Quality of Malaria Care Service Delivery by Treatment Cascades in 25 Low-Income and Middle-Income Countries

Abstract

Introduction: Even with accessible and effective diagnostic tests and treatment, malaria remains a leading cause of death among children under-five. Malaria case management requires prompt diagnosis and correct treatment but the degree to which this happens in low-income and middle-income countries (LMICs) remains largely unknown. Using multiple sources, we examine the quality of malaria care across 25 malaria-endemic LMICs, the distribution of poor quality of care across the treatment cascades, and how poor quality of care vary across the regions of each studied country. Methods: Data were available through the most recent 2006-2017 Malaria Indicators Survey for 132,566 children under-five in 25 LMICs. We estimated the percentage of patient encounters with problems on quality of malaria care and examined quality of malaria care by treatment cascade and by region. Results: Across the study countries, 48,316 (58%) of patient encounters of febrile children under-five received sub-standard quality of care for suspected malaria. When comparing by treatment cascade, 62% of cases were not blood tested despite reporting fever in the last two weeks, 82% did not receive any antimalarial drug, 17% received one drug, and 72% received treatment more than 24 hours after onset of fever. Of the four countries where we had more detailed malaria testing data, we found that, 35% of patients were incorrectly managed (26% were undertreated, while 9% were overtreated). Poor malaria care quality varies widely within and between countries. Conclusion: Quality of malaria care remains poor and varies widely in endemic LMICs. Treatments are often prescribed regardless of malaria results, suggesting that presumptive diagnosis is still commonly practiced amongst cases of suspected malaria, rather than the WHO recommendation of test and treat. To reach the 2030 global malaria goal of reducing mortality rates by at least 90%, focusing on improving the quality of malaria care is needed. Funding Statement: The authors stated that they received no specific funding for this work. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Not required.