Status of the use and compliance with malaria rapid diagnostic tests in formal private health facilities in Nigeria

Fever prevalence from the health facilities’ records was 38.5 %. The prevalence varied from 28 to 47 % across the various geo-political zones of the country. The fever prevalence in this study is lower than previously reported rate of 60 % among outpatients [29]. It is also slightly lower than the weighted average of 43 and 45 % reported among children taken to formal hospitals in northeastern and southern parts of the country, respectively [48]. The reasons for this lowering in fever prevalence may be connected to overall reductions and gains made in the control of malaria and acute respiratory tract infections [2, 46]. However, an additional possibility is that there is a wider range of non-febrile conditions that may be seen at the formal private health facilities since most users of such facilities tend to subscribe as families and they report there as their primary point of call for a variety of non-febrile conditions.

Among the 2077 patients with fever, there were a number of concomitant symptoms. The most frequent being generalized weakness, cough, vomiting, and diarrhoea. The predictive importance of the individual symptoms in relation to malaria was not undertaken in this study. However, the combination of these features continues to underscore the challenge of developing a reliable clinical algorithm for the diagnosis of malaria. Most efforts in this regard have resulted in relatively poor sensitivity and specificity, making the diagnosis of malaria solely reliant on parasitological testing [49‐51]. This was the basis of Nigeria’s recent policy change, in alignment with the global recommendation on testing before treatment, that until proven by test, a case of fever regardless of the clinical symptomatology, is ‘suspected’ malaria [52]. This study’s finding on the status of the implementation of the ‘test before treatment’ strategy in a national survey of private health facilities is therefore instructive.

This study showed that about three-quarters, 73.8 % (95 % CI 71.9–75.7 %) of fever cases were tested for malaria in private health facilities in Nigeria. This is much higher than testing rates reported in public health facilities in the country [38]. The 2013 Nigeria Demographic and Health Survey (NDHS) reported that only 11.1 % of children under 5 years with fever had blood taken for testing [41]. The finding could be considered counter-intuitive when it is considered that unlike public facilities, private facilities, which are classified under ‘alternative healthcare system’ in Nigeria’s three-tier structure (National Health Policy), are less supervised for quality of care and adherence to guidelines. Conversely, this finding is comforting, given the fact that more Nigerians seek care for fever in private health facilities despite the relatively larger size of the public health sector [39, 41]. It perhaps lends some support to the underrated successes of the country’s decade-old Roll Back Malaria campaign aimed at achieving universal coverage of malaria interventions. It also probably reflects the support from RBM partners and the Global Fund to malaria case management in the private sector.

A further possible reason for the high testing rate in private health facilities could be motivation for income generation, fear of litigation or simply an adherence to policy/practice regulation. Anecdotal evidence in informal medical discourse in Nigeria favours the notion that, because of economic gain, private practitioners are ‘quick on the draw’ to order tests for care-seekers. That said, the outcome of this study regarding the status of testing for malaria before treatment in private health facilities is commendable.

Testing with RDTs was not observed to be as common as testing by microscopy, which, although considered the gold standard, requires more stringent conditions [14, 53, 54]. This appears consistent with some other studies where it has been observed that availability of RDTs was limited in a sample of private facilities that were studied [55]. This is probably because formal private facilities are expected to be less resource-constrained than public facilities, even in low- and middle-income countries such as Nigeria, owing to their ‘for-profit’ orientation. There may also be concerns that the quality of RDTs could limit their preference in the private health facilities [55]. Concerns about quality may have been why the double test of RDT and microscopy, was performed. The recent scale-up of RDT deployment in the NMEP has been largely directed at the public sector. Among the febrile patients, there was a very high prevalence of malaria positivity. This would appear somewhat discordant with the overall reduction in fever prevalence as observed in hospitals. Considering that microscopy was the dominant means of diagnosis, this finding raises concern about its quality assurance. This observation may need further exploration in studies that will focus significantly on quality assurance issues for malaria diagnosis in private health facilities. In the meanwhile, there might be the need for NMEP and RBM partners to strengthen quality assurance in malaria diagnosis in private sector by ensuring compliance with the provision of implementation guide for parasite-based diagnosis of malaria in Nigeria. Current findings will however suggest the need for more concerted outreach to formal private health facilities in order to improve their uptake of RDTs, especially given the challenges on quality assurance with malaria microscopy.

The high rate of test-before-treatment practice in the private facilities was also complimented by a high level of compliance to the result of the malaria test. This study’s composite measure of ‘compliance’ to appropriate treatment with ACT following malaria test result was a high 80.9 % (95 % CI 78.7–83.0 %), inclusive of those whose tests were negative and were not given ACT. The level of compliance was not affected by type of test or age of patients. There is virtually no parallel national study to compare this important finding with, except the NDHS household-based surveys reporting that 6.0 % of children under five with fever were appropriately given ACT, irrespective of test-result status or the health provider type [41]. ‘Compliance’ may also have been incentivised by the prospect of additional economic gain by prescribing a treatment, for a private establishment. However, as noted, the weighting of ‘compliance’ in this study also included not treating with ACT when the malaria test was negative. This balanced rational drug use is one of the cardinal indicators or measures of quality care. Several studies have already reported the cost-effectiveness of the test-before-treatment policy in case management of malaria [33, 35‐37, 56]. In this study, the cost of test was about $2.5 and this did not appear to be a disincentive to the testing rate. Overall, 9.3 % of the clients had any form of medical insurance. It is, therefore, unlikely that insurance coverage will be an important explanation for the testing rate in spite of the cost of testing. A peculiarity within the Nigerian system is the general belief that laboratory testing is part of the evidence of the quality of care and may serve as a facilitator of willingness to pay. The authors postulate that this may the underlying factor behind the sustained high testing rate despite the cost of testing.

The spread of cadre of health workers reported in the present study is similar to that reported by Uzochukwu et al. [42]. Their study showed that awareness and knowledge by health workers was higher among the public (72.2 %) than the private (50.0 %) health workers. The correct knowledge by over 70 % (range 71.7–91.7) of private health workers reported in the present study was higher than the 61.1 % reported by Uzochukwu et al. [42]. The reason for this could be attributed to training on RDT conducted by several non-governmental organizations working in collaboration with the NMEP. These workers in the private health facilities reported a higher level of 79.5 % in the usefulness of RDT for malaria diagnosis than the 65.6 % health workers reported by the previous study [38].

The perception of the usefulness of RDT for malaria diagnosis and treatment among health workers in the private facilities was favourable. The perceived usefulness of the RDT test for diagnosis by the health workers in this study was 79.5 % (95 % CI 73–85 %) against 65.6 % previously reported [42]. Health workers’ opinion that RDT took a “short time” was consistently high with that reported by same authors [38]. These positive attitudes provide important opportunity for the scale up of RDT use in formal private health facilities with information targeted on addressing other areas of concerns that might limit their absolute confidence in the use of RDTs.

Regardless of the point of care, when health providers adhere to or comply with malaria test results, it is expected that there will be a lot of benefit to the health systems, the patients and the health facilities.