Examining appropriate diagnosis and treatment of malaria: availability and use of rapid diagnostic tests and artemisinin-based combination therapy in public and private health facilities in south east Nigeria

Fidelity of implementation of national guidelines on malaria diagnosis for children under-five years in Rivers State, Nigeria

BACKGROUND

Malaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the "test and treat" strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country's roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria.

METHODS

This was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll's Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (β) and 95% confidence intervals.

RESULTS

The median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (β = - 1.89 [- 3.42, - 0.34]). Increase in participant responsiveness (β = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, β = 16.90 [6.78, 27.03]; microscopy vs. no test, β = 21.88 [13.60, 30.16]) were positively associated with fidelity score.

CONCLUSIONS

This study showed that core elements of the "test and treat" strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved.

Knowledge and practices of private pharmacy auxiliaries on malaria in Abidjan, Côte d'Ivoire

BACKGROUND

The emergence of resistance to artemisinin derivatives in Southeast Asia constitutes a serious threat for other malaria endemic areas, particularly in Côte d'Ivoire. To delay this resistance, the application of the control measures recommended by the National Malaria Control Programme (NMCP) for a correct management, in the private pharmacies, is a necessity. The purpose of this study was, therefore, to assess the level of knowledge and practices of private pharmacy auxiliary in Abidjan about the management of malaria.

METHODS

A descriptive cross-sectional study was conducted from April to November 2015. It included auxiliaries of private pharmacies in Abidjan. Data collection material was a structured an open pretested questionnaire. Data analysis was carried out using Package for Social Science (SPSS) software version 21.1. Chi square test was used to compare proportions for a significance threshold of 0.05 for the p value.

RESULTS

A total, 447 auxiliaries from 163 private pharmacies were interviewed. It was noted that the auxiliaries had a good knowledge of clinical signs of uncomplicated malaria (99.1%), biological examinations (54.6% for the thick film and 40.7% for rapid diagnostic tests (RDTs) and anti-malarial drugs (99.3% for artemether + lumefantrine, AL). The strategies of vector control (long-lasting insecticide-treated mosquito nets (LLITNs, Repellent ointments, cleaning gutters, elimination of larvae breeding site and intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) in pregnant women were also known by the auxiliaries, respectively 99.8% and 77.4%. However, the malaria pathogen (25.1%) and the NMCP recommendations (e.g. use of AL or AS + AQ as first-line treatment for uncomplicated malaria and IPTp-SP in pregnant women) were not well known by the auxiliaries (28.2% and 26.9% for uncomplicated and severe malaria). Concerning the practices of the auxiliaries, 91.1% offered anti-malarial drugs to patients without a prescription and 47.3% mentioned incorrect dosages. The combination artemether + lumefantrine was the most recommended (91.3%). The delivery of anti-malarial drugs was rarely accompanied by advice on malaria prevention, neither was it carried out on the result of an RDT.

CONCLUSION

The epidemiology and the NMCP recommendations for the diagnostic and therapeutic management of malaria, are not well known to auxiliaries, which may have implications for their practices. These results show the need to sensitize and train private pharmacy auxiliaries, and also to involve them in NMCP activities.

Economic Burdens of Uncomplicated Malaria in Primary Health Care (PHC) Facilities of Plateau State, Nigeria: Patients' Perspectives

OBJECTIVES

This study aims at evaluating the costs incurred by patients in Primary Healthcare facilities of Plateau State, Nigeria, due to uncomplicated malaria management.

METHODS

Patients' information on resources used and absence from the labour market due to uncomplicated malaria illness were collected using the self-reported cost of illness instruments across 24 selected Primary Health Care (PHC) facilities in Plateau State. The collated data were used to estimate the direct medical and non-medical costs incurred by patients through the summation of the various costs paid out of pocket for the services; while the indirect cost was estimated using the human capital theory. All analyses were conducted through Microsoft Excel and IBM Statistical Package for Social Sciences (SPSS®) version 23 software.

RESULTS

The average direct cost per episode of uncomplicated malaria was estimated at NGN 2808.37/USD 7.39, while the indirect average money equivalence of the time lost due to the ailment was estimated at NGN 2717/USD 7.55, giving an average cost of treating uncomplicated malaria borne by patients in Plateau State per episode to be NGN 5525.37/USD 14.94. The projected annual cost of the disease was NGN 9, 921,671,307.22 (USD 27, 560,198.08).

CONCLUSIONS

The study showed substantial financial costs borne by patients due to uncomplicated malaria in Plateau State, comprising 50.83% of direct cost and 49.17% of the indirect cost of medications.

Health workers' perception of malaria rapid diagnostic test and factors influencing compliance with test results in Ebonyi state, Nigeria

Background

The standard practice in treating uncomplicated malaria is to prescribe artemisinin-based combination therapy (ACT) for only patients with positive test results. However, health workers (HWs) sometimes prescribe ACTs for patients with negative malaria rapid diagnostic test (mRDT) results. Available evidence on HWs perception of mRDT and their level of compliance with test results in Nigeria lacks adequate stratification by state and context. We assessed HWs perception of mRDT and factors influencing ACTs prescription to patients with negative mRDT results in Ebonyi state, Nigeria.

Methods

A cross-sectional survey was conducted among 303 HWs who treat suspected malaria patients in 40 randomly selected public and private health facilities in Ebonyi state. Health workers’ perception of mRDT was assessed with 18 equally weighted five-point likert scale questions with maximum obtainable total score of 90. Scores ≥72 were graded as good and less, as poor perception. Data were analysed using descriptive statistics and logistic regression model at 5% significance level.

Results

Mean age of respondents was 34.6±9.4 years, 229 (75.6%) were females, 180 (59.4%) community health workers and 67 (22.1%) medical doctors. Overall, 114 (37.6%) respondents across healthcare facility strata had poor perception of mRDT. Respondents who prescribed ACTs to patients with negative mRDT results within six months preceding the survey were 154 (50.8%) [PHCs: 50 (42.4%), General hospitals: 18 (47.4%), tertiary facility: 51 (79.7%) and missionary hospitals: 35 (42.2%)]. Poor HWs’ perception of mRDT promoted prescription of ACT to patients with negative mRDT results (AOR = 5.6, 95% C.I = 3.2–9.9). The likelihood of prescribing ACTs to patients with negative mRDT results was higher among HWs in public health facilities (AOR = 2.8, 95% C.I = 1.4–5.5) than those in the private.

Conclusions

The poor perception of mRDT and especially common prescribing of ACTs to patients with negative mRDT results among HWs in Ebonyi state calls for context specific interventions to improve their perception and compliance with mRDT test results.

Knowledge, Attitude, and Practice Related to Malaria Diagnosis among Healthcare Workers in Hospitals: A Cross-Sectional Survey

Malaria is a potential medical emergency and should be treated immediately because delays in diagnosis and treatment are the leading causes of death in many countries. This study aimed to assess the knowledge, attitude, and practice related to malaria diagnosis for early detection among healthcare workers in the laboratories of hospitals in Thailand. The design of the study was a descriptive cross-sectional study carried out between January 2016 and March 2017 at 11 hospitals in Thailand. The interviewees included any scientists who were currently working in a medical laboratory. Mean scores for knowledge, attitude, and practice for each healthcare group were calculated and compared between groups. Data analysis was performed using the SPSS version 11.5 software package (SPSS Inc., Chicago, IL, USA). Among a total of 118 healthcare workers, most of the healthcare workers had fair to good knowledge, attitude, and practice related to malaria detection. Among the various positions of healthcare workers, medical technologists possessed a greater knowledge on malaria detection than medical technician assistants or laboratory assistants (X2 = 9.822, d.f. = 2, and P value=0.007). This study infers that knowledge, attitude, and practice related to malaria detection among healthcare workers in laboratories were adequate. However, some points of knowledge and practice must be updated. There is a very urgent need to update knowledge on malaria, especially about the number of Plasmodium species causing relapse in malaria patients. In addition, there is an urgent need to update the practice related to malaria detection, especially about the staining process for early detection of malaria.

Preference for Artemisinin-based combination therapy among healthcare providers, Lokoja, North-Central Nigeria

Background

In Nigeria, Artemisinin-based Combination Therapy (ACT) is the recommended first line antimalarial medicine for uncomplicated malaria. However, health care providers still continue the use of less efficacious medicines such as Sulphadoxine-pyrimethamine and chloroquine. We therefore determined preference for ACT (PFA) and factors associated with PFA among healthcare providers (HCP) in Lokoja, North-Central Nigeria as well as assessed healthcare providers' knowledge of malaria case management.

Methods

We conducted a cross-sectional study among physicians, nurses, pharmacists, community health officers (CHOs), community health extension workers (CHEWs) and, patent and proprietary medicine vendors (PPMVs). Interviewer-administered questionnaires were administered to collect data on respondents' characteristics, previously received malaria case management training and knowledge of malaria treatment. Knowledge scores ≥3 were categorised as good, maximum obtainable being 5.

Results

Of the 404 respondents, 214 (53.0%) were males. Overall, 219 (54.2%) respondents who received malaria case management training  included PPMVs: 79 (65.8%), CHEWs: 25 (64.1%), CHOs: 5 (55.6%), nurses: 72 (48.7%), physicians: 35 (47.3%) and pharmacists: 3 (23.1%). Overall, 202 (50.0%) providers including physicians: 69 (93.2%), CHO: 8 (88.9%), CHEWs: 33 (84.6%), pharmacists: 8 (61.5%), nurses: 64 (43.2%) and PPMVs: 20 (16.5%), had good knowledge of malaria treatment guidelines. Overall, preference for ACT among healthcare providers was 39.6%. Physicians: 50 (67.6%), pharmacists: 7 (59.3%) CHOs: 5 (55.6%), CHEWS: 16 (41.0%), nurses: 56 (37.8%) and PPMV: 24 (19.8%) had PFA. Receiving malaria case management training (adjusted odds ratio [aOR]) = 2.3; CI = 1.4 - 3.7) and having good knowledge of malaria treatment (aOR = 4.0; CI = 2.4 - 6.7) were associated with PFA.

Conclusions

Overall preference for ACT use was low among health care providers in this study. Preference for ACTs and proportion of health workers with good knowledge of malaria case management were even lower among PPMVs who had highest proportion of those who received malaria case management training. We recommend evaluation of current training quality, enhanced targeted training, follow-up supportive supervision of PPMVs and behavior change communication on ACT use.

Predictors of malaria Rapid Diagnostic Tests' utilisation among healthcare workers in Zamfara State

INTRODUCTION

Early diagnosis and prompt and effective treatment is one of the pillars of malaria control. Malaria case management guidelines recommend diagnostic testing before treatment using malaria Rapid Diagnostic Test (mRDT) or microscopy and this was adopted in Nigeria in 2010. However, despite the deployment of mRDT, the use of mRDTs by health workers varies by settings. This study set out to assess factors influencing utilisation of mRDT among healthcare workers in Zamfara State, Nigeria.

METHODS

A cross-sectional study was carried out among 306 healthcare workers selected using multistage sampling from six Local Government Areas between January and February 2017. Mixed method was used for data collection. A pre-tested self-administered questionnaire was used to collect information on knowledge, use of mRDT and factors influencing utilization. An observational checklist was used to assess the availability of mRDT in the six months prior to this study. Data were analyzed using descriptive statistics such as means and proportions. Association between mRDT use and independent variables was tested using Chi square while multiple regression was used to determine predictors of use at 5% level of significance.

RESULTS

Mean age of respondents was 36.0 ± 9.4years. Overall, 198 (64.7%) of health workers had good knowledge of mRDT; mRDT was available in 33 (61.1%) facilities. Routine use of mRDT was reported by 253 (82.7%) healthcare workers. This comprised 89 (35.2%) laboratory scientists/technicians, 89 (35.2%) community health extension workers/community health officers; 59 (23.3%) nurses and 16 (6.3%) doctors. Health workers' good knowledge of mRDT, trust in mRDT results, having received prior training on mRDT, and non-payment for mRDT were predictors of mRDT utilisation.

CONCLUSION

This study demonstrated that healthcare worker utilisation of mRDT was associated with health worker and health system-related factors that are potentially modifiable. There is need to sustain training of healthcare workers on benefits of using mRDT and provision of free mRDT in health facilities.

A scoping review on the field validation and implementation of rapid diagnostic tests for vector-borne and other infectious diseases of poverty in urban areas

BACKGROUND

Health personnel face challenges in diagnosing vector-borne and other diseases of poverty in urban settings. There is a need to know what rapid diagnostic technologies are available, have been properly assessed, and are being implemented to improve control of these diseases in the urban context. This paper characterizes evidence on the field validation and implementation in urban areas of rapid diagnostics for vector-borne diseases and other diseases of poverty.

MAIN BODY

A scoping review was conducted. Peer-reviewed and grey literature were searched using terms describing the targeted infectious diseases, diagnostics evaluations, rapid tests, and urban setting. The review was limited to studies published between 2000 and 2016 in English, Spanish, French, and Portuguese. Inclusion and exclusion criteria were refined post hoc to identify relevant literature regardless of study design and geography. A total of 179 documents of the 7806 initially screened were included in the analysis. Malaria (n = 100) and tuberculosis (n = 47) accounted for the majority of studies that reported diagnostics performance, impact, and implementation outcomes. Fewer studies, assessing mainly performance, were identified for visceral leishmaniasis (n = 9), filariasis and leptospirosis (each n = 5), enteric fever and schistosomiasis (each n = 3), dengue and leprosy (each n = 2), and Chagas disease, human African trypanosomiasis, and cholera (each n = 1). Reported sensitivity of rapid tests was variable depending on several factors. Overall, specificities were high (> 80%), except for schistosomiasis and cholera. Impact and implementation outcomes, mainly acceptability and cost, followed by adoption, feasibility, and sustainability of rapid tests are being evaluated in the field. Challenges to implementing rapid tests range from cultural to technical and administrative issues.

CONCLUSIONS

Rapid diagnostic tests for vector-borne and other diseases of poverty are being used in the urban context with demonstrated impact on case detection. However, most evidence comes from malaria rapid diagnostics, with variable results. While rapid tests for tuberculosis and visceral leishmaniasis require further implementation studies, more evidence on performance of current tests or development of new alternatives is needed for dengue, Chagas disease, filariasis, leptospirosis, enteric fever, human African trypanosomiasis, schistosomiasis and cholera.

Malaria Knowledge and Treatment Practices in Enugu State, Nigeria: A Qualitative Study

Background: Malaria accounts for 60% of outpatient visits in Nigeria. The aim of the study was to assess the knowledge of malaria and its treatment practices in Enugu state, Nigeria.

Methods: Qualitative data was collected through the use of focus group discussions (FGDs), from six villages three each from urban and rural areas of Enugu state, Nigeria. A total of 18 FGDs involving 189 participants were conducted and data on place of treatment for malaria and drug of choice for malaria treatment were collected.

Results: Most discussants had a good knowledge of the signs and symptoms of malaria. They reported late for treatment when they had symptoms suggestive of malaria. Treatment timing was affected by financial capability and perceived severity of disease. There was preference for patent medicine dealers (PMDs) and pharmacies for malaria treatment. The reasons included drug affordability, obtaining preferred drug, short waiting time and polite treatment from the providers. Treatment in most cases was without proper malaria diagnosis. Cost was an important factor in determining the drug of choice for malaria treatment. This could explain why people were not aware of the use of artemisininbased combination therapy while preferring mono-therapies and herbal drugs. Public hospitals were considered as good sources of treatment for malaria although they remain the last resort when treatment from these drug outlets failed.

Conclusion: The community members preferred PMDs and pharmacies for malaria treatment. Unfortunately, these drug outlets do not encourage the use of artemisinin combination therapy (ACT). This makes it necessary that pharmacists and PMDs are trained on management of malaria. Also, improving the knowledge of the public on the need for malaria diagnosis before treatment and use of artemisinin-based combination therapy will improve the control of malaria. The populace should be instructed to seek treatment early while also discouraging the use of herbal drugs for malaria treatment. There is also the need to improve service delivery at public health facilities.

The role of the Deki Reader™ in malaria diagnosis, treatment and reporting: findings from an Africare pilot project in Nigeria

BACKGROUND

The Deki Reader is a diagnostic device used with rapid diagnostic tests (RDTs) and linked to an online database for real-time uploads of patient information and results. This is in contrast to visual interpretation of malaria RDTs recorded on the District Health Information System (DHIS). This paper compares records for use of the Deki Reader with DHIS records of visual interpretation of RDTs.

RESULTS

A total of 4063 patient encounters/tests were recorded on the Deki Reader database between June 1st and December 31st, 2016. These tests were for 2629 persons who presented with fever and had RDT done. In comparison, data from DHIS 2.0 for same period recorded 7201 persons presenting with fever. 2421 out of the 2629 persons (92.1%), received RDT using Deki Reader compared to 6535 out of 7201 persons (90.4%) recorded on DHIS (p = 0.04). From DHIS records, malaria positivity rate was 51.6% (3375 out of 6535 persons) compared to Deki Reader records of 23.6% (572 out of 2421 persons). The difference between these two rates was significant (p < 0.001). The odds ratio (95% CI) for the association between use of Deki Reader and having a positive malaria result was 0.29 (0.26-0.32). DHIS showed that 4008 persons received Artemisinin-based combination therapy (ACT) while 3989 persons tested positive with RDT or microscopy, compared to 691 out of 705 persons (98.0%) using Deki Reader. Finally, Deki Reader identified 618 processing and manufacturers errors with an error rate of 15.3%.

CONCLUSION

The Deki Reader is likely a useful tool for malaria diagnosis, treatment, and real-time data management. It potentially improves diagnostic quality, reduces wastage in ACT administration and improves data quality.

Provider and patient perceptions of malaria rapid diagnostic test use in Nigeria: a cross-sectional evaluation

Background

Nigeria commenced a phased programmatic deployment of rapid diagnostic tests (RDT) at the primary health care (PHC) facility levels since 2011. Despite various efforts, the national testing rate for malaria is still very low. The uptake of RDT has been variable. This study was undertaken to determine the provider and patient perceptions to RDT use at the PHC level in Nigeria with their implications for improving uptake and compliance.

Methods

A cross-sectional survey was conducted in 120 randomly selected PHCs across six states, across the six-geopolitical zones of Nigeria in January 2013. Health facility staff interviews were conducted to assess health workers (HW) perception, prescription practices and determinants of RDT use. Patient exit interviews were conducted to assess patient perception of RDT from ten patients/caregivers who met the eligibility criterion and were consecutively selected in each PHC, and to determine HW’s compliance with RDT test results indirectly. Community members, each selected by their ward development committees in each Local Government Area were recruited for focus group discussion on their perceptions to RDT use.

Results

Health workers would use RDT results because of confidence in RDT results (95.4%) and its reduction in irrational use of artemisinin-based combination therapy (ACT) (87.2%). However, in Enugu state, RDT was not used by health workers because of the pervasive notion RDT that results were inaccurate. Among the 1207 exit interviews conducted, 549 (45.5%) had received RDT test. Compliance rate (administering ACT to positive patients and withholding ACT from negative patients) from patient exit interviews was 90.2%. Among caregivers/patients who had RDT done, over 95% knew that RDT tested for malaria, felt it was necessary and liked the test. Age of patients less than 5 years (p = 0.04) and “high” educational status (p = 0.0006) were factors influencing HW’s prescription of ACT to RDT negative patients.

Conclusion

The study demonstrated positive perception to RDT use by HW and among community members with good compliance rate among health workers at the PHC level. This positive perception should be explored in improving the current low level of malaria testing in Nigeria while addressing the influence of age on HW administration of ACT to RDT negative cases.

End malaria for good: a review of current strategies and future novelties for malaria elimination in Nigeria

Malaria is endemic in 91 countries and territories. Currently, over half of the world's population is at risk for malaria with malaria prevalence in sub-Saharan Africa remaining the highest in the world. Nigeria accounts for 56% of malaria cases in the West African sub-region. Malaria control is historically the oldest control programme in Nigeria, having been in existence since 1948. Malaria control in Nigeria is guided by National Malaria Strategic Plans. The goal of the NMSP (2014-2020) is 'to reduce malaria burden to pre-elimination levels and bring malaria-related mortality to zero' using strategies under seven strategic objectives. The theme for the 2017 World Malaria Day activities was 'End Malaria for Good'. This theme indicates a sustained push for national and international commitments toward goal zero. Although the prevalence of malaria has dropped significantly, from 42% in 2010 to 27.4% in 2015, a lot of effort needs to be made to actualise a malaria-free Nigeria. This review discusses the current strategies in place to control and eliminate malaria. It also describes some future novelties available to sub-Saharan Africa and Nigeria to 'End Malaria for Good.'

Private sector malaria RDT initiative in Nigeria: lessons from an end-of-project stakeholder engagement meeting

The malaria rapid diagnosis testing (RDT) landscape is rapidly evolving in health care delivery in Nigeria with many stakeholders playing or having potential for critical roles. A recent UNITAID grant supported a pilot project on the deployment of quality-assured RDTs among formal and informal private service outlets in three states in Nigeria. This paper describes findings from a series of stakeholder engagement meetings held at the conclusion of the project. The agreed meeting structure was a combination of plenary presentations, structured facilitated discussions, and nominal group techniques to achieve consensus. Rapporteurs recorded the meeting proceeding and summaries of the major areas of discussion and consensus points through a retrospective thematic analysis of the submitted meeting reports. Key findings indicate that private providers were confident in the use of RDTs for malaria diagnosis and believed it has improved the quality of their services. However, concerns were raised about continued access to quality-assured RDT kits. Going forward, stakeholders recommended increasing client-driven demand, and continuous training and supervision of providers through integration with existing monitoring and supervision mechanisms.

Rethinking the Design of Low-Cost Point-of-Care Diagnostic Devices

Reducing the global diseases burden requires effective diagnosis and treatment. In the developing world, accurate diagnosis can be the most expensive and time-consuming aspect of health care. Healthcare cost can, however, be reduced by use of affordable rapid diagnostic tests (RDTs). In the developed world, low-cost RDTs are being developed in many research laboratories; however, they are not being equally adopted in the developing countries. This disconnect points to a gap in the design philosophy, where parameterization of design variables ignores the most critical component of the system, the point-of-use stakeholders (e.g., doctors, nurses and patients). Herein, we demonstrated that a general focus on reducing cost (i.e., "low-cost"), rather than efficiency and reliability is misguided by the assumption that poverty reduces the value individuals place on their well-being. A case study of clinicians in Kenya showed that "zero-cost" is a low-weight parameter for point-of-use stakeholders, while reliability and standardization are crucial. We therefore argue that a user-driven, value-addition systems-engineering approach is needed for the design of RDTs to enhance adoption and translation into the field.

Engaging the private sector in malaria surveillance: a review of strategies and recommendations for elimination settings

BACKGROUND

In malaria elimination settings, all malaria cases must be identified, documented and investigated. To facilitate complete and timely reporting of all malaria cases and effective case management and follow-up, engagement with private providers is essential, particularly in settings where the private sector is a major source of healthcare. However, research on the role and performance of the private sector in malaria diagnosis, case management and reporting in malaria elimination settings is limited. Moreover, the most effective strategies for private sector engagement in malaria elimination settings remain unclear.

METHODS

Twenty-five experts in malaria elimination, disease surveillance and private sector engagement were purposively sampled and interviewed. An extensive review of grey and peer-reviewed literature on private sector testing, treatment, and reporting for malaria was performed. Additional in-depth literature review was conducted for six case studies on eliminating and neighbouring countries in Southeast Asia and Southern Africa.

RESULTS

The private health sector can be categorized based on their commercial orientation or business model (for-profit versus nonprofit) and their regulation status within a country (formal vs informal). A number of potentially effective strategies exist for engaging the private sector. Conducting a baseline assessment of the private sector is critical to understanding its composition, size, geographical distribution and quality of services provided. Facilitating reporting, referral and training linkages between the public and private sectors and making malaria a notifiable disease are important strategies to improve private sector involvement in malaria surveillance. Financial incentives for uptake of rapid diagnostic tests and artemisinin-based combination therapy should be combined with training and community awareness campaigns for improving uptake. Private sector providers can also be organized and better engaged through social franchising, effective regulation, professional organizations and government outreach.

CONCLUSION

This review highlights the importance of engaging private sector stakeholders early and often in the development of malaria elimination strategies.

Evaluation of the knowledge and attitude of pharmacists about the national malaria control policy in southern Benin

Background

The national strategy against malaria in an endemic country should involve all the health stakeholders. In Benin, the private sector is rarely present in the activities of the National Malaria Control Programme (NMCP), and its surveillance system does not cover private sector outlets that are a non-negligible part of the healthcare system.

Objective

The aim of this study was to describe the drug delivery practices within private pharmacies of Cotonou and Porto-Novo and the awareness of medicine providers concerning the national policy of malaria treatment.

Methods

A survey was performed among pharmacy staff members responsible for dispensing medicines and providing advice to patients within pharmacies of Cotonou and Porto-Novo. Dispensing/pharmacy assistants (‘dispensators’) from 82 pharmacies in Cotonou and 19 in Porto-Novo were surveyed. Data entry was performed using Epidata 3.1 software and data analysis was carried out using SPSS software version 21.1. Chi square test was used to compare proportions. A significance threshold of 0.05 was defined for the p value.

Results

46% of providers did not know the artemisinin-based combination therapy recommended by the NMCP for treating uncomplicated malaria. 58.7% were not able to recognize the gravity signs of malaria. 89.8% of dispensators were used to deliver an anti-malarial upon patient request, without prior biological confirmation as requested by the NMCP policy.

Conclusions

Dispensing practices within the studied pharmacies from Cotonou and Porto-Novo were not in adequacy with the NMCP guidelines for uncomplicated malaria, which is a striking weakness in the training of drug providers on key elements of the guidelines for managing malaria. The NMCP needs to help dispensator from private pharmacies sector to standardize drug delivery practices according to its guidelines.

Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015

Background

The World Health Organization guidelines have recommended that all cases of suspected malaria should receive a confirmatory test with microscopy or a malaria rapid diagnostic test (RDT), however evidence from sub-Saharan Africa (SSA) illustrates that only one-third of children under five with a recent fever received a test. The aim of this study was to evaluate availability, price and market share of microscopy and RDT from 2009/11 to 2014/15 in 8 SSA countries, to better understand barriers to improving access to malaria confirmatory testing in the public and private health sectors.

Results

Repeated national cross-sectional quantitative surveys were conducted among a sample of outlets stocking anti-malarial medicines and/or diagnostics. In total, 169,655 outlets were screened. Availability of malaria blood testing among all screened public health facilities increased significantly between the first survey wave in 2009/11 and the most recent in 2014/15 in Benin (36.2, 85.4%, p < 0.001), Kenya (53.8, 93.0%, p < 0.001), mainland Tanzania (46.9, 89.9%, p < 0.001), Nigeria (28.5, 86.2%, p < 0.001), Katanga, the Democratic Republic of the Congo (DRC) (76.0, 88.2%, p < 0.05), and Uganda (38.9, 95.6%, p < 0.001). These findings were attributed to an increase in availability of RDTs. Diagnostic availability remained high in Kinshasa (the DRC) (87.6, 97.6%) and Zambia (87.9, 91.6%). Testing availability in public health facilities significantly decreased in Madagascar (88.1, 73.1%, p < 0.01). In the most recent survey round, the majority of malaria testing was performed in the public sector in Zambia (90.9%), Benin (90.3%), Madagascar (84.5%), Katanga (74.3%), mainland Tanzania (73.5%), Uganda (71.8%), Nigeria (68.4%), Kenya (53.2%) and Kinshasa (51.9%). In the anti-malarial stocking private sector, significant increases in availability of diagnostic tests among private for-profit facilities were observed between the first and final survey rounds in Kinshasa (82.1, 94.0%, p < 0.05), Nigeria (37.0, 66.0%, p < 0.05), Kenya (52.8, 74.3%, p < 0.001), mainland Tanzania (66.8, 93.5%, p < 0.01), Uganda (47.1, 70.1%, p < 0.001), and Madagascar (14.5, 45.0%, p < 0.01). Blood testing availability remained low over time among anti-malarial stocking private health facilities in Benin (33.1, 20.7%), and high over time in Zambia (94.4, 87.5%), with evidence of falls in availability in Katanga (72.7, 55.6%, p < 0.05). Availability among anti-malarial stocking pharmacies and drug stores—which are the most common source of anti-malarial medicines—was rare in all settings, and highest in Uganda in 2015 (21.5%). Median private sector price of RDT for a child was equal to the price of pre-packaged quality-assured artemisinin-based combination therapy (QAACT) treatment for a two-year old child in some countries, and 1.5–2.5 times higher in others. Median private sector QAACT price for an adult varied from having parity with an RDT for an adult to being up to 2 times more expensive. The exception was in both Kinshasa and Katanga, where the median price of QAACT was less expensive than RDTs.

Conclusions

Significant strides have been made in the availability of testing, mainly through the widespread distribution of RDT, and especially in public health facilities. Significant barriers to universal coverage of diagnostic testing can be attributed to very low availability in the private sector, particularly among pharmacies and drug stores, which are responsible for most anti-malarial distribution. Where tests are available, price may serve as a barrier to uptake, particularly for young children. Several initiatives that have introduced RDT into the private sector can be modified and expanded as a means to close this gap in malaria testing availability and promote universal diagnosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1829-5) contains supplementary material, which is available to authorized users.

Impact of introducing subsidized combination treatment with artemether-lumefantrine on sales of anti-malarial monotherapies: a survey of private sector pharmacies in Huambo, Angola

BACKGROUND

Artemisinin-based combination therapies (ACTs) against malaria are subsidized in many African countries, but the impact of subsidy programs in reducing the sales of concomitantly available antimalarial monotherapies is poorly defined.

METHODS

Data from The MENTOR initiative, that introduced subsidized artemether-lumefantrine (sAL) in the private sector of Huambo province, Angola, were used. The main response variable was represented by sales of sAL and of monotherapies, measured as number of treatment courses. Sales in private pharmacies of sAL and four antimalarial monotherapies between 2009 and 2013 were organized in four time-periods, and analyzed using generalized linear models for repeated measures. A secondary analysis evaluated changes in relative market share.

RESULTS

We analyzed data from 34 pharmacies at four time points, taken from a larger survey that involved 165 pharmacies between June 2009 and March 2013. The sAL, following its introduction, became the dominant antimalarial treatment in the private sector, usually exceeding the total sales of all antimalarial monotherapies combined (1480/2800 total treatment courses, 52.8% of all sales in March 2013). Sales of monotherapies decreased significantly, but did not stop, representing 36.7% (1028/2800) of sales at the end of the survey.

CONCLUSIONS

Subsidized ACTs can attain rapidly a high relative market share. Their introduction reduced, but did not eliminate the demand for less effective monotherapies, that might favor parasite resistance.

Towards subsidized malaria rapid diagnostic tests. Lessons learned from programmes to subsidise artemisinin-based combination therapies in the private sector: a review

The idea of a private sector subsidy programme of artemisinin-based combination therapies (ACTs) was first proposed in 2004. Since then, several countries around the world have hosted pilot projects or programmes on subsidized ACTs and/or the Affordable Medicines Facility-malaria programme (AMFm). Overall the private sector subsidy programmes of ACTs have been effective in increasing availability of ACTs in the private sector and driving down average prices but struggled to crowd out antimalarial monotherapies. The results obtained from this ambitious strategy should inform policy makers in the designing of future interventions aimed to control malaria morbidity and mortality. Among the interventions recently proposed, a subsidy of rapid diagnostic tests (RDTs) in the private sector has been recommended by governments and international donors to cope with over-treatment with ACTs and to delay the emergence of resistance to artemisinin. In order to improve the cost-effectiveness of co-paid RDTs, we should build on the lessons we learned from almost 10 years of private sector subsidy programmes of ACTs in malaria-endemic countries.

Adherence to malaria diagnosis and treatment guidelines among healthcare workers in Ogun State, Nigeria

Background

Malaria case management remains a vital component of malaria control strategies. Despite the introduction of national malaria treatment guidelines and scale-up of malaria control interventions in Nigeria, anecdotal evidence shows some deviations from the guidelines in malaria case management. This study assessed factors influencing adherence to malaria diagnosis and treatment guidelines among healthcare workers in public and private sectors in Ogun State, Nigeria.

Methods

A comparative cross-sectional study was carried out among 432 (216 public and 216 private) healthcare workers selected from nine Local Government Areas using a multistage sampling technique. A pre-tested interviewer administered questionnaire was used to collect information on availability and use of malaria Rapid Diagnostic Test (mRDT) and artemisinin combination therapy (ACT), for management of uncomplicated malaria. Adherence was defined as when choice of antimalarials for parasitological confirmed malaria cases was restricted to recommended antimalarial medicines. Association between adherence and independent variables were tested using Chi-square at 5 % level of significance.

Results

Malaria RDT was available in 81.9 % of the public health facilities and 19.4 % of the private health facilities (p = 0.001). Its use was higher among public healthcare workers (85.2 %) compared to 32.9 % in private facilities (p = 0.000). Presumptive diagnosis of malaria was higher among private healthcare workers (94.9 %) compared to 22.7 % public facilities (p = <0.0001). The main reason for non-usage of mRDT among private healthcare workers was its perceived unreliability of mRDT (40.9 %). Monotherapy including artesunate (58.3 % vs 12.5 %), amodiaquine (38.9 % vs 8.3 %) and chloroquine (26.4 % vs 4.2 %) were significantly more available in private than public health facilities, respectively. Adherence to guidelines was significantly higher among public healthcare workers (60.6 %) compared to those in private facilities (27.3 %). Availability of antimalarial medicine was the main factor that influenced treatment prescription in both healthcare settings (p = 0.27). However, drug promotion by manufactures (45.8 %) has a major influence on private healthcare workers’ prescription practice.

Conclusion

The findings of this study demonstrate significant difference between public and private healthcare workers on adherence to national malaria diagnosis and treatment guidelines. Interventions to improve private sector engagement in implementation of the guidelines, training and supply of recommended antimalarial medicines should be intensified.

Comparison of Partec Rapid Malaria Test with Conventional Light Microscopy for Diagnosis of Malaria in Northwest Ethiopia

Background. Laboratory diagnosis of malaria is the key for effective disease management. Diagnosis of malaria infection requires rapid, sensitive, and specific test methods with an affordable cost. This study was aimed to assess the diagnostic performance of Partec rapid malaria test with reference to light microscopy for the diagnosis of malaria in Northwest Ethiopia. Methods. A total of 180 febrile patients were tested for malaria using Giemsa stain microscopy and Partec rapid malaria test from June to July 2013 at Gendewuha health centers, Metema district. Data were analyzed using SPSS version 20 statistical software. Odds ratio with 95% CI was calculated. Result. The sensitivity and specificity of Partec rapid malaria test were 93.8% (95% CI = 87.1%–100%) and 87.9% (95% CI = 79.7%–96.1%), respectively, while the positive predictive value and negative predictive value were 6.4% (95% CI = 77.2%–95.5%) and 94.6% (95% CI = 88.7%–100%), respectively. There was also an excellent agreement between two tests with Kappa value of 0.811 (95% CI = 0.625–0.996). Conclusion. Partec rapid malaria test showed good sensitivity and specificity with an excellent agreement to the reference light microscopy. Therefore PT can be considered as alternative diagnostic tools in malaria endemic areas.

Status of the use and compliance with malaria rapid diagnostic tests in formal private health facilities in Nigeria

Background

Nigeria has the largest number of malaria-related deaths, accounting for a third of global malaria deaths. It is important that the country attains universal coverage of key malaria interventions, one of which is the policy of universal testing before treatment, which the country has recently adopted. However, there is a dearth of data on its implementation in formal private health facilities, where close to a third of the population seek health care. This study identified the level of use of malaria rapid diagnostic testing (RDT), compliance with test results and associated challenges in the formal private health facilities in Nigeria.

Methods

A cross-sectional study that involved a multi-stage, random sampling of 240 formal private health facilities from the country’s six geo-political zones was conducted from July to August 2014. Data were collected using health facility records, healthcare workers’ interviews and an exit survey of febrile patients seen at the facilities, in order to determine fever prevalence, level of testing of febrile patience, compliance with test results, and health workers’ perceptions to RDT use.

Results

Data from the 201 health facilities analysed indicated a fever prevalence of 38.5 % (112,521/292,430). Of the 2077 exit interviews for febrile patients, malaria testing was ordered in 73.8 % (95 % CI 71.7–75.7 %). Among the 1270 tested, 61.8 % (719/1270) were tested with microscopy and 38.2 % (445/1270) with RDT. Compliance to malaria test result [administering arteminisin-based combination therapy (ACT) to positive patients and withholding ACT from negative patients] was 80.9 % (95 % CI 78.7–83 %). Compliance was not influenced by the age of patients or type of malaria test. The health facilities have various cadres of the health workers knowledgeable on RDT with 70 % knowing the meaning, while 84.5 % knew what it assesses. However, there was clearly a preference for microscopy as only 20 % reported performing only RDT.

Conclusion

In formal private health facilities in Nigeria there is a high rate of malaria testing for febrile patients, high level of compliance with test results but relatively low level of RDT utilization. This calls for improved engagement of the formal private health sector with a view to achieving universal coverage targets on malaria testing.

Design, implementation and evaluation of a training programme for school teachers in the use of malaria rapid diagnostic tests as part of a basic first aid kit in southern Malawi

Background

With increasing levels of enrolment, primary schools present a pragmatic opportunity to improve the access of school children to timely diagnosis and treatment of malaria, increasingly recognised as a major health problem within this age group. The expanded use of malaria rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACT) by community health workers (CHWs) has raised the prospect of whether teachers can provide similar services for school children. We describe and evaluate the training of primary school teachers to use a first aid kit containing malaria RDTs and ACT for the diagnosis and treament of uncomplicated malaria in school children in southern Malawi.

Methods

We outline the development of the intervention as: (1) conception and design, (2) pilot training, (3) final training, and (4) 7-month follow up. The training materials were piloted at a four-day workshop in July 2013 following their design at national stakeholders meetings. The evaluation of the pilot training and materials were assessed in relation to increased knowledge and skill sets using checklist evaluations and questionnaires, the results of which informed the design of a final seven-day training programme held in December 2013. A follow up of trained teachers was carried out in July 2014 following 7 months of routine implementation. A total of 15 teachers were evaluated at four stages: pilot training, two weeks following pilot, final training and seven months following final training.

Results

A total of 15 and 92 teachers were trained at the pilot and final training respectively. An average of 93 % of the total steps required to use RDTs were completed correctly at the final training, declining to 87 % after 7 months. All teachers were observed correctly undertaking safe blood collection and handling, accurate RDT interpretation, and correct dispensing of ACT. The most commonly observed errors were a failure to wait 20 minutes before reading the test result, and adding an incorrect volume of buffer to the test cassette.

Conclusion

Following training, teachers are able to competently use RDTs and ACTs test and treat children at school for uncomplicated malaria safely and accurately. Teachers demonstrate a comparable level of RDT use relative to non-health professional users of RDTs, and sustain this competency over a period of seven months during routine implementation.

Implementation of the integrated management of childhood illness with parasitological diagnosis of malaria in rural Ghana: health worker perceptions

BACKGROUND

Timely and appropriate management of febrile illness among children under five years of age will contribute to achieving Millennium Development Goal-4. The revised World Health Organization-Global Malaria Programme's policy on test-based management of malaria must integrate effectively into the Integrated Management of Childhood Illness (IMCI). This study reports on perceptions of health workers on the health system factors influencing effective delivery of test-based diagnosis of malaria with IMCI.

METHODS

A qualitative study was conducted among a range of health workers at different levels of the health system in the Brong Ahafo Region of Ghana. Interview transcripts were transferred into Nvivo 8 software for data management and analysis. A frame-work approach at two levels was used in the analysis, which included the processes required for implementation of test-based management of malaria and the health systems context.

RESULTS

Forty-nine in-depth interviews were conducted. The National Health Insurance Scheme (NHIS) was perceived to have led to an increase in health facility attendance, thereby increasing the workload of health workers. Workload was reported as the main reason that health workers were not able to complete all of the examinations included in the IMCI algorithm. The NHIS financing guidelines were seen to be determining diagnosis and treatment practices by health-care givers. Concern was expressed about the erratic supply of malaria rapid diagnostic test kits (RDTs), the quality of RDTs related to potential false negative results when clinical symptoms were consistent with malaria. IMCI was seen as important but practically impossible to fully implement due to workload.

CONCLUSIONS

Implementation of the WHO-revised IMCI guideline is confronted with a myriad of health systems challenges. The perceptions of front-line health workers on the accuracy and need for RDTs together with the capacity of health systems to support implementation plays a crucial role. The NHIS financing guidelines of diagnostics and treatments are influencing clinical decision-making in this setting. Further study is needed to understand the impact of the NHIS on the feasibility of integrating test-based management for malaria into the IMCI guidelines.

Predictors of malaria in febrile children in Sokoto, Nigeria

Background:

Presumptive diagnosis of malaria is widespread, even where microscopy is available. As fever is very nonspecific, this often leads to over diagnosis, drug wastage and loss of opportunity to consider alternative causes of fever, hence the need to improve on the clinical diagnosis of malaria.

Materials and Methods:

In a prospective cross-sectional comparative study, we examined 45 potential predictors of uncomplicated malaria in 800 febrile children (0-12 years) in Sokoto, Nigeria. We developed a clinical algorithm for malaria diagnosis and compared it with a validated algorithm, Olaleye's model.

Results:

Malaria was confirmed in 445 (56%). In univariate analysis, 13 clinical variables were associated with malaria. In multivariate analysis, vomiting (odds ratio, OR 2.6), temperature ≥ 38.5°C (OR 2.2), myalgia (OR 1.8), weakness (OR 1.9), throat pain (OR 1.8) and absence of lung crepitations (OR 5.6) were independently associated with malaria. In children over age 3 years, any 3 predictors had a sensitivity of 82% and specificity of 47% for malaria. An Olaleye score ≥ 5 had a sensitivity of 62% and a specificity of 51%.

Conclusion:

In hyperendemic areas, the sensitivity of our algorithm may permit presumptive diagnosis of malaria in children. Algorithm positive cases can be presumptively treated, and negative cases can undergo parasitological testing to determine need for treatment.

Drugs use pattern for uncomplicated malaria in medicine retail outlets in Enugu urban, southeast Nigeria: implications for malaria treatment policy

Background

Malaria treatment policy recommends regular monitoring of drug utilization to generate information for ensuring effective use of anti-malarial drugs in Nigeria. This information is currently limited in the retail sector which constitutes a major source of malaria treatment in Nigeria, but are characterized by significant inappropriate use of drugs. This study analyzed the use pattern of anti-malarial drugs in medicine outlets to assess the current state of compliance to policy on the use of artemisinin-based combination therapy (ACT).

Methods

A prospective cross-sectional survey of randomly selected medicine outlets in Enugu urban, southeast Nigeria, was conducted between May and August 2013, to determine the types, range, prices, and use pattern of anti-malarial drugs dispensed from pharmacies and patent medicine vendors (PMVs). Data were collected and analyzed for anti-malarial drugs dispensed for self-medication to patients, treatment by retail outlets and prescription from hospitals.

Results

A total of 1,321 anti-malarial drugs prescriptions were analyzed. ACT accounted for 72.7%, while monotherapy was 27.3%. Affordable Medicines Facility-malaria (AMFm) drugs contributed 33.9% (326/961) of ACT. Artemether-lumefantrine (AL), 668 (50.6%) was the most used anti-malarial drug, followed by monotherapy sulphadoxine-pyrimethamine (SP), 248 (18.8%). Median cost of ACT at $2.91 ($0.65-7.42) per dose, is about three times the median cost of monotherapy, $0.97 ($0.19-13.55). Total cost of medication (including co-medications) with ACT averaged $3.64 (95% CI; $3.53-3.75) per prescription, about twice the mean cost of treatment with monotherapy, $1.83 (95% CI; $1.57-2.1). Highest proportion 46.5% (614), of the anti-malarial drugs was dispensed to patients for self-treatment. Treatment by retail outlets accounted for 35.8% while 17.7% of the drugs were dispensed from hospital prescriptions. Self-medication, 82%, accounted for the highest source of monotherapy and a majority of prescriptions, 85.6%, was adults.

Conclusion

Findings suggest vastly improved use of ACT in the retail sector after eight years of policy change, with significant contributions from AMFm drugs. However the use of monotherapy, particularly through self-medication remains significant with increasing risk of undermining treatment policy, suggesting additional measures to directly target consumers and providers in the sector for improved use of anti-malarial drugs in Nigeria.

Malaria, Typhoid Fever, and Their Coinfection among Febrile Patients at a Rural Health Center in Northwest Ethiopia: A Cross-Sectional Study

Background. Malaria and typhoid fever are major public health problems in tropical and subtropical countries. People in endemic areas are at risk of contracting both infections concurrently. Objectives. The study was aimed at determining the prevalence and associated risk factors of malaria, typhoid, and their coinfection among febrile patients. Methods. A cross-sectional study was conducted on 200 febrile patients suspected for malaria and/or typhoid fever from April to May, 2013, at Ayinba Health Center, Northwest Ethiopia. Blood samples were collected for blood culture, Widal test, and blood film preparation. Data were analyzed using SPSS version 20 statistical software. Results. The prevalence of malaria was 36.5% (n = 73). Among these 32 (43.8%), 30 (41.1%) and 11 (15.1%) were positive for P. falciparum, P. vivax, and mixed infections, respectively. The seroprevalence of typhoid fever was 38 (19%), but 1 (0.5%) with blood culture. Malaria typhoid fever coinfection was 13 (6.5%). 2-5-year-old children and poor hand washing habit were significantly associated with malaria and typhoid infection, respectively (P < 0.05). Conclusions. The prevalence of malaria and typhoid fever was found high. Further studies should be done on the other determinants of malaria and typhoid fever coinfection in different seasons and different study areas.

Adherence to treatment guidelines for uncomplicated malaria at two public health facilities in Nigeria; Implications for the 'test and treat' policy of malaria case management

Objectives

Adherence to treatment guidelines for uncomplicated malaria is critical to the success of malaria case management. Poor adherence has implications for increased malaria burden, in view of the risk of widespread parasite resistance and treatment failures. This study analyzed the diagnostic and prescription pattern for uncomplicated malaria at two public health facilities, south east Nigeria, to assess the current state of compliance to policy guidelines on the use of artemisinin-based combination therapy (ACT).

Methods

Retrospective audit of patients’ records, treated for uncomplicated malaria, between the months of January and March 2013, was undertaken at two public health facilities. Demographics, diagnostic information, medication and cost data were extracted. Questionnaires were distributed to providers to assess their malaria treatment intent. Data from the facilities were analyzed and compared for similarities and systematic differences, and conformity to malaria treatment policy, in terms of laboratory diagnosis, use of ACT, co-medication and cost of medication.

Results

A total of 2,171 records of patients who had been treated for uncomplicated malaria were analyzed. Of these, 1066 (49%) were sent for laboratory confirmation of malaria using mostly microscopy, out of which 480 (45%) tested positive. 51% (1105) of the prescriptions was on the basis of presumptive treatment. 58% of slide negative results received antimalarial drugs. 93% of patients received ACT, with artemether-lumefantrin, AL (50.5%) as the most prescribed antimalarial drug. Monotherapy accounted for 7% of prescriptions, comprising mostly sulphadoxine + pyrimethamine, SP (46.5%) and monotherapy artemisinin, AS (29.2%). 97% of the prescriptions received at least one co-medication. Antibiotics were prescribed to 50% of patients. Overall, median cost of medication was N1160.00 (US$7.48 (US$0.19 - 267.87) per case, higher in tertiary than the secondary facility. There were significant variations in treatment practices between the two facilities.

Conclusion

Evidence suggests good compliance to policy on the use of ACT as first line treatment for uncomplicated malaria. However, there exists significant scope for improved diagnosis and rational drug use, to enhance accuracy of treatment, reduced wastages and risks of adverse drug reactions, in line with the goals of ‘test and treat’ policy of malaria case management.

Health worker factors associated with prescribing of artemisinin combination therapy for uncomplicated malaria in rural Tanzania

Background

Improving malaria case management is partially dependent on health worker compliance with clinical guidelines. This study assessed health worker factors associated with correct anti-malarial prescribing practices at two sites in rural Tanzania.

Methods

Repeated cross-sectional health facility surveys were conducted during high and low malaria transmission seasons in 2010 and collected information on patient consultations and health worker characteristics. Using logistic regression, the study assessed health worker factors associated with correct prescription for uncomplicated malaria defined as prescription of artemisinin-based combination therapy (ACT) for patients with fever and Plasmodium falciparum asexual infection based on blood slide or malaria rapid diagnostic test (RDT) according to national treatment guidelines.

Results

The analysis included 685 patients with uncomplicated malaria who were seen in a health facility with ACT in stock, and 71 health workers practicing in 30 health facilities. Overall, 58% of malaria patients were correctly treated with ACT. Health workers with three or more years’ work experience were significantly more likely than others to prescribe correctly (adjusted odds ratio (aOR) 2.9; 95% confidence interval (CI) 1.2-7.1; p = 0.019). Clinical officers (aOR 2.2; 95% CI 1.1-4.5; p = 0.037), and nurse aide or lower cadre (aOR 3.1; 95% CI 1.3-7.1; p = 0.009) were more likely to correctly prescribe ACT than medical officers. Training on ACT use, supervision visits, and availability of job aids were not significantly associated with correct prescription.

Conclusions

Years of working experience and health worker cadre were associated with correct ACT prescription for uncomplicated malaria. Targeted interventions to improve health worker performance are needed to improve overall malaria case management.

The potential impact of improving appropriate treatment for fever on malaria and non-malarial febrile illness management in under-5s: a decision-tree modelling approach

Background

As international funding for malaria programmes plateaus, limited resources must be rationally managed for malaria and non-malarial febrile illnesses (NMFI). Given widespread unnecessary treatment of NMFI with first-line antimalarial Artemisinin Combination Therapies (ACTs), our aim was to estimate the effect of health-systems factors on rates of appropriate treatment for fever and on use of ACTs.

Methods

A decision-tree tool was developed to investigate the impact of improving aspects of the fever care-pathway and also evaluate the impact in Tanzania of the revised WHO malaria guidelines advocating diagnostic-led management

Results

Model outputs using baseline parameters suggest 49% malaria cases attending a clinic would receive ACTs (95% Uncertainty Interval:40.6–59.2%) but that 44% (95% UI:35–54.8%) NMFI cases would also receive ACTs. Provision of 100% ACT stock predicted a 28.9% increase in malaria cases treated with ACT, but also an increase in overtreatment of NMFI, with 70% NMFI cases (95% UI:56.4–79.2%) projected to receive ACTs, and thus an overall 13% reduction (95% UI:5–21.6%) in correct management of febrile cases. Modelling increased availability or use of diagnostics had little effect on malaria management outputs, but may significantly reduce NMFI overtreatment. The model predicts the early rollout of revised WHO guidelines in Tanzania may have led to a 35% decrease (95% UI:31.2–39.8%) in NMFI overtreatment, but also a 19.5% reduction (95% UI:11–27.2%), in malaria cases receiving ACTs, due to a potential fourfold decrease in cases that were untested or tested false-negative (42.5% vs.8.9%) and so untreated.

Discussion

Modelling multi-pronged intervention strategies proved most effective to improve malaria treatment without increasing NMFI overtreatment. As malaria transmission declines, health system interventions must be guided by whether the management priority is an increase in malaria cases receiving ACTs (reducing the treatment gap), reducing ACT waste through unnecessary treatment of NMFI or expanding appropriate treatment of all febrile illness.

Treatment of fevers prior to introducing rapid diagnostic tests for malaria in registered drug shops in Uganda

Background

Since drug shops play an important role in treatment of fever, introducing rapid diagnostic tests (RDTs) for malaria at drug shops may have the potential of targeting anti-malarial drugs to those with malaria parasites and improve rational drug use. As part of a cluster randomized trial to examine impact on appropriate treatment of malaria in drug shops in Uganda and adherence to current malaria treatment policy guidelines, a survey was conducted to estimate baseline prevalence of, and factors associated with, appropriate treatment of malaria to enable effective design and implementation of the cluster randomized trial.

Methods

A survey was conducted within 20 geographical clusters of drug shops from May to September 2010 in Mukono district, central Uganda. A cluster was defined as a parish representing a cluster of drug shops. Data was collected using two structured questionnaires: a provider questionnaire to capture data on drug shops (n=65) including provider characteristics, knowledge on treatment of malaria, previous training received, type of drugs stocked, reported drug sales, and record keeping practices; and a patient questionnaire to capture data from febrile patients (n=540) exiting drug shops on presenting symptoms, the consultation process, treatment received, and malaria diagnoses. Malaria diagnosis made by drug shop vendors were confirmed by the study team through microscopy examination of a blood slide to ascertain whether appropriate treatment was received.

Results

Among febrile patients seen at drug shops, 35% had a positive RDT result and 27% had a positive blood slide. Many patients (55%) had previously sought care from another drug shop prior to this consultation. Three quarters (73%) of all febrile patients seen at drug shops received an anti-malarial, of whom 39% received an ACT and 33% received quinine. The rest received another non-artemisinin monotherapy. Only one third (32%) of patients with a positive blood slide had received treatment with Coartem^® while 34% of those with a negative blood slide had not received an anti-malarial. Overall appropriate treatment was 34 (95% CI: 28 – 40) with substantial between-cluster variation, ranging from 1% to 55%.

Conclusion

In this setting, the proportion of malaria patients receiving appropriate ACT treatment at drug shops was low. This was due to the practice of presumptive treatment, inadequate training on malaria management and lack of knowledge that Coartem^® was the recommended first-line treatment for malaria. There is urgent need for interventions to improve treatment of malaria at these outlets.

Overcoming health systems barriers to successful malaria treatment

The success of malaria control programmes is recognised to be handicapped by the capacity of the health system to deliver interventions such as first-line treatment at optimal coverage and quality. Traditional approaches to strengthening the health system such as staff training have had a less sustained impact than hoped. However, novel strategies including the use of mobile phones to ease stockouts, task-shifting to community health workers, and inclusion of the informal sector appear more promising. As global health funding slows, it is critical to better understand how to deliver a proven intervention most effectively through the existing system.

Exploring health providers' and community perceptions and experiences with malaria tests in South-East Nigeria: a critical step towards appropriate treatment

BACKGROUND

The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers' perceptions and experiences with malaria tests in south east Nigeria.

METHODS

The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty-six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area.

RESULTS

Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test.

CONCLUSION

The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people's attitude towards malaria test results.

In vitro-reduced susceptibility to artemether in P. falciparum and its association with polymorphisms on transporter genes

Plasmodium falciparum with reduced sensitivity to artemisinin derivatives has been observed in endemic areas, but the molecular mechanisms for this reduced sensitivity remain unclear. We evaluated the association between in vitro susceptibility of P. falciparum isolates obtained from southwest Nigeria and polymorphisms in selected putative transporter genes (PFE0775C, PF13_0271, pfmrp1, pfcrt, and pfmdr1). Modified schizont inhibition assay was used to determine the in vitro parasite susceptibility to artemether (ATH). Polymorphisms in selected genes were detected by polymerase chain reaction followed by direct DNA sequencing. The half-maximal inhibitory concentration (IC(50)) geometric mean (GM) for all P. falciparum isolates was 1.78 nM (range, 0.03-10.43 nM). Polymorphisms at codons 241, 86, and 76 of PFE0775C, pfmdr1, and pfcrt genes, respectively, were associated with reduced susceptibility to ATH. A new S263P single-nucleotide polymorphism on the PFE0775C gene was also detected in 27% of the isolates. Patient isolates harboring V241L or S263P polymorphisms on the PFE0775C gene showed increased IC(50) (GM: 3.08 nM and 1.79 nM, respectively). Plasmodium falciparum isolates harboring mutant Y86 pfmdr1 and P263 PFE0775C alleles showed a 2.5-5.5-fold increase in ATH IC(50.) This study shows that polymorphisms on the PFE0775C and pfmdr1 genes are associated with reduced sensitivity to ATH in fresh isolates of P. falciparum from Nigeria.

Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review

INTRODUCTION

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

METHODS AND FINDINGS

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

CONCLUSIONS

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

Treatment of uncomplicated malaria at public health facilities and medicine retailers in south-eastern Nigeria

Background

At primary care facilities in Nigeria, national treatment guidelines state that malaria should be symptomatically diagnosed and treated with artemisinin-based combination therapy (ACT). Evidence from households and health care providers indicates that many patients do not receive the recommended treatment. This study sought to determine the extent of the problem by collecting data as patients and caregivers leave health facilities, and determine what influences the treatment received.

Methods

A cross-sectional cluster survey of 2,039 respondents exiting public health centres, pharmacies and patent medicine dealers was undertaken in urban and rural settings in Enugu State, south-eastern Nigeria.

Results

Although 79% of febrile patients received an anti-malarial, only 23% received an ACT. Many patients (38%) received sulphadoxine-pyrimethamine (SP). A further 13% of patients received an artemisinin-derivative as a monotherapy. An estimated 66% of ACT dispensed was in the correct dose. The odds of a patient receiving an ACT was highly associated with consumer demand (OR: 55.5, p < 0.001).

Conclusion

Few febrile patients attending public health facilities, pharmacies and patent medicine dealers received an ACT, and the use of artemisinin-monotherapy and less effective anti-malarials is concerning. The results emphasize the importance of addressing both demand and supply-side influences on malaria treatment and the need for interventions that target consumer preferences as well as seek to improve health service provision.