; 2012, Volume 73-74, Issue 1, 17-24
2

TB management infrastructure, typical urban/rural mix of the population, and a relatively robust
community pharmacy system compared with other districts in Uganda
3
. The interventions for this
project shall act in greater synergy with all other interventions already in place in public and
private sector while focussing on the peculiarities of community pharmacies. The project had
entail three months of intensive intervention to provide basis for scale-up.
2.1.2. Project approach
This project used a continuous quality improvement model that looks at identifying gaps and
challenges in service delivery in the community pharmacies and initiating small but incremental
changes that will be monitored for outcomes. This involves improving capacity of community
pharmacies in case detection, linkages provision, and provide evidence for scalability of
pharmacy level TB control models. The key project strategies are Capacity building and systems
strengthening, linkages and referral mechanisms development, Behavioural change, and
partnerships. Selected pharmacies shall be provided with mentorship over the pilot period
followed up with a carefully structured case management approach.
2.1.3. Background to PSU
Founded in 1960 and governed by The Pharmacy and Drugs Act of 1970, the PSU is the national
professional organisation and governing body for pharmacy in Uganda. PSU is responsible for
ethical practice of pharmacy in Uganda. Governed by a twelve member council, PSU functions
through the Secretariat headed by a Secretary. The functions of the council are executed through
committees, of which the Research and Development Committee is responsible for this particular
pilot project.
2.2. TB situation in the country
2.2.1. TB epidemiology
With an estimated and highly growing population of 32.9 million people, Uganda is among the
TB high burden countries ranked 16th on the list of 22 high-burden countries in the world. The
TB control and prevention is exacerbated by the high burden of HIV infection with an estimated
38.7% of new TB patients being HIV positive. To date, further attempts to manage this problem
have been made in area of integrating TB and HIV infection and treatment as appropriate. The
summary of the epidemiology is shown in table 1.

3
Draft Profile of Jinja Municipality, accessed from
http://www.skelleftea.se/Skol%20och%20kulturkontoret/Innehallssidor/Bifogat/JINJA%20MUNICIPALITY%20PROFIL
E.pdf April 2012
3

Table 1: TB epidemiology in Uganda
4

Parameter
2011 2010
Male Female Total Male Female Total
Total disease burden 15,246 9,174 24,420 28,071 17,475 45,546

New cases 8,285 4,555 12,840 14,939 8,517 23,456
Relapses reported 379 173 552 926 366 1,291
Total defaulters 447 1331 580 910 299 1,209
Treatment failures 90 50 140 174 90 321
The national burden of TB continues to remain stable but there is a noted rise in treatment failures
and MDR-TB cases which is indicative of challenges with treatment adherence and possible
decline in effectiveness of strategies to prevent antimicrobial resistance. There is therefore a
greater need to develop strong policies and interventions that call for wider public and private
sector involvement if the country is to effectively meet global targets for TB control and
prevention.
2.2.2. TB control in Uganda
The country TB program is managed under the National TB and Leprosy Control Program
(NTLP) with significant support from development and bilateral partners. The NTLP which is the
national disease prevention organisation has continued to face challenges with continuity of
medicines. The resent increase in cases of insufficient supply of TB medicines in the country
5

coupled with challenges in coordination of private sector players increases the risk of MDR-TB
and possible emergence of Extremely Drug-Resistant Tuberculosis (XDR-TB) if nothing is done.
The rise in case load cannot be exclusively associated with lack on medicines but also extends to
challenges with diagnostic capacity, poor patient adherence and possible community acquired
resistance through direct contact with the MDR-TB patients.
The emergence of MDR-TB is believed to be linked to poor adherence to prescribed TB
treatment, social barriers such as stigma, discrimination, poverty, poor DOT system and non
compliance to the guidelines from prescribers partly due to drug stock-outs in some facilities.
Particularly, many patients come to health facilities with advanced TB cases owing to them
seeking medical care in private health outlets such as clinics, drug shops and pharmacies.
Whereas these outlets provide options for primary health care services, their role in effectively
diagnosing and referring TB patients for treatment remains unabated. As such, country TB case

4
Source: National Tuberculosis and Leprosy Control Program (NTLP) cohort analysis reports
5
MoH Pharmacy Stock Status Reports for August 2011, October 2011, January 2012 and March 2012; Published
online by MoH at http://health.go.ug/mohweb/?page_id=388
4

detection is affected and this could be linked to poor access to health care services, and a limited
number of skilled staff and diagnostic facilities.
The country has been able to adopt and implement the DOTS with varying level of success in the
different regions of the country. Whereas the DOTS appeared to have worked, dwindling
resources for contact tracing and follow-up has affected sustainability. Despite the ban on sale of
TB medicines in private pharmaceutical outlets, illegal quantities continue to find their way there
and this affects the national strategies for follow up. Also not all persons in need of TB treatment
are receiving it with vaccination coverage continuing to elude about 10% of newborn children.
6

2.2.3. Evidence of feasibility of TB case detection in pharmacies
Referral of patients to clinical care centres including hospitals and other established health
facilities remain a key requirement for pharmacy practice and is well enshrined in the concept of
provision of pharmaceutical care. It has been shown that this referral is very feasible and can
work very for cases of suspected TB but if significant impact on case detection is to be achieved,
the roles of the pharmacists and expectations of the clients have to be clearly managed
7
. The key
challenges are in the way the community looks at the pharmacies and how the pharmacies are
positioning themselves to carry on the additional role. Community pharmacies are therefore prime
candidates for effective detection and referral of suspected cases of TB to centres for diagnosis.
Strengthening the community pharmacies role in early case detection could lead to formation of
public-private partnerships which can be used to provide a service that is liked by the patients
produces an increased rate of patient notification and there high rates of treatment success. This
uses the strength that pharmacies have where there places of first contact for many of patients
with cough
8
. Community pharmacies are generally privately owned and together with other drug
seller outlets is one of the commonest points of first contact care with the health system in many
low and middle income countries including Uganda. This situation therefore underscores their
role in the public-private partnership arrangement for delivery of primary health care services.
This form of arrangement has been demonstrated to provide results and improve health systems
outcomes when they are carefully and strategically utilised
9
.

6
Ministry of Health Uganda; Health Sector Strategic & Investment Plan 2010/11 2014/15;2010, Kampala, Uganda
7
Lnnroth K et al; Referring TB suspects from private pharmacies to the National Tuberculosis Programme:
experiences from two districts in Ho Chi Minh City, Vietnam; Int. J. of TB & Lung Disease 2003 Dec;7(12):1147-53
8
Mukund Uplekar; Involving private health care providers in delivery of TB care: global strategy; Journal of
Tuberculosis (2003): 83, 156-164
9
Lambert ML, Delgado R, Michaux G, Vols A, Speybroeck N, Van der Stuyft P.; Collaboration between private
pharmacies and national tuberculosis programme: an intervention in Bolivia; Tropical Medicine and International
Health. 2005 Mar;10(3):246-50
5

In Cambodia with a high burden of T.B, the National Centre for T.B and Leprosy Control (MOH)
developed a Public-Private Mix DOTS strategy and the Phase 1 of the strategy was to improve
referrals from private facilities to the public facilities and the results of the 1
st
phase showed that
pharmacies were an excellent location for identification of the undiagnosed cases.
10
This and
other studies demonstrate the greater interest in enhancing the place of pharmacy services in the
provision and delivery of health care. It is important that more evidence is generated in areas of
capacity and quality of services of local pharmacies in providing TB early diagnosis and
prevention.
2.3. Project objectives, design and approach
2.3.1. Overall Project Goal
To contribute to reduction of spread and incidence of multi-drug resistant tuberculosis in
Uganda through strengthening of community pharmacies involvement in early case detection and
effective referral and follow up.
2.3.2. Project Objectives
The project and service delivery/development objectives to be addressed are to:
i) Conduct a baseline and needs assessment among community pharmacies;
ii) Design evidence based interventions to improve TB case detection, referral and follow up of
TB in community pharmacies;
iii) Implement the designed interventions to improve TB case detection, referral and follow up
of TB care among the community pharmacies
This report is a summative evaluation of the pilot project to understand possible bottlenecks and
opportunities for full scale-up of interventions within community pharmacies to address MDR-TB
challenges in Uganda.

10
Hara Mihalea and DArcy Richardson, (2009); Public-Private Mix Involving Pharmacies And Other Providers In TB
Control -- A Cambodia Case Study; submitted to the United States Agency for International Development (USAID) by
PATH under TB IQC Task Order 01
6

3. METHODOLOGY
3.1. Assessment design and approaches
3.1.1. Design of overall project/assessment
The assessment used the before and after outcomes mapping approach in targeted community
pharmacies in Jinja municipality. The two assessments involved a cross-sectional study/review
using semi-structured questionnaire administered to the staffs working in the community
pharmacies. The questionnaire was structured in key thematic areas of knowledge and practices in
management of cough and tuberculosis; referral systems and mechanisms; and overall services
offering of the sampled pharmacies.
3.1.2. Exposure provided to the selected pharmacies
Out of the target pharmacies, five (5) were given a training and mentorship program on the key
aspects of TB diagnosis, treatment, prevention and referral systems. The exposure period lasted
up to six weeks after initial assessment.
3.2. Study population
3.2.1. Definition of study population
The primary review unit for the assessments were a community pharmacy. At each community
pharmacy a member authorized to handle medicines and provide health care to patients/clients
was chosen for the interview. This interviewee was either the Pharmacist, the pharmacy
technician, midwife, nurse or any other auxiliary staff.
3.2.2. I nclusion and exclusion criteria
The inclusion criteria for community pharmacies in the assessments included:
Being located in Jinja municipality,
Providing medicines and health services directly to the patients or clients (a retailer),
Having a minimum of retail operating license issued by NDA during the study period, and
Provision of consent to participate.
The inclusion criteria for respondents from the community pharmacy included:
Being employed by the community pharmacies selected to participate in the study,
Having authorisation to handle medicines and provide healthcare services, and
Consenting to participate in the study
7

3.3. TB presentation and predisposing signs and symptoms
The central focus of the assessments was to look at how the pharmacy persons are able to identify
suspected TB cases and the capacity to effectively refer these patients for prompt diagnosis. This
therefore focussed around identifying the classical signs and symptoms of TB infection as well as
carrying differential diagnosis from all other conditions with similar presentations. The
pharmacies were compared before and after period of exposure to tailor-made training on TB case
management and effective referral systems.
3.3.1. Definition of suspected TB case
11

A patient is suspected of having an infection of TB if he/she presents with the following signs and
symptoms:
Productive cough: prolonged cough of three or more weeks
Chest pain, and hemoptysis
Symptoms of low grade remittent fever, chills, night sweats, appetite loss, easy fatigue
Fever, chills and night sweats
Weight loss of greater than three kilograms over last one month
History of contact with a TB patient
Pharmacy workers are expected to identify these signs, understand drug treatment, and be able to
refer the patient for further investigations.
3.4. Data collection and management
3.4.1. Data collection process
Data was collected using a structured tool. The data collectors were trained on use of the tool as
well as principles of research ethics. The structured tool was the same tool used in the baseline
survey. The team were able to revise the tools before embarking on data collection.
The data collection exercise involved two teams over two days. Each pharmacy was coded and
given a unique identification number. The pharmacies were informed a week prior to the exercise
and contacts were made directly with the supervising pharmacists and directors. During the two
day data collection exercise, the teams planned to visit 14 pharmacies each time
12
.

11
These definitions were adapted from the Uganda NTLP guidelines for TB diagnosis and treatment. They are well in
line with the recommended signs and symptoms as defined by the WHO STOP-TB Partnership
12
The target of 14 pharmacies was based on the number registered by NDA in Jinja municipality that met the
inclusion and exclusion criteria for the assessment
8

3.4.2. Storage and cleaning of data
There were no identifiers collected, the community pharmacies were only identified by a one or
two digit code and only the study coordinator, the principal investigator and data collectors had
access to the definition of the codes.
3.4.3. Data analysis approach
The data was pre-coded, entered into Epi-Data and exported to SPPSS for cleaning and analysis.
The analysis of the data was carried out based on key thematic areas of demographics, knowledge
and practices in cough management, knowledge and practices of tuberculosis management and
control, systems to manage and refer suspected TB cases, and overall suitability of the pharmacy
for increased responsibility.
3.5. Ethical considerations
This assessment was approved and registered with the Uganda National Council of Science and
Technology (UNCST) before commencing. All pharmacies consented in writing to participating
in the assessment while all respondents were able to provide oral consent. No identifiers were
collected and the codes were excluded during analysis of data.
3.6. Limitations
This study has a number of limitations that includes the following:
Lack of generalizability: the findings from this study cannot be generalised to the whole
country but it only provides inferences to what could be a national situation
The study does not attempt to prove causation or direct linkage between cases of MDR-TB
and role of community pharmacies. It only describes their current situation in the study area
The outcomes of the evaluation are biased by the level of education of the respondents. Not
all the supervising pharmacists were respondents during the process of the data collection.
Respondents from some pharmacies claimed had no time for the full length of the
questionnaire.

9

4. RESULTS
Below here are the results of the two assessments presented based on the key thematic areas of the
study namely: practice in management of cough; knowledge and practice of TB diagnosis and
treatment; referral system in place; and current services being offered by the assessed pharmacies.
4.1. Demographic characteristics of the pharmacies
4.1.1. Characteristics of pharmacies and respondents
Table 2: Type of pharmacy license
Generally, there was little difference in the
pharmacies license type with only one
changing to have additional wholesale
service. More than half of the pharmacies
provided both wholesale and retail services.
In the end-line survey, all respondents in the four pharmacies provided with the exposure after the
baseline attended the project workshop. The workshop was on the management of cough and TB
and was organized by PSU in Jinja. The mean length of stay of all the pharmacies interviewed
was 191 months in Jinja meaning averagely the pharmacies have been in place for 15 years.
4.1.2. Staffing norms of assessed Pharmacies
Table 3: Staffing norms in the assessed pharmacies
The average number of staff
in these pharmacies was 3
with the minimum number
being 2 and the maximum
being 5 members of staff.
Nurses are most commonly
found in the pharmacies with
generally no pharmacy
technicians.
The staffing norms are well in line with the task-shifting approaches practiced in the country
arising from shortage of skilled manpower. The existing non-pharmacy trained personnel were
not assessed for their level of competencies to handle medicines or if they had ever received the
mandatory training of pharmacy auxiliary staffs routinely organised by PSU.
Type Baseline End-line
Wholesale and retail 8 (61.5%) 7 (53.8%)
Retail only 5 (38.5%) 6 (46.2%)
Total 13 (100%) 13 (100%)
Type/cadre of staff
in pharmacy
Number of pharmacies
Total Mean Minimum Maximum
All health workers 11 3.27 2 5
Nurses 11 2.27 1 4
Midwives 10 0.00 0 0
Pharmacy technicians 10 0.00 0 0
Pharmacists 11 0.36 0 2
Nursing assistants 10 0.30 0 1
Others 10 0.10 0 2
10

4.1.3. Opening Times/hours of the pharmacies visited
On average all the pharmacies visited open for about 12.64 hours from Monday to Friday, then
11.73 hours on Saturday, and 9.5 hours on Sunday. There was no significant difference in opening
hours at baseline and at end-line of the project period that was a little
too short a period. This is important parameter for purpose of access to
prompt referral and presumptive diagnostic services to patients who
always prefer pharmaceutical outlets as first point of primary care.
4.1.4. Level of the nearest Health Facility
Table 4: Level of nearest health facility
The level of the nearest public health facility to
most of the pharmacies is the regional referral
Hospital. Most of the pharmacies (5 Pharmacies)
indicated that the nearest private health facility is
not at a level of a Health center II, III, IV, or even
a general Hospital. This is indicative of
challenges with the primary care system.
4.1.5. Time to the nearest health facility
Generally, most pharmacies are located within proximity of a known health facility with an
average of four minutes walk away. The preferred facilities were at least five to ten minutes away
for private and public respectively. On average, the pharmacies are within walkable distances
from facilities able to carry out prompt and effective TB diagnosis.
4.1.6. Number of patients served at the Pharmacy
When asked for their load of patients, the pharmacies noted a higher number coming for retail
than for wholesale with median numbers of 50 and 20 patients respectively. The retail clientele is
at least 2 times higher than the wholesale one not considering total monetary value. The daily
average number of patients served in the retail section is about 93 patients while that for
wholesale is about 22 clients.
Table 5: Clientele load in the pharmacies per day
Clientele service type N Minimum Maximum Median Mean
Retail services 11 40 400 50 93
Wholesale services 7 0 50 20 22
Level of health facility Public Private
Regional Referral Hospital 11 0
General Hospital 0 1
Health Centre IV 0 1
Health Centre III 0 1
Health centre II 0 3
Other 0 5
11

4.1.7. Service available and offered at the pharmacy premises
More pharmacies indicated availability of different primary health care services although very
few were actually being offered to the patients who require them (Figure 1 below). On the overall,
the level of availability of the services is much lower than it should be since the pharmacies are
expected to provide emergency support to patients in need of treatment and support before referral
for the appropriate medical attention.
Figure 1: Availability of different services in the pharmacies

4.2. Practices in Management of Patients with Cough
4.2.1. Management of cough at the pharmacy
Figure 2: Main actions taken in managing cough at the pharmacy

0% 5% 10% 15% 20%
HIV rapid tests
Malaria rapid tests
Immunisation for children
Pregnancy tests
First aid
Wound dressing
Injectable contraception
0%
0%
8%
0%
8%
8%
0%
0%
11%
0%
10%
0%
20%
10%
End-line Baseline
0% 20% 40% 60% 80% 100%
Take history
Ask about current medication
Provide antibiotic treatment
Review treatment notes
Provide any medication
Refer difficult cases
Recommend non-drug therapy
Give out cough syrup
100%
38%
23%
15%
15%
15%
8%
8%
91%
64%
55%
18%
9%
27%
0%
18%
A
c
t
i
o
n
s

t
a
k
e
n

End line (N=11) Baseline (N=13)
12

There is a general improvement in the key areas of management of cough in the pharmacies at
end-line. Referral and review of current antibiotics before giving further treatment increased
showing possibly better case management.
4.2.2. Options taken when unable to manage cough at the pharmacy
Figure 3: Action taken by pharmacy when unable to manage cough

The community pharmacies prefer to refer their patients with cough to Jinja RRH hospital more
than to any other facility. There was an increase in number of referrals to health centres while the
referrals to Jinja RRH decreased.
4.2.3. Medicines pharmacies supply to cough patients
When asked for which medicines they supply in management of cough at the pharmacy, a number
of key responses were provided as in figure 4.use of penicillin antibiotics is the highest overall
while use of Erythromycin reduced to by 75% indicating better understanding of the risks.
Figure 4: Main medicines supplied in management of cough

0% 50% 100%
Refer to Jinja RRH
Refer to any clinic
Refer to any hospital
Refer to any government health centre
Other action
92%
31%
31%
8%
8%
91%
9%
18%
27%
9%
A
c
t
i
o
n

t
a
k
e
n

0% 10% 20% 30% 40% 50% 60% 70%
Penicillin antibiotics
Erythromycin
Other antibacterials
Antipyretics
Cough preparations
Other remedies
52%
31%
23%
8%
23%
69%
52%
9%
9%
0%
41%
27%
M
e
d
i
c
i
n
e

s
u
p
p
l
i
e
d

13

Figure 5: Key penicillin used for cough
Amoxicillin and the Ampicillin with
Cloxacillin are the predominant
antibacterial products supplied for
management of cough. This could be
driven mainly by their cost as the
other products used are way too
expensive for the common population
in the municipality. Generally,
penicillin products are used more
than the macrolides group to which
erythromycin belongs. The extent to
which penicillins are supplied not
being very different in the baseline and end-line surveys. The drop in use of erythromycin from
30.8% to 9.1% is good in reducing the extent to which T.B infection may be masked.
4.2.4. Key factors taken into consideration while managing cough
The respondents were asked about the key factors they took into consideration the last time they
managed cough at the pharmacy. A range of responses were given as shown in table 6.
Table 6: Key issues considered last time a patient with cough was managed
Key issues for consideration
No. of pharmacies (%)
Baseline (N=13) End line (N=11)
Number Proportion Number Proportion
Type of cough 11 84.6% 9 81.9%
How long the cough has lasted 11 84.6% 9 81.9%
Age of patient 4 30.8% 4 36.4%
Possible allergies of patient 3 23.1% 0 0.0%
Current medications 3 23.1% 2 18.2%
Economic status of the patient 1 7.7% 1 9.1%
Other 4 30.8% 0 0.0%
None 1 7.7% 0 0.0%
There was no significant change in the key factors put into consideration when managing cough at
the pharmacies. Many of the pharmacies appear to have common approach to managing cough
with the priority issues being type of cough, length of cough and age of the patient.

0%
20%
40%
60%
80%
100%
92%
69%
31%
15%
91% 91%
9%
18%
N
u
m
b
e
r

o
f

p
h
a
r
m
a
c
i
e
s

14

4.3. Knowledge of TB Diagnosis and Treatment among Health Workers
The second key component of the assessments was to understand and compare the knowledge of
the health workers regarding diagnosis and treatment of TB at baseline and at end-line.
4.3.1. Understanding the epidemiology of TB
When asked about the ways in which people can contract TB in the general setting, the
respondents provided responses indicated in table 7.
Table 7: Methods of transmission of TB reported
Methods of transmission reported
No. of pharmacies (%)
Number Proportion Number Proportion
Inhaling or ingesting droplets or aerosols from
infected person
10 76.9% 8 72.7%
Contact/touch with a TB infected person 6 46.2% 8 72.7%
Having HIV/AIDS infection 3 23.1% 1 9.1%
Sleeping in damp poorly ventilated rooms 1 7.7% 0 0%
Other 2 15.4% 1 9.1%
There is a good understanding of the key methods for transmission of TB. However, the
respondents appear not to clearly understand the role of the pre-disposing factors such as contact
and underlying HIV infection. There was no significant difference on the knowledge on the ways
in which one could contract tuberculosis between the two assessments.
4.3.2. Handling suspected TB cases
When asked for ways in which they
handle suspected TB patients in the
pharmacies, majority indicated that
they refer for diagnosis and care at
an appropriate facility (Figure 6).
Generally, many of the pharmacies
provide supportive care and pre-
referral support and treatment. They
are not mandated to treat TB cases
within their settings. They only
focus on referral as their key role.
Figure 6: Steps taken to handle suspected TB

0% 20% 40% 60% 80% 100%
Assess for danger signs
Take detailed history
Counsel as appropriate
Provide supportive treatment
Refer for full diagnosis/care
8%
15%
31%
8%
100%
22%
22%
11%
11%
89%
15

When asked for where they make their referrals, more than 95% of the facilities reported referring
to Jinja RRH due to both proximity and the possibility of quick diagnosis and turn-around time.
There was no significant difference between the baseline and end-line performance.
4.3.3. Referral of suspected TB cases
In carrying out the referral process, the different pharmacies were asked about which treatment
they (they would) provide to the suspected cases.
Figure 7: Pre-referral Treatments given
Generally, the pharmacies supply
patients with penicillin type of
antibacterial agents alongside a
cocktail of painkillers. There was
a drop in number of cases
receiving erythromycin as part of
referral treatment in the end-line
survey.
The other treatments given
include anti-depressants,
treatment of other underlying
illnesses and overall supportive therapy including the psycho-social support required.
The key activities carried out in the
referral process are indicated in figure
8. Generally, the pharmacies are keen
on providing counselling and
indicating a form of referral for the
patients.
The focus on these two areas showed
some marginal improvement in the
end-line survey as compared to
baseline. There appear to be a clear
understanding of requirements for
effective referral of cases to another
health facility, a central pillar of
primary health care.

Figure 8: Key pre-referral activities carried out

0%
10%
20%
30%
40%
50%
60%
70%
15%
8%
23%
8% 8%
15%
62%
13%
25%
13% 13% 13% 13%
38%
Baseline (N=13)
0 5 10
Counsel the patient
Write a referral note
Just send the patient away
Leave it to the patient to
decide
Other
5
2
1
1
3
6
4
1
1
2
16

4.3.4. Managing confirmed TB cases in the pharmacy
On the other hand, majority of the respondents reported referring confirmed TB cases with
appropriate counselling of patient (Figure 9). Preference for referral improved almost two fold
after the intervention period. The other actions remain inconclusive and with little variation
among the pharmacies.
Figure 9: Actions taken to confirmed TB cases in the pharmacy

4.3.5. Knowledge of TB treatment in the clinical setting
The specific knowledge of TB treatment remains poor among the respondents. While 50% noted
that it is with anti-TB drugs, only 30% could clearly differentiate that the treatment is divided into
two phases (i.e. initial and continuation phase) and that 4 drugs are given in the initial phase and 2
are given in the continuation phase. The end-line survey observed s a slight increase in knowledge
on the specifics of the treatment such as the phases of treatment.
Knowledge about the specific treatment for TB remains wanting
among the respondents with Rifampicin and streptomycin are
the most commonly known medicines by over 65% of
respondents. There is limited appreciation of the different
formulations especially the Fixed Dose used for TB treatment.
There was no difference in the level knowledge on the
other/ancillary medicines administered with anti-TBs during the
management of TB.
0% 20% 40% 60% 80%
Assess for danger signs
Counsel as appropriate
Provide supportive treatment
Refer for follow-up elsewhere
Supply treatment in pharmacy
Send patient away
None
Other
15%
15%
15%
38%
8%
8%
8%
31%
0%
10%
0%
80%
10%
0%
0%
0%
End line (N=10) Baseline(N=13)
17

4.3.6. Knowledge of signs and symptom of TB
When assessed for what would alert them of possibility of patient having TB infection, many of
the respondents (over 70%) noted that persistent cough for over two weeks and night sweats were
key signs as indicated in figure 10.
Figure 10: Reported signs and symptoms indicative of TB in the pharmacy

The understanding of the signs and symptoms of TB infection is relatively fine with many of the
cardinal ones coming out clearly. There was a marked improvement in the understanding of these
signs and symptoms in the end-line as compared to baseline survey.
4.4. Infrastructure/System to Refer and Follow-Up
4.4.1. Linkage with facilities for referral
None of the pharmacies had any formal linkage or agreement with a facility for any form of
referral. Informal linkages were reported but are mainly for purpose of complimentary services
and business competitiveness especially for congested areas. This situation remained the same
after the period of pilot intervention.
Table 8: Presence of any agreement between the pharmacy and a health facility for referral
Item N Frequency Percent
Agreement available 11 0 0
Agreement not available 11 11 100
0% 20% 40% 60% 80% 100%
Chest pain at coughing or breathing
Coughing
Persistent cough > two weeks
Coughing up blood (hemoptysis)
Night Sweats
Poor Appetite
Weight loss
Fatigue or Weakness
Trouble Breathing
Dizziness
Other
31%
31%
85%
8%
62%
31%
31%
15%
8%
8%
8%
0%
20%
80%
30%
70%
70%
60%
0%
0%
0%
20%
18

4.4.2. Keeping records of referrals and I EC materials
Overall, the record keeping of the pharmacies in relation to referrals and display of IEC materials
for control of TB remains low. Keeping of records improved slightly while all pharmacies
exposed to the intervention were able to have and at least display IEC materials (Figure 11).
Figure 11: Record keeping and display of TB IEC materials in the pharmacies

Keep any records of
referred patients
Keep any records of
suspected TB cases
Keep any record for
confirmed TB cases
Pharmacy displayed
TB IEC materials

4.4.3. Maintaining directory and procedures for referrals
The pharmacies generally do not maintain directories of health facilities within the municipality
to allow for effective linkage (Figure 12). Only the pharmacies in the intervention arm developed
and put in place procedures for referral and reporting suspected and confirmed cases of TB. While
the pharmacies were all trained to follow-up clients, only 2 were able to do so at end-line.
Figure 12: maintaining directory and procedures for referrals

Maintained directory of
possible TB referral facilities
Had written procedures for
referral/reporting cases
Follow up any referred cases

0%
20%
40%
60%
80%
100%
12
8
1
3
Yes No
0
2
13
8
Yes No
1 1
12 10
Yes No
0
3
13
8
Yes No
0%
20%
40%
60%
80%
100%
Baseline Endline
1
2
10
8
Yes No
Baseline Endline
0
2
12
9
Yes No
Baseline Endline
1
2
11
9
Yes No
19

5. DISCUSSIONS
5.1. Primary care services at pharmacy level
Primary Health Care (PHC) as defined by the World Health Organization in 1978 is essential
health care; based on practical, scientifically sound, and socially acceptable method and
technology; universally accessible to all in the community through their full participation; at an
affordable cost; and geared toward self-reliance and self-determination.
13
As a philosophy, PHC
is based on the overlap of mutuality, social justice and equality; while as a strategy it on
individual and community strengths (assets) and opportunities for change (needs); maximizes the
involvement of the community; includes all relevant sectors but avoids duplication of services;
and uses only health technologies that are accessible, acceptable, affordable and appropriate
14
.
Pharmacy outlets in Uganda are by law designed to mainly offer dispensing of medicines (both
prescription only and over the counter medicines) as well as advisory services to patients and
other health care workers. Over the years, provision of emergency prescription services as well
disease prevention has been taken as acceptable although not fully prescribed in the existing
regulations within the country. Generally, these pharmacies are open for long hours from Monday
to Friday during the week and for at least three hours on Sundays making them suitable for
improving access to basic PHC services. This has not been matched with the level of services they
provide beyond being an outlet for supply medicines to patients yet they are within the reach of
many people within Jinja municipality.
5.1.1. Provision of complimentary primary care services
Generally community pharmacies remain as point of access to Medication Therapy Experts that
should in their course of work integrate knowledge, skills and professional attitudes to
effectively contribute to improved quality of drug therapy through the provision of patient-centred
care and in collaboration with health care providers
15
. With increased drive for pharmacies to
move towards patient-centred care where a lot of time and emphasis is placed on the patient as
opposed to drugs/medicines, community pharmacy practice has not been demonstrated here.
Many of the pharmacies only note availability of essential PHC services but do not extend them.

13
Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 612
September, 1978, jointly sponsored by the World Health Organization and the United Nations Childrens Fund.
Geneva, World Health Organization, 1978 (Health for All Series No. 1)
14
WHO, 2008; The world health report 2008: primary health care now more than ever; Geneva, World Health
Organization, 2008.
15
Kennie-Kaulbach, N., Farrell, B., Ward, N., Johnston, S., Gubbels, A., Eguale, T. et al. (2012). Pharmacist provision
of primary health care: a modified Delphi validation of pharmacists' competencies. BMC Family Practice, 13, 27
20

To be able to qualify this preference, the pharmacies still need to be able to provide
complimentary services such as first aid and as well as rapid diagnostic testing. Community
pharmacies in Jinja havent leveraged their full capacities to be able to provide comprehensive
PHC complimentary to the other health systems that is driven by collection of nurses, doctors and
other paramedical staff. They report availability of many of these services but have not been able
to provide these services even within the confines of the regulations in Uganda. In order to be able
to support effective presumptive diagnosis and prompt referrals for TB, these pharmacies have to
look at expanding their basic services beyond the current norm of dispensing and patient advisory
roles and move towards strengthening additional services.
5.1.2. Gaps in and opportunities for delivery of TB diagnostic services
Primary health care needs to be delivered close to the people; thus, should rely on maximum use
of both lay and professional health care practitioners. While TB diagnosis is still requires a
laboratory with capacity to handle the technical issues desired, the need to have early and prompt
referral for suspected cases remain within one component of PHC: education for the identification
and prevention / control of prevailing health challenges
16
. Community pharmacies and drug seller
outlets are considered the first contact point for majority of the population in Uganda accounting
for many more treatments than the conventional clinical care settings
17
. With private sellers also
accounting for rise in MDR-TB as a result of unclear diagnosis of diseases, there are still a lot of
gaps in service delivery to control TB spread.
The pharmacies in Jinja municipality require additional skills and training to fully incorporate TB
suspected case detection as well as capacity to effectively refer them for prompt diagnosis. The
basic infrastructure for these services exists although not exploited. It is a regulatory requirement
for all pharmacies to maintain a directory of all services providers and this has hardly been
implemented in the country as a whole. As a result, the pharmacies prefer to refer patients directly
to Jinja RRH which is a tertiary referral institution despite availability of many other primary and
secondary care (first referral) facilities within the municipality. This is a mentality that it is in only
such facilities that specialized services such as TB care and management are found. These
pharmacies are well suited to provide an active linkage with other PHC facilities that should carry
out first contact care.

16
Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 612
September, 1978, jointly sponsored by the World Health Organization and the United Nations Childrens Fund.
Geneva, World Health Organization, 1978 (Health for All Series No. 1)
17
Management Sciences for Health (MSH), 2011; East African Drug Sellers Initiative (EADSI) Project Report
21

5.2. Practice in the Management of cough at the pharmacies
5.2.1. Effectiveness of cough management
Effective cough management requires a greater understanding of the classification and possible
causes of cough. While generally not agreed upon, the most fitting definition of cough is a
forced expulsive manoeuvre, usually against a closed glottis and which is associated with a
characteristic sound
18
. Multiple algorithms have been applied in evaluation of cough and they
have all had different opinions and conclusions for adults
19
. While these have all been used, the
evaluation of cough to ensure that TB suspicion diagnosis is made remains a critical issue
especially in resource constrained setting where uptake and effective utilisation of national
guidelines remains poor in the private sector. Critically, not all cough can be managed in similar
way further complicating medication and non-medication therapies in both adults and children
20
.
There is significantly high number of patients who come to these pharmacies with cough and they
are at risk of being mismanaged without proper expertise. Over 80% of the pharmacies considered
in this evaluation were able to identify type and length of cough as critical factor in their
management. This together with age of patients ensures that correct choice of treatment option is
made to the patient. The pharmacies however complicate their management of cough with high
use of antibiotics (over 50% in many cases) and evidently more utilisation of medicines that can
mask symptoms of TB treatment. With this approach, all borderline patients and atypical patients
with possible TB can easily be missed out. However, at end-line with the minimum exposure
period, it was possible to demonstrate a decline in use of potent medicines that can mask TB as
well as better understanding of cough algorithm. Referral and review of current antibiotics before
giving further treatment improved at end-line showing possibly better case management yet still
the management of the cough many times is not standardized; it is subjective to who provides the
treatment and experience.
5.2.2. Cough management and TB
Generally, the pharmacies had greater awareness of the need to ensure TB is not missed out in
consideration for a patient with long history of coughing. Majority of the pharmacies considered
history taking for a patient as a key issue in determining the options to take in provision of
treatment and possible referral services at their level. While it is desirable for the pharmacies to

18
Widdicombe J, Fontana G.; Cough: what's in a name? European Respiratory Journal 2006; 281015.15
19
Morice A H, McGarvey L , and Pavord I; Recommendations for the management of cough in adults; Thorax, 2006
September; 61(Suppl 1): i1i24
20
McGarvey L P; Which investigations are most useful in the diagnosis of chronic cough; Thorax, 2004 April;
59(4):342-6
22

make TB as a critical differential, the high expansion of workers within these units makes it hard
a target and task to achieve overnight.
The non-judicious use of erythromycin and possibly other macrolides pose a big threat to not only
prompt diagnosis of cough but as well the possibility of further exacerbating the MDR-TB crisis
in the country. This together with lack of clear understanding of the hierarchical need for
functional PHC services continues to hamper effective delivery of required healthcare in
reproducible manner outside conventional public sector system. This situation is very reversible
with putting in place of proper systems as well as providing a mechanism to routinely support the
pharmacy staff to improve in their practice. The difference in findings from the end-line
assessment was further evidence to this overall process.
A final area of critical consideration here is the poly-pharmacy and over-prescription of penicillin
class of antibacterial agents for many cases of cough. While this has provided remissions it
increases risk of development of antimicrobial resistance within the community pharmacy setting.
Amoxicillin and the Ampicillin with Cloxacillin are the predominant antibacterial products
supplied for management of cough and their choice is possibly driven mainly by their cost as the
other products used are way too expensive for the common populace. This still compounds the
key challenge of ensuring that right diagnosis is obtained for every case presenting to the
community pharmacies while working within the confines of national regulations.
5.3. Knowledge of TB diagnosis and treatment among Health Workers
5.3.1. Awareness about signs and symptoms
Awareness and appreciation of the signs and symptoms of any disease is a critical factor in
ensuring proper and prompt diagnosis and treatment of any presenting illness including TB. There
was an improvement in awareness of the key signs and symptoms that would alert one of a
possible TB suspect despite many of the respondents not having had any proper training on TB
management and referral of suspects. Most of the health workers from the pharmacies that were
involved in the study had knowledge on the transmission of TB from one individual to another
and an improvement on the information regarding signs and symptoms of TB and a significant
number able to tell a notifiable and a non notifiable disease. Notification of any TB infection is
considered critical in success of fight against MDR-TB as well as XDR-TB in resource
constrained settings like Uganda.
There was a reduction in the number of respondents that intimated that they supply antibiotics to
suspected TB cases with a big number of the respondents giving no therapy to suspected cases but
refer them to where they can be better managed. This together with the improved understanding
of need to carry out effective referral remains central in ensuring the community pharmacies and
23

other medicines outlets are better positioned to handle the need to part of global response in fight
against antimicrobial resistance. If well planned, harmonised and trained in, the staff have
capacity to provide excellent referral systems that could speed up diagnosis and improve quality
of care. There is a correlation between the improvement in the knowledge and the number of
respondents that attended the pilot project training.
5.3.2. Understanding of TB care and treatment
Unlike many other infectious diseases, TB is a condition that if well managed (inclusive of patient
adherence issues) gets to full remission. Unfortunately, majority of TB cases in developing
countries like Uganda continues to be poorly handled at community practice level. The
Knowledge on the specific drugs used in the management of TB and how TB is managed in a
clinical setting improved in the after exposure to the intervention arm. The basic appreciation of
the overall TB care process in the country remains poor with not so many respondents able to
appreciate or remember the guidelines from NTLP/MoH. As such, the risk of misuse of TB
medicines remains much higher than estimated. The duration of treatment of TB was averagely
known and the different medicines that are not classified as Anti-TBs but administered during the
management of TB were somehow mentioned.
While stringent regulations exist for importation and sale of TB medicines, a number of
community pharmacies in Jinja had not just residual stocks
21
. There were few respondents who
mentioned on the fixed dose combinations that are used in the management of TB while over 67%
knew about the single medicines that are incidentally stocked within their premises. Community
pharmacies continue to possibly reap significant benefits from selling these medicines in time of
scarcity; a situation which is evident within the national system
22
. It is therefore important that the
national system for treatment of TB is considered using a more comprehensive approach that is
able to address both knowledge gaps and sustainable supply systems.
5.4. Infrastructure/System to refer and follow up
5.4.1. Requirements for effective referral:
Referral systems in both clinical and community systems do not work in isolation but as a
network. There are certain essential elements to optimize the referral systems operational
effectiveness and outcomes and they include Referral Network, Coordinating Agency, A Focal
Person at each agency/organization, A Directory of Resources, A standardized referral forms, A

21
Okumu M, et al, 2012; Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and
Referrals Case Study of Jinja Municipality: Baseline Report; Pharmaceutical Society of Uganda
22
MoH Pharmacy Stock Status Reports for August 2011, October 2011, January 2012 and March 2012; Published
online by MoH at http://health.go.ug/mohweb/?page_id=388
24

feedback loop to track referrals, and Documentation of referrals.
23,24
While there is some slim
direction, the current infrastructures in the community pharmacies are adequate for effective
referral if fully expanded and utilised. Community pharmacies have been unable to have basic
records in place and where available, they normally represent less than 5% of actual performance
outside sales information. A lot of tailoring to suit the changing dynamics of the population and
service sector remains critical in ensuring the community pharmacies keep relevant to fight
against TB drug resistance.
In consideration, referral is not necessarily between lower and higher level of the health system
but as well between health facilities of the same classification with an aim of achieving overall
goal of health system
25
. Referral is considered to be a set of activities undertaken by a healthcare
provider or facility in response to its inability to provide the quality or type of intervention
suitable for the need of the patient. While many of the pharmacies indicated having to do
referrals, the formal structures for this were not there before the pilot in Jinja. This project clearly
demonstrates that effective referrals is actually feasible between public and private (including for
profit) facilities in provision of PHC services.
5.4.2. Pharmacy operations and referrals
To meet the requirements above, pharmacies need to maintain adequate records, understand the
need to refer and know who to refer to. In addition, the referral centres should be those that are
accessible to the patient and have the required expertise to diagnose and treat TB. With some
marginal improvement in record keeping, there is a greater opportunity to utilise these records
more to improve delivery of services at community pharmacy level. However the pharmacies are
still not in position to exploit their capacity to carry out effective referral services in an
environment where profitability greatly outweighs the need for linkages.
There are over twenty (20) facilities within Jinja that have capacity to diagnose and treat TB and
are accredited by NTLP; however the awareness by the respondents of these facilities is low, as
indicated by the centre to which the referrals were made. Over the exposure period, the number of
pharmacies who were able to know and appreciate the other centres that can offer the required TB
services increased. Capacitating these pharmacies appropriately would most probably lead to
better care and advice to suspected TB patients. There is need to further address gaps in record
keeping, maintenance of directories of health facilities as well as other key challenges.

23
DSWD and UNDP Philippines, 2010; A Referral System for Care and Support Services for Persons Living with HIV
and their Families in the Community
24
Family Health International (FHI), 2005; Establishing Referral Networks for Comprehensive HIV Care in Low-
Resource Settings; Arlington, VA
25
World Health Organization, 2006; The world health report 2006: working together for health, Geneva
25

5.4.3. Legal framework for pharmacies
Pharmacies in Uganda are supervised by pharmacies, who in Uganda are not licensed prescribers
for Prescription Only Medicines (POM) thus decisions to treat in a pharmacy are limited to OTCs
and support services such as first aid. In addition Pharmacies are not authorised to provide
diagnostic services except if they open up a laboratory with an additional license independent of
that of the pharmacy for this particular purpose. Pharmaceutical care goes beyond provision of a
medicine and by extension there is need to include other complimentary services to improve
quality of services. With such limitations, provision of pharmaceutical care is still limited yet the
opportunities to do so exist within the network of pharmacies.

26

6. CONCLUSION AND RECOMMENDATIONS
6.1. Level of Achievement of the pilot project
Looking at the overall project implementation and key outcomes, the following key outputs were
demonstrated in the pilot phase:
i) The design of basic referral infrastructure and system to improve linkage with the other TB
diagnosis and treatment centres within the municipality. This was a clear initiation of the
basic structure for linkages and referrals.
ii) Mapping of the key gaps and opportunities for effective TB case detection within the
pharmacies was carried out. This provides benchmark for getting full-scale project
iii) Standard operating procedures and algorithm for TB case detection within community
pharmacies to support referrals were developed and rolled out.
Based on utilisation of the outputs, the appreciation of risks of antimicrobial resistance in relation
to TB improved among the pharmacies with more understanding key risks factors. The exposed
pharmacies were able to strengthen their internal record keeping and management of cough. The
process of referral improved marginally.
6.2. Scalability of the project
The basic ingredients for conducting the project were all available in the pharmacies and in the
environment considering the three critical elements of technical and organisational capacity,
financial viability and environmental suitability.
6.2.1. Technical and organisational requirements
The principal implementer of the project, PSU had the necessary technical persons to carry out
the activity and within the pharmacies, there were human resources available were adequate to
meet the scope of the project. The pharmacy staffs were provided with orientation and mentorship
in the area of TB prevention, diagnosis, control and treatment.
6.2.2. Environment issues/relevance to the stakeholders
The concept of use of community pharmacies (and other medicines outlet) as alternative to
provision of PHC service having been tried in Uganda and received great support from the
principal consumers of the services the clients, the project was piloted using the same concept
having the client in mind. While the policy limitations/barriers do exist use of pharmacies to carry
out simple presumptive diagnosis using clearly defined algorithm can support the call for
effective reduction in the incidence of delayed diagnosis of TB.
27

6.3. Recommendations
Based on the pilot period, the following key recommendations are being made to scale-up the
interventions beyond the current geographical region.
6.3.1. Policy level recommendations
c) The current guidelines on licensing of pharmacies as well as code of practice needs to be
revisited to allow pharmacies carry out more primary health care services including diagnosis
of common ailments.
d) Institute strong public-private partnerships in the management of TB that should involve role
of pharmacies especially in the TB DOTS programme. Pharmacies can then be accredited to
dispense medicines and refills for patients who do not need to go to hospitals.
6.3.2. Recommendations for further research
a) Attitudes of the population on receiving part of their TB care in the private pharmacies
b) Impact of availability of single TB medicines on growth of MDR-TB in Uganda

28

ANNEX: STUDY TEAM
Project Lead/ Principal I nvestigator
1. Mr. Morris Okumu

Deputy Project Lead/ Co-Principal I nvestigator
1. Mr. Kitutu Freddy Eric

Project Coordinator
1. Mr. Aguma Bush Herbert

Core Project Team Members
1. Asha Nabbale,
2. Brian Sekayombya
3. Bush Herbert Aguma
4. Freddy Eric Kitutu
5. Morris Okumu

Data Collection
Name Designation, Institution
1. Mr. Brian Arinitwe Pharmacist, Kawolo Hospital
2. Mr. Peter Niwagaba Pharmacist, Kambuga Hospital
3. Ms. Murungi Marion Intern Pharmacist, Mulago Hospital
4. Mr. Katwesigye Rogers Intern Pharmacist, Mulago Hospital
Data Management and Reporting
1. Mr Morris Okumu
2. Mr. Freddy Eric Kitutu
3. Mr. Brian Denis Sekayombya

Strengthening Community Pharmacies Role in Early Tuberculosis Case Detection and Referrals in Jinja Municipality, Uganda - End of Project Report

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