Sexually Transmitted Disease Care Services in Developing Countries

THE BACTERIAL sexually transmitted diseases (STDs) represent a major global health burden.1 Their effective treatment is important to prevent serious sequelae, such as pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, infertility, and the many complications of syphilis. Treatment is also an effective secondary prevention measure, reducing STD transmission by shortening the duration of infection.2 Furthermore, the recognition that treatable sexually transmitted infections that cause genital tract inflammation or ulceration facilitate HIV transmission,3 and that effective STD treatment can reduce HIV incidence,4 further underscores the importance of quality STD treatment. However, as shown by Somsé and colleagues in this issue of Sexually Transmitted Diseases, the quality of STD treatment can be problematic.5 Somsé et al make two main points. First, that the majority of persons with genital tract infections in the Central African Republic's capital city Bangui prefer to seek care in the private sector, particularly from informal or quasiinformal practitioners, where the efficacy of STD treatment is extremely poor. Second, even in the public sector, the relatively small proportion of persons who seek treatment there are managed suboptimally. The situation in other developing counties is similar6; however, the efficacy of the treatment provided is only one aspect of health service quality. Attracting more clients to the public sector for STD treatment will require significant improvements in all aspects of health service quality, not only treatment efficacy. Unless service quality can be improved, the promise of one of the few available effective strategies for reducing HIV transmission in developing countries will not be realized. Clients preferentially seek care in the informal sector for many reasons. As observed by Somsé et al and by other groups in Africa,7 cost is one of these reasons. Contrary to what some economists have maintained,8 demand for many health services in developing countries, including STD treatment, is dependent to a significant extent on price. Although these services are highly valued, even relatively small out-of-pocket expenses can act as a significant deterrent to seeking care.9 As the cost of care in the public sector increases (which is now occurring in many developing counties, with user fees increasingly being levied to help offset the government's cost of health service provision), clients will inevitably turn to the private sector for care. Because the cost of care in the formal private sector is often prohibitive, the informal private sector may be the only recourse that is open to them. Cost is not the only deterrent to seeking STD care. Inconvenient hours of operation, long waiting times, and concerns about confidentiality and stigmatization all mitigate against seeking care in public clinics.5,10,11 Somsé et al argue for an increased role of pharmacists and informal sector practitioners in the provision of STD care. Pharmacists, with additional training and other incentives, are well placed to deliver STD care services, and these providers are largely underused. Attempts have been made in developing countries to enhance the quality of their services, with mixed success.12,13 An enhanced role for informal sector operators, particularly street-drug peddlers, is more problematic. These providers have generally proven to be difficult to work with and monitor. Although they provide a service that many clients find attractive, their primary motive is profit, their interest in the genuine welfare of their clients is suspect, and in addition to providing services that are largely illegal, these providers are often involved in other overtly criminal activities.14 It remains to be seen whether efforts to work with informal sector providers to improve the quality of the services that they provide can be of value. It is also important to try to improve the quality of STD services provided by private medical practitioners, and many of the concerns about quality of care in the informal sector also apply to this setting. There are relatively few reports of programs that have tried to work with physicians in private practice to improve quality of STD care,15 and it may be nearly as formidable a task as working with informal sector providers for some of the same reasons. What about the quality of STD services in the public sector? Improving the quality of many healthcare services in this setting is an issue that is receiving increasing attention in the health field, not only as a means of improving diagnosis and treatment, but also as a way of developing more efficient, effective, and sensitive services that will be attractive to clients. Improvement of services cannot be achieved overnight and cannot be mandated by standards and regulations. Attention must be paid to the rights of clients and to the needs of the staff who deliver services, including appropriate training in management, supervision, provision of clinical care and counseling, availability of the necessary equipment and supplies, and an orientation to the rights of their clients. A useful framework for defining the rights of clients has been used in the family planning field, where providers work toward improving their clients' right to information, access, choice, safe services, dignity, privacy, confidentiality, and continuity of services.16 In many successful family planning programs, providers participate in defining what quality means and how it might be achieved by problem identification and resolution.17 It has been shown that when family planning service quality improves and clients perceive this improvement, service and contraceptive use increases.18 Patients with STDs prefer the services provided by the informal sector not because these providers offer superior clinical treatment, but because they are accessible, have available medications (even if not efficacious), and involve no waiting time or judgmental treatment. Too often the formal health sector is unable to offer these service elements. However, with relatively modest inputs, including appropriate training, the establishment of regular supportive supervision, and assurance of a reliable supply of drugs, primary care level facilities and programs can deliver high-quality STD services.19–22 The optimal models for service delivery may vary,23 but surely this approach holds the most promise for improving the overall quality of STD care services. Most of the documented achievements, however, have been in the context of relatively small-scale projects with dedicated and highly motivated implementers. The challenge now is to scale up high-quality STD care services from the project level to the municipal, district, regional, and national level. In W. P. Kinsiella's novel Shoeless Joe, the building of an attractive baseball facility was sufficient to cause professionals and the general public to flock to it (“If you build it, they will come”); however, this is clearly not sufficient for STD services. Perhaps the mantra should read, “If you build it and offer high-quality, accessible, affordable, and nonstigmatizing STD care services, they will come.” They deserve no less.