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

Abstract

Background: Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries.

Methods and findings: We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied.

Conclusions: In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.

Fig 1. Clinical management of children diagnosed with malaria.

Estimates are among the sample of children diagnosed with malaria. “Blood test diagnosis” indicates that the child’s malaria diagnosis was based on either a blood slide microscopy test or a rapid diagnostic test. “Appropriate medication” indicates that the child received either an oral ACT, parenteral artemisinin, or injectable quinine. For Senegal, all 5 survey rounds were combined. Data are weighted by SPA-supplied sampling weights to be nationally representative, and 95% confidence intervals are adjusted for clustering within facilities. ACT, Artemisinin Combination Therapy; DRC18, Democratic Republic of the Congo 2018; ET14, Ethiopia 2014; KE10, Kenya 2010; MW13, Malawi 2013; NM09, Namibia 2009; RW07, Rwanda 2007; SN13-17, Senegal 2013–2017; SPA, Service Provision Assessment; TZ15, Tanzania 2015; UG07, Uganda 2007.

Fig 2. AM prescriptions among children diagnosed with malaria.

“Other AM” includes chloroquine, sulfadoxine-pyremethamine, amodiaquine, quinine, and a few other very infrequently prescribed types of AMs not specified in the survey tool. Data are weighted using SPA-provided survey weights. ACT, Artemisinin Combination Therapy; AM, antimalarial; ART, artemisinin; SPA, Service Provision Assessment.

Fig 3. Estimated prevalence of clinical management of children diagnosed with malaria with universal stocking and provider training (N = 6,955 child visits).

Estimates are among the sample of children diagnosed with malaria for which covariates included in the model presented in Table 3 are available. “Blood test diagnosis” indicates that the child’s malaria diagnosis was based on either a blood slide microscopy test or a rapid diagnostic test. “Appropriate medication” indicates that the child received an oral ACT, parenteral artemisinin, or injectable quinine. Predicted estimates are based on the model presented in Table 3, under the assumption that all children are seen at a facility that had observed, verified stocking of malaria diagnostic tests and ACTs and that all children are seen by a provider with training in malaria diagnosis and/or treatment, holding all other covariates at their mean value. Data are weighted by SPA-supplied sampling weights to be nationally representative, and 95% confidence intervals are adjusted for clustering within facilities. ACT, Artemisinin Combination Therapy; SPA, Service Provision Assessment.