Influence of health systems in malaria case management as part of malaria control in Tanzania

The World Health Organization report in 2007, declared that, it will not be possible to achieve national and international health goals without greater investments in health systems. It is a known fact that today, the advancement in science has led to a better understanding of aetiologies and risk factors of most diseases burden in the world. However, the capacity to deliver these innovations to the population that needs them the most is severely handicapped by fragile and poor health systems, particularly in developing countries. The differing diseases burden spectrum between and within countries, underscores the complexity and the need for context specific measures to address disease burdens and major causes of poor ill health in respective societies. Today, malaria continues to be a public health problem and important cause of morbidity and mortality in countries with ongoing transmission. In Tanzania, malaria is among the leading causes of hospital attendance and mortality in prevalent areas. Efficacious interventions to combat malaria have advanced such that endemic regions are seeing a decline in malaria related deaths and morbidity. These gains however, are threatened with the emergency of drugs and insecticide’s resistance, environmental, vectors and hosts’ related challenges. Despite these challenges, malaria is a preventable disease and historically the disease, once prevalent in the North, was successfully eradicated. This provides hope for elimination and possible eradication of malaria in endemic regions in future if efficacious interventions are adopted in scale. The current malaria control strategies in Tanzania can broadly be categorized as; vector control activities which includes use of treated bed nets, indoor residual praying and environmental management; chemoprevention to specific vulnerable groups; and prompt, effective treatment of cases. Health care provision in the country is facing many bottlenecks such as shortage of qualified workforce, lack of appropriate technologies and frequent stock-out of essential medicines. In addition, reports of poor providers’ compliance to treatment recommendations undermine the effectiveness of the health system. Through a phase four platform of effectiveness and safety studies of antimalarials (INESS), we assessed the quality of malaria case management in the study areas. The goal was to understand factors influencing treatment outcomes in real world settings, with focus in diagnostic accuracy and provider’s compliance for malaria treatment. This work involved a pair of cross-sectional health facility surveys that interviewed patients, providers and inventoried health facilities for availability of products related to malaria treatment. Complimentary data were obtained from the IMPACT-Tz project which introduced artemisinin based combination therapy (ACT) in similar study areas, before the national adoption of ACT for malaria treatment. Findings from this work demonstrated that, increased use of malaria rapid tests (RDTs) for routine care reduced over-treatment with ACT during high malaria transmission period from 45.8% in a pre-RDT area to 20.9% in a post-RDT area. Conversely, correct treatment with ACT was higher in the post-RDT area 85.9% as compared to pre-RDT area 58.3%. This implies that, having appropriate technology in place improves targeting of resources and facilitates providers’ compliance. Further assessment on correct dosing revealed that age based dosing were more prone to errors. The proportion of patients receiving correct dosing as per national guideline was lower in middle aged groups; 42% for 9-12 years old and 50% for 3-9 years old patients. Analysis of health facility data from 2002 to 2010 showed that presence of parasitemia at health facility was generally declining to children below 5 and increasing to above 5 years. However, significant intra-group’s differences were observed. While children below age of 2 showed a declining trend, those above 2-5 years had an increasing trend (p<0.001). This was in contrary to the findings from population based surveys. This work also described health workers’ specific factors that influences correct treatment of malaria and showed that, work experience does influence quality of care. Providers with 3 or more years of work experience had higher of odds of giving a correct treatment than otherwise [aOR: 2.6 (1.2-5.6)]. In the same pattern, lower cadre health workers [aOR: 4.2 (1.5-11.7)] and having a confirmatory test [aOR: 2.6 (1.2-5.8)] were significant predictors of correct treatment. Furthermore, this work revealed that provider’s attitudes towards treatment recommendations have little influence in their personal practices; a good proxy indicator of their general practice. Factors like type of patients, place of work and level of health care, had more influence in their personal use of treatment recommendation. Findings from this work underscore the multidisciplinary nature of health problems. Concentrating in only certain aspects of the health system than others may lead to undesirable consequences. Addressing a common health problem requires looking at the problem holistically, with systems thinking approach. Understanding the complexity nature of systems is the underlying principle of systems thinking. The problems highlighted here in relation to malaria case management may constitute a small part of disease burden in Tanzania, but provides important lessons for harmonization of technical and organizational challenges that hinders progress to better health outcomes with the right pace. This work made evident the need to advocate transparency and harmonization of health system actors, towards a common goal; empower policy makers and health managers to understand and adopt systems thinking approach in their daily endeavours as well, provide more scientific evidence for what does or doesn’t work, to guide policy making decisions. Unless we change the status-quo, health systems performance will remain sub-optimal and an impediment for moving malaria elimination agenda forward.