Improving malaria treatment and prevention in India by aiding district managers to manage their programmes with local information: a trial assessing the impact of Lot Quality Assurance Sampling on programme outcomes

Abstract

Objectives: This paper reports the first trial of Lot Quality Assurance Sampling (LQAS) assessing associations between access to LQAS data and subsequent improvements in district programming. This trial concerns India's approach to addressing an increase in malaria-attributable deaths by training community health workers to diagnose, treat and prevent malaria, while using LQAS to monitor sub-district performance and make programme improvements.

Methods: The Ministry of Health introduced LQAS into four matched high malaria burden districts (Annual Parasite Incidence >5) (N > 5 million). In each sub-district, we sampled four populations in three 6-monthly surveys: households, children <5 years, people with fever in the last 2 weeks and community health workers. In three districts, trained local staff collected, analysed and used data for programme management; in one control district, non-local staff collected data and did not disseminate results. For eight indicators, we calculated the change in proportion from survey one to three and used a Difference-in-Differences test to compare the relative change between intervention and control districts.

Results: Coverage increased from survey one to three for 24 of 32 comparisons. Difference-in-Differences tests revealed that intervention districts exhibited significantly greater change in four of six vertical strategies (insecticide treated bed-nets and indoor residual spraying), one of six treatment-seeking behaviours and four of 12 health worker capacity indicators. The control district displayed greater improvement than two intervention districts for one health worker capacity indicator. One district with poor management did not improve.

Conclusions: In this study, LQAS results appeared to support district managers to increase coverage in underperforming areas, especially for vertical strategies in the presence of diligent managers.

Keywords: Echantillonnage par Assurance de la Qualité du Lot; Inde; India; Lot Quality Assurance Sampling; community-based management of malaria; control malaria; ensayo de muestreo de aceptación de lotes (LQAS); lutte contre le paludisme; malaria; malaria control; malaria prevention; malaria treatment; manejo de la malaria basado en la comunidad; prevención malaria; prise en charge communautaire du paludisme; prévention du paludisme; traitement du paludisme; tratamiento malaria.