Quality of Care for Children with Malaria at Private Health Facilities in Mid-Western Region of Uganda: A Cross Section Study

Background Approximately 50 percent of the population in Uganda seeks health care from private facilities but there is limited data on the quality of care for malaria in these facilities. This study aimed to document the quality of malaria case management in private health facilities in nine districts in the Mid-Western region of Uganda, an area of moderate malaria transmission. Methods This was a cross sectional study in which purposive sampling was used to select fifteen private-for-profit facilities from each district. An interviewer-administered questionnaire that contained both quantitative and open-ended questions was used. Information was collected on availability of treatment aides, knowledge on malaria, malaria case management, laboratory practices, malaria drugs stock and data management. We determined the proportion of health workers that adequately provided malaria case management according to national standards. Results Of the 135 health facilities staff interviewed, 61.48% (52.91 - 69.40) had access to malaria treatment protocols while 48.89% (40.19 - 57.63) received malaria training. The majority of facilities, 98.52% (94.75 - 99.82) had malaria diagnostic services and the most commonly available antimalarial drug was artemether-lumefantrine, 85.19% (78 - 91), followed by Quinine, 74.81% (67 - 82) and intravenous artesunate, 72.59% (64 – 80). Only 14.07% (8.69 – 21.10) responded adequately to the acceptable cascade of malaria case management practice. Specifically, 33.33% (25.46 - 41.96) responded correctly to management of a patient with a fever, 40.00% (31.67 - 48.79) responded correctly to the first line treatment for uncomplicated malaria, whereas 85.19% (78.05 - 90.71) responded correctly to severe malaria treatment. Only 28.83% submitted monthly reports, where malaria data was recorded, to the national database. Conclusion This study revealed sub-optimal malaria case management practices at private health facilities with approximately 14% of health care workers demonstrating correct malaria case management cascade practices. This was due to limited access to malaria case management protocols and guidelines, lack of adequate staff training and supportive supervision, stock-outs of essential anti-malarial commodities and inadequate malaria related community level sensitization. Information System HMIS:Health Management Information System, IMM:Integrated Malaria Management, IPTp:Intermittent Preventive Therapy during pregnancy, MIS:Malaria Indicator Survey, MTR:Mid Term Review, NMCD:National Malaria Control Division, PFPs:Private For Profit Health Facilities, RDTs:Rapid Diagnostic Test, UDHS:Uganda Demographic Health Survey, UMRSP:Uganda Malaria Reduction and Strategic Plan, WHO:World Health Organization

4 focus for strengthening malaria case management in the private health facilities.

Background
Malaria remains a significant public health concern in Uganda [1] with approximately 8.6 million cases reported in 2017 alone [2], one of the highest malaria estimates in the sub-Saharan Africa region.
Malaria alone contributes to between 30 to 50% of outpatient visits, 15-20% of hospital admissions and 20% of hospital deaths; most of these in children under 5 years and pregnant women [1].
Strengthening malaria case management is a key strategy of the Uganda National Malaria Control Division (NMCD) to reduce morbidity and mortality attributed to malaria [1]. This is also one of the objectives of the 2014-2020 Uganda Malaria Reduction Strategic Plan, which is to achieve and sustain at least 90% of malaria cases in the public and private sectors and community level who receive prompt diagnosis and treatment according to national policy.
However, findings from the 2014 Malaria program Mid-term Review (MTR) indicated that programmatic focus has largely been on public health sector facilities [3]. This is a concern given that the private sector is an invaluable source of health care delivery to a significant proportion of Ugandans. According to the 2016 Uganda Demographic Health Survey (UDHS), approximately 60% of all children under five years with fever sought care and advice at a private health facility [4]. Whereas the NMCD recognizes the important role played by this sector, there has been limited engagement with private health facilities in activities such as training, quality assurance and data management [3], which may contribute to poor quality of care for malaria case management in these facilities.
Overall, sub-optimal quality of care reduces the effectiveness of interventions and also increases the risks for morbidity complications and mortality [5]. This observation is supported by 2016 WHO statistics which showed that of 5.6 million children under 5 years who died mostly from preventable causes, the majority of deaths were attributed poor quality of service delivery at the health facility level [6,7].
The importance of quality of health care in services delivery and its potential impact on child survival is progressively being recognized [8][9][10] as an important additional component to improvement of health and well-being. Currently, in Uganda, there is limited data on the quality of malaria case management in private health facilities. Understanding areas of substandard quality of care is an important step towards the design and implementation of targeted interventions for improvement of health service delivery [11][12][13][14][15][16]. The overall objective of this study was to assess the quality of malaria case management provided by health workers in private health facilities and to document the challenges for malaria case management at this level of health care.

Study design and setting
This was a mixed cross sectional study using both quantitative and qualitative data collection methods. It was conducted in October 2018, in private-for-profit health facilities across nine districts in the Mid-Western region of Uganda, an area with moderate to high malaria transmission [17]. The districts included Hoima, Masindi, Kiboga, Kiryandongo, Kibale, Kakumiro, Buliisa, Kagadi and Kyankwanzi districts (Fig. 1).

Private health facility definition, sample size and sampling
In this study, the operational definition for a Private-For-Profit (PFP) facility was limited to those hospitals or clinics that are supervised by a medical doctor, clinical officer or nurse/midwife and utilize a business model that seeks to make a profit. From each of the nine districts, fifteen PFP facilities that fulfilled this operational definition were selected based on the assumption 15 PFPs were representative of the district PFP coverage when considered against the average number of at least 25 PFPs found in each district [18]. However, the study also considered that all PFPs will be sampled in some districts with less than 15 PFPs, with over-sampling in districts with more than 15 PFPs.
Additional selection criteria for the PFPs included having a moderate to high volume of patients, employing two or more qualified medical staff and geographical spread within the district to minimize clustering and ensure representation of the district. With the assistance of the district malaria focal persons, purposive sampling was used to select these facilities giving a total of 135 PFPs across the nine (9) districts.

Selection of survey participants
The assessment targeted health care workers that were responsible for clinical care and health facility management and included different cadres like medical and clinical officers (attained a medical diploma), nurses and nursing assistants, midwives and administrators. These staff members were also usually the most senior or the most knowledgeable staff in the areas of focus.

Data Collection and study variables
A standard interviewer-administered pre-tested questionnaire with both quantitative and open-ended qualitative questions was used. Data was collected by three teams each comprising of four trained research assistants.
Data was collected on knowledge on malaria case management, availability of malaria treatment guidelines, malaria case management practices, laboratory practice, availability of antimalarial drugs and their stock management and reporting of malaria data (either weekly or monthly according to standard national reporting guidelines). Details of the variables assessed for during the survey are summarized in Box 1. The main outcome of interest was adequate malaria case management practices among the health facility staff. This indicator considered staff that correctly reported identifying suspected malaria cases (presenting with a fever), sending them for a confirmatory malaria test and prescribing an artemisinin based combination therapy (ACT) for uncomplicated malaria or intravenous artesunate for complicated malaria. Malaria case management service provision

Patient delays, malaria complications and referral
Other challenges were related to delayed care seeking and referral practices. It was noted that some patients report late to facilities often presenting with severe disease, others refused referrals preferring instead to continue treatment at the facilities, the latter usually occurred among those who couldn't afford in-patient care or those who did not believe in the services offered at public health facilities. Some staff also reported difficulty in managing complicated cases such as severe anemia.

Stock outs of anti-malaria drugs and malaria testing kits
Stock-outs also presented significant challenges for these health facilities. This included stock outs of the recommended anti-malarial drugs such as ACTs and malaria test kits (mainly RDTs). Most staff in these facilities resorted to using any other available anti-malarial drugs, some of which are not part of the currently recommended medications like oral quinine for first line treatment. Reporting completeness of the weekly and monthly HMIS data reports was assessed among all private health facilities that were required to report into the DHIS2. The denominator used in this assessed is greater than the study sample size. This was considered as a more accurate measure for this parameter since the national DHIS2 system includes all facilities beyond the study sample.
Therefore, as shown in Table 3, only 31/163 (19%) of the included facilities were reporting the weekly HMIS data into the DHIS and increasing to 47/163 (28%) for those reporting the monthly HMIS data into the DHIS2.

Discussion
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 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] 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.

Ethics approval and consent to participate
The data for this manuscript were derived from a Training Needs Assessment aimed at identifying the gaps in management of malaria in children in the private health care facilities. The project was categorized as a Quality Improvement project and therefore did not require approval of an Institutional Review Board. However, administrative clearance was sought from the District Health Offices who are responsible for the service delivery in the private facilities according to the Ministry of Health structures. Additional verbal consent was sought from the health centre in-charge staff or their representative to carry out the assessment.

Consent for publication
Not applicable

Availability of data and material
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare no competing interests practices Malaria case management