Abstract
BackgroundMalaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients.MethodsIn April–May 2011, we conducted a nationwide, geographically-stratified health facility survey to assess the quality of outpatient malaria diagnosis and treatment. We enrolled patients presenting for care and conducted exit interviews and re-examinations, including reference blood smears. Moreover, we assessed health worker readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and antimalarials) to provide malaria case management. All analyses accounted for clustering and unequal selection probabilities. We also used survey weights to produce estimates of national caseloads.ResultsAt the 107 facilities surveyed, most of the 136 health workers interviewed (83%) had received training on malaria case management. However, only 24% of facilities had functional microscopy, 15% lacked a thermometer, and 19% did not have the first-line artemisinin-based combination therapy (ACT), artemether-lumefantrine, in stock. Of 2,019 participating patients, 34% had clinical malaria (measured fever or self-reported history of fever plus a positive reference blood smear). Only 67% (95% confidence interval (CI): 59%, 76%) of patients with malaria were correctly prescribed an ACT, primarily due to missed malaria diagnosis. Among patients without clinical malaria, 31% (95% CI: 24%, 39%) were prescribed an ACT. By our estimates, 1.5 million of the 4.4 million malaria patients seen in public facilities annually did not receive correct treatment, and 2.7 million patients without clinical malaria were inappropriately given an ACT.ConclusionsMalawi has a high burden of uncomplicated malaria but nearly one-third of all patients receive incorrect malaria treatment, including under- and over-treatment. To improve malaria case management, facilities must at minimum have basic case management tools, and health worker performance in diagnosing malaria must be improved.
Highlights
Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients
Little was known about the quality of malaria case management at publicly-funded facilities, which are commonly used for treatment of fever and were reported to have managed nearly seven million suspected cases of malaria in 2010 based on routine National Malaria Control Programme data [5]
A total of 107 health facilities, 136 health workers, and 2,019 patients with complete exit interview and blood smear data were surveyed across all 28 districts of Malawi (Table 1 and Figure 1)
Summary
Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients. Health workers must still systematically identify patients with suspected malaria for testing, and must prescribe treatment and counsel patients appropriately. These activities have long been challenges for malaria case management in sub-Saharan Africa [3]. Little was known about the quality of malaria case management at publicly-funded facilities, which are commonly used for treatment of fever and were reported to have managed nearly seven million suspected cases of malaria in 2010 based on routine National Malaria Control Programme data [5]
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