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Modelling health systems barriers to successful malaria management
Malaria Journal volume 11, Article number: P126 (2012)
The success of national malaria control strategies is increasingly recognised to be limited by the capacity of the health system to deliver interventions at the required levels of coverage and quality . It is critical to better understand how to deliver a proven intervention, such as Artemisinin Combination therapies (ACTs), most effectively through an existing system, and where the barriers are to achieving its predicted potential. Few models address the delivery of case management: the Piot model  or the “community effectiveness framework”  has been used to describe how a cascade of interacting health-systems barriers may sequentially reduce the effectiveness of treatment interventions. [4, 5] However the end-estimate of correct treatment is lower than estimates from health facility surveys. [1, 4–12] We investigated whether an alternative decision-tree approach may more closely estimate rates of appropriate treatment for malaria and also non-malarial febrile illness (NMFI).
We systematically reviewed the sequential process of and barriers to, malaria case management through primary health care in sub-Saharan Africa. We thus developed community effectiveness and decision tree models to case management in the public sector. Articles published since the rollout of ACTs were used to obtain a range of estimates for malaria management steps. Parameters were sampled from between these ranges of estimates and used to inform the two models. We then explored scenarios of lifting different case management barriers.
The decision analysis model more accurately reflected reported levels of appropriate management of fever (malarial and non-malarial) in the public sector (>60% attendees), compared with a systems effectiveness approach (<2%). Scenarios of perfect case management steps all improved correct fever management using both models, except in the case of perfect ACT stock; a decision tree approach predicted a 12% reduction in correct management of all cases compared with a 63% increase with the community effectiveness approach.
Using the decision-tree model, increases in availability and rapid diagnostic tests (RDTs) improved overall management of fever upto 65% of all attendees, and reduced overtreatment of NMFI with unnecessary antimalarials by over 35%, but did not substantially improve appropriate treatment rates of malaria cases. The greatest impact on the proportion of malaria cases correctly treated resulted from improving ACT stock (over 65% increase from baseline), even without increased RDT use. Under conditions of perfect availability and use of RDTs, test adherence and drug availability appropriate treatment rates rose to over 85%.
The relationship between improving delivery through health systems and resulting impact on health outcomes of infectious diseases is not straightforward, however simple decision analysis models can provide insight into which aspects of delivering care are most likely to impact on care quality and treatment effectiveness. Unlike the community-effectiveness framework, the decision-tree approach accounts for clinical (non-RDT guided) treatment of malaria, under-diagnosis of malaria and unnecessary antimalarial use in NMFI cases, which are all of policy interest impacting on health outcomes and ongoing transmission. Further work into the amenability of health systems to change is required to explore the most cost-effective targets in expanding the delivery of antimalarials.
WHO: World Malaria report, Global malaria programme. 2011, World Health Organization: Geneva, Switzerland
Mumba M: A Piot model to analyse case management in malaria control programmes. Trop Med Int Health. 2003, 8 (6): 544-551. 10.1046/j.1365-3156.2003.01064.x.
Tanner M: From the efficacy of disease control tools to community effectiveness. Case studies from the biomedical and health systems research activities of the Swiss Tropical Institute in Africa. Transactions of the Royal Society of Tropical Medicine. 1993, 87: 518-523. 10.1016/0035-9203(93)90070-7.
Hetzel MW: Obstacles to prompt and effective malaria treatment lead to low community-coverage in two rural districts of Tanzania. BMC Public Health. 2008, 8: 317. 10.1186/1471-2458-8-317.
Krause G, Sauerborn R: Comprehensive community effectiveness of health care. A study of malaria treatment in children and adults in rural Burkina Faso. Ann Trop Paediatr. 2000, 20 (4): 273-282.
Zurovac D: Effects of revised diagnostic recommendations on malaria treatment practices across age groups in Kenya. Trop Med Int Healt. 2008, 13 (6): 784-7. 10.1111/j.1365-3156.2008.02072.x.
Bastiaens GJ: Malaria diagnostic testing and treatment practices in three different Plasmodium falciparum transmission settings inTanzania: before and after a government policy change. Malar J. 2011, 10: 76. 10.1186/1475-2875-10-76.
Nicastri E: Accuracy of malaria diagnosis by microscopy, rapid diagnostic test, and PCR methods and evidence of antimalarial overprescription in non-severe febrile patients in two Tanzanian hospitals. Am J Trop Med Hyg. 2009, 80 (5): 712-7.
Nankabirwa J: Malaria misdiagnosis in Uganda--implications for policy change. Malar J. 2009, 8: 66. 10.1186/1475-2875-8-66.
Nyandigisi A: Malaria Case-Management following Change of Policy to Universal Parasitological Diagnosis and Targeted Artemisinin-Based Combination Therapy in Kenya. PLoS One. 2011, 6 (9): e24781. 10.1371/journal.pone.0024781.
Sserwanga A: Improved malaria case management through the implementation of a health facility-based sentinel site surveillance system in Uganda. PLoS One. 2011, 6 (1): e16316. 10.1371/journal.pone.0016316.
Masanja IM: Increased use of malaria rapid diagnostic tests improves targeting of anti-malarial treatment in rural Tanzania: implications for nationwide rollout of malaria rapid diagnostic tests. Malar J. 2012, 11 (1): 221. 10.1186/1475-2875-11-221.
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Rao, B., Schellenberg, D. & Ghani, A. Modelling health systems barriers to successful malaria management. Malar J 11, P126 (2012). https://doi.org/10.1186/1475-2875-11-S1-P126
- Case Management
- Malaria Case
- Rapid Diagnostic Test
- Decision Analysis Model