Perspectives on Implementation Considerations and Costs of Malaria Case Management Supportive Supervision

The American Journal of Tropical Medicine and Hygiene

et al. 2019

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Although light microscopy is the reference standard for diagnosing malaria, maintaining skills over time can be challenging. Between 2015 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported outreach training and supportive supervision (OTSS) visits at 1,037 health facilities in seven African countries to improve performance in microscopy slide preparation, staining, and reading. During these visits, supervisors observed and provided feedback to health-care workers (HCWs) performing malaria microscopy using a 30-step checklist. Of the steps observed in facilities with at least three visits, the proportion of HCWs that performed each step correctly at baseline ranged from 63.2% to 94.2%. The change in the proportion of HCWs performing steps correctly by the third visit ranged from 16.7 to 23.6 percentage points (n = 916 observations). To assess the overall improvement, facility scores were calculated based on the steps performed correctly during each visit. The mean score at baseline was 85.7%, demonstrating a high level of performance before OTSS. Regression analysis predicted an improvement in facility scores of 3.6 percentage points (P < 0.001) after three visits across all countries. In reference-level facilities with consistently high performance on microscopy procedures and parasite detection, quality assurance (QA) mechanisms could prioritize more advanced skills, such as proficiency testing for parasite counting and species identification. However, in settings with high staff turnover and declining use of microscopy in favor of rapid diagnostic tests, additional supervision visits and/or additional QA measures may be required to improve and maintain performance. * Checklist steps in bold ("minimum standard" steps) are considered more important and are collectively weighted twice as much as the other steps when calculating scores. † Health facilities preferred to use the 10% Giemsa solution because of its rapid turnaround when compared with the 3% Giemsa solution.

Section: Discussionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

Effect of Supportive Supervision on Malaria Microscopy Competencies in Sub-Saharan Africa

Alombah

The American Journal of Tropical Medicine and Hygiene

et al. 2019

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“…Each observed clinician was evaluated using a 25-point checklist developed by the MalariaCare clinical team through an iterative process with field testing before this study period. 7 Although development of this tool was largely a de novo process, several country-level and WHO malaria case management tools were reviewed in preparation. [8][9][10] The checklist focuses on the most important clinical steps in conducting a clinical assessment as determined by MalariaCare's technical team in consultation with the NMCPs (Table 1) and is designed to assess an individual clinician's case management decision-making process, independent of whether all critical supplies were present during the visit.…”

Section: Methodsmentioning

confidence: 99%

“…Under OTSS, trained supervisors used a standardized checklist to observe clinical staff conducting a febrile consultation, provided individualized feedback on steps carried out correctly and incorrectly, and developed action plans together with facility staff to address broader health facility issues. 7 Using MalariaCare program data, we evaluated the impact of OTSS on health facility performance toward meeting clinical competencies during outpatient department consultations.…”

Section: Introductionmentioning

confidence: 99%

Effect of Supportive Supervision on Competency of Febrile Clinical Case Management in Sub-Saharan Africa

Martin

The American Journal of Tropical Medicine and Hygiene

et al. 2019

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Since 2010, the WHO has recommended that clinical decision-making for malaria case management be performed based on the results of a parasitological test result. Between 2015 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported the implementation of this practice in eight sub-Saharan African countries through 5,382 outreach training and supportive supervision visits to 3,563 health facilities. During these visits, trained government supervisors used a 25-point checklist to observe clinicians' performance in outpatient departments, and then provided structured mentoring and action planning. At baseline, more than 90% of facilities demonstrated a good understanding of WHO recommendations-when tests should be ordered, using test results to develop an accurate final diagnosis, severity assessment, and providing the correct prescription. However, significant deficits were found in history taking, conducting a physical examination, and communicating with patients and their caregivers. After three visits, worker performance demonstrated steady improvement-in particular, with checking for factors associated with increased morbidity and mortality: one sign of severe malaria (72.9-85.5%), pregnancy (81.1-87.4%), and anemia (77.2-86.4%). A regression analysis predicted an overall improvement in clinical performance of 6.3% (P < 0.001) by the third visit. These findings indicate that in most health facilities, there is good baseline knowledge on the processes of quality clinical management, but further training and on-site mentoring are needed to improve the clinical interaction that focuses on second-order decision-making, such as severity of illness, management of non-malarial fever, and completing the patient-provider communication loop.

“…They provided individualized, real-time feedback on steps performed correctly and incorrectly, and developed action plans to address broader issues at the health facility level. 19 We present here an analysis of programmatic data representing more than 9,000 observations from eight countries focusing on performance of both clinical and laboratory staff using RDTs at health facilities across administrative levels of health-care systems. The results provide an indication of the impact of supportive supervision on RDT performance, within the context of providing comprehensive case management in busy health facilities in resource-challenged countries.…”

Section: Introductionmentioning

confidence: 99%

Effect of Supportive Supervision on Performance of Malaria Rapid Diagnostic Tests in Sub-Saharan Africa

The American Journal of Tropical Medicine and Hygiene

Burnett

et al. 2019

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Rapid diagnostic tests (RDTs) are one of the primary tools used for parasitological confirmation of suspected cases of malaria. To ensure accurate results, health-care workers (HCWs) must conduct the RDT test correctly. Trained supervisors visited 3,603 facilities to assess RDT testing performance and conduct outreach training and supportive supervision activities in eight African countries between 2015 and 2017, using a 12-point checklist to determine if key steps were being performed. The proportion of HCWs performing each step correctly improved between 1.1 and 21.0 percentage points between the first and third visits. Health-care worker scores were averaged to calculate facility scores, which were found to be high: the average score across all facilities was 85% during the first visit and increased to 91% during the third visit. A regression analysis of these facility scores estimated that, holding key facility factors equal, facility performance improved by 5.3 percentage points from the first to the second visit (P < 0.001), but performance improved only by 0.6 percentage points (P = 0.10) between the second and third visits. Factors strongly associated with higher scores included the presence of a laboratory worker at the facility and the presence of at least one staff member with previous formal training in malaria RDTs. Findings confirm that a comprehensive quality assurance system of training and supportive supervision consistently, and often significantly, improves RDT performance.