Prompt access to effective malaria treatment among children under five in sub-Saharan Africa: a multi-country analysis of national household survey data

Malaria burden remains high in sub-Saharan Africa (SSA) and affects mostly children under five years of age [1]. Several strategies have been proposed to reduce this burden, including improved vector control, intermittent preventive treatment during pregnancy, and standardized case management. For these interventions to be most effective, however, they must reach national and global coverage targets [2].

The World Health Organization (WHO) recommends prompt treatment, usually within 24 h of the onset of fever, with recommended anti-malarial medicines after confirmation of malaria through appropriate diagnostic tests [1]. Timely access to effective treatment with first-line artemisinin combination therapy (ACT) is fundamental to preventing progression of Plasmodium falciparum malaria to severe malaria and death, particularly among children under five years of age. Across SSA, only a small proportion of malaria patients, including children, receive prompt and effective treatment [1]. In Kenya, a systematic review documented a delay in treatment for fever, with only 5 % of fever cases receiving prompt treatment with an anti-malarial drug [3]. Similarly, in Tanzania, Khatib and colleagues found that less than 50 % of fever cases received treatment with ACT within 24 h [4]. Potential reasons for low access to prompt and effective treatment among children revolve around affordability, acceptability, availability, and adequacy to meet expectations in quality of care [5‐9].

Several studies have looked into a specific context, dimension, or population related to prompt and effective treatment for malaria; however, few studies systematically look across all children in SSA [10, 11]. This study aims to fill this gap by examining the extent to which children under five years of age in selected countries in SSA received prompt and effective treatment and describing profiles of children who received this recommended treatment. The study also identifies subgroups that, when successfully targeted, may optimize benefits of interventions within the entire population. Although no longer recommended as a key malaria control indicator due to challenges in its interpretation [12], ‘promptness’ was assessed by whether treatment commenced the same day or day after onset of fever. The work involves the following US President’s Malaria Initiative (PMI) focus countries that have relevant national survey data and that were selected for impact evaluations: Angola, Benin, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Rwanda, Senegal, United Republic of Tanzania (mainland and Zanzibar), Uganda, and Zambia.

This study presented coverage of prompt treatment with ACT among febrile children under five years of age and also profiled those children who received this recommended treatment in selected countries in SSA. Most countries with high coverage of treatment with any anti-malarial medicine also had high coverage of treatment with ACT, perhaps since one is dependent on the other. Mali and Benin both depart from this trend; treatment with ACT was much less likely than treatment with other anti-malarial drugs. This may be due to ACT holding a particularly small share of the market compared to other anti-malarial drugs [18] or the fact that ACT policy was implemented only shortly before the surveys were conducted [1]. These countries show how important policy and markets are to ensuring access to prompt and effective treatment for malaria.

The cross-country CHAID analysis revealed that the country of residence is the best predictor of prompt and effective treatment, followed by maternal education, household wealth quintile, maternal age, and place of residence. It is perhaps unsurprising that country is the best predictor of prompt and effective treatment since malaria treatment policies differ among countries and are in various stages of implementation (Table 1). National drug regulations also affect the availability of anti-malarial drugs, including ACT, and may therefore also affect the uptake of prompt and effective treatment. This analysis highlights the importance of ensuring that first-line drug policies are synchronized with latest epidemiological information and are accompanied by efficient rollout and awareness raising campaigns. Results related to country of residence may also be a reflection of malaria transmission and epidemiology. For example, Node 2 comprises Kenya and Madagascar, which are the only two countries in the study with a majority of the population living outside of high-transmission areas [1]. Uganda and Liberia, which have the highest parasite prevalence of the countries in the study, each made up their own node.

Children were more likely to have received prompt and effective treatment if their mothers had at least a secondary education (Angola, Ghana, Zambia, Kenya, and Madagascar). With the exception of Angola, these countries also have higher than average proportions of women with at least a secondary education. Similar findings were reported by a study in which febrile children of educated women were more likely to receive a malaria test than children of non-educated women [19]. Furthermore, there is substantial literature showing positive correlations between children’s uptake of health services and mother’s level of education, independent of other social and economic factors [20, 21]. Educated mothers may be more open to advances in public health and medicine, more aware of malaria symptoms and related health risks, more trusting of providers, or more aware and better able to negotiate first-line services and treatment [22]. These characteristics may facilitate quick decision-making and therefore increase likelihood of prompt treatment. In SSA, women’s educational attainment is ever increasing, which suggests that the trend of accelerating gains in children’s health is also likely to continue [23].

In Mozambique and Zanzibar, children whose mothers were in their twenties were more likely to receive prompt and effective treatment than children whose mothers were older or younger. This is consistent with literature that suggests that adolescents are less likely to access maternal and child health services [24, 25]. Older mothers may be less likely to seek prompt and effective treatment if they are caring for multiple children. If they draw upon prior experience with febrile children, they also may be less inclined to follow new health messaging, thereby inhibiting prompt treatment. Further research on the relationships among mother’s age and education and prompt and effective treatment may help ensure that the mothers least likely to seek health services can and will access timely malaria treatment for their children.

In Angola, Ghana, Zambia, and Liberia, children from both the lowest and highest wealth quintiles were among those most likely to receive prompt and effective treatment. Children from the lowest wealth quintile may be most likely to take advantage of free ACT offered in the public sector in Angola, Zambia, and Liberia [1]. On the other hand, children from the highest wealth quintile may be more likely to seek care outside the public sector or may be able to afford first-line ACT from private retailers. Having access to these additional options for malaria care may facilitate prompt treatment, particularly if the locations are closer to home. This may change as community case management interventions improve access to prompt treatment by reducing the distance between febrile children and trained prescribers of ACT. Increasing coverage of malaria interventions has improved equity [26‐28], so it is possible that further gains in coverage may cancel inequities both within and across countries. Targeted research on equity will help ensure universal access to prompt and effective treatment.

Availability of prompt and effective treatment or quality of care issues may also explain why place of residence was a secondary predictor of prompt and effective treatment in Uganda. Urban areas tend to have more options for health care (i.e., both public and private providers) and better access to preferred treatment compared to rural areas, which are mostly considered remote areas [29]. Affordable Medicines Facility-malaria evaluators reported higher availability of ACT in urban outlets in Uganda than rural areas, and even with an increase in availability at endline, rural areas remained behind [30]. This evidence supports the findings of the CHAID analysis, which showed that urban children in Uganda were more likely to receive prompt and effective treatment than rural children.

These are the predictors of which children are most likely to receive prompt and effective treatment, but a next step is strategizing for future interventions. The gain index from the CHAID analysis can help highlight whether it is more efficient to target specific groups or to invest in the overall population, with potential trickle-down effects to those groups. Increasing coverage in a particular node or cluster will yield corresponding returns at the population level, quantified by the gain index. For example, the gain index of Cluster 3 is just 70.9, showing that these children are much less likely to receive prompt and effective treatment than the overall population. Since Cluster 3 comprises only 14.4 % of children who received treatment with any anti-malarial medicine (i.e., this study’s target population), it is a relatively small population that may be easier to target with an intervention to increase access to prompt treatment. However, it may not be cost effective to invest significant resources into a small group like this because the benefits to national coverage goals may be limited. On the other hand, efforts to increase the proportion of children in Cluster 2 who receive prompt and effective treatment from 62.4 to 100 % may be more feasible since baseline coverage is higher. Investing in these children may also yield more visible public health impact since this cluster represents a majority (53.1 %) of the target population. These results may be useful in strategic planning for malaria control interventions at the national and subnational levels. Close monitoring can help malaria control programs determine if these children are being reached by future interventions in the quest for universal coverage.

Although this study presents informative findings, it does have limitations. It is difficult to track the extent to which patients with diagnosed malaria receive prompt and effective treatment using self-reported survey data because testing and treatment information are traditionally not linked in survey data. Self-reported survey data also require caretakers to identify specific drugs, which may be especially difficult in countries where many malaria drugs are on the market, compared to countries where only ACT is available [31]. Finally, timeliness data rely on the ability of caretakers to determine whether treatment commenced the same day or next day as the onset of fever, which can be difficult to ascertain.

In addition, data were collected from surveys during a 6-year span from 2006 to 2012. This time difference in survey implementation could affect comparability in pooled results, as could the type of survey conducted (DHS, MIS, or A&PS). Furthermore, varying amounts of time between malaria policy implementation and ACT rollout could differently affect coverage and access to prompt and effective treatment within countries and across countries. There is also considerable variation in the distribution of wealth quintiles and in equity of health interventions over time and among countries [32]. There is substantial subnational variation in malaria prevalence in several countries in SSA, which may affect expectations regarding ACT use and access to prompt treatment.

Finally, the data collected in these surveys do not examine additional factors related to access and social acceptability of malaria treatment and services. This information could help refine the profiles of children who received prompt and effective treatment. Future CHAID analyses could also include more complex covariates, such as source of treatment.

This study reveals that country of residence, maternal education, place of residence, and socio-economic status are key predictors of prompt access to malaria treatment. The prominence of country as a predictor variable highlights the roles ACT policy implementation and rollout may play in access to prompt and effective treatment. The other key variables were of differing importance across countries, reminding implementers that understanding the context of their programmes is critical to success. Achieving universal coverage and the elimination agenda will require effective monitoring and early detection of coverage disparities within populations. Although national surveys provide a sporadic opportunity for this work, investing in routine surveillance will improve real-time tracking of ACT coverage and corresponding action, in line with recent recommendations from WHO’s Global Technical Strategy for Malaria.