Determinants of malaria testing at health facilities: the case of Uganda

Malaria remains one of the main global health challenges with 3.4 billion people at risk leading to 229 million cases and 409,000 deaths each year, the bulk of which are reported in sub-Saharan Africa [1]. Uganda ranks 5th among the highest contributors of malaria cases in this region. Malaria is endemic in 95% of Uganda, and is responsible for 20% of outpatient visits, 15% of hospital admissions and up to 5–10% of inpatient deaths [2, 3]. The World Health Organization (WHO) recommends prompt and effective diagnosis and treatment as one of the key interventions to control malaria [4]. Diagnosis should be guided by parasitological confirmation with either microscopy or malaria rapid diagnostic tests (RDTs) for all persons of all ages in all epidemiological settings [4]. Microscopic examination of blood smears has been considered the gold standard for malaria diagnosis, but maintaining adequate microscopy standards is challenging in resource limited settings and thus parasite based rapid diagnostic tests have been recommended as having comparable precision and incorporated into clinical guidelines for malaria endemic countries [5]. However, in sub-Saharan Africa, malaria diagnosis is still influenced by clinical symptoms with patients and care providers often attributing all fevers as due to malaria. This practice stems from high malaria endemicity where most fevers are assumed to be malaria, traditional health perceptions, and issues related to laboratory testing including inadequate supplies, low numbers of laboratory staff numbers coupled with limited diagnostic capacity and high backlog, among others [6].

In Uganda, the Ministry of Health and National Malaria Control Division (NMCD) established a policy of test and treat for malaria in 2005. This policy requires diagnostic testing for every suspected malaria case (defined as those presenting with fever) and restricting treatment for malaria to only those cases with evidence of a positive parasitological test result. Implementation of this policy was limited in the first decade of its adoption. Testing among those suspected was at only 24% in 2010, though this rose impressively to 59% in 2013 [7, 8]. Uganda hoped, through its 5-year (2014–2020) malaria reduction strategy, to have at least 75% of those suspected malaria cases being tested in 2019, increasing to 84% in 2021 [8]. To ensure Uganda can reach its test and treat goal, there is a need to understand the factors that influence and can possibly sustain malaria parasitological testing at health facilities. This study was conducted with this purpose in mind and to generate knowledge that will help malaria control programmes ensure that all health facilities are able to implement the recommendation of parasitological testing for all patients suspected to have malaria.

In order to effectively control malaria, the WHO recommends parasitological testing of all patients suspected to have malaria before treatment [4]. In 2017, Uganda adopted national guidelines that require at least 75% of patients with suspected malaria to be tested [8] before treatment with anti-malarials. Achieving such a target coupled with adherence to test results is critical for progress in malaria control, with benefits of improving patient management, in addition to saving on the cost of ACT due to rational use. Of equal importance is collecting and recording appropriate data to allow measurement of progress on implementation of this policy. Six years ago, during the revision of HMIS tools, Uganda introduced into the outpatient register a data element for recording the presence or absence of fever, on top of patient diagnosis and treatment. Since this introduction, unpublished health facility support supervision reports have reported improvements in the completion of this data element in outpatient register, resulting in a more accurate estimation of testing rates.

This study showed high malaria testing rates among those suspected to have malaria at health facilities. Results showed that 86% of the facilities were testing over 75% of the patients suspected to have malaria; an impressive improvement from 59% in 2014 [8]. It also showed an impressive testing rate (88%) among private for-profit facilities which was slightly higher than that observed among public facilities (84%). Similarly, the Uganda malaria indicator survey 2018/19 (population-based survey) indicated that the children under 5 years of age with a fever in the 2 weeks preceding the survey who had blood taken from a finger or heel for testing could go as high as 70% in some district [12]. While adherence to test results was not the focus of this study, in Uganda adherence to test results has improved. A qualitative study conducted in rural health facilities in western Uganda in 2016 observed 55 patients, 38 tested negative and only one of these was prescribed an anti-malarial [13].

Malaria commodities were widely available in the study facilities at the time of the survey, with over 80% of the facilities reporting availability of RDTs or microscopy, ACT as well as SP. Wide availability of malaria commodities may be attributed to increased commitments, investments, and funding towards malaria control efforts by key international funding agencies such as the PMI, the Global Fund, and the UK Department for International Development (DFID) among others. For example, PMI and Global Fund resources combined increased from USD 50 million in 2008 to 219 million in 2017/18 [14, 15]. Long term availability of such commodities is, however, critical for effective malaria control.

The study showed supportive supervision and having at least one health worker trained in malaria diagnosis using RDTs were statistically significant factors in having at least 75% of patients suspected to have malaria tested. Previous studies have also demonstrated the role of supportive supervision in provision of quality health care services. One study observed noticeable improvements in maternal and newborn services following regular conduct of support supervision in 28 facilities in central Uganda [16]. Similarly, another study noted maintenance of supervision and training among features for successful interventions towards improvement of malaria related services among health care providers in sub-Saharan Africa [17]. In India, interventions combined with supportive supervision have been observed to result in better improvement in malaria control than those with no supportive supervision [18]. Study results are also consistent with what was observed in a multi-site study in Uganda where malaria testing rates at lower level facilities increased to over 90% as a result of regular support visits to health facilities [19]. Unfortunately, supportive supervision to health facilities is not always regularly provided in many developing countries for varying reasons [19]. Some studies noted that district health management teams schedule to have regular support visits, but these do not frequently happen as planned due to conflicting responsibilities on supervisors’ time and challenges with accessibility and adequacy of funds, with remote facilities most affected [20, 21]. Amidst such challenges, however, it is important for malaria control programmes to proactively support and ensure regular supervision visits to health facilities.

This study also showed that training in the use of RDT was a key determinant of high testing rates at health facilities, independent of supportive supervision. Having at least one health worker trained in the use of RDTs influenced a facility’s ability to achieve the testing target. These results correlate with other findings in Uganda, which reported very high levels of malaria testing rates following training in use of RDTs and malaria supportive supervision at health facilities [19]. While microscopy has been considered the gold standard for malaria diagnosis, its requirements (technical expertise, a functional microscope, electricity, and specialized reagents) for functionality often fall short at health facilities and where it is functional, time and human resource constraints may prevent testing of all those suspected to have malaria when patient volume is high [22]. Having at least one health worker trained in use of RDTs enables the facility to use RDTs for malaria diagnosis where and when microcopy is not functional or feasible, and/or when the patient load is high. High patient load is often the case at health facilities in Uganda, and sub-Saharan Africa in general, especially during peak malaria season [23]. Moreover, microscopic capability is often limited to high level or larger health facilities [24]. Although the presence of power supply seems to be associated with lower testing in the bivariate analysis, since association loses its significance in the multiple logistic regression model.

This study did not find availability of malaria management guidelines, availability of clocks/timers, availability of disinfectants in the laboratory, availability of running water, and availability of sharps containers significantly affecting malaria testing at health facilities. However, literature on these factors in regard to malaria diagnostic testing is also limited.

This study used routine data reported through DHIS2. In Uganda, improvements in the quality of data reported through DHIS2 have been documented. A study assessing completeness and timeliness of these data showed significant improvements with completeness increasing from36% in 2011/12 to 85.3% in 2012/13 and timeliness of OPD data increasing from 22% (2011/12) to 78% (2012/13) [25]. Another study that assessed DHIS2 data for the period 2015–2019 for all districts in Uganda, showed that completeness of reporting by facilities was near 100% and that study noted that extreme outliers (defined as at least 3.5 standard deviations from expected value) in the data assessed were rare. In addition, the study observed data consistencies over time. Despite these improvements, however, challenges still remain including limited access to computers and internet, inadequate technical support, and limited human resources [26].

Additionally, data quality issues including inaccuracies in reporting and recording by health facilities, and transparent documentation of data corrections or adjustments by data officers, among others, still persist [27]. Nonetheless, this data still provides valuable insights into health worker practices and other health related needs. Results from DHIS2 data in this study are consistent with other studies conducted in Uganda and they therefore seem to provide a near accurate representation of what is happening in the health facilities [12].

This study did not assess individual level health worker factors that might influence malaria parasitological testing among suspected cases at health facilities. The study only looked at health facility contextual factors. As such, factors like health worker level of education, their cadre, experience, and practice of identifying patients suspected of having malaria, and other potential covariates like workload at the facility, transmission setting, health facility staffing, among others were not assessed were not examined.

This study assessed predictors of high malaria testing rates in order to better understand how to support and sustain the implementation of the Uganda test and treat guideline. Results showed that supportive supervision to a health facility within 6 months and a facility having at least one health worker trained in the use of RDTs are key factors that influence a facility’s ability to achieve the target of testing at least 75% of patients with suspected malaria who report to the facility. This study underpins the value of malaria control programmes and district health teams conducting regular supportive supervision to health facilities as well as training health workers to use RDTs to ensure testing of malaria suspects before treatment.