Translation of artemether–lumefantrine treatment policy into paediatric clinical practice: an early experience from Kenya*

D Zurovac,W Akhwale,D H Hamer,R W Snow,J Njogu

doi:10.1111/j.1365-3156.2007.01980.x

Abstract

ObjectiveTo describe the quality of outpatient paediatric malaria case-management approximately 4–6 months after artemether–lumefantrine (AL) replaced sulfadoxine–pyrimethamine (SP) as the nationally recommended first-line therapy in Kenya.MethodsCross-sectional survey at all government facilities in four Kenyan districts. Main outcome measures were health facility and health worker readiness to implement AL policy; quality of antimalarial prescribing, counselling and drug dispensing in comparison with national guidelines; and factors influencing AL prescribing for treatment of uncomplicated malaria in under-fives.ResultsWe evaluated 193 facilities, 227 health workers and 1533 sick-child consultations. Health facility and health worker readiness was variable: 89% of facilities stocked AL, 55% of health workers had access to guidelines, 46% received in-service training on AL and only 1% of facilities had AL wall charts. Of 940 children who needed AL treatment, AL was prescribed for 26%, amodiaquine for 39%, SP for 4%, various other antimalarials for 8% and 23% of children left the facility without any antimalarial prescribed. When AL was prescribed, 92% of children were prescribed correct weight-specific dose. AL dispensing and counselling tasks were variably performed. Higher health worker's cadre, in-service training including AL use, positive malaria test, main complaint of fever and high temperature were associated with better prescribing.ConclusionsChanges in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa.

Highlights

Artemisinin-based combination therapies (ACTs) are a major breakthrough in the clinical management of malaria
In this paper we report on the quality of outpatient paediatric malaria case-management in Kenyan health facilities, approximately 4–6 months after artemether– lumefantrine (AL) was introduced to replace sulfadoxine–pyrimethamine (SP) as the nationally recommended first-line therapy for uncomplicated malaria
We evaluated outpatient malaria management at 193 health facilities where 228 health workers performed outpatient consultations on the day of the survey

Summary

Introduction

Artemisinin-based combination therapies (ACTs) are a major breakthrough in the clinical management of malaria. The implementation of effective case-management using ACTs faces a number of challenges, notably complex ordering and financing procedures, unfamiliarity with the drugs among prescribers and their introduction into weak health systems with suboptimal drug management and clinical practices (Rowe et al 2000, 2001, 2003; Font et al 2001; Nshakira et al 2002; Armstrong Schellenberg et al 2004; Eriksen et al 2007). There are very few studies that have examined the operational use of ACTs following national policy change (Zurovac et al 2005a, 2007)

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