Abstract
BackgroundFever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management. This study evaluated the quality of malaria service provision offered in public health facilities in Mozambique.MethodsA cross-sectional assessment was conducted in April–May 2018 in three provinces of Mozambique: Maputo Province (low malaria burden), Cabo Delgado (high), and Zambézia (high). The study included all secondary and tertiary facilities and a random sample of primary facilities in each province. Data collection included exit interviews and re-examinations of 20 randomly selected outpatient service patients, interviews with up to five health care providers and the health facility director, a stockroom inventory and routine data abstraction.ResultsA total of 319 health care providers and 1840 patients from 117 health facilities were included. Of these, 1325 patients (72%) had suspected malaria (fever/history of fever) and 550 (30%) had febrile, confirmed malaria with the highest burden in Cabo Delgado (43%), followed by Zambézia (34%) and Maputo Province (2%). Appropriate management of malaria cases, defined as testing malaria suspects and treating confirmed cases with the correct dose of anti-malarial, was highest in Zambézia and Cabo Delgado where 52% (95% CI 42–62) and 49% (42–57) of febrile malaria cases were appropriately managed, respectively. Only 14% (5–34) of febrile cases in Maputo Province were appropriately managed. The biggest gap in the malaria case management pathway was failure to test febrile patients, with only 46% of patients with this indication tested for malaria in Maputo Province. Additionally, anti-malarial treatment of patients with a negative malaria test result was common, ranging from 8% (2–23) in Maputo Province to 22% (14–32) of patients with a negative test in Zambézia. Only 58–62% of patients prescribed an anti-malarial correctly recited dosing instructions. Provider training and malaria knowledge was low outside of Zambézia and supervision rates were low in all provinces. Factors associated with correct case management varied by province and included patient age, facility type, treatment and testing availability, supervision, and training.ConclusionThese findings underscore the need to strengthen provider testing of all patients with fever, provider adherence to negative test results, and effective counselling of patients across epidemiological settings in Mozambique.
Highlights
Fever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management
In Mozambique, malaria testing is done using rapid diagnostic tests (RDTs) that are available at all levels, including at the community, or microscopy, which is limited to hospitals and certain health centres with laboratory capacity
Researchers in Mozambique completed a retrospective analysis of routine patient register data in 2011, a few years after the introduction of RDTs and of AL; the analysis found that 72% of patients with negative RDT results received treatment [25]
Summary
Fever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management. This study evaluated the quality of malaria service provi‐ sion offered in public health facilities in Mozambique. In Mozambique, malaria testing is done using RDTs that are available at all levels, including at the community, or microscopy, which is limited to hospitals and certain health centres with laboratory capacity. First-line treatment in public health facilities is artemether-lumefantrine (AL) for uncomplicated malaria cases, oral quinine for pregnant women in their first trimester, and injectable artesunate for all severe cases. Stockouts at the facility level remain a perennial challenge
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