Abstract
BackgroundChange of severe malaria treatment policy from quinine to artesunate, a major malaria control advance in Africa, is compromised by scarce data to monitor policy translation into practice. In Kenya, hospital surveys were implemented to monitor health systems readiness and inpatient malaria case-management.MethodsAll 47 county referral hospitals were surveyed in February and October 2016. Data collection included hospital assessments, interviews with inpatient health workers and retrospective review of patients’ admission files. Analysis included 185 and 182 health workers, and 1162 and 1224 patients admitted with suspected malaria, respectively, in all 47 hospitals. Cluster-adjusted comparisons of the performance indicators with exploratory stratifications were performed.ResultsMalaria microscopy was universal during both surveys. Artesunate availability increased (63.8–85.1%), while retrospective stock-outs declined (46.8–19.2%). No significant changes were observed in the coverage of artesunate trained (42.2% vs 40.7%) and supervised health workers (8.7% vs 12.8%). The knowledge about treatment policy improved (73.5–85.7%; p = 0.002) while correct artesunate dosing knowledge increased for patients < 20 kg (42.7–64.6%; p < 0.001) and > 20 kg (70.3–80.8%; p = 0.052). Most patients were tested on admission (88.6% vs 92.1%; p = 0.080) while repeated malaria testing was low (5.2% vs 8.1%; p = 0.034). Artesunate treatment for confirmed severe malaria patients significantly increased (69.9–78.7%; p = 0.030). No changes were observed in artemether–lumefantrine treatment for non-severe test positive patients (8.0% vs 8.8%; p = 0.796). Among test negative patients, increased adherence to test results was observed for non-severe (68.6–78.0%; p = 0.063) but not for severe patients (59.1–62.1%; p = 0.673). Overall quality of malaria case-management improved (48.6–56.3%; p = 0.004), both for children (54.1–61.5%; p = 0.019) and adults (43.0–51.0%; p = 0.041), and in both high (51.1–58.1%; p = 0.024) and low malaria risk areas (47.5–56.0%; p = 0.029).ConclusionMost health systems and malaria case-management indicators improved during 2016. Gaps, often specific to different inpatient populations and risk areas, however remain and further programmatic interventions including close monitoring is needed to optimize policy translation.
Highlights
Change of severe malaria treatment policy from quinine to artesunate, a major malaria control advance in Africa, is compromised by scarce data to monitor policy translation into practice
After decades of quinine use for severe malaria treatment in Kenya, the National Malaria Control Programme (NMCP) launched in 2012 the new guidelines for the management of severe malaria [1] and recommended change of treatment policy to injectable artesunate—the treatment recommended by the World Health Organization (WHO) [2] and shown to reduce malaria mortality in multicentre trials, including those undertaken in Kenya [3, 4]
Since 2012, health workers have been exposed to two types of NMCP coordinated in-service trainings: (a) 3-day NMCP malaria case-management workshops, implemented annually for health workers through the counties and various training institutions following standard curriculum with half a day devoted to severe malaria [21]; and (b) artesunate focused trainings for hospital health workers implemented through one nationwide round of half a day continuous medical education (CME) sessions
Summary
Change of severe malaria treatment policy from quinine to artesunate, a major malaria control advance in Africa, is compromised by scarce data to monitor policy translation into practice. Few studies across Africa have examined this topic and of published reports, various assessments were commonly limited to paediatric populations, rarely examined coverage with interventions, included small numbers of facilities, and if done on larger scale, were often not followed up to monitor trends of the policy implementation [8,9,10,11,12,13,14,15,16] This has been in contrast with outpatient studies often reporting major improvements in the implementation of test and treat policy for malaria, both in Kenya [17] and in other African countries [18]. The main findings of the first two inpatient surveys undertaken in 2016 are reported
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