Simplified Referral for Tuberculosis Testing via Medicine Stores

How might we increase tuberculosis (TB) case detection?

Country: Nigeria

Health Area: Tuberculosis

Context and Insights

Nigeria has one of the lowest rates of tuberculosis (TB) case detection in the world, with authorities receiving notification of less than 26% of projected cases in 2018 (WHO, 2019). TB testing and treatment are free in Nigeria, and community members can get information from a toll-free National TB Hotline, including Directly Observed Treatment Short course (DOTS) locations where they can go for free testing and treatment. Some patients spend a lot of time seeking care from different providers such as religious leaders, pharmacies, and informal community medicine stores, and they are often reluctant to visit a health facility due to concerns about cost. Many people with undiagnosed TB regularly buy cough syrup, often returning to one or another medicine store to buy more cough syrup as soon as they run out.

The Solution

Medicine store staff recommend anyone with a cough for two or more weeks to get tested for TB by referring them to the National TB hotline. Breakthrough ACTION-Nigeria designed a simple pad of referral slips attached to a desktop calculator which staff can simply tear off and hand to any coughing customer. Each referral slip had a serial number to tie it back to the store, which Breakthrough ACTION used to generate the data for monitoring and evaluation (M&E). The calculator referral pad design was useful to store staff, so they therefore were likely to keep it on the counter. Rather than using a training workshop approach, project staff conducted brief orientations in the medicine store with its personnel about the benefits of TB testing and how to refer someone for it.

1 2 3 4 5 6

“Our approach appeals to their conscience—emphasizes how community members hold [medicine stores] in high esteem and trust them so much. We sensitize them on the epidemiology of TB—one undetected case can infect 10 other people. We point out that the person who is coughing may have children who go to school with their children to motivate them to help. If you’re not infected, you’re affected. The best incentive for you, family members, and the community is to eradicate TB in your community.” — Ahmad Muaz, Breakthrough ACTION-Nigeria, Kano State Team Lead

The Innovation

Earlier attempts by other programs relied on store staff to complete long M&E forms when making a referral, which store staff were unlikely to do even with some form of incentive. Breakthrough ACTION-Nigeria removed the burden on the medicine store staff to fill out a form when making a referral, making them much more likely to do so. Instead, the project used serial numbers to track completed referrals from the DOTS center back to the medicine store, allowing the project to generate the M&E data it needed without relying on medicine store staff.

The Evidence

During design and testing, the project oriented medicine store staff, left the referral slips with them, and went away. Later that afternoon, “Mystery Clients” visited the same medicine store complaining of a persistent cough and asking for cough syrup. About two out of three medicine stores gave a referral slip to the Mystery Client to call the National TB hotline.

During implementation, Breakthrough ACTION found small community medicine stores were more likely to issue referrals than busy roadside pharmacies.

59,173 referrals issued by the stores.
40,608 referrals completed.
10% positive cases from referrals from October 2021 through June 2024.

Scale-Up & Adapt

Over 9,000 medicine stores are issuing referrals for TB testing across eight states in Nigeria.

Over 40,000 people received testing after being getting a referral from a store.

Who can I speak with about this solution?

Bolatito Aiyenigba, Deputy Project Director for Tuberculosis

Justin DeNormandie, SBC and Innovation Advisor

Jen Orkis, Senior Program Officer II

Other resources

Continue exploring breakthroughs

Breakthrough ACTION-DRC

This website is made possible by the support of the American people through the United States Agency for International Development (USAID). The Breakthrough awards are supported by USAID’s Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreements: #AID-OAA-A-17-00017 and #AID-OAA-A-17-00018. Breakthrough ACTION is based at the Johns Hopkins Bloomberg School of Public Health’s Center for Communication Programs. Breakthrough RESEARCH is based at Population Council. The contents of this website are the sole responsibility of Breakthrough ACTION and Breakthrough RESEARCH. The information provided on this website is not official U.S. Government information and does not necessarily represent the views or positions of USAID, the United States Government, Johns Hopkins University, or Population Council.