This study assessed the association of health facility and patient characteristics to correct AL dosing for the treatment of uncomplicated malaria in rural Tanzania. Malaria treatment guidelines in Tanzania follow manufacturers’ recommendations, which allow for both age- and weight-based AL dosing . More than four years after the introduction of AL, correct AL dosing was suboptimal in some patient groups, especially children aged three to 12 years. Other health facility and patient factors were not associated with correct dosing.
Concerns about incorrect dosing of anti-malarial drugs have been reported in other settings [6, 7, 14]. In particular, a study from Kenya showed that infants were more likely to receive appropriate treatment than older children ; the authors suggested that health workers were being more careful with the younger age group, which seems a logical explanation for the observation. In this study, 35.2% of all patients receiving AL were children aged three to 12 years, many of whom did not receive correct AL dosing. Correct AL dosing is particularly important for children as they are more likely to contract malaria, more likely to progress to severe illness, and more likely to die from malaria than adults.
Although, 92.1% of patients received correct AL dosing by age or weight criteria, fewer received correct dosing by weight-based criteria alone (85.7%) or age-based criteria alone (78.5%). Our analysis of weight versus age profile of this patient population suggests that the weight-to-age profile needs to be adapted to the local population context. Although, the weight-to-age profile matches for children <3 kg (98.8% concordant with age) and persons >35 kg (95.3% concordant with age), the weight-to-age profile does not match for children 15 to <25 kg (50.7% concordant) and for children 25 to <35 kg (42.4% concordant); most of the dosing errors based on age alone would lead to overdosing compared to dosing based on weight alone. In addition, weight-based prescriptions should be better implemented to ensure appropriate dosing. In this study, almost all (95.8%) of patients had their age assessed, but only 33.8% of patients had their weight assessed. Thus, to improve weight-based dosing health workers should be encouraged to assess weight in all patients.
AL is supplied to health facilities in four different dose packs. An informal observation during the survey found that in the event that a correct AL dose pack for the appropriate age or weight group was not in stock, the provider would use any AL package to compensate for the missing package. For example, an 11 year old who needs three AL tablets dose (pink package), may receive two packs: one blue pack (toddler package with two AL tablets per dose) and one yellow pack (baby package with one tablet per dose). This strategy might not always work well and might confuse the patient about the appropriate number of pills required. More assessment of this phenomenon is needed to understand its effect in providing adequate care for malaria patients. In addition, we do not know the impact of uniform AL packaging (e.g. adults only, or loose tablets) on correct AL dosing.
During treatment policy change it is customary to train health workers on new guidelines and provide reference materials for use upon returning to the health facility. In this assessment, neither health workers’ training on AL use nor possession of reference material improved the odds of correct AL dosing. One explanation for this finding could be that it takes time and experience for trainees to be competent in new topics. This underscores the need for frequent supervision from health management teams, with possibilities of refresher training and/or on-the-job training, to complement formal training. Moreover, training content, modality, and duration could influence providers’ understanding and performance post-training; all of which were not assessed in this study.
Receipt of supervisory visits was not associated with correct dosing, and very few patients (21.8%) were seen by providers who have had a supervisory visit in the previous six months. The study did not assess the type or content of supervision, which might be important factors. The role of supervision visits in improving quality of malaria case management has provided inconsistent conclusions in other settings . However, understanding predictors of appropriate care for malaria patients can assist health managers in planning resources and performing supportive supervision with emphasis on areas seem to be challenging, in order to improve the quality of services and support disease control measures.
No information was collected on total number of patients attended by a provider to assess caseload and how it may have affected quality of care, but all patients and providers on the day of survey were included, hence the patient sample is self-weighting on the basis of utilization for the days surveyed, assuming survey days were typical for the rest of the year. The importance of caseload assessment has been described elsewhere [6, 11, 15].