Provider compliance to artemisinin-based combination therapy at primary health care facilities in the middle belt of Ghana

Significant progress has been made in the last decade towards achieving global malaria targets although the disease burden is still relatively high in sub-Saharan African countries, especially among children <5 years of age [1, 2]. According to a recent report by the World Health Organization (WHO), malaria accounted for approximately 1800 admissions and 10 deaths for every 100,000 population in Ghana [2].

Prompt and effective malaria case management has been the main control strategy [3, 4]. Ghana implemented the artemisinin-based combination therapy (ACT) policy in 2004 with artesunate–amodiaquine as the first-line drug to replace chloroquine which is no more effective due to widespread development of Plasmodium resistance across Africa [5]. The anti-malarial drug policy of ACT was revised in 2009 to include artemether–lumefantrine and dihydroartemisinin–piperaquine as alternative first-line treatment drugs due to poor tolerability of artesunate–amodiaquine by sections of the Ghanaian community [6]. The successful implementation of an ACT policy to a large extent depends on the availability of the ACT drugs and the ability of health professionals to adhere to national malaria treatment guidelines [7, 8]. The introduction of Affordable Medicine Facility for Malaria (AMFm) to subsidize ACT, has expanded access to ACT and gave hope to endemic countries that piloted the scheme [9, 10].

Ghana revised her national guidelines for malaria case management to address changes in the anti-malarial drug policy [11]. The policy recommends parasitological diagnosis (using malaria rapid diagnostic test or microscopic examination of malaria blood smear) of all suspected cases prior to treatment with ACT. Specifically, the policy allowed presumptive diagnoses and treatment for malaria for children below 5 years due to operational considerations and the fact that Ghana is a high malaria risk area [12]; but with a long-term goal of deploying a test, treat and track policy of all suspected cases. Treatment with ACT is recommended for positive test results for all children and adults except for pregnant women in the first trimester who are required to use quinine.

Restricting treatment to parasitological diagnosis of malaria among older children and adults is expected to reduce over-diagnosis of malaria and inappropriate use of relatively expensive ACT in the treatment of fevers [13]. Proper clinical interpretation based on test results remains the main challenge in a change process after many years of believing that presence of fever denotes malaria [14].

In this study, 66.7 % of patients presenting at HFs for primary illness consultation received treatment that was in line with the 2009 national malaria case-management guidelines 5 years after the deployment of the ACT policy in Ghana. Appropriate treatment with ACT was significantly higher in <5 children (85.9 %) than in older patients (59.7 %). The prescription of ACT based on a correct diagnosis of malaria as indicated by the national guidelines was high (89.2 %). However, 45 % of patients received ACT based on a wrong diagnosis of malaria. As a result of the low sensitivity of routine test, 8 % of patients who were confirmed by reference microscopy to have malaria missed the opportunity for any anti-malarial treatment.

HWs non-compliance with the guidelines was a major cause of over-treatment with ACT. HW non-compliant behaviour observed in this study is similar to results from southern Ghana [19] and across many malaria endemic African countries namely Kenya [21], Angola [22], Zambia [23], Benin [24] and The Gambia [25] after anti-malarial policy change.

The lower compliance with ACT treatment based on presumptive diagnosis with its attendant over-treatment justifies the transition to new guidelines by the WHO requiring parasitological diagnosis of malaria universally regardless of age and malaria transmission levels (Table 4). Unfortunately, despite the universal availability of malaria diagnostic tools such as RDT and microscopy during patient consultations, they were often not used to guide treatment [26] neither were existing guidelines restricting ACT to only positive test in older patients complied with [27].

HW disregard to the existing guidelines raises questions about HW attitude and confidence in test results. For example, about 17 % of patients ≥5 years who presented with fever but had a negative test of malaria received ACT. Arguably, the unacceptably low sensitivity and NPV of routine diagnostics especially malaria microscopy compared to the reference microscopy could possibly explain the mistrust and low use of diagnostic tools. A study conducted in Tanzania corroborates these observations [28]. The long held notion of equating fever as a proxy for malaria and the emphasis of malaria as a fatally dangerous disease have also contributed to the tendency for HWs to ignore test results [29]. As a result, a positive test result is often judged as a confirmation of their clinical judgment and a negative test is still regarded as a suspected case of malaria rather than an absence of malaria. Such practices are likely to result in over-treatment with greater cost implications [30]. It is, however assuring that HWs belief in test results are likely to improve with confidence and trust gained through positive outcomes on appropriate prescribing practice. Such change in practice has been observed in a study in Senegal where HW reliance on test results in clinical decision improve with time [31].

The management of <5 children was more likely to conform to the guidelines compared to older patients (Table 4). The high level of appropriate ACT treatment among <5 children is most likely attributable to their higher fever prevalence, and the tendency for HWs to resort to presumptive treatment with ACT perhaps due to practices over the years whereby presence of fever is indicative of malaria. This assertion is supported by the equal proportions of ACT prescribed for under-five children and older patients presenting with fever who had a routine positive test of malaria (Fig. 2).

CHNs and midwives are low in the hierarchy of the HW professional ladder due to their limited scope of practice compared to medical officers. Their relatively huge presence seen in the management of most patients presenting for primary consultations notwithstanding their training on malaria case-management shows major task shifting, an indication of the shortage of medical doctors/medical assistants at the HFs in rural communities. The findings that lower cadre of health staff adhered much more closely to the guidelines compared to medical doctors as found in studies conducted in Kenya and rural Tanzania [8, 32] underscores task shifting as a tool to address shortage of human resource in the health system.

Results from this study also highlights the need for improved laboratory capacity at the primary care level for early and effective management of both malarial and non-malarial fevers. Under-diagnosis of malaria due to low sensitivity of routine diagnostics is a major concern with far-reaching clinical consequences. The “missed opportunity” for early treatment of malaria especially in children could result in severe malaria with high fatality outcome [12]. Likewise, the management of non-malaria febrile illnesses such as sepsis and meningitis require a comprehensive laboratory investigation to narrow down to the cause of fever for effective administration of antibiotic. In the absence of efficient laboratory capacity and proper interpretation of malaria test results based on the guidelines, HWs are likely to continue the wrong prescription of anti-malarial or resort to the use of antibiotics for managing non-malarial febrile illnesses [33, 34].

Although a high proportion of <5 children presenting with fever and older patients with uncomplicated malaria received ACT in accordance with the national malaria guidelines, inappropriate treatment with ACT was still high especially among older patients five years after anti-malarial policy change. This was due to poor interpretation of the national malaria treatment guidelines particularly on malaria test result and low quality of routine malaria diagnostics.

Concerted effort towards improving rational use of ACT by HWs is urgently needed if the anticipated benefits of the policy change are to be realized. The Ghana NMCP needs to strengthen the capacity of HWs through regular training [39] and supervision [40] on the malaria guidelines especially on treatment decisions made on the basis of a test result. The capacity of laboratories at the primary health care level needs to be enhanced through regular training for laboratory technicians and development of effective quality control measures.