Background
Methods
Data sources
Survey
|
n Febrile under-fives taken to any care
a
|
% receiving a diagnostic test
b
(95% CI)
|
% receiving any anti-malarial drug
c
(95% CI)
|
% receiving ACT
d
(95% CI)
|
% receiving any antibiotic drug
e
(95% CI)
|
Year of national policy change
f
| |
---|---|---|---|---|---|---|---|
Benin DHS 2011-2012 | Total | 620 | 20.0 (16.1-24.0) | 48.0 (43.2-52.9) | 17.5 (14.0-21.0) | 28.6 (24.5-32.6) | 2011 |
Tested
|
124
|
-
|
59.9 (48.3-71.5)
|
22.1 (14.0-30.3)
|
30.8 (21.3-40.2)
| ||
Not tested
|
492
|
-
|
44.8 (39.8-49.7)
|
16.0 (12.3-19.7)
|
27.9 (23.2-32.5)
| ||
Burkina Faso DHS 2010-2011 | Total | 1,823 | 7.7 (6.1-9.2) | 48.0 (44.8-51.1) | 12.5 (10.6-14.4) | 44.0 (40.9-47.1) | 2009 |
Tested
|
140
|
-
|
61.1 (51.9-70.3)
|
16.9 (10.5-23.3)
|
44.2 (35.0-53.4)
| ||
Not tested
|
1,671
|
-
|
46.8 (43.6-50.1)
|
12.1 (10.1-14.1)
|
43.8 (40.6-47.0)
| ||
Burundi DHS 2010-2011 | Total | 1,432 | 36.9 (33.4-40.4) | 25.9 (22.8-29.0) | 18.0 (15.2-20.9) | 54.6 (50.7-58.5) | 2007 |
Tested
|
528
|
-
|
38.3 (32.5-44.0)
|
24.9 (19.3-30.6)
|
48.8 (42.7-54.9)
| ||
Not tested
|
895
|
-
|
18.8 (15.7-21.9)
|
14.1 (11.1-17.0)
|
58.1 (53.9-62.2)
| ||
Cote d’Ivoire DHS 2011-2012 | Total | 965 | 13.6 (10.7-16.4) | 22.7 (18.8-26.7) | 3.3 (1.7-4.9) | 34.6 (30.3-38.9) | - |
Tested
|
131
|
-
|
42.4 (32.1-52.7)
|
9.2 (3.3-15.1)
|
45.9 (35.9-56.0)
| ||
Not tested
|
821
|
-
|
19.2 (15.3-23.2)
|
2.4 (0.7-4.1)
|
33.0 (28.4-37.6)
| ||
Gabon DHS 2012 | Total | 738 | 16.8 (11.3-22.3) | 26.2 (20.0-32.4) | 10.6 (6.9-14.4) | 59.0 (51.5-66.5) | 2009 |
Tested
|
124
|
-
|
32.9 (20.5-45.3)
|
8.6 (3.6-13.5)
|
51.2 (37.6-64.8)
| ||
Not tested
|
596
|
-
|
25.0 (17.6-32.3)
|
10.8 (5.9-15.6)
|
60.9 (53.2-68.6)
| ||
Guinea DHS 2012 | Total | 931 | 12.7 (9.8-15.6) | 44.3 (39.9-48.7) | 2.2 (1.0-3.4) | 40.6 (35.9-45.2) | 2010 |
Tested
|
118
|
-
|
53.0 (40.9-65.0)
|
4.1 (0.7-7.5)
|
54.6 (43.7-65.4)
| ||
Not tested
|
808
|
-
|
43.0 (38.4-47.7)
|
1.9 (0.6-3.2)
|
38.3 (33.5-43.1)
| ||
Malawi DHS 2010 | Total | 4,337 | 21.4 (19.2-23.6) | 55.0 (52.5-57.4) | 46.5 (44.0-49.1) | 29.6 (27.6-31.7) | 2011 |
Tested
|
928
|
-
|
64.2 (59.1-69.3)
|
50.6 (45.3-55.9)
|
33.8 (29.2-38.5)
| ||
Not tested
|
3,363
|
-
|
52.6 (50.1-55.1)
|
45.6 (43.0-48.1)
|
28.5 (26.3-30.7)
| ||
Mozambique DHS 2011 | Total | 888 | 43.4 (38.8-48.1) | 41.8 (37.1-46.5) | 25.3 (20.7-29.9) | 12.0 (9.6-14.5) | 2009 |
Tested
|
386
|
-
|
55.5 (48.9-62.0)
|
39.7 (32.5-46.9)
|
12.8 (9.0-16.6)
| ||
Not tested
|
502
|
-
|
31.3 (25.9-36.8)
|
14.3 (10.2-18.3)
|
11.4 (8.0-14.8)
| ||
Rwanda DHS 2010-2011 | Total | 657 | 36.6 (32.6-40.6) | 20.4 (17.3-23.5) | 19.6 (16.5-22.7) | 49.1 (45.0-53.2) | 2009 |
Tested
|
240
|
-
|
20.4 (15.5-25.3)
|
19.9 (15.1-24.7)
|
65.4 (59.2-71.6)
| ||
Not tested
|
413
|
-
|
20.6 (16.5-24.7)
|
19.6 (15.6-23.6)
|
39.5 (34.4-44.5)
| ||
Senegal DHS 2010-2011 | Total | 1,275 | 14.9 (11.9-17.9) | 14.1 (10.5-17.7) | 5.5 (3.1-8.0) | 43.0 (37.6-48.3) | 2007 |
Tested
|
190
|
-
|
20.4 (11.2-29.6)
|
8.8 (3.6-13.9)
|
51.9 (40.1-63.6)
| ||
Not tested
|
1,078
|
-
|
13.0 (9.4-16.7)
|
4.9 (2.3-7.6)
|
41.5 (36.2-46.8)
| ||
Uganda DHS 2011 | Total | 2,440 | 28.6 (25.5-31.6) | 69.9 (67.0-72.7) | 47.5 (43.8-51.1) | 35.3 (32.3-38.2) | 1997 |
Tested
|
697
|
-
|
76.4 (71.9-80.8)
|
52.7 (47.2-58.1)
|
40.9 (35.4-46.5)
| ||
Not tested
|
1,726
|
-
|
67.6 (64.1-71.1)
|
45.5 (41.3-49.7)
|
33.1 (29.7-36.5)
| ||
Zimbabwe DHS 2010-2011 | Total | 217 | 12.6 (7.8-17.5) | 5.0 (1.3-8.7) | 2.6 (0.2-5.0) | 38.8 (31.9-45.8) | 2008 |
Tested
|
27
|
-
|
20.5 (3.8-37.1)
|
10.9 (−2.0-23.8)
|
30.2 (12.1-48.3)
| ||
Not tested
|
189
|
-
|
2.8 (0.3-5.2)
|
1.4 (−0.6-3.5)
|
40.1 (32.7-47.5)
|
Outcomes
Main explanatory predictor
Other explanatory covariates
Statistical analysis
Case study methods
Results
Quantitative results
Country
|
n
Febrile under-fives taken to any care
|
n
any anti-malarial drug use
|
Any anti-malarial use
|
n
ACT use
|
ACT use
|
n any
antibiotic drug use
|
Any antibiotic use
| ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
COR (95% CI)
|
AOR (95% CI)
|
p value
|
COR (95% CI)
|
AOR (95% CI)
|
p value
|
COR (95% CI)
|
AOR (95% CI)
|
p value
| |||||
Benin | 620 | 298 | 2.61 (1.51-4.51) | 1.65 (0.92-2.98) | 0.096 | 109 | 2.37 (1.20-4.70) | 1.96 (0.91-4.19) | 0.084 | 177 | 1.83 (1.06-3.17) | 1.15 (0.64-2.08) | 0.636 |
Burkina Faso | 1,823 | 875 | 2.08 (1.39-3.11) | 1.32 (0.84-2.05) | 0.225 | 228 | 1.64 (0.99-2.71) | 1.45 (0.84-2.52) | 0.180 | 803 | 1.22 (0.82-1.81) | 0.89 (0.57-1.40) | 0.616 |
Burundi | 1,432 | 371 | 3.62 (2.64-4.96) | 3.71 (2.63-5.25) | <0.001 | 258 | 2.62 (1.79-3.83) | 2.78 (1.81-4.27) | <0.001 | 782 | 0.62 (0.47-0.81) | 0.53 (0.40-0.72) | <0.001 |
Cote d’Ivoire* | 965 | 220 | 3.29 (2.05-5.25) | 1.89 (1.14-3.13) | 0.013 | 32 | 7.09 (2.45-20.54) | 16.83 (1.03-276.13) | 0.048 | 334 | 1.99 (1.31-3.01) | 1.08 (0.68-1.74) | 0.737 |
Gabon | 738 | 194 | 2.25 (1.40-3.61) | 2.00 (1.16-3.44) | 0.013 | 78 | 2.74 (1.45-5.16) | 2.45 (1.13-5.33) | 0.024 | 436 | 0.88 (0.58-1.35) | 0.84 (0.52-1.35) | 0.467 |
Guinea* | 931 | 412 | 1.70 (1.08-2.67) | 1.28 (0.78-2.11) | 0.330 | 20 | 4.29 (1.25-14.68) | 2.42 (0.43-13.68) | 0.319 | 378 | 1.76 (1.11-2.78) | 1.05 (0.63-1.75) | 0.862 |
Malawi | 4,337 | 2,384 | 1.65 (1.40-1.94) | 1.34 (1.11-1.61) | 0.002 | 2,019 | 1.26 (1.07-1.48) | 1.12 (0.94-1.34) | 0.206 | 1,285 | 1.12 (0.94-1.33) | 1.00 (0.82-1.22) | 1.000 |
Mozambique | 888 | 371 | 2.85 (2.02-4.02) | 2.79 (1.92-4.05) | <0.001 | 225 | 3.65 (2.45-5.42) | 3.54 (2.33-5.39) | <0.001 | 107 | 1.04 (0.67-1.61) | 1.01 (0.64-1.59) | 0.966 |
Rwanda* | 657 | 134 | 0.93 (0.57-1.52) | 0.83 (0.48-1.44) | 0.506 | 129 | 0.96 (0.59-1.56) | 0.88 (0.51-1.51) | 0.633 | 322 | 3.70 (2.38-5.74) | 2.95 (1.82-4.79) | <0.001 |
Senegal | 1,275 | 180 | 1.75 (1.11-2.75) | 1.69 (1.04-2.76) | 0.036 | 70 | 2.54 (1.24-5.19) | 2.99 (1.32-6.79) | 0.009 | 547 | 1.90 (1.27-2.85) | 1.50 (0.97-2.31) | 0.070 |
Uganda | 2,440 | 1,704 | 1.50 (1.19-1.89) | 1.24 (0.96-1.61) | 0.097 | 1,158 | 1.13 (0.92-1.39) | 0.84 (0.66-1.06) | 0.133 | 860 | 1.45 (1.18-1.78) | 1.37 (1.09-1.72) | 0.007 |
Zimbabwe* | 217 | 11 | 13.23 (1.56-112.52) | 170.9 (0.30-98480.04) | 0.113 | 6 | 12.18 (1.94-76.45) | 25.55 (1.69-385.68) | 0.019 | 84 | 0.62 (0.24-1.60) | 0.55 (0.20-1.51) | 0.244 |
ACT use
Any anti-malarial use
Any antibiotic use
Sub-national results
Country
|
Outcome
|
Strata
|
n febrile under fives taken to any care
|
% with outcome (95% CI)
|
% with a diagnostic test (95% CI)
|
AOR (95% CI)
|
p value
|
---|---|---|---|---|---|---|---|
Malaria risk
| |||||||
Benin | Any anti-malarial use | High risk | 403 | 50.8 (45.3-56.3) | 20.0 (16.1-24.4) | 2.30 (1.10-4.82) | 0.028 |
Moderate risk | 212 | 41.4 (32.9-50.5) | 18.7 (11.9-28.1) | 0.32 (0.08-1.29) | 0.108 | ||
Burundi* | Any antibiotic use | Moderate risk | 1,239 | 54.0 (49.8-58.2) | 37.7 (33.8-41.6) | 0.44 (0.32-0.60) | <0.001 |
Low risk | 125 | 57.3 (42.7-71.8) | 37.1 (27.2-47.0) | 6.75 (1.30-35.00) | 0.023 | ||
Malawi | Any anti-malarial use | High risk | 1,870 | 56.9 (53.8-60.1) | 19.5 (16.8-22.2) | 1.63 (1.26-2.11) | <0.001 |
Moderate risk | 2,361 | 53.2 (49.5-56.9) | 22.8 (19.3-26.3) | 1.12 (0.85-1.47) | 0.410 | ||
Uganda | ACT use | High risk | 1,730 | 46.1 (41.5-50.9) | 26.9 (23.3-30.8) | 0.95 (0.70-1.28) | 0.736 |
Moderate risk | 625 | 51.6 (46.2-57.1) | 34.7 (28.9-41.1) | 0.67 (0.46-0.98) | 0.040 | ||
Any antibiotic use | High risk | 1,730 | 36.6 (32.9-40.4) | 26.9 (23.3-30.8) | 1.24 (0.93-1.65) | 0.146 | |
Moderate risk | 625 | 33.0 (28.3-38.1) | 34.7 (28.9-41.1) | 1.68 (1.12-2.52) | 0.012 | ||
Source of care
| |||||||
Malawi | Any antibiotic use | Public | 2,978 | 27.6 (25.2-30.0) | 19.3 (17.2-21.4) | 0.85 (0.67-1.09) | 0.199 |
Private | 1,358 | 34.0 (30.2-37.8) | 26.0 (21.7-30.4) | 1.36 (0.95-1.96) | 0.097 | ||
Rwanda* | Any anti-malarial use | Public | 522 | 24.4 (20.8-28.4) | 40.3 (35.8-44.8) | 0.59 (0.31-1.14) | 0.119 |
Private | 134 | 5.0 (2.3-10.8) | 22.4 (15.6-31.1) | 29.38 (2.25-383.63) | 0.010 | ||
Symptoms
| |||||||
Benin* | Any anti-malarial use | Fever alone | 380 | 46.6 (40.9-52.5) | 15.5 (11.8-20.1) | 0.94 (0.39-2.29) | 0.893 |
Fever, cough, rapid breaths | 239 | 50.5 (43.1-57.8) | 27.2 (21.0-34.5) | 5.48 (1.27-23.63) | 0.022 | ||
Burkina Faso | Any anti-malarial use | Fever alone | 1,253 | 48.5 (44.9-52.2) | 6.9 (5.5-8.6) | 2.03 (1.13-3.66) | 0.018 |
Fever, cough, rapid breaths | 570 | 46.7 (42.0-51.5) | 9.5 (6.9-12.8) | 0.69 (0.34-1.41) | 0.304 | ||
Malawi | ACT use | Fever alone | 1,980 | 51.7 (48.4-54.9) | 21.9 (19.3-24.5) | 0.87 (0.66-1.13) | 0.298 |
Fever, cough, rapid breaths | 2,355 | 42.2 (39.1-45.4) | 21.0 (18.1-23.9) | 1.40 (1.09-1.79) | 0.008 | ||
Any antibiotic use | Fever alone | 1,980 | 18.2 (16.0-20.4) | 21.9 (19.3-24.5) | 1.46 (1.07-1.99) | 0.017 | |
Fever, cough, rapid breaths | 2,355 | 39.2 (36.2-42.2) | 21.0 (18.1-23.9) | 0.77 (0.60-1.00) | 0.052 | ||
Senegal* | ACT use | Fever alone | 527 | 5.6 (3.3-9.1) | 15.1 (11.5-19.6) | 75.42 (1.09-5212.78) | 0.045 |
Fever, cough, rapid breaths | 747 | 5.5 (3.2-9.3) | 14.8 (11.1-19.4) | 1.69 (0.50-5.73) | 0.400 |
Malaria risk
Source of care
Symptoms
Case studies
Rwanda
|
Uganda
|
Malawi
|
Benin
|
Mozambique
|
Burundi
| ||
---|---|---|---|---|---|---|---|
DHS 2010-2011
|
DHS 2011
|
DHS 2010
|
DHS 2011-2012
|
DHS 2011
|
DHS 2010-2011
| ||
AOR (any anti-malarial use) | 0.83 (0.48-1.44) | 1.24 (0.96-1.61) | 1.34 (1.11-1.61) | 1.65 (0.92-2.98) | 2.79 (1.92-4.05) | 3.71 (2.63-5.25) | |
AOR (ACT use) | 0.88 (0.51-1.51) | 0.84 (0.66-1.06) | 1.12 (0.94-1.34) | 1.96 (0.91-4.19) | 3.54 (2.33-5.39) | 2.78 (1.81-4.27) | |
AOR (any antibiotic use) | 2.95 (1.82-4.79) | 1.37 (1.09-1.72) | 1.00 (0.82-1.22) | 1.15 (0.64-2.08) | 1.01 (0.64-1.59) | 0.53 (0.40-0.72) | |
Available diagnostics and medicines
| National ACT scale-up initiated | Yes | Yes | Yes | Yes | Yes | Yes |
National RDT scale-up initiated | Yes | No | No | Yes | Yes | No | |
Reported inconsistent RDT supplies | No | N/A | N/A | Yes | N/A | ||
Reported inconsistent ACT supplies | No | Yes | No [20] | Yes | Yes | Yes | |
Diagnostics at community-level | Yes [61] | No | No | No | No | No | |
Diagnostics at peripheral facilities | Yes | Yes* | No | Yes** | Yes** | No | |
Diagnostics at hospitals | Yes | Yes | Yes | Yes | Yes | Yes | |
Quality of care
| Diagnostic test adherence (% test-negative patients prescribed malaria treatment) | Perceived good | Poor [20%] [20] | Poor [38%] [9] | Perceived poor | Perceived poor | |
Care-seeking behaviour
| Extensive use of informal private sector | No | Yes [62] | No | Yes | No | No |
Malaria epidemiology
| Malaria endemicity in 2010 [37] | Malaria-free to moderate-risk | Malaria-free to high-risk | Moderate to high-risk | Moderate to high-risk | Moderate to high-risk | Malaria-free to high-risk |
“Children getting tested are probably at locations that also have medicines, and those not tested likely have worse access to ACT. That’s a key issue.” (Benin case study).
“(In Mozambique) there was little experience with testing at peripheral facilities at this time (with the lack of widely available RDT stocks), and poor case management practices in general.” (Mozambique case study).
“The private sector is small and more developed in Kigali. Clients attending these facilities often expect or demand certain medicines and some health providers want to maintain client satisfaction.” (Rwanda case study).
“In Benin care-seeking often goes: child has fever, taken to shop, gets medicines, doesn’t get better, goes to facility (where finally tested).” (Benin case study).
“(In Burundi) microscopy is basically in hospitals and healthcare access is difficult - remote, hilly communities. These results really show poor access to care.” (Burundi case study).
“There are three main reasons I can think of that could explain (Mozambique) results: (1) high malaria prevalence in certain areas even in the dry season (2) poor case management practices (3) access to testing and care (rural, bad infrastructure, hard to get tested and treated).” (Mozambique case study).