Quality of Malaria Case Management in Malawi: Results from a Nationally Representative Health Facility Survey

<div><p>Background</p><p>Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients.</p><p>Methods</p><p>In April–May 2011, we conducted a nationwide, geographically-stratified health facility survey to assess the quality of outpatient malaria diagnosis and treatment. We enrolled patients presenting for care and conducted exit interviews and re-examinations, including reference blood smears. Moreover, we assessed health worker readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and antimalarials) to provide malaria case management. All analyses accounted for clustering and unequal selection probabilities. We also used survey weights to produce estimates of national caseloads.</p><p>Results</p><p>At the 107 facilities surveyed, most of the 136 health workers interviewed (83%) had received training on malaria case management. However, only 24% of facilities had functional microscopy, 15% lacked a thermometer, and 19% did not have the first-line artemisinin-based combination therapy (ACT), artemether-lumefantrine, in stock. Of 2,019 participating patients, 34% had clinical malaria (measured fever or self-reported history of fever plus a positive reference blood smear). Only 67% (95% confidence interval (CI): 59%, 76%) of patients with malaria were correctly prescribed an ACT, primarily due to missed malaria diagnosis. Among patients without clinical malaria, 31% (95% CI: 24%, 39%) were prescribed an ACT. By our estimates, 1.5 million of the 4.4 million malaria patients seen in public facilities annually did not receive correct treatment, and 2.7 million patients without clinical malaria were inappropriately given an ACT.</p><p>Conclusions</p><p>Malawi has a high burden of uncomplicated malaria but nearly one-third of all patients receive incorrect malaria treatment, including under- and over-treatment. To improve malaria case management, facilities must at minimum have basic case management tools, and health worker performance in diagnosing malaria must be improved.</p></div

Household characteristics in eight districts, Malawi, 2009 (N = 7,407).

a<p>Data from 2008 Malawi census.</p>b<p>95% confidence interval.</p

Factors associated with insecticide treated bednet (ITN) use by person who reside in households with at least one ITN in eight districts, Malawi, 2009 (N = 18,967).

a<p>95% confidence interval.</p

Insecticide treated bednet (ITN) use by persons who reside in any household and in a household that owns an ITN in eight districts, Malawi, 2009 (N = 29,806).

a<p>95% confidence interval.</p

Estimated national annual outpatient caseloads and malaria commodity needs at publically-funded health facilities in Malawi, 2011.

<p>Note: Estimates by age may not sum to total due to rounding. Estimates may overestimate the number of outpatients with malaria annually in Malawi, as the survey was conducted during the high transmission season, and annualization of malaria caseload was not adjusted for seasonality, given the lack of necessary data required to do this.</p><p>*Assuming one RDT needed for each febrile patient, not accounting for buffer stocks, etc.</p><p>**Actual number needed for RDTs and AL courses, assuming ACTs are used only for patients with malaria after they receive a diagnostic test and not accounting for buffer stocks, lost materials, expiring stocks, etc. Estimate is based on diagnosis of patients by expert microscopy, and use of RDTs at facilities may require additional ACTs, given the higher test positivity rate of RDTs compared to microscopy. In addition to ACTs, 68,705 courses of quinine are also needed for the 0.8% of malaria patients <5 kg and the0.4% who are pregnant women in their first trimester.</p

Districts and census enumeration areas included in the household survey in eight districts, Malawi 2009.

<p>Districts included in the household survey are shaded green and sampled census enumeration areas are represented by black circles.</p

Factors associated with household insecticide treated bednet (ITN) ownership in eight districts, Malawi, 2009 (N = 7,407).

a<p>95% confidence interval.</p

Map of surveyed health facilities.

<p>Note: Each yellow dot represents one surveyed facility.</p

Study sample.

<p>*Non-surveyed include those not visited for logistical reasons, (one in Likoma) or those visited but not functional (one in Balaka and another in Phalombe).</p

Estimated household insecticide treated bednet (ITN) possession using different campaign-based distribution strategies in eight districts, Malawi, 2009.

<p>Note: Based on total population of 4,339,876 persons in the eight surveyed districts according to the 2008 Malawi census.</p>a<p>Estimated number of ITNs currently in the eight surveyed districts.</p>b<p>Estimated 1.91 sleeping spaces per household in the eight surveyed districts.</p>c<p>In households with an odd number of household members, number of ITNs distributed is equal to number of household members divided by two plus one additional ITN (e.g. a household with 5 persons will receive 3 ITNs).</p