Improved malaria case management in formal private sector through public private partnership in Ethiopia: retrospective descriptive study

BACKGROUND

Malaria is a major public health problem and still reported among the 10 top causes of morbidity and mortality in Ethiopia. More than one-third of the people sought treatment from the private health sector. Evaluating adherences of health care providers to standards are paramount importance to determine the quality and the effectiveness of service delivery. Therefore, the aim of this study was to evaluate the contribution of public private mix (PPM) approach in improving quality of malaria case management among formal private providers.

METHODS

A retrospective data analysis was conducted using 2959 facility-months data collected from 110 PPM for malaria care facilities located in Amhara, Dire Dawa, Hareri, Oromia, Southern Nation Nationalities and Peoples and Tigray regions. Data abstraction formats were used to collect and collate the data on quarterly bases. The data were manually cleaned and analysed using Microsoft Office Excel 2010. To claim statistical significance non-parametric McNemar test was done and decision accepted at P < 0.05.

RESULTS

From April 2012-September 2015, a total of 873,707 malaria suspected patients were identified, of which one-fourth (25.6 %) were treated as malaria cases. Among malaria suspected cases the proportion of malaria investigation improved from recorded in first quarter 87.7-100.0 % in last quarter (X(2) = 66.84, P < 0.001). The majority (96.0 %) were parasitologically-confirmed cases either by using microscopy or rapid diagnostic tests. The overall slid positivity rate was 25.1 % of which half (50.7 %) were positive for Plasmodium falciparum and slightly lower than half (45.2 %) for Plasmodium vivax; the remaining 8790 (4.1 %) showed mixed infections of P. falciparum and P. vivax. Adherence to appropriate treatment using artemether-lumefantrine (AL) was improved from 47.8 % in the first quarter to 95.7 % in the last quarter (X(2) = 12.89, P < 0.001). Similarly, proper patient management using chloroquine (CQ) was improved from 44.1 % in the first quarter to 98.12 % in the last quarter (X(2) = 11.62, P < 0.001).

CONCLUSIONS

This study documented the chronological changes of adherence of health care providers with the national recommended standards to treat malaria. The PPM for malaria care services significantly improved the malaria case management practice of health care providers at the formal private health facilities. Therefore, regional health bureaus and partners shall closely work to scale up the initiated PPM for malaria care service.

Community and healthcare providers' perceptions of quality of private sector outpatient malaria care in North-western Ethiopia: a qualitative study

BACKGROUND

Malaria is one of the most important public health problems in Ethiopia contributing to significant patient morbidity and mortality. Prompt diagnosis and effective malaria case management through public, private and community health facilities has been one of the key malaria prevention, control and elimination strategies. The objective of this study was to evaluate adult malaria patients and healthcare providers' perception of the quality of malaria management at private sector outpatient facilities.

METHODS

An exploratory, descriptive, contextual and qualitative research methodology was conducted with 101 participants (33 in-depth interviews (INIs) and ten focus group discussions (FGDs) with 68 participants). All interview and focus group discussions were audio recorded, transcribed verbatim and analysed, using eight steps of Tesch.

RESULTS

During data analysis a single theme, two categories and six sub-categories emerged, namely (1) perceived quality of malaria management at outpatient facilities; (a) essential resources; (a1) safe outpatient services; (a2) anti-malarial drugs and supplies; (a3) health workers; (b) factors influencing service utilization; (b1) physical accessibility; (b2) "art of care''; and (b3) efficient malaria diagnosis and treatment services. Both FGDs and INIs participants had a positive perception of the quality of malaria outpatient services at private health facilities. The positive perceptions include safe and clean facility; availability of supplies and comprehensive services; convenient working hours; short waiting hours and motivated, competent and compassionate health workers. However, some participants raised their safety concerns due to perceived poor infection control practices, small working areas, interruption of anti-malarial supplies and inefficient malaria diagnosis and treatment services.

CONCLUSION

Both community members and healthcare providers had more positive perceptions towards outpatient malaria services offered at private health facilities. However, positive behaviour must be maintained and concerns must be dealt with by enhancing functional public private partnership for malaria care services to improve private sector malaria case management; build the service providers' capacity; ensure uninterrupted anti-malarial supplies and empower the community with early health-seeking behaviour.

Adherence of healthcare providers to malaria case management guidelines of the formal private sector in north-western Ethiopia: an implication for malaria control and elimination

BACKGROUND

Malaria is an infectious disease which has been globally targeted for elimination in at least 35 of 90 endemic countries by 2030. Most successful malaria elimination country programmes have engaged the private health sector in an effort to identify, document, investigate, provide effective treatment, and follow-up cases. However, there has been limited rigorous research showing evidence of adherence among healthcare providers of the formal private health sector to national malaria diagnosis and treatment guidelines in Ethiopia, starting from malaria control to elimination phases. The aims of this study were to investigate and explain the level of adherence to malaria diagnosis and treatment guidelines among healthcare providers working in formal private health facilities in north-western Ethiopia.

METHODS

An explanatory sequential mixed method design was conducted in the West Gojjam Zone of Ethiopia. Quantitative data were extracted from 1650 medical records of adult uncomplicated malaria outpatients served in 11 private-for-profit health facilities. In addition, using a qualitative approach, 33 in-depth interviews (IDIs) with healthcare providers were conducted. All interviews were audio-recorded, transcribed verbatim, and analysed using eight steps.

RESULTS

Of 1650 suspected malaria cases in adult outpatients, 80.6% (1330/1650) were screen tested using microscopy and the remainder 19.4% (320/1650) were tested using multispecies rapid diagnosis tests (RDTs). Hence, the results revealed that private healthcare providers universally adhered to diagnosis guidelines. In addition, after following-up and excluding other causes of fever, 4.1% (56/1376) patients were clinically diagnosed with uncomplicated malaria. Despite this, the proportion of private healthcare provider adherence with confirmed malaria case treatment guidelines was 20.9% (69/330). In addition, 1320 (95.9%) of adult outpatients with negative laboratory results were not treated. Some of the identified determinant factors for sub-optimal adherence of healthcare providers to malaria guidelines were interruptions in supply and lack of availability of recommended anti-malarial drugs, lack of availability of quality assured laboratory supplies, and poor knowledge of the recommendations of the national standards.

CONCLUSIONS

Private healthcare providers adhered to universal parasitological diagnosis, providing comprehensive counseling, and linking patients with community health workers. In addition, almost all laboratory negative patients were not treated with anti-malarial drugs. However, only one-fifth of confirmed patients were treated in line with national guideline recommendations. Malaria control and elimination efforts across Ethiopia could be improved through establishing a collaborative function of a win-win public private mix partnership model. In addition, including the data of the private health sector in the health information system could show real malaria burden and use the information to improve the adherence to malaria diagnosis, treatment, and reporting standards within the targeted era of elimination. Therefore, building the capacity of private healthcare providers and ensuring the availability of all nationally recommended drugs and supplies in private health sector facilities is recommended to improve the quality of services.