Malaria outpatient management in government health facilities in Kenya : an evaluation of current practice

Abstract

Background: Effective case management is a key element of malaria control. Health workers’ performance of assessment, diagnosis, treatment and counseling tasks in accordance with evidence-based standards is critical to ensure adequate quality of malaria case management. Methods: In children below 5 years, the quality of outpatient case management in accordance with national guidelines and factors influencing treatment practices were measured. In older children and adults, the quality of clinical assessment, the accuracy of diagnosis and the ability of clinical signs and symptoms to predict malaria were evaluated. The effects of routine microscopy on malaria case management were described across all-age groups. Data were collected from government facilities in 4 Kenyan districts, in a series of age-specific surveys using a full range of quality of care assessment tools. Results: The majority (89%) of children with malaria were diagnosed in line with national recommendations; however, only 55% of children with uncomplicated malaria had recommended treatment prescribed. The assessment and counselling components were the weakest parts of the case management. Associations between several programmatic interventions (i.e. training, guidelines, wall charts...) and higher quality of treatment were demonstrated. In older children and adults, the performance of clinical assessment tasks was sub-optimal and massive overdiagnosis (80%) of malaria was apparent. Clinical signs and symptoms showed little promise of being able to improve health worker’s ability to predict malaria. While routine microscopy might overcome the problem it was characterised by inaccuracy (SEN = 67%; SPE = 61%; PPV = 23%; NPV = 92%) and an extremely common practice of ignoring negative results across all age groups (67-78%). Conclusions: As we embark upon a new era of more expensive and more complex to use antimalarial treatments, improvement in clinical practice and careful consideration of malaria diagnostic strategies are urgently needed. This thesis highlighted the problems, suggests some solutions and provides some support for the view that programmatic approaches might improve health workers performance if implemented effectively at scale