Quality of malaria case management at outpatient health facilities in Angola

Abstract

BackgroundAngola's malaria case-management policy recommends treatment with artemether-lumefantrine (AL). In 2006, AL implementation began in Huambo Province, which involved training health workers (HWs), supervision, delivering AL to health facilities, and improving malaria testing with microscopy and rapid diagnostic tests (RDTs). Implementation was complicated by a policy that was sometimes ambiguous.MethodsFourteen months after implementation began, a cross-sectional survey was conducted in 33 outpatient facilities in Huambo Province to assess their readiness to manage malaria and the quality of malaria case-management for patients of all ages. Consultations were observed, patients were interviewed and re-examined, and HWs were interviewed.ResultsNinety-three HWs and 177 consultations were evaluated, although many sampled consultations were missed. All facilities had AL in-stock and at least one HW trained to use AL and RDTs. However, anti-malarial stock-outs in the previous three months were common, clinical supervision was infrequent, and HWs had important knowledge gaps. Except for fever history, clinical assessments were often incomplete. Although testing was recommended for all patients with suspected malaria, only 30.7% of such patients were tested. Correct testing was significantly associated with caseloads < 25 patients/day (odds ratio: 18.4; p < 0.0001) and elevated patient temperature (odds ratio: 2.5 per 1°C increase; p = 0.007). Testing was more common among AL-trained HWs, but the association was borderline significant (p = 0.072). When the malaria test was negative, HWs often diagnosed patients with malaria (57.8%) and prescribed anti-malarials (60.0%). Sixty-six percent of malaria-related diagnoses were correct, 20.1% were minor errors, and 13.9% were major (potentially life-threatening) errors. Only 49.0% of malaria treatments were correct, 5.4% were minor errors, and 45.6% were major errors. HWs almost always dosed AL correctly and gave accurate dosing instructions to patients; however, other aspects of counseling needed improvement.ConclusionBy late-2007, substantial progress had been made to implement the malaria case-management policy in a setting with weak infrastructure. However, policy ambiguities, under-use of malaria testing, and distrust of negative test results led to many incorrect malaria diagnoses and treatments. In 2009, Angola published a policy that clarified many issues. As problems identified in this survey are not unique to Angola, better strategies for improving HW performance are urgently needed.

‘As a clinician, you are not managing lab results, you are managing the patient’: How the enactment of malaria at health facilities in Cameroon compares with new WHO guidelines for the use of malaria tests

“…This persists even when they perform the test themselves and particularly when the results clash with observed signs and symptoms (Kyabayinze et al, 2010;Moonasar et al, 2007;Rowe et al, 2009;Uzochukwu et al, 2010). Results from a recent survey of health facilities in Cameroon in 2009 indicate malaria is significantly overdiagnosed and mistreated (Mangham et al, 2011).…”

The Role of Laboratory Supervision in Improving the Quality of Malaria Diagnosis: A Pilot Study in Huambo, Angola

“…[6][7][8] Three years after these guidelines were disseminated, over half of providers continued to treat clinically suspected cases of malaria despite negative laboratory testing. 9 Fever alone is frequently the only clinical criterion for diagnosis, and yet one study showed that only 3.6% of fevers in children under 5 years of age in Luanda, the densely populated urban capital, had a positive malaria diagnostic test. 10 Misdiagnosis results in overrepresentation of the burden of malaria and derails clinical investigation into other, potentially life-threatening, causes of illness.…”

Factoring Quality Laboratory Diagnosis into the Malaria Control Agenda for Sub-Saharan Africa

“…5,6 A consequence of the prolonged neglect of laboratories in malaria case management is that, even when quality laboratory services are available, clinicians too frequently ignore negative results. [7][8][9][10][11][12] The reduction in clinical malaria in several countries [13][14][15][16] and the use of expensive artemisinin-based combination therapeutic (ACT) antimalarial drugs call for case management practices that emphasize parasitologic confirmation, because continued use of ACTs in non-malaria cases represents a waste of resources and eventually, is unsustainable. Indiscriminate use of ACTs could create sufficient drug pressure that hastens development of resistant parasites, a situation that has begun to develop in Southeast Asia.…”