A cost-effectiveness analysis of provider interventions to improve health worker practice in providing treatment for uncomplicated malaria in Cameroon: a study protocol for a randomized controlled trial

BACKGROUND: Governments and donors all over Africa are searching for sustainable, affordable and cost-effective ways to improve the quality of malaria case management. Widespread deficiencies have been reported in the prescribing and counselling practices of health care providers treating febrile patients in both public and private health facilities. Cameroon is no exception with low levels of adherence to national guidelines, the frequent selection of non-recommended antimalarials and the use of incorrect dosages. This study evaluates the effectiveness and cost-effectiveness of introducing two different provider training packages, alongside rapid diagnostic tests (RDTs), designed to equip providers with the knowledge and practical skills needed to effectively diagnose and treat febrile patients. The overall aim is to target antimalarial treatment better and to facilitate optimal use of malaria treatment guidelines. METHODS/DESIGN: A 3-arm stratified, cluster randomized trial will be conducted to assess whether introducing RDTs with provider training (basic or enhanced) is more cost-effective than current practice without RDTs, and whether there is a difference in the cost effectiveness of the provider training interventions. The primary outcome is the proportion of patients attending facilities that report a fever or suspected malaria and receive treatment according to malaria guidelines. This will be measured by surveying patients (or caregivers) as they exit public and mission health facilities. Cost-effectiveness will be presented in terms of the primary outcome and a range of secondary outcomes, including changes in provider knowledge. Costs will be estimated from a societal and provider perspective using standard economic evaluation methodologies. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00981877

Providers’ knowledge, preference and practice in treating patients with suspected malaria in Cameroon and Nigeria

Working as agents for their patients, health care providers often make treatment decisions on the patient’s behalf. By establishing common standards, clinical guidelines are central to efforts to improve patient care and can expedite the introduction of new technologies. Each year considerable resources are used to disseminate clinical guidelines, though conventional public health interventions often have a limited effect in changing providers’ practice. Using economic theory and methods, research was undertaken to design and evaluate interventions to support the roll-out of malaria rapid diagnostic testing. This thesis contains five research papers on providers’ knowledge, preference and practice in treating patients with malaria symptoms in Cameroon and Nigeria. In this setting, uncomplicated malaria is routinely diagnosed and treated by health workers in outpatient departments and primary health centres, or self-treated using antimalarials purchased at pharmacies and drug stores. Major problems with malaria diagnosis and treatment were identified. Relatively few febrile patients were tested for malaria, many did not receive the recommended antimalarial, and when patients were tested for malaria the test result was often ignored when treatment was prescribed. Moreover, there was no significant relationship between providers’ knowledge and their practice, and preferences over alternative antimalarials were similar among providers working in the same facility or locality. The results of a cluster randomized trial in Cameroon demonstrated that introducing rapid diagnostic tests with enhanced training, which targeted providers’ practice, was more cost-effective than introducing rapid diagnostic tests with basic training, when each was compared to current practice. Since the trial concluded, the Ministry of Health has incorporated the enhanced training in the nationwide roll-out of rapid diagnostic testing. The findings are also relevant for policy makers elsewhere, and highlight the value in developing strategies to improve providers’ adherence to malaria treatment guidelines when expanding access to malaria testin