Malaria Case-Management following Change of Policy to Universal Parasitological Diagnosis and Targeted Artemisinin-Based Combination Therapy in Kenya

Abstract

BackgroundThe change of malaria case-management policy in Kenya to recommend universal parasitological diagnosis and targeted treatment with artemether-lumefantrine (AL) is supported with activities aiming by 2013 at universal coverage and adherence to the recommendations. We evaluated changes in health systems and case-management indicators between the baseline survey undertaken before implementation of the policy and the follow-up survey following the first year of the implementation activities.Methods/FindingsNational, cross-sectional surveys using quality-of-care methods were undertaken at public facilities. Baseline and follow-up surveys respectively included 174 and 176 facilities, 224 and 237 health workers, and 2,405 and 1,456 febrile patients. Health systems indicators showed variable changes between surveys: AL stock-out (27% to 21%; p = 0.152); availability of diagnostics (55% to 58%; p = 0.600); training on the new policy (0 to 22%; p = 0.001); exposure to supervision (18% to 13%; p = 0.156) and access to guidelines (0 to 6%; p = 0.001). At all facilities, there was an increase among patients tested for malaria (24% vs 31%; p = 0.090) and those who were both tested and treated according to test result (16% to 22%; p = 0.048). At facilities with AL and malaria diagnostics, testing increased from 43% to 50% (p = 0.196) while patients who were both, tested and treated according to test result, increased from 28% to 36% (p = 0.114). Treatment adherence improved for test positive patients from 83% to 90% (p = 0.150) and for test negative patients from 47% to 56% (p = 0.227). No association was found between testing and exposure to training, supervision and guidelines, however, testing was significantly associated with facility ownership, type of testing, and patients' caseload, age and clinical presentation.ConclusionsMost of the case-management indicators have shown some improvement trends; however differences were smaller than expected, rarely statistically significant and still leaving a substantial gap towards optimistic targets. The quantitative and qualitative improvement of interventions will ultimately determine the success of the new policy.

Anti-malarial prescription practices among outpatients with laboratory-confirmed malaria in the setting of a health facility-based sentinel site surveillance system in Uganda

“…One study in Kenya did show that AL was prescribed to 90% of patients with uncomplicated laboratory-confirmed malaria when data were limited to health facilities with both AL and diagnostic testing in stock [4]. Various barriers to ACT adoption have been cited, including low numbers of clinicians with advanced degrees and inadequate provider training which often focused on in-service lectures and dissemination of written guidelines without chart audits, feedback, and follow-up training.…”

“…Currently, limited data exist on recent anti-malarial prescription practices in Africa following these changes. In Kenya, where case management practices have been published following a policy change promoting universal parasitological diagnosis before treatment, a majority of patients were not getting diagnostic testing or treatment according to test result, although those with positive tests and uncomplicated malaria did receive recommended treatment with artemether-lumefantrine (AL) in 90% of cases when AL was available [4]. …”

Case management of malaria in Swaziland, 2011–2015: on track for elimination?

“…19 Several studies have found that cost, patient preference and the availability of drugs and diagnostics all influence provider adherence to case management guidelines. 20,21 In this study, the NMCP provided diagnostic and antimalarial drugs free of charge, along with provider training.…”

A national health facility survey of malaria infection among febrile patients in Kenya, 2014

“…Quality of malaria diagnosis and treatment studies have been undertaken in Kenya on a bi-annual basis since 2010 [19–21]. These surveys have focused on describing routine clinical practices among febrile patients presenting to government out-patient departments and have highlighted that while the practice of parasitological diagnosis has increased significantly since 2010, testing rates for malaria have remained suboptimal.…”