Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial

Abstract

Objective To test whether strict implementation of a standardised protocol for the management of malaria and provision of a financial incentive for health workers reduced mortality. Design Randomised controlled intervention trial. Setting Paediatric ward at the national hospital in Guinea-Bissau. All children admitted to hospital with severe malaria received free drug kits. Participants 951 children aged 3 months to 5 years admitted to hospital with a diagnosis of malaria randomised to normal or intervention wards. Interventions Before the start of the study, all personnel were trained in the use of the standardised guidelines for the management of malaria, including strict follow-up procedures. Nurses and doctors were randomised to work on intervention or control wards. Personnel in the intervention ward received a small financial incentive ($50 (£25; €35)/month for nurses and $160 for doctors) and their compliance with standard case management was closely monitored. Main outcome measures In-hospital mortality and cumulative mortality within 4 weeks of hospital admission. Results In-hospital mortality was 5% for the intervention group and 10% in the control group (risk ratio 0.48, 95% confidence interval 0.29 to 0.79). The effect may have been stronger in patients with positive malaria slides (0.36, 0.16 to 0.80). Cumulative mortality 4 weeks after discharge was also lower in the intervention group (0.61, 0.40 to 0.95). Conclusions Supervising healthcare workers to adhere to a standardised treatment protocol was associated with greatly reduced in-hospital mortality. Financial incentives may be important for the dedication and compliance of staff members. Trial registration Clinical Trials NCT00465777.

Causes of pediatric mortality and case-fatality rates in eight Médecins Sans Frontières-supported hospitals in Africa

“…This is supported by a study from Guinea-Bissau in a national referral hospital showing that the introduction of standardized guidelines and fi nancial incentives reduced mortality rates. 5 Whether or not these hospitals would have fared as well under typical local government support is open to question.…”

Motivation, money and respect: A mixed-method study of Tanzanian non-physician clinicians

“…Some researchers have argued that non-financial motivators such as "a sense of achievement" and "recognition" are more important than salary in low-income country settings (Alihonou, Soude, & Hounye, 1998;Mathauer & Imhoff, 2006;Stilwell, 2001). However, others point out that in environments where salaries are very low, low motivation is to be expected (Ferrinho, Van Lerberghe, Fronteira, Hipolito, & Biscaia, 2004) and financial incentive schemes have had some success in improving healthworker motivation and performance in low-income country settings (Biai, Rodrigues, Gomes, Ribeiro, Sodemann, Alves et al, 2007;Mliga, 2003;Rodrigues, 1989). Herzberg categorised salary as a "dissatisfier" rather than a "satisfier" (Herzberg, Mausner, & Snyderman, 1959), arguing that low salaries have the potential to demotivate workers but that salary in itself does not motivate workers.…”

Costing of Malaria treatment in a rural district hospital

“…Also, total cost can be estimated already at the moment of admission and provide planning reliability to the health care provider as well as to the patient or his accompanying relatives. In Guinea-Bissau, for instance, it was shown, that a standardised protocol for the management of paediatric Malaria can lead to a decrease in mortality and average hospital stay, when going along with monitoring and a financial incentive for the staff [43].…”