Effect of Supportive Supervision on Malaria Microscopy Competencies in Sub-Saharan Africa

Can Outreach Training and Supportive Supervision Improve Competency in Malaria Service Delivery? An Evaluation in Cameroon, Ghana, Niger, and Zambia

Outreach Training and Supportive Supervision (OTSS) of malaria services at health facilities has been adopted by numerous malaria-endemic countries. The OTSS model is characterized by a hands-on method to enhance national guidelines and supervision tools, train supervisors, and perform supervision visits. An independent evaluation was conducted to evaluate the effectiveness of OTSS on health worker competence in the clinical management of malaria, parasitological diagnosis, and prevention of malaria in pregnancy. From 2018 to 2021, health facilities in Cameroon, Ghana, Niger, and Zambia received OTSS visits during which health workers were observed directly during patient consultations, and supervisors completed standardized checklists to assess their performance. Mixed-effects logistic regression models were developed to assess the impact of increasing OTSS visit number on a set of eight program-generated outcome indicators, including overall competency and requesting a confirmatory malaria test appropriately. Seven of eight outcome indicators showed evidence of beneficial effects of increased OTSS visits. Odds of health workers reaching competency thresholds for the malaria-in-pregnancy checklist increased by more than four times for each additional OTSS visit (odds ratio [OR], 4.62; 95% CI, 3.62-5.88). Each additional OTSS visit was associated with almost four times the odds of the health worker foregoing antimalarial prescriptions for patients who tested negative for malaria (OR, 3.80; 95% CI, 2.35-6.16). This evaluation provides evidence that successive OTSS visits result in meaningful improvements in indicators linked to quality case management of patients attending facilities for malaria diagnosis and treatment, as well as quality malaria prevention services received by women attending antenatal services.

Outreach Training and Supportive Supervision for Quality Malaria Service Delivery: A Qualitative Evaluation in 11 Sub-Saharan African Countries

Quality improvement of malaria services aims to ensure that more patients receive accurate diagnosis, appropriate treatment, and referral. The Outreach Training and Supportive Supervision Plus (OTSS+) approach seeks to improve health facility readiness and provider competency through onsite supportive supervision, troubleshooting, and on-the-job training. As part of a multicomponent evaluation, qualitative research was conducted to understand the value of the OTSS+ approach for malaria quality improvement. Semistructured key informant interviews, focus group discussions, and structured health facility-based interviews were used to gather stakeholder perspectives at subnational, national, and global levels. Data were collected globally and in 11 countries implementing OTSS+; in-depth data collection was done in four: Cameroon, Ghana, Niger, and Zambia. Study sites and participants were selected purposively. Verbatim transcripts were analyzed thematically, following the Framework approach. A total of 262 participants were included in the analysis; 98 (37.4%) were supervisees, 99 (37.8%) were supervisors, and 65 (24.8%) were other stakeholders. The OTSS+ approach was perceived to improve provider knowledge and skills in malaria service delivery and to improve data and supply management indirectly. Improvements were attributed to a combination of factors. Participants valued the relevance, adaptation, and digitization of supervision checklists; the quality and amount of contact with problem-solving supervisors; and the joint identification of problems and solutions, and development of action plans. Opportunities for improvement were digitized checklist refinement, assurance of a sufficient pool of supervisors, prioritization of health facilities, action plan dissemination and follow-up, and data review and use. The OTSS+ approach was perceived to be a useful quality improvement approach for malaria services.

The U.S. President's Malaria Initiative's Support for Improving the Quality of Malaria Case Management Services: Fifteen Years of Progress and Learning

Since its launch in 2005, the U.S. President's Malaria Initiative's (PMI) investment in malaria case management has evolved based on lessons learned from its support to countries. An initial focus on updating malaria treatment policies to adopt artemisinin-based combination therapies achieved limited success, in part because of the poor quality of diagnostic and treatment services in targeted countries. In response, the PMI supported the development, refinement, and expansion of Outreach Training and Supportive Supervision (OTSS), a quality improvement approach that combines structured, competency-based supervision with corrective measures, including on-the-job training, coaching, troubleshooting, action planning, and timely follow-up. With 15 years of experience, the OTSS approach has been adopted by more than a dozen countries, and its effectiveness in improving the quality of malaria case management services has been documented. Through the PMI Impact Malaria Project, launched in 2018, the OTSS approach was expanded beyond case management of uncomplicated malaria to support quality improvement of inpatient management of severe malaria and malaria in pregnancy services delivered through antenatal care clinics. The OTSS platform also enabled targeted countries to respond rapidly to the COVID-19 pandemic by adding modules related to clinical management and laboratory diagnosis of suspected cases. The OTSS approach has been established as an effective approach to improve the quality of clinical malaria services and can be expanded to cover other health priorities. Further innovations to improve the quality of inpatient and community-based services, and further integration and institutionalization of OTSS into country health systems are needed.

Measuring quality of facility-based ITN distribution in Ghana

BACKGROUND

Continuous distribution channels are effective methods to deliver malaria interventions such as insecticide treated nets (ITNs) to pregnant women attending antenatal care clinics and children under five attending immunization visits. Facility-based and provider-based checklists were used during supportive supervision visits to measure the quality of facility-based services and interventions. This study looks at ITN distributions at health facilities in Ghana, with the aim of providing insights on how quality can be measured and monitored.

METHODS

Various quality improvement approaches for malaria services occur in Ghana. Selected indicators were analysed to highlight the similarities and differences of how the approaches measured how well the channel was doing. Generally, the approaches assessed (1) service data management, (2) logistics data management, and (3) observation of service provision (ITN issuance, malaria education, ITN use and care education). Two approaches used a binary (Yes/No) scale, and one used a Likert scale.

RESULTS

Results showed that most data reported to the national HMIS is accurate. Logistics data management remained an issue at health facilities, as results showed scores below average across facility stores, antenatal care, and immunization. Though the supervision approaches differed, overall results indicated that almost all eligible clients received ITNs, data were recorded accurately and reported on-time, and logistics was the largest challenge to optimal distribution through health facilities.

CONCLUSION

The supervision approaches provided valuable insights into the quality of facility-based ITN distribution. Ghana should continue to implement supportive supervision in their malaria agenda, with additional steps needed to improve reporting of collected data and increase the number of facilities visited for supportive supervision and the frequency. There were various supervision approaches used with no clear guidance on how to measure quality of facility-based ITN distribution, so there is also need for the global community to agree on standardized indicators and approaches to measuring quality of facility-based ITN distribution. Additionally, future studies can review the effect of multiple rounds of supervision visits on the quality of ITN distribution as well as understand the facilitators and barriers to scaling up supervision of facility-based ITN distribution.

Assessment of malaria diagnostic methods and treatments at a Ghanaian health facility

INTRODUCTION

it has been more than a decade since the World Health Organization (WHO) recommended parasitological confirmation of malaria before treatment begins. Light microscopy and rapid diagnostic tests are currently being used for diagnosing malaria in routine clinical care settings. Many clinicians have however raised questions about the competencies of laboratory staff who perform these tests and the performance of these diagnostic methods. This study aimed at assessing the performance of microscopy and two rapid diagnostic test kits in the hands of routine laboratory staff compared to expert microscopy as well as assess the performance of clinical diagnosis.

METHODS

this was a cross sectional study involving 799 participants of all ages who visited the out patient department of the University of Cape Coast Hospital with symptoms suggestive of malaria.

RESULTS

when the different methods were compared to expert microscopy, the rapid diagnostic test kits had the highest sensitivities, Wondfo 94.83% (95% CI: 85.62-98.20) and CareStart 91.38 (95% CI: 81.02-97.14). Microscopy by laboratory staff had a sensitivity of 68.79 (95% CI: 55.46-80.46) whilst clinical diagnosis had the lowest sensitivity of 17.24 (95% CI: 8.59-29.43). Cohen´s kappa coefficient was used to measure the level of agreement of the methods with expert microscopy. Microscopy by laboratory staff, CareStart and Wondfo showed substantial measures of agreement (k = 0.737, 0.683, and 0.691 respectively).

CONCLUSION

these findings suggest that clinical diagnosis is highly unreliable whilst rapid diagnostic tests and microscopy performed by routine laboratory staff could be trusted by clinicians as reliable diagnostic methods.

Perspectives on Implementation Considerations and Costs of Malaria Case Management Supportive Supervision

Between 2012 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported national malaria control programs in sub-Saharan Africa to implement a case management quality assurance (QA) system for malaria and other febrile illnesses. A major component of the system was outreach training and supportive supervision (OTSS), whereby trained government health personnel visited health facilities to observe health-care practices using a standard checklist, to provide individualized feedback to staff, and to develop health facility-wide action plans based on observation and review of facility registers. Based on MalariaCare's experience, facilitating visits to more than 5,600 health facilities in nine countries, we found that programs seeking to implement similar supportive supervision schemes should consider ensuring the following: 1) develop a practical checklist that balances information gathering and mentorship; 2) establish basic competency criteria for supervisors and periodically assess supervisor performance in the field; 3) conduct both technical skills training and supervision skills training; 4) establish criteria for selecting facilities to conduct OTSS and determine the appropriate frequency of visits; and 5) use electronic data collection systems where possible. Cost will also be a significant consideration: the average cost per OTSS visit ranged from $44 to $333. Significant variation in costs was due to factors such as travel time, allowances for government personnel, length of the visit, and involvement of central level officials. Because the cost of conducting supportive supervision prohibits regularly visiting all health facilities, internal QA measures could also be considered as alternative or complementary activities to supportive supervision.

Introduction and Evaluation of an Electronic Tool for Improved Data Quality and Data Use during Malaria Case Management Supportive Supervision

Although on-site supervision programs are implemented in many countries to assess and improve the quality of care, few publications have described the use of electronic tools during health facility supervision. The President's Malaria Initiative-funded MalariaCare project developed the MalariaCare Electronic Data System (EDS), a custom-built, open-source, Java-based, Android application that links to District Health Information Software 2, for data storage and visualization. The EDS was used during supervision visits at 4,951 health facilities across seven countries in Africa. The introduction of the EDS led to dramatic improvements in both completeness and timeliness of data on the quality of care provided for febrile patients. The EDS improved data completeness by 47 percentage points (42-89%) on average when compared with paper-based data collection. The average time from data submission to a final data analysis product dropped from over 5 months to 1 month. With more complete and timely data available, the Ministry of Health and the National Malaria Control Program (NMCP) staff could more effectively plan corrective actions and promptly allocate resources, ultimately leading to several improvements in the quality of malaria case management. Although government staff used supervision data during MalariaCare-supported lessons learned workshops to develop plans that led to improvements in quality of care, data use outside of these workshops has been limited. Additional efforts are required to institutionalize the use of supervision data within ministries of health and NMCPs.

Evaluation of malaria microscopy diagnostic performance at private health facilities in Tanzania

Background

The World Health Organization (WHO) recommends use of parasitological diagnosis of malaria for all age groups in all malaria transmission settings. Many private health facilities rely on malaria microscopy for malaria diagnosis. However, quality of malaria microscopy is affected by number of factors including availability of skilled laboratory microscopists and lack of quality assurance systems in many malaria endemic countries. This study was carried out to assess quality of malaria microscopy in selected private health facilities in Tanzania.

Methods

A cross sectional study was conducted from August to September, 2017. A total of 40 private health laboratories in five regions were invited to participate in the study. Data were collected by distributing standardized pre-validated malaria slide-panels to each health facility. Sensitivity, specificity, and strength of agreement (with kappa score) were calculated to assess performance in detecting and quantification of Plasmodium species.

Results

Among the 40 health facilities, 31 (77.5%) returned their results to the reference centre (Muhimbili University of Health and Allied Sciences). Overall, the measures of malaria diagnostic accuracy were high, i.e. the sensitivity and specificity of malaria parasite detection by microscopy in the health facilities were 84.3% (95% CI 77–90) and 90.8% (95% CI 83.3–95.7), respectively. There was substantial agreement in parasite detection with (Kappa value: 0.74 (95% 0.65–0.83). However, only 17.8% (24 of 134) of blood slides were interpreted correctly at the health facilities in terms of parasite density counts.

Conclusion

Although there was substantial agreement between the private health microscopists and experienced microscopists in malaria parasite detection, there was poor performance in parasite counts. This calls for regular in-service training and external quality assessments at private health facilities to enhance the skills of private health facility microscopists in malaria microscopy.