Background
The Integrated Management of Childhood Illness (IMCI) initiative was developed by the World Health Organization (WHO) with the aim of reducing childhood mortality, particularly for children under five years of age [
1]. IMCI aims to integrate management of the common conditions that children present with at health facilities, to improve the quality of care for children and reduce severe morbidity and mortality. IMCI recommended that every fever presenting at a health facility be treated as malaria in malaria-endemic areas based on the fact that the health system is weak in malaria-endemic countries and the capacity to conduct parasitological tests to confirm malaria was very limited [
2]. The WHO-Global Malaria Programme (WHO-GMP) revised guidelines in 2010 stating that regardless of the age of the patient and the endemicity of malaria, case management of malaria should be test based [
3] and that IMCI guidelines needed to be revised in accordance with this new policy. The successful implementation of a universal rule of ‘test and treat’ may, however, be challenging. For example, for rapid diagnostic test (RDT)-based management of malaria to be accepted and sustained, caregiver-health worker interactions need to be understood and improved [
4]. Lack of adherence to negative parasitological tests has been reported in studies in several settings [
5,
6] including a hospital in the Kintampo Municipality, and has become a focus for studies of test-based diagnosis of malaria [
7]. This study reports the perceptions of health workers on the wider issues they face in integrating parasitological diagnosis into their working practices within the context of existing health systems.
Discussion
Implementation of the WHO revised IMCI guidelines faces a wide variety of challenges given the weak health systems in most developing counties [
14]. The findings of this study suggest that the problem is heightened by beliefs and habits of front-line health staff in health facilities in developing countries that are used to presumptive treatment and perceive every fever to be malaria. It is worth noting that this study was carried out in a high-transmission setting and the results may differ from any carried out in a low-transmission setting where there is less belief that every fever is malaria. In health facilities, malaria RDT kits are intermittently unavailable or there is a communication gap between managers of health facilities and DHMTs who are responsible for their medical supplies. In hospital settings where microscopes are available and remain the gold standard of diagnosis and treatment, other co-morbids are easily detected making the prescription of approved ACT quite easy. This is the ideal situation and this is what the new IMCI guideline seeks to implement. Application of the IMCI guidelines is constrained by lack of training and retraining of medical staff in hospitals.
This study found perceived high workload to be a challenge leading to poor adherence to guidelines. Similar factors, such as cost of training health staff, duration of IMCI procedures and reluctance in referring to the guidelines were identified as important contributory factors in East Africa [
15]. An E-IMCI package has been tested in rural Tanzania and found to be feasible, to increase adherence to the IMCI protocol [
16] and to improve health care delivery [
17]. Motivation supported by all stakeholders seeking to improve implementation of IMCI could be instituted, as motivation was directly correlated to the quality and contribution of community volunteers to the implementation of community IMCI in Benin [
18]. Supportive supervision and health system strengthening have been identified as key to the sustainable implementation of IMCI in Tanzania [
19]. To address the barriers of ambiguous roles and responsibilities among stakeholders, which in some cases translates into lack of supply and logistics, a joint assessment of the situation by all stakeholders and streamlining IMCI implementation within the district through sound planning, training supervision and logistic support, was suggested by a study in rural Pakistan [
20]. Similar recommendations are made in another study on integrated management of childhood and neonatal illness in India (IMNCI) [
21]. The level of commitment of the health worker or the unit of the Ghana Health Service/Ministry of Health responsible for IMCI remains a key factor in its proper implementation.
The findings of this study suggest that a range of health workers perceive that the NHIS, which aims at health care financing for all Ghanaians, is gradually determining diagnosing, prescription and treatment of all illnesses, including malaria through government health facilities in the study health facilities. This is due to the strict application of its national guidelines [
22] which defines what drugs will be paid and whether this is dependent upon a pathological diagnosis having taken place. Cost of any treatment not included in the guidelines will not be honoured by the NHIS. This means that the diagnosing, prescribing and treatment practice of some health workers and health facilities are primarily guided by NHIS funding rules.
Attendance to health facilities at both in- and outpatients departments was perceived to have increased due to the introduction of the NHIS, leading to increased workload and consequently the inability of care providers to strictly adhere to the revised IMCI guidelines. This perception is upheld by a study in southern Ghana [
23] which showed an increase in both in- and outpatients in health facilities, attributable to the introduction of the NHIS. Removal of out-of-pocket payment has been shown to impact on health care-seeking behaviour in Ghana [
24] but not on the health outcomes measured [
24]. Factors accounting for this may be attributed to the broad benefits package that the scheme offers related to its new payment system and the growing membership.
Erratic supply of malaria RDTs and the use of the syndromic approach when facilities experience stock-outs of RDTs contribute to the perceptions and practice of malaria over-diagnosis. This may lead to inappropriate case management of malaria resulting in an increase in the economic burden to governments [
25]. Findings from this study demonstrate the presence of erratic supply of malaria RDTs among facilities. Stock-outs of RDTs are common in other parts of Africa [
26], where this impacts on fever case management and is a threat to the practice of test-based management of malaria.
Lack of trust of negative RDT results and the practice of prescribing an ACT despite this, was reported by the majority of health workers interviewed in this study. Similar findings have been reported from several other sites, including Zambia [
27], Ghana and the Republic of Benin [
28]. The Zambia study investigators suggested innovative approaches to health worker adherence to malaria diagnosis and treatment guidelines. Research findings by a study in Tanzania [
29] identified the practice of prescribing an ACT even though a RDT result was negative as a solution to conflict in health worker-patient interaction in test-based management of malaria; formative research to understand malaria over-diagnosis is recommended. Lack of trust in RDT negatives has also been recorded among community health workers in community case management of malaria in some countries in sub-Saharan Africa [
30]. Clinicians who received enhanced training in Cameroon on designing and implementing interventions to change clinicians’ practice in the management of uncomplicated malaria however strongly agreed that it is not appropriate to prescribe anti-malarials to a patient if they have a negative RDT result [
31].
Preferences for either RDT or microscopy for malaria diagnosis varied. The comparability of results of both microcopy and some RDT kits [
32-
34] has been assessed and RDTs have been found to be acceptable to caregivers in rural Ghana [
4], communities in Uganda [
35] and among health workers in Uganda. The sensitivity and specificity of some RDTs have been well documented [
36] and their specificity, sensitivity and acceptability as an alternative to microcopy established in a study in India [
37]. RDTs have been found to improve malaria diagnosis in low level health care facilities in Uganda [
38]. However, seasonality has been found to have some effect on the accuracy of RDTs as noted in a study in Burkina Faso in West Africa; different ranges of figures for RDT sensitivity and specificity were recorded in both dry and wet seasons [
39]. In some parts of Uganda and Kenya, RDTs were found to be effective when used in low endemicity situations, but high false positive error rates occurred in areas with moderately high transmission [
40]. It is worth noting that malaria microscopy is challenging: a study on the standardization of malaria microscopy in health facilities in Ethiopia on the availability of laboratory logistics and technical practices, concluded that most facilities fell below WHO standard [
41]. Gaps were also noted in the continuity of supply of reagents and laboratory supplies for malaria microscopy in some health facilities in Ethiopia [
42]. Perhaps in the future, modern methods, such as computer-based screening and visualization of blood smears may be a considered for malaria diagnostics [
43]. The adoption of these methods by front-line health workers however may be problematic.
To be able to surmount the problem of lack of prompt supply of good quality malaria RDTs, the application of short message service (SMS) to deliver messages on RDT stock availability could be adopted as used in a pilot study ‘SMS for Life’ in Tanzania [
44]. This system allows the use of mobile phones to send SMS messages on stock levels of drugs to supply points at different levels of the health system This has been found to be feasible for monitoring of stock levels of anti-malarials in Tanzania [
45]. This method could be adopted and adapted to aid reporting of stock-outs of required supplies and to trigger the supply of such supplies, including the supply of RDTs and ACT.
Adherence to the revised guidelines may improve if revised to a shorter version. Training and continuous training of health workers on the new revised IMCI guidelines should be part of the curricula of educational institutions that train middle-level manpower for the Ministry of Health. Re-orientation of medical practitioners and other senior health officers involved in clinical consultation at the health centres and hospitals may be institutionalized by the various DHMTs as part of their quarterly activities.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
LGF analysed the data and drafted the manuscript. FB, JW, S0-A, and DC conceived, designed and implemented the study. AJ, RD and MT implemented the study and reviewed the manuscript. BA and NA analysed the data and reviewed manuscript. JW, FB, DC, and S O-A critically reviewed the manuscript. All authors read and approved the final manuscript.