Access to reproductive health services remains a big challenge in rural remote areas in Tanzania, due to limited health personnel, the public’s poor health seeking behaviour, distance between the villages and facilities as well as medicine stock-outs in public facilities. Due to these reasons, people resort to visiting informal providers based in their communities such as drug stores, for sexual and reproductive health (SRH) related services especially family planning, HIV prevention and STI treatment. Drug stores in Tanzania are not licensed to treat STIs, because these require antibiotics that can only be prescribed after diagnosis by skilled personnel at formal health facilities. But evidence shows that drug stores stock and sell antibiotics and offer family planning consultations, although they are neither qualified nor licensed to do so.
Public health actors at policy, research and implementation levels are looking for solutions to counter this situation, because it could lead to precarious public health consequences such as misleading the communities on how SRH services are provided and how SRH as a service, should be accessed by the patients and general populations. Drug resistances and increase in prevalence of STIs due to such unlicensed practices cannot be discounted.
IntHEC is a four year programme of research to develop evidence-based strategies to increase equity, integration and effectiveness of reproductive health services for poor communities in sub-Saharan Africa. The consortium is led by the Liverpool School of Tropical Medicine, where I work. The consortium is very interested in the challenge of providing reproductive health services in rural areas.
Communities in Tanzania are aware of the challenge. We discussed with actors in SRH service delivery to organise a community referral service that can provide and increase access to prescriptions by drug stores and their patients from formal health facilities. We wanted such a service to be backed by evidence so that we can give recommendations to policy makers on how to implement it. Our aim was to conduct a study in an enhanced, implementation, community referral intervention setting with specific objectives (Fig.1).
Figure 1 Objective of the community referral study
These discussions led to an agreement with the actors to design an intervention that can benefit everybody involved. Members of the communities, drug stores, dispensaries and health centres expressed that they wanted an intervention which addressed each of their concerns: the communities wanted it to be accessible and confidential, drug stores wanted it to recognise their contribution to and integrate them into the health system, while dispensaries and health centres wanted it to be clinically effective and support their overall handling of SRH services provided, especially drug dispensing for SRH conditions. The intervention we decided to adopt in the end was to use a short-message service (SMS) of mobile phones to enhance communication and patient referral between the drug stores and health facilities. We favoured this intervention because mobile telephony is among the fastest growing industries in Africa. In Tanzania, up to 95% of the population (currently 45 million) have access to a mobile phone.
The actors welcomed this idea and we obtained funding from the Indigo trust to fund the electronic management of the intervention. We designed it in partnership with Minoxsys Ltd – experts on mhealth systems design and cloud computing – to implement a system that prioritised the patient’s ease of access to SRH services (fig.2).
Figure 2 Design of the text messaging referral system
When a patient comes to a drug store to buy medicines for an SRH related problem that may require a prescription drug, the drug store explains the referral system. If the patient accepts, the drug store sends a text message with the patient details to a toll-free number connected to a web-system. The system processes and forwards the patient details including a password to a dispensary matched with the referrer drug store. At the same time, that password is sent back to the referrer drug store so that it can be passed on to the patient. While at dispensary, patients with a password are received, matched with details received in text messages, and given fast track RH service, after which the dispensary sends a text message to the toll-free number confirming the completeness of patient treatment. This intervention is implemented in all 9 intervention communities in Mwanza. No intervention is implemented in the 9 comparison wards.
Thanks to funding from Indigo Trust, we have been able to monitor the implementation, engage with district stakeholders as well as collect data on drug stores, health facilities and patients directly from the Minoxsys Snapshot platform. Currently, a total of 89 health facilities including drug stores, dispensaries and health centres use the system. It sends and receives text messages received from these participants, taking approximately 1.3 minutes to send and receive a text message. Further updates and evaluations on this intervention for its effectiveness are ongoing.
By John Dusabe, Research Assistant at Liverpool School of Tropical Medicine