Treatment-seeking rates in malaria endemic countries

Abstract

Background: The proportion of individuals who seek treatment for fever is an important quantity in understanding access to and use of health systems, as well as for interpreting data on disease incidence from routine surveillance systems. For many malaria endemic countries (MECs), treatment-seeking information is available from national household surveys. The aim of this paper was to assemble sub-national estimates of treatment-seeking behaviours and to predict national treatment-seeking measures for all MECs lacking household survey data.

Methods: Data on treatment seeking for fever were obtained from Demographic and Health Surveys, Malaria Indicator Surveys and Multiple Cluster Indicator Surveys for every MEC and year that data were available. National-level social, economic and health-related variables were gathered from the World Bank as putative covariates of treatment-seeking rates. A generalized additive mixed model (GAMM) was used to estimate treatment-seeking behaviours for countries where survey data were unavailable. Two separate models were developed to predict the proportion of fever cases that would seek treatment at (1) a public health facility or (2) from any kind of treatment provider.

Results: Treatment-seeking data were available for 74 MECs and modelled for the remaining 24. GAMMs found that the percentage of pregnant women receiving prenatal care, vaccination rates, education level, government health expenditure, and GDP growth were important predictors for both categories of treatment-seeking outcomes. Treatment-seeking rates, which varied both within and among regions, revealed that public facilities were not always the primary facility type used.

Conclusions: Estimates of treatment-seeking rates show how health services are utilized and help correct reported malaria case numbers to obtain more accurate measures of disease burden. The assembled and modelled data demonstrated that while treatment-seeking rates have overall increased over time, access remains low in some malaria endemic regions and utilization of government services is in some areas limited.

Fig. 1

Treatment-seeking data in malaria-endemic countries by WHO region. MECs with treatment-seeking data available are shaded yellow and those missing data are shown in white. Country borders are coloured based on WHO region: Central Africa (AFRO-C, red), East Africa and high-transmission areas in Southern Africa (AFRO-E, blue), low-transmission Southern African countries (AFRO-S, green) West Africa (AFRO-W, purple), Americas (PAHO, brown), Eastern Mediterranean (EMRO, orange), Europe (EURO, yellow), Southeast Asia (SEARO, pink) and Western Pacific (WPRO, grey). Areas shaded grey outside the coloured borders have no malaria risk

Fig. 2

Predicted and observed treatment-seeking proportions. The predicted proportions estimated for 2013 are shown alongside observed values from 2010 onwards for government treatment-seeking (a) and treatment-seeking from any facility (b). Points are coloured by WHO region and shown with 95 % CI error bars. Predicted estimates are overlaid with black points. Each point represents a spatial aggregate of a single national survey. Countries with multiple points indicate multiple survey types or years

Fig. 3

Observed and predicted treatment-seeking proportions. The observed treatment-seeking values in the regions shown in Fig. 1 are mapped along with the national-level predicted values for the proportions seeking a government/public treatment and b any treatment. Treatment-seeking rates are shown from red (low access) to blue (high). Dark grey areas are those with no data and light grey regions are at no malaria risk