Knowledge and practices of providers
Providers’ correct knowledge of doses, especially for children, and of the importance of adherence to the treatment course are essential for effective treatment. The studies showed great variations between providers, with CHWs consistently demonstrating retention and use of knowledge and good practice.
A survey in Burundi found that 96% of a public sector sample was familiar with the indication of ACT use, compared with 39% in the private sector[
9]. However, in some countries, such as DRC, knowledge of malaria treatment was low in all sectors[
10].
Informal private medicine retailers performed much worse in many settings. Only one in ten in a Nigerian study could correctly state the recommended first-line treatment for uncomplicated malaria, as opposed to one in four providers from formal pharmacies and a little less than one in two public providers[
11]. Even where retailers were aware of treatment guidelines, and stocked ACT in their shops, few adhered to the recommendations. In a study in Kenya, only 48% of retailers would recommend ACT to adults and only 37% to children[
12].
Studies of the formal private sector produced mixed results. A study in Tanzania found that drug dispensers in private pharmacies had poor knowledge of treatment guidelines, despite selling ACT[
13]. However, a household survey in Kenya found that nurses from private outpatient clinics were more compliant with national treatment guidelines than workers from public facilities[
13].
CHWs scored well in their knowledge and practices of treatment provision in most studies. In a multi-centred study in Ghana, Nigeria, and Uganda, an average 85 per cent of children receiving ACT from ‘community medicine distributors’ (CMDs) were correctly treated[
14]. This was confirmed by a study in Ghana, where trained CHWs provided correct doses of ACT and also systematically observed the intake of the first dose. More than half of children’s care-givers came back to CHWs two to three days after administering drugs, as recommended[
15]. In Zambia and Cambodia, services (delivery and explanation of correct doses) provided by CHWs were evaluated as positive[
5,
16].
Diagnosis
WHO guidelines on malaria treatment state that treatment should be based on test results. Microscopy-based diagnostic capacities are supposed to be available within public health centres at intermediary level, but this is not the case in some developing countries. A study of referral units in rural Uganda found that only a minority had effective laboratories. As a result, only 9% of patients were examined for parasites[
17]. However, microscopy and/or RDT were widely available in the public sector in Zambia, Madagascar, Cambodia, and DRC[
18].
The availability of malaria diagnostics was very low among private outlets, except in Cambodia, Zambia, and Uganda, and almost none of the informal for-profit private outlets offered malaria diagnostics[
19]. ACT watch surveys in six countries revealed that “children treated in the private sector are less likely to receive appropriate diagnostic testing and treatment as compared with children treated in the public sector” even though “the public sector was far from ideal”[
20].
In general, studies showed that a high percentage of providers prescribed anti-malarials on the basis of positive test results[
21]. However, some studies raised concerns that there was evidence that health workers prescribed ACT even for negative tests. For example, studies in Tanzania, Ghana, and Zambia showed that around 50% of febrile patients with negative malaria tests in the public sector were prescribed anti-malarials[
22,
23]. However, other studies documented higher levels of health workers adhering to test results and not prescribing ACT to patients with negative results[
24]. This is illustrated by studies in the public sector in mainland Tanzania where over-treatment was only 20.9%, in Uganda (23.4%), and in Sudan (17%)[
21,
25,
26].
All studies pointed to the fact that CHWs were the best providers in terms of ability to use RDTs, and to adhere to the test results[
27]. They showed substantially lower rates of over-prescription of anti-malarials, and in some cases were also able to target the use of antibiotics. Two studies in Zambia found that CHWs were compliant with test results, leading to a dramatic decline in the number of unnecessary treatments with anti-malarials, reaching zero% in one study[
5]. A study in Ethiopia confirmed these findings, that CHWs use RDTs effectively in better targeting positive patients[
3].
In Cambodia, where testing and compliance are of particular importance due to rising resistance to artemisinin, CHWs have demonstrated good case management. For example, in the areas covered by ‘village malaria workers’ (VMWs) in rural Cambodia, individuals were 11 times more likely to receive a confirmed diagnosis than in areas where people used services from the private sector[
28]. VMWs were able to restrict anti-malarials to those who had positive RDT results[
28].
Referral practices
Referral practices depended on a number of factors: whether care providers identified clinical reasons for referring, whether they properly advised patients on the need for referral, and whether patients were able to overcome cost and accessibility barriers. Only six studies reported on referral practices, yet they provide some indicators about providers’ performance on this parameter.
A study in Malawi in ‘hard-to-reach’ villages found that 89% of individuals who sought assistance from CHWs did not proceed to attend a formal health facility, despite CHWs being taught to refer febrile children[
29]. Another study in Ghana found that only five out of 17 children with warning signs were referred to a health facility. CHWs argued that, even when referred, most care-givers would not go to the health facility because of the expense[
15].
Limited data is available on referral practices by informal private retailers. However, a survey measuring the satisfaction of patients and care-givers in Nigeria showed that people were least satisfied with the follow-up service of ‘patent medicine dealers’ and pharmacy shops. One reason for this was that people were not properly counselled on what to do if their health did not improve after therapy[
30].
Referral is particularly important in negative cases. A Médecins sans Frontières (MSF) study in Sierra Leone showed a generally low referral completion rate but more patients referred with severe malaria than with negative tests[
31].
Availability and use of ACT versus ineffective anti-malarials
Comparative surveys by ACT watch highlighted the persistence of non-recommended anti-malarials in private drug stores. In all countries except Cambodia, the private sector distributed substantially fewer doses of ACT than other anti-malarials. In DRC and Nigeria, oral artemisinin monotherapies (AMT) were found in as many as 50% of private outlets[
19]. This was confirmed by a study in Burundi, where recommended ACT was available in 87% of public and 33% of private retail outlets, but non-recommended anti-malarials – including halofantrine, which is known for its dangerous side-effects and cross-resistance patterns with lumefantrine – were found more frequently in private outlets (39%) compared with public facilities (4%)[
9]. However, chloroquine and sulphadoxine-pyrimethamine (SP) were no longer available in any outlet after they were banned nationally. This suggests that banning ineffective medicines could be an effective way for governments to stop the use of undesirable anti-malarials and monotherapy.
Surveys in Senegal and Madagascar showed that poor-quality medicines were not limited to any particular type of distributor. In Uganda, the public sector performed best, while in Nigeria, a country with weak drug regulations, oral AMT accounted for 10% of prescriptions in the public sector[
30,
32]. There was no significant difference in stocking ineffective medicines between the regulated and the informal private sector in those countries. This raises the question of whether the private sector (professional or informal) would stop selling ineffective medicines without a government ban.
Availability of ACT in the public sector is an important determinant of case management.[
33]. Fear of stock-outs was an important factor in health workers ‘rationing’ ACT, reserving it for cases seen as ‘priority’[
25].
Affordability
Most public sector facilities provided ACT free of charge, although some charged consultation fees[
10]. In the private sector the price of ACT, if not subsidized, was much higher than that of ineffective anti-malarials such as chloroquine or SP. A survey in Burundi found that private sector medicine sellers were reluctant to simply stock artesunate-amodiaquine (ASAQ) as they were not able to match the price in the public sector[
9].
Subsidizing ACT in the private sector (non-AMFm) demonstrated mixed results and challenges. Subsidy and social marketing in Madagascar reduced the price of ACT[
18]. However, although private outlets in Senegal appeared to apply reasonable mark-ups on subsidized ASAQ, the retail price remained higher than that of SP. This could explain the fact that the availability of ASAQ hardly increased in private shops and that SP was still available in almost all private shops[
34].
Two studies in Tanzania looked at subsidizing ACT at the top of the supply chain, to be sold to the local main drug wholesaler who, in turn, committed to sell those drugs only to specialized drug shops. The shops kept the retail price at a similar level to that of SP. A significant increase in the proportion of customers purchasing ACT was observed in the intervention districts, from 1% at baseline to 44% one year later compared with no increase in the control district[
13]. Yet the Tanzanian experience showed that ACT was stocked more often in shops located closer to district towns and major roads and used more by individuals of higher socio-economic status. Shops in very remote areas were much less likely to stock subsidized ACT[
13].
ACT subsidy in the public sector could take the form of the removal of user fees and provision of free medicines. According to the WHO, ACT is available free of charge for all age-groups in the public sector in 52 out of 77 countries where it is used for the treatment of
Plasmodium falciparum[
35]. Mothers interviewed in urban Tanzania said that the introduction of highly subsidized ACT in public health centres significantly reduced the cost of treating a malarial episode[
36]. However, despite there being no official user fees at government facilities, in a sample in rural Uganda two-thirds of children with fever were taken to drug shops as the first source of care outside the home. The authors concluded that removing user fees did not necessarily make health care affordable, as other costs persist, such as cost of transport and loss of working time[
37].
Analysis
This review covered 31 studies of different outlets that provided malaria diagnosis and treatment: public services, private services, and CHWs. The studies were investigated for evidence of performance by different providers across six parameters: knowledge and practices; diagnosis; referral practices; availability and use of ACT; affordability; and treatment coverage.
The studies highlighted that all outlets face challenges in delivering their services, but that CHWs scored highly in almost all parameters. With the right training and supervision, CHWs can be effective agents in providing correct diagnosis and treatment of malaria, as well as other common childhood illnesses[
40]. On the whole, CHWs retained and effectively used knowledge about diagnosis, treatment, and referral.
The level of knowledge was better in the public sector than with private providers, although there was room for improvement in the former. There was strong evidence that the current level of knowledge of malaria treatment guidelines among informal private retailers is very low in most of the settings[
41]. Even where knowledge has improved, there were high levels of inappropriate treatment of fever[
42].
Although knowledge did not necessarily translate to adherence to treatment guidelines and correct advice, CHWs consistently performed better than other providers. Public sector workers rationed the use of ACT, saving it for severe cases because of fears of stock-outs. Retailers dispensed ACT on the basis of customer requests and their ability to pay[
43].
The characteristics of providers’ training were not described in most studies and it was, therefore, difficult to draw conclusions about the impact of types of training on prescribing. A study in Kenya analysed the prescribing practices of rural health professionals before and after in-service training and found hardly any change in the proportion of febrile children treated with ACT, or in the workers’ education practices[
44]. In-depth interviews with providers found that the concomitant introduction of RDTs had actually led to confusing messages about the use of ACT[
43]. This case highlights the importance of appropriate provider-oriented training and supervision.
RDTs are becoming more widely available in developing countries, making it more feasible to comply with the WHO treatment guidelines to provide ACT only after testing. However, cost and correct actions based on the test results, especially dealing with negative results, remain critical challenges. CHWs provided free testing and were more likely to act on RDT results than other providers. In comparison with private medicine retailers, qualified public providers generally performed better, but a significant proportion did not comply with test results. However, there are indications that the percentage of providers treating negative cases is decreasing. Practices are deeply rooted following decades of presumptive treatment with chloroquine and SP. Relevant training and supervision is necessary to deliver effective care, irrespective of the nature of the provider.
Despite the evidence of the superior competence of trained CHWs in using RDTs and ACT, the emphasis continues to be on scaling up RDTs in the private sector[
45]. This is despite potential public health risks of the use of ACT in informal private outlets, including inadequate regulation, the potential for over-prescribing to maximize profit, and inability to address non-malarial fevers. A study in six countries highlighted the importance of regulation and quality control to ensure effective case management[
46].
Even the experience of Cambodia, which has been implementing social marketing managed by NGOs in the private sector for nearly a decade, has not shown that increased knowledge leads to an increase in the correct use of ACT, based on confirmed diagnosis, in the private sector. A study in the country highlighted the need for intense communication/education, support, and monitoring of programmes[
47]. Another study, also in Cambodia, confirmed these findings and added that despite the popularity of the private sector, with good availability of medicines, the sale of medicine cocktails that did not in fact contain any anti-malarials was prevalent. The use of RDTs did not improve quality of treatment[
48].
Many studies identified two factors as being essential to successful prescribing and use of RDTs: sufficient training and supervision[
39]. Well-designed and implemented training with follow-up support was seen as an effective way to change even deeply rooted clinical practices. These are important interventions that need to be well planned and implemented whether the provider is public, an NGO, CHWs, or the private sector, including shops.
An essential aspect of malaria control is the ability to refer severe malaria and negative results to health facilities. While providing correct diagnosis and treatment in the community by trained CHWs may contribute to a decreased need for referral as illness is caught and treated early, better diagnosis may lead to increased need for referral, e.g. for children with severe pneumonia. Therefore, it is important to deal with malaria in the context of community health, designing strategies that enable diagnosis and treatment of common illnesses, including malaria, rather than focusing on treating malaria only.
Availability of anti-malarials was generally higher in the private sector than in the public sector. Given that treatment was offered for ‘presumptive malaria’, the size of the market is not a success indicator for malaria control.
In the public sector, fear of stock-outs caused workers to ration the use of ACT to save medicines for the most serious cases, even when the RDT was positive[
49]. Improving supply chains for the public sector will therefore not only increase the availability of ACT in health centres, but also convince providers to
systematically prescribe ACT for uncomplicated malaria. The World Bank supported a programme in Zambia which reinforced health districts by only one additional commodity planner responsible for helping facilities to order directly from the central level. This intervention led to impressive results: the availability rate of paediatric ACT reached 88%, in comparison with 51% in the control districts[
50].
Non-AMFm studies on subsidizing ACT highlighted the equity issue, in that poor people and people in remote areas were less likely to benefit from the subsidy. The authors suggested that distribution of ACT through CHWs might have better results in reaching remote communities[
51].
An MSF study in rural Mali provides useful insights into the factors that increase the use of services. Free RDTs and ACT in the public sector led to a 20% increase in the number of malaria cases treated with ACT. Greater use occurred only when user fees for all febrile children and pregnant women were removed, and CHWs were deployed[
38]. The study indicated that subsidizing ACT may not be a strong enough incentive to attract a large proportion of poor children and pregnant women with fever into health facilities. Free treatment, comprehensive care for febrile conditions, and expanded use of CHWs are key factors in increasing access to and use of malaria treatment.