The main objective of this study was to assess the quality of malaria case management provided by health care workers in private health facilities and to document the unique challenges for malaria case management at this level of health care. Overall, malaria case management in these private facilities was sub-optimal with only 14 percent of health care workers reporting that they correctly followed the malaria case management guidelines. This was defined as correctly identifying suspected malaria cases, conducting a confirmatory malaria test and prescribing an artemisinin based combination therapy (ACT) for uncomplicated malaria or intravenous artesunate for complicated malaria [1, 19]. This was lower than what was reported in the 2014 MIS that showed 36% of children with a fever were tested for malaria before receiving treatment[17]. Whereas most health workers could correctly define a suspected malaria case, many were unable to correctly prescribe the first line treatment for uncomplicated malaria or the correct antimalarial drug for IPTp. This kind of underperformance, in both private and public health facilities, could delay the achievement of the 2015–2020 UMRSP objective of attaining and sustaining prompt diagnosis and treatment for at least 90% of malaria cases in the public and private sectors and community level, and potentially leading to higher mortality and morbidity due to malaria.
Possible reasons for this poor performance include the unavailability of the current malaria treatment protocols and guidelines for reference at the private health facilities, and lack of training, mentorship and support supervision on malaria case management. Similar findings have been previously reported by Baily et al [20] and in other low and middle income countries with lack of training of heath facility staff frequently reported as a major contributor to poor performance [21]. Though the NMCD in Uganda has made significant progress in the provision of malaria case management documents and related training job aids[19], this activity did not target the private sector and largely focused on public health facilities with resulting improvements in parasitological diagnosis and treatment of confirmed malaria cases in these public facilities [1, 3]. The inclusion of private health facilities as part of the strategy to strengthen health worker capacities for malaria diagnosis and treatment through regular training is one of the strategies of the 2014–2020 UMRSP which need to be implemented if the similar results are to be realized in this sector. It is essential to recognize that any planned training sessions should consider that most of the private health facilities are lower level facilities and therefore training should be tailored to the cadres running these facilities like clinical officers, enrolled nurses and laboratory assistants.
Interestingly, some positive aspects of case management were also noted in these PFP facilities. Knowledge on treatment and referral practices for severe malaria was significantly high with 85% of health care workers reporting correct management practices. In addition, the majority of the facilities were also able to provide malaria laboratory services with RDTs mostly available. Although, almost half of the facilities lacked the requisite skilled laboratory personnel, the available facility staff were able to conduct RDT tests. The reported availability of ACTs for treatment of uncomplicated malaria and artesunate for the treatment of complicated malaria, in most of the facilities, was yet another positive finding. However, as previously reported in other studies conducted in Uganda [22, 23], stock out of essential medical commodities, such as ACTs and RDTs in some facilities, was also reported in this study. The NMCD ensures consistent and sustainable supply and access to all malaria commodities by providing them free or highly subsidized[1], however, there is no clear strategy of how this would be implemented among private health facilities. This partly explains the use of anti-malarials such as quinine injections, as first line treatment for both uncomplicated and complicated malaria, instead of AL or artesunate as recommended in the national guidelines.
The insistence of patients to be treated based on clinical diagnosis such as when they are not tested at all or when the test results are negative, contrary to the national guidelines[19], could be explained because of a lack of community awareness of correct malaria case management. This is further compounded by the practice that patients pay for the services and therefore demand to be provided a treatment of their choice irrespective of whether it is according to the national guidelines. Focused and adequately planned behavior change communication could change this practice. Evidence from other studies and reviews shows that community level sensitization improves health seeking behavior for malaria prevention and treatment [24, 25]. One of the strategies of the UMRSP is to strengthen malaria communication through the objective of ensuring that at least 85% of the population practices correct malaria prevention and management measures[1]. Strategies under this objective such as; strengthening national communication framework, develop messages for different communication platforms, strengthen community behavioral change activities for malaria and improve advocacy for support for malaria control both in public and private sector should be implemented to ensure that all community members including those that seek health care in private health facilities are reached.
Approximately a third of the private health facilities submitted reports with malaria related data, for monthly HMIS forms, and much less for the weekly reports (a fifth of the facilities), into the national DHIS2 system. This data unavailability and quality have been frequently reported problem in low income countries, including Uganda [26, 27]. This finding continues to undermine the capacity to make decisions about the health of the population and target resources to improve health system coverage, efficiency and quality for the country. This is especially important, in the context that a significant proportion of the population seeks care from private health facilities[4].
Study Strengths And Limitations
One of the strengths of this study was the large representative sample size of private health facilities covering a large region, making this study finding generalizable to other similar settings. The use of both quantitative and qualitative approaches allowed for data triangulation and better understanding of the context to explain the quantitative information. One major weaknesses of this study is the possibility of reporting bias from the respondents who may have reported what they deemed as appropriate instead of what was accurate. However, this was minimized by data triangulation from both the quantitative and qualitative approaches.