Bringing the state into the clinic? Incorporating the rapid diagnostic test for malaria into routine practice in Tanzanian primary healthcare facilities

Abstract

The roles that rapid, point-of-care tests will play in healthcare in low-income settings are likely to expand over the coming years. Yet, very little is known about how they are incorporated into practice, and what it means to use and rely upon them. This paper focuses on the rapid diagnostic test for malaria (mRDT), examining its introduction into low-level public health facilities in Tanzania within an intervention to improve the targeting of costly malaria medication. We interviewed 26 health workers to explore how a participatory training programme, mobile phone messages, posters and leaflets shaped the use and interpretation of the test. Drawing on notions of biopolitics, this paper examines how technologies of the self and mechanisms of surveillance bolstered the role mRDT in clinical decision-making. It shows how the significance of the test interacted with local knowledge, the availability of other medication, and local understandings of good clinical practice. Our findings suggest that in a context in which care is reduced to the provision of medicines, strict adherence to mRDT results may be underpinned by increasing the use of other pharmaceuticals or may leave health workers with patients for whom they are unable to provide care.

The complexities of simple technologies: re-imagining the role of rapid diagnostic tests in malaria control efforts

“…This caused moral dilemmas that for some clinicians triggered creative action, such as ‘lying’ that adherence to test results was a matter of the law. The RDT thereby emerged not as a tool per guidelines, to enable the treatment of other diseases previously labelled malaria (perhaps unsurprising as no additional diagnostics or medication were provided to enable that to be the case), but rather appeared as a tool of governance, aligning clinician activities with the aims of the state and enabling the reorientation of relationships between health workers, patients and medicines in these previously hard to reach settings in the peripheries of the health system [ 14 ].…”

Implementing Radical Cure Diagnostics for Malaria: User Perspectives on G6PD Testing in Bangladesh

“…The study results indicate that implementing and using the biosensor can mean offering better care and facilitating elimination of P. vivax malaria, while strengthening one's expertise and professional role in the healthcare system, it can help to mobilize support/funding for an NGO, it can be perceived as an indicator of good quality care, but also as a tool that increases workload in already strained work environments. Research on malaria RDTs, for example, shows the importance that such meanings and values take on for adhering to test results, and how local knowledge and understanding of good clinical practice interact with the availability of medication and contexts of scarcity in determining the meaning of these diagnostics for health workers and patients (25,(30)(31)(32). For the policymaker, the biosensor signi es extra work obtaining funding and setting up implementation plans, guidelines and work ows.…”

Current accounts of antimicrobial resistance: stabilisation, individualisation and antibiotics as infrastructure

“…This is occurring to a certain degree, with an ongoing review of governance interventions (Rogers Van Katwyk et al, 2017) and for example through the Wellcome Trust’s (2016b) proposal for ‘enhanced ‘gating’ of antibiotics, ‘so more use is routed through healthcare professionals and over-the-counter use is minimised’ (p. 2). Although such proposals are challenging to negotiate given parallel concerns around access to lifesaving antimicrobial drugs (Laxminarayan et al, 2016), such concerns might equally be applied to individual-oriented interventions (see, e.g., the unintended consequences of malaria rapid diagnostic tests on access to antimalarials (Hutchinson et al, 2017a, 2017b)). Nonetheless, analysis of current discourse suggests most often a doubling-down on the individual; following the pastoral model of biopolitics characterised by Rose (2001) and which stands in contrast to the securitised form of geopolitics described in the One Health framework (Braun, 2007).…”