title: District level external quality assurance (EQA) of malaria microscopy in Pakistan: pilot implementation and feasibility.
abstract: BACKGROUND
  Prompt, quality assured laboratory diagnosis is key to effective malaria case management and control, especially since the introduction of the more expensive artemisinin combination therapy (ACT). The malaria programme and its non-government partners, on the basis of WHO recommended Lot Quality Assurance methods, have developed a district level external quality assurance (EQA) system. This study was designed to assess the feasibility, under programme conditions, of an integrated district level external quality assurance and supervision approach for malaria microscopy.
  
  
  METHODS
  A prospective study conducted over seven months period (May-November 2007). In addition to the standard WHO EQA elements, three operational innovations were introduced, with the a district laboratory supervisor: a) on site re-checking of slides, b) in ensuring uninterrupted availability of laboratory reagents and supplies at diagnostic centers, and c) supervision of administrative and technical components. The quantitative data for the study came from the service records/documents, whereas the qualitative data came from the key informant interviews.
  
  
  RESULTS
  During the seven month period in four districts, a total of 8,118 slides were examined of which 209 (2.6%) were found positive for malaria parasites (slide positivity range between 1.6% to 6.0%). The District Laboratory Supervisors in four districts reexamined a total of 1,770 slides (22%). The proportion of slides found discordant ranged from 0.5% to 1%. The quality of smear preparation was found acceptable in 73% slides.
  
  
  CONCLUSIONS
  A district-based EQA, based on lot quality assurance methods was implemented, using context-specific operational guidelines, tools and training modules, and other inputs from the malaria control programme and partners. This EQA and supervision approach was found to be feasible and acceptable to those involved. Further study is required on the microscopy quality and cost-effectiveness of adding external quality assurance and supervision to district malaria microscopy services.
authors.affiliation: Association for Social Development, Islamabad, Pakistan. asd@asd.com.pk
authors.forename: Muhammad Amir
authors.initials: MA
authors.lastname: Khan
authors.forename: John D
authors.initials: JD
authors.lastname: Walley
authors.forename: Muhammad Arif
authors.initials: MA
authors.lastname: Munir
authors.forename: Muhammad Aslam
authors.initials: MA
authors.lastname: Khan
authors.forename: Nayyar Ghias
authors.initials: NG
authors.lastname: Khokar
authors.forename: Zarfishan
authors.initials: Z
authors.lastname: Tahir
authors.forename: Athar
authors.initials: A
authors.lastname: Nazir
authors.forename: Nazia
authors.initials: N
authors.lastname: Shams
mesh_terms: D019411:Clinical Laboratory Techniques / Q000191:economics / Q000592:standards*; D017408:Guidelines as Topic; D055810:Lot Quality Assurance Sampling; D008288:Malaria / Q000175:diagnosis*; D008853:Microscopy / Q000191:economics / Q000592:standards*; D010154:Pakistan; D010961:Plasmodium / Q000302:isolation & purification*; D011446:Prospective Studies; D011786:Quality Control