REACT Working Paper, London School of Hygiene and Tropical Medicine, 2010, London.
Prompt access to effective malaria treatment is important, and many individuals rely on providers to diagnose malaria and dispense the recommended treatment. Whether the emphasis is on presumptive or parasitological diagnosis, ensuring that providers are able to supply treatment in line with national guidelines is critical for patient care. There are, however, longstanding problems with the care available at many public health facilities and private sector outlets. Given these problems and the recent interest in the use of RDTs, there is a need for interventions that improve the ability and practice of providers to treat patients that present at a health facility with a fever. This literature review examines the evidence available on interventions to improve providers’ ability to diagnose or treat uncomplicated malaria.
A comprehensive search of the published literature was undertaken using bibliographic databases. Relevant publications in the grey literature were identified from review articles, reference lists of relevant publications and from websites of development agencies. Publications since 1990 were eligible if they met all of the following inclusion criteria:
- The intervention was intended to improve providers’ ability to diagnose or treat uncomplicated malaria.
- The population exposed to the intervention are providers.
- The study design included a comparison group.
- The effect was reported on a malaria-related outcome.
- The study setting was an area of endemic malaria transmission in sub-Saharan Africa or Asia.
Evidence on effectiveness was synthesized using three types of outcome: i) presumptive treatment of uncomplicated malaria; ii) appropriate treatment of uncomplicated malaria (following a diagnostic test); and iii) the accuracy of prescribing antimalarial treatment regimens.
Twenty-nine publications were eligible for the review, which report on 27 studies and 32 different interventions. The majority of the studies were from Africa, with 8 from Kenya, 5 from Tanzania, 4 from Uganda and 3 from Nigeria. The majority of the interventions were designed to focus on malaria, though several included malaria within the Integrated Management of Childhood Illnesses (IMCI). Provider training was dominant, and the principal activity in 21 of 32 interventions. The training interventions included studies focusing on presumptive treatment of malaria, and studies on diagnostic testing.
Most interventions had a significant positive effect on the presumptive treatment of uncomplicated malaria, and the accuracy of the doses and advice given. The provision of RDTs and training on diagnostic tests improved the appropriate treatment of malaria, though the proportion of test negative patients receiving antimalarials often remained relatively high. No studies compared an intervention in both public and private sector providers and only two programmes reported on the cost-effectiveness of the intervention.
Further work on interventions to improve the appropriate treatment of febrile patients would be valuable. The studies show that provider training and the provision of RDTs can be beneficial, though suggest that conventional approaches may have only a limited effect.
Click here for article | PDF