The quality of malaria care in 25 low-income and middle-income countries

Abstract

IntroductionEven with accessible and effective diagnostic tests and treatment, malaria remains a leading cause of death among children under five. Malaria case management requires prompt diagnosis and correct treatment but the degree to which this happens in low-income and middle-income countries (LMICs) remains largely unknown.MethodsCross-sectional study of 132 566 children under five, of which 25% reported fever in the last 2 weeks from 2006 to 2017 using the latest Malaria Indicators Survey data across 25 malaria-endemic countries. We calculated the per cent of patient encounters of febrile children under five that received poor quality of care (no blood testing, less or more than two antimalarial drugs and delayed treatment provision) across each treatment cascade and region.ResultsAcross the study countries, 48 316 (58%) of patient encounters of febrile children under five received poor quality of care for suspected malaria. When comparing by treatment cascade, 62% of cases were not blood tested despite reporting fever in the last 2 weeks, 82% did not receive any antimalarial drug, 17% received one drug and 72% received treatment more than 24 hours after onset of fever. Of the four countries where we had more detailed malaria testing data, we found that 35% of patients were incorrectly managed (26% were undertreated, while 9% were overtreated). Poor malaria care quality varies widely within and between countries.ConclusionQuality of malaria care remains poor and varies widely in endemic LMICs. Treatments are often prescribed regardless of malaria test results, suggesting that presumptive diagnosis is still commonly practiced among cases of suspected malaria, rather than the WHO recommendation of ‘test and treat’. To reach the 2030 global malaria goal of reducing mortality rates by at least 90%, focussing on improving the quality of malaria care is needed.

Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007–2018

“…Our results are consistent with prior evidence from population-representative household surveys suggesting important gaps in diagnostic testing and ACT taking for children with malaria [ 22 , 25 , 65 ]. While these studies have the advantage of capturing children who are not brought for formal care, household surveys may be subject to recall bias and misunderstanding of clinical actions [ 66 , 67 ].…”

“…Following these guideline changes, major efforts were made to improve access to testing and antimalarial treatment, including the free or heavily subsidized provision of ACTs to public sector health facilities and the large-scale distribution of malaria RDTs ( Table 1 ). Evidence suggests that the scale-up of RDTs has contributed to higher rates of malaria testing [ 2 , 9 , 20 ] and that the widescale distribution of subsidized ACTs has contributed to declines in malaria morbidity and mortality [ 3 , 21 ], yet important gaps in clinical management of malaria remain [ 22 – 25 ].…”

“…While a number of studies have assessed quality of care for malaria patients, most are based on interviews with patients or record reviews, though some studies at the national or subnational level also include direct observation of clinical practice [ 22 , 24 , 34 – 36 ]. One cross-country study that explores management of febrile illnesses using observation with a standardized checklist was conducted in the context of a program to improve clinical care with supportive supervision [ 37 ].…”

Associations of childhood exposure to malaria with cognition and behavior outcomes: a systematic review protocol

“…Malaria remains a public global health challenge that disproportionally affects children who already face multiple other risk factors for growth and development, such as poverty and malnutrition especially in low and middle-income countries (LMICs) [1,2]. Between 300-600 million people suffer from malaria each year, and 90% of these cases occur in young children in sub-Saharan Africa [3].…”

“…This systematic review is necessary to help find, appraise, and summarize the current evidence that malaria infection is associated with cognitive and behavioral performance and may provide evidence to inform clinical care, identify knowledge gaps, and highlight further areas for investigation. We focus on LMICs where malaria is still greatly endemic with moderate and high transmissions and malaria burden [1,2]. For example in 2018, nineteen countries in sub-Saharan Africa and India carried almost 85% of the global malaria burden with six countries (Uganda Mozambique, Nigeria, the Democratic Republic of the Congo, Côte d'Ivoire, and Niger) bearing more than half of all malaria cases worldwide [2].…”