title: Quality of malaria case management in Malawi: results from a nationally representative health facility survey.
abstract: BACKGROUND
  Malaria is endemic throughout Malawi, but little is known about quality of malaria case management at publicly-funded health facilities, which are the major source of care for febrile patients.
  
  
  METHODS
  In April-May 2011, we conducted a nationwide, geographically-stratified health facility survey to assess the quality of outpatient malaria diagnosis and treatment. We enrolled patients presenting for care and conducted exit interviews and re-examinations, including reference blood smears. Moreover, we assessed health worker readiness (e.g., training, supervision) and health facility capacity (e.g. availability of diagnostics and antimalarials) to provide malaria case management. All analyses accounted for clustering and unequal selection probabilities. We also used survey weights to produce estimates of national caseloads.
  
  
  RESULTS
  At the 107 facilities surveyed, most of the 136 health workers interviewed (83%) had received training on malaria case management. However, only 24% of facilities had functional microscopy, 15% lacked a thermometer, and 19% did not have the first-line artemisinin-based combination therapy (ACT), artemether-lumefantrine, in stock. Of 2,019 participating patients, 34% had clinical malaria (measured fever or self-reported history of fever plus a positive reference blood smear). Only 67% (95% confidence interval (CI): 59%, 76%) of patients with malaria were correctly prescribed an ACT, primarily due to missed malaria diagnosis. Among patients without clinical malaria, 31% (95% CI: 24%, 39%) were prescribed an ACT. By our estimates, 1.5 million of the 4.4 million malaria patients seen in public facilities annually did not receive correct treatment, and 2.7 million patients without clinical malaria were inappropriately given an ACT.
  
  
  CONCLUSIONS
  Malawi has a high burden of uncomplicated malaria but nearly one-third of all patients receive incorrect malaria treatment, including under- and over-treatment. To improve malaria case management, facilities must at minimum have basic case management tools, and health worker performance in diagnosing malaria must be improved.
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Laura C
authors.initials: LC
authors.lastname: Steinhardt
authors.affiliation: Malaria Alert Centre, College of Medicine, Blantyre, Malawi.
authors.forename: Jobiba
authors.initials: J
authors.lastname: Chinkhumba
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Adam
authors.initials: A
authors.lastname: Wolkon
authors.affiliation: Malaria Alert Centre, College of Medicine, Blantyre, Malawi.
authors.forename: Madalitso
authors.initials: M
authors.lastname: Luka
authors.affiliation: National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
authors.forename: Misheck
authors.initials: M
authors.lastname: Luhanga
authors.affiliation: National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
authors.forename: John
authors.initials: J
authors.lastname: Sande
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Lilongwe, Malawi.
authors.forename: Jessica
authors.initials: J
authors.lastname: Oyugi
authors.affiliation: National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
authors.forename: Doreen
authors.initials: D
authors.lastname: Ali
authors.affiliation: Malaria Alert Centre, College of Medicine, Blantyre, Malawi.
authors.forename: Don
authors.initials: D
authors.lastname: Mathanga
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Jacek
authors.initials: J
authors.lastname: Skarbinski
mesh_terms: D000293:Adolescent; D037621:Artemisinins / Q000627:therapeutic use; D019090:Case Management / Q000191:economics / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D003625:Data Collection; D005260:Female; D006268:Health Facilities / Q000191:economics / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy / Q000628:therapy*; D008295:Malawi; D008297:Male; D011787:Quality of Health Care
chemical_list: D037621:Artemisinins; C031327:artemisinin