Abstract
BackgroundThe change of malaria case-management policy in Kenya to recommend universal parasitological diagnosis and targeted treatment with artemether-lumefantrine (AL) is supported with activities aiming by 2013 at universal coverage and adherence to the recommendations. We evaluated changes in health systems and case-management indicators between the baseline survey undertaken before implementation of the policy and the follow-up survey following the first year of the implementation activities.Methods/FindingsNational, cross-sectional surveys using quality-of-care methods were undertaken at public facilities. Baseline and follow-up surveys respectively included 174 and 176 facilities, 224 and 237 health workers, and 2,405 and 1,456 febrile patients. Health systems indicators showed variable changes between surveys: AL stock-out (27% to 21%; p = 0.152); availability of diagnostics (55% to 58%; p = 0.600); training on the new policy (0 to 22%; p = 0.001); exposure to supervision (18% to 13%; p = 0.156) and access to guidelines (0 to 6%; p = 0.001). At all facilities, there was an increase among patients tested for malaria (24% vs 31%; p = 0.090) and those who were both tested and treated according to test result (16% to 22%; p = 0.048). At facilities with AL and malaria diagnostics, testing increased from 43% to 50% (p = 0.196) while patients who were both, tested and treated according to test result, increased from 28% to 36% (p = 0.114). Treatment adherence improved for test positive patients from 83% to 90% (p = 0.150) and for test negative patients from 47% to 56% (p = 0.227). No association was found between testing and exposure to training, supervision and guidelines, however, testing was significantly associated with facility ownership, type of testing, and patients' caseload, age and clinical presentation.ConclusionsMost of the case-management indicators have shown some improvement trends; however differences were smaller than expected, rarely statistically significant and still leaving a substantial gap towards optimistic targets. The quantitative and qualitative improvement of interventions will ultimately determine the success of the new policy.
Highlights
Universal parasitological testing and subsequent treatment of test positive patients with artemisinin-based combination therapy (ACT) are the critical components of the latest international recommendations for malaria case-management [1]
The success of the implementation of the new case-management policy is dependent upon series of factors of which availability of commodities at health facilities and casemanagement practices are of vital importance to ensure costbenefit of the diagnostics and ACT based case-management strategies [2,3,4]
By 2013, the new National Malaria Strategy (NMS) specified programmatic directions to ensure universal availability of AL and malaria diagnostics as well as universal health worker’s adherence to the new malaria case-management guidelines [7]. In this manuscript we report levels and changes in the availability of commodities and malaria case-management practices between two national health facility surveys; the baseline survey undertaken at the beginning of 2010, prior to the implementation of the new NMS, and the follow-up survey undertaken at the end of 2010, following the first year of the implementation activities
Summary
Universal parasitological testing and subsequent treatment of test positive patients with artemisinin-based combination therapy (ACT) are the critical components of the latest international recommendations for malaria case-management [1]. By 2013, the new NMS specified programmatic directions to ensure universal availability of AL and malaria diagnostics as well as universal health worker’s adherence to the new malaria case-management guidelines [7]. In this manuscript we report levels and changes in the availability of commodities and malaria case-management practices between two national health facility surveys; the baseline survey undertaken at the beginning of 2010, prior to the implementation of the new NMS, and the follow-up survey undertaken at the end of 2010, following the first year of the implementation activities. We evaluated changes in health systems and case-management indicators between the baseline survey undertaken before implementation of the policy and the follow-up survey following the first year of the implementation activities
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