Quality of malaria case management at outpatient health facilities in Angola

Abstract

Background: Angola's malaria case-management policy recommends treatment with artemether-lumefantrine (AL). In 2006, AL implementation began in Huambo Province, which involved training health workers (HWs), supervision, delivering AL to health facilities, and improving malaria testing with microscopy and rapid diagnostic tests (RDTs). Implementation was complicated by a policy that was sometimes ambiguous.

Methods: Fourteen months after implementation began, a cross-sectional survey was conducted in 33 outpatient facilities in Huambo Province to assess their readiness to manage malaria and the quality of malaria case-management for patients of all ages. Consultations were observed, patients were interviewed and re-examined, and HWs were interviewed.

Results: Ninety-three HWs and 177 consultations were evaluated, although many sampled consultations were missed. All facilities had AL in-stock and at least one HW trained to use AL and RDTs. However, anti-malarial stock-outs in the previous three months were common, clinical supervision was infrequent, and HWs had important knowledge gaps. Except for fever history, clinical assessments were often incomplete. Although testing was recommended for all patients with suspected malaria, only 30.7% of such patients were tested. Correct testing was significantly associated with caseloads < 25 patients/day (odds ratio: 18.4; p < 0.0001) and elevated patient temperature (odds ratio: 2.5 per 1 degrees C increase; p = 0.007). Testing was more common among AL-trained HWs, but the association was borderline significant (p = 0.072). When the malaria test was negative, HWs often diagnosed patients with malaria (57.8%) and prescribed anti-malarials (60.0%). Sixty-six percent of malaria-related diagnoses were correct, 20.1% were minor errors, and 13.9% were major (potentially life-threatening) errors. Only 49.0% of malaria treatments were correct, 5.4% were minor errors, and 45.6% were major errors. HWs almost always dosed AL correctly and gave accurate dosing instructions to patients; however, other aspects of counseling needed improvement.

Conclusion: By late-2007, substantial progress had been made to implement the malaria case-management policy in a setting with weak infrastructure. However, policy ambiguities, under-use of malaria testing, and distrust of negative test results led to many incorrect malaria diagnoses and treatments. In 2009, Angola published a policy that clarified many issues. As problems identified in this survey are not unique to Angola, better strategies for improving HW performance are urgently needed.

Figure 1

Algorithm used to analyse the quality of malaria diagnosis and treatment, as it was applied in outpatient health facilities, Huambo Province, Angola. ^a Defined as either fever (history of fever or axillary temperature > 37.5°C), or at least 3 of the following: headache, joint pain, chills, sweating, anaemia (palmor pallor), cough (applies to children only), anorexia, fatigue, vomiting, or diarrhoea. ^b Error (health worker's decision did not follow policy documents and training materials). ^c Result not available on the day of the consultation, patient asked to return the next day (this only occurred for 2 patients). ^d This part of the algorithm was not explicitly included in policy documents or training materials; however, the decision could be logically inferred from policy documents or training materials. ^e Defined as cerebral dysfunction, cerebral malaria, disseminated intravascular coagulopathy, haemoglobinuria, hepatic dysfunction, hyperthermia, pulmonary oedema, renal insufficiency, severe anaemia, or shock. For details, see Figure 2. ^f Do not treat for malaria now; wait until result is ready and treat only if test is positive. ^g Defined as dysentery, hepatitis, influenza-like illness, measles, otitis, pneumonia, or urinary tract infection. For details, see Figure 2.

Figure 2

Definitions used in the survey analysis.

Figure 3

Dosage for artemether-lumefantrine used in the survey analysis.

Figure 4

Graphical pathway analysis of the case-management process for 40 patients without suspected malaria. AL = artemether-lumefantrine; HW = health worker.

Figure 5

Graphical pathway analysis of the case-management process for 78 patients with suspected malaria but no gold standard malaria diagnosis. AL = artemether-lumefantrine; HW = health worker.

Figure 6

Graphical pathway analysis of the case-management process for 59 patients with a gold standard malaria diagnosis. AL = artemether-lumefantrine; HW = health worker. ^a None of these 26 patients had been tested for malaria, although all were seen at health facilities in which testing was available.

Figure 7

Causal diagram of the case-management process in outpatient health facilities, Huambo Province, Angola.