Abstract
BackgroundNigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate. Seven years after the policy change health systems readiness and quality of inpatient malaria case-management practices were evaluated in Kano State of Nigeria.MethodsA cross-sectional survey was undertaken in May 2019 at all public hospitals. Data collection comprised hospital assessments, interviews with inpatient health workers and data extraction from medical files for all suspected malaria patients admitted to the paediatric and medical wards in April 2019. Descriptive analyses included 22 hospitals, 154 health workers and 1,807 suspected malaria admissions analysed from malaria test and treat case-management perspective.Results73% of hospitals provided malaria microscopy, 27% had rapid diagnostic tests and 23% were unable to perform any parasitological malaria diagnosis. Artemisinin-based combination therapy (ACT) was available at 96% of hospitals, artemether vials at 68% while injectable quinine and artesunate were equally stocked at 59% of hospitals. 32%, 21% and 15% of health workers had been exposed to relevant trainings, guidelines and supervision respectively. 47% of suspected malaria patients were tested while repeat testing was rare (7%). 60% of confirmed severe malaria patients were prescribed artesunate. Only 4% of admitted non-severe test positive cases were treated with ACT, while 76% of test negative patients were prescribed an anti-malarial. Artemether was the most common anti-malarial treatment for non-severe test positive (55%), test negative (43%) and patients not tested for malaria (45%). In all categories of the patients, except for confirmed severe cases, artemether was more commonly prescribed for adults compared to children. 44% of artesunate-treated patients were prescribed ACT follow-on treatment. Overall compliance with test and treat policy for malaria was 13%.ConclusionsTranslation of new treatment policy for severe malaria into inpatient practice is compromised by lack of malaria diagnostics, stock-outs of artesunate and suboptimal health workers’ practices. Establishment of the effective supply chain and on-going supportive interventions for health workers accompanied with regular monitoring of the systems readiness and clinical practices are urgently needed.
Highlights
Nigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate
Nigeria was among the first African countries to adopt the 2012 World Health Organization (WHO) recommended artesunate treatment policy for severe malaria and implement a series of programmatic activities to facilitate readiness of hospitals and health workers to deliver new recommendations countrywide [2,3,4]
The findings revealed several strengths and major readiness and clinical practice deficiencies which severely compromise the quality of service delivery for patients admitted with malaria in Kano State
Summary
Nigeria was among the first African countries to adopt and implement change of treatment policy for severe malaria from quinine to artesunate. Despite the differences in scope, scale, context and methodological aspects of these studies, most have reported deficiencies related to the suboptimal coverage of interventions and common practices in discordance with national guidelines In this manuscript, an evaluation from Kano state, Northern Nigeria where hospital and health worker readiness for the policy implementation, health worker knowledge about case-management recommendations, and the quality of inpatient management for patients admitted with suspected malaria has been evaluated seven years after the change of treatment policy from parenteral quinine to artesunate, is reported
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