Determinant of malaria service readiness at health facility: Evidence from 2018 Service Availability and Readiness Assessment: Cross sectional study

Background: Globally, an estimated 3.3 billion people are at the risk of malaria. The majority of cases have occurred in the African Region. This study aims to assess the determinant of malaria service readiness at the health facility level. Method: Data from the 2018 Service Availability and Readiness Assessment was used for this analysis. The study was a facility-based cross-sectional study and a stratified sampling technique was used. Data was collected from October December 2017. Mean readiness score was used by computing six tracer items (Available of at least one trained staff for malaria diagnosis & treatment, Available malaria diagnosis & treatment guideline, Malaria diagnostic capacity, First-line anti-malarial drug in-stock, Paracetamol cap/tab, and ITN). Linear regression was used to identify factors associated with the mean readiness score of health facility to provide malaria service. The proportion test was used to check any change between 2016 and 2018 malaria service readiness. Result: A total of 764 facilities were included in the study, of these only 682(89.3%) of facilities were provide malaria service. Eighty-nine percent of facilities offer diagnosis or treatment of malaria service and 70% of the facility diagnosis malaria by clinical symptom followed by microscopy (67%) and Rapid Diagnostic Tests (RDT) (46%). Only 3%facilities had all the six tracer items. Hospitals and health centers had the availability of tracer items above the average mean readiness score (52%). Facilities managed by other than public authorities were had lower mean score readiness for malaria service compared with those managed by the public. Higher & medium clinics, health posts, and Lower clinics were had lower mean score readiness for malaria service compared with hospitals. A significant change was not Conclusion: The medium by and the determinate factor of malaria service readiness.Keyword: A facility-based cross-sectional study was conducted in nine regions (Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, SNNP, Gambella, and Harari) and two city administrations (Addis Ababa and Dire Dawa) of Ethiopia. Data was collected from October - December 2017. A stratified sampling technique was used to select the facility. Through this, all health facilities were stratified by region. From all-region and administrative cities, all hospitals and selected health centers, clinics and health posts were included in the sample. The total sample size for the study is 764. Data source: Data was obtained from Ethiopia Service Availability and Readiness Assessment 2018 and full of the methodology was hired over there.

observed for malaria service readiness of tracer items between 2016 and 2018 (p-value=0.732).
Conclusion: The study revealed that higher & medium clinics, lower clinics, health posts, facilities managed by other authorities and region were the determinate factor of malaria service readiness.Keyword: Malaria, Service availability, and readiness Background Malaria is a life-threatening disease caused by the protozoan parasite of the genus Plasmodium which is transmitted by female Anopheles mosquitoes through biting (1). There are four human malaria parasite species which are Plasmodium falciparum, Plasmodium vivax, Plasmodium malaria and Plasmodium ovale (2).
Plasmodium falciparum is the most dangerous and responsible for the majority of malaria-related deaths (2,3). Malaria is a preventable and curable disease that remains an important cause of illness and death in children and adults (1).
Malaria has a significant effect on the health and wealth of individuals as well as nations (4). In pregnancy, it imposes a serious threat to the mother, fetus, and neonate (4) and one of the main reasons that children miss school and adults miss work and it hampers further educational achievement, contributes to food insecurity and entrenches poverty (4,5).
According to the 2017 global malaria report indicates that more than 3.3 billion people were at risk of malaria (6). Of these, the majority of cases (92%) were found in the African Region followed by South-East Asia Region (5%) and the Eastern Mediterranean Region (2%) (6). More than 480 million malaria cases were reported from sub-Saharan Africa (5). Malaria is one of the fatal causes of death that affect the nation of the country. In the region of Africa, 2017 global malaria reports show that there are an estimated 435,000 deaths among these 61% were children (6).
Malaria is a major public health problem in Ethiopia. It is more dominate in the area of altitude below 2000 meters above sea level. In Ethiopia, more than two-thirds of the population live an area that is highly affected by malaria (7). About 60% of the population living in this area is at risk for malaria and more than 1.5 million malaria cases are reported annually (8-10). Based on the President's Malaria Initiative annual performance report in 2015, 2.2 million cases and 662 deaths were reported (11). According to the Ethiopian Federal Ministry of Health Public Health Emergency Management (PHEM) report in 2018 shows that more than 1.2 million malaria cases and 158 deaths were reported annually. Out of these cases, 88% were confirmed cases through microscopy or rapid diagnostic tests (RDT), the majority (83%) were laboratory-confirmed Plasmodium falciparum and 17% were Plasmodium vivax cases (10).
As compared to the previous year, there is a significant reduction of a new case of malaria in Ethiopia. The number of new cases of malaria declined from 2.8 million in 1990 and 621,345 in 2015 and malaria death also reduced from 30,323 in 1990 to 1,561in 2015. Age-standardized mortality rate declined by 96.5% between 1990 and 2015 and the number of disability-adjusted life years lost (DALY) due to malaria decreased from 2.2 million in 1990 to 0.18 million in 2015, with a total reduction of 91.7% (12). This was achieved by ensuring the availability of rapid diagnostic tests, anti-malaria drugs, trained health care workers, diagnostic capacity at the health facility level and high coverage of ITNs distribution and spraying of households (13).
But, despite this reduction or improvement, malaria remains among the 10 most common causes of death and serious public health problem in Ethiopia (14). The possible barriers to achieving a further reduction in disease burden might be associated with service availability and readiness of each level of the health facility and community involvement in prevention activities.
Due to this global burden of malaria and the previous rapid signs of progress, WHO developed a Global technical strategy for malaria 2016-2030 with different milestones for measuring progress in 2020 and 2025 (2). Through this, all countries set their own national or sub-national targets to accelerate activities for eliminating malaria transmission and prevention and its re-establishment (15). The National Malaria Prevention, Control and Elimination Program (NMCP) strategy (NSP 2014-2020) in Ethiopia aim to achieve the goals of near-zero malaria deaths, reduction of malaria cases by 75% from a baseline of 2013 and elimination of malaria in the selected low transmission areas (11). To achieve these goal and the stated objectives, the NMCP will appropriately planned and targeted delivery of essential malaria interventions, including: early diagnose of suspected malaria, treatment of confirmed malaria cases with effective anti-malarial drug, and application of appropriate vector control interventions, particularly the use of insecticide-treated nets (ITN) & indoor residual spraying (IRS) (6). Ethiopia develops a strategic plan to eliminate malaria by 2020 and to eradicate by 2030, and go for a sub-national malaria elimination program. Therefore, there is a critical need for having welltrained health care workers, availability of adequate logistics and supply to offer malaria diagnosis and treatment service at all times in each level of health facility by strengthening the public-private partnership. To achieve those strategic goals, availability and readiness of health facilities for malaria diagnosis and treatment services are mandatory. Thus, the aim of this study was to assess the determinate of malaria service the availability and readiness of the health facility.

Health facility distribution
Seven hundred sixty-four facilities were had selected for malaria service availability and readiness. Of these, 40% were Hospital, 21% Health center, 17% health post, 12% higher & medium clinic and 9% were a lower clinic. Concerning the regional distribution of health facilities, a large proportion of health facilities were found in the Oromia region 16% (125), Amhara region 15% (114) and SNNP region 14% (105).
Seventy-one percent of health facilities were public facilities and 66% were found in Urban ( Table 1)..

Malaria Service Availability of health facility
Nationally malaria service is given in all the tier health systems of each health facility. From the selected facilities for malaria service availability and readiness assessment, 89% of facilities offered malaria diagnosis or treatment service.
Facilities found in the Gambela region offered malaria service and 46% of facilities found in this region were diagnosis malaria by microscopy through Rapid Diagnostic Test (RDT) (76%) and clinical symptom (83%). Almost all (98%) hospitals and health centers provide malaria diagnosis or treatment service and 53% of lower clinics offer malaria service. Except for RDT service (35%), more than 75% of malaria service was available in an urban facility. Seventy-two percent of facilities managed by other than the public were diagnosing malaria through clinical symptoms ( Table   2).. The readiness of the health facility to provide Malaria diagnosis and treatment The readiness of health facility to offer malaria diagnosis or treatment service has assessed by the availability of the six tracer items (Table 3).. Six hundred eightytwo facilities were assessed for malaria readiness service based on the availability of tracer items. Of which, 85% of facilities were had malaria diagnostic capacity, 72% were had Paracetamol cap/tab and 65% were had first anti-malaria drug. Only 19% of the facilities were had ITN and lower clinics were had no ITN service. Eightytwo percent and 58% of health posts had malaria diagnostic capacity through RDT and first-line anti-malarial drugs in stock respectively. Facilities managed by the public authority were had more likely availability of all tracer items compared with facilities managed by others (4% Vs 1.7%). Seven percent of the facility found in the Tigray region had availability of all tracer items. Nearly, 7% of the health centers and 4% of hospitals had the availability of all malaria tracer items but the rest health facilities were not had all tracer items. Overall, 3% (23) facilities were had all the six tracer items, 40% (274) were having more than three tracer items and nearly 4% (25) of facilities were had no malaria tracer items. The availability of tracer items was slightly higher than half, while 59% of Hospitals and nearly 62% of health centers were had the availability of tracer items above the average mean score readiness (52%) ( Table 3)..   Table 4)..

discussion
Health facility readiness to offer malaria diagnosis or treatment service is basic and boldly seen in each level of health facility to control, eliminate and eradicate malaria from its public health problem. At 5% level of significant, facility type (Higher & medium clinic, Lower clinic, and health post), facility managed by other than public authority and region (Amhara, Oromia Somali, SNNP, Harari and Addis Ababa) were the determinant of mean score readiness of tracer item for malaria service. The current study revealed that 89% of health facilities offered malaria diagnosis or treatment services. Which is higher than another study conducted in Ethiopia (81%) (16), in Somalia (57%) (17) but lower than the study conducted in Tanzania (93%) (18). This might be due to the presence of a security problem in Somalia to address malaria service and had a scale-up of different interventions in Ethiopia. Seventy percent of the facilities were conducted malaria diagnosis by clinical symptoms followed by microscopy (46 %) and RDT (67%). Which is higher than from the previous study conducted in Ethiopia, 81% offer malaria diagnosis or treatment, 69% diagnosed by clinical symptom, 54% by microscopy and 39% by RDT(16) which is higher than study in Somalia, 32% by clinical symptom, 14% malaria by microscopy and 52% malaria by RDT(17). In this study, facilities that are managed by government authority were more likely to provide malaria service compared to non-governmental facilities (93% Vs 81%) which are in line with the study in Tanzania (95% Vs 86%) (18). But, the results from Somalia indicate that facilities managed by government authorities were less likely to offer malaria diagnosis or treatment service compared with facilities managed by others (59% Vs 56%) (17). Urban facilities in Ethiopia were more likely to offer malaria diagnosis or treatment service (92% Vs 82%) and also health centers were more likely to offer malaria service than health posts which is supported by other studies (16,17).
Concerning malaria service readiness, 3% of the facilities have had the availability of all malaria tracer items which is nearly similar to the previous study in Ethiopia 3% (16) and higher than the study conducted in Somalia 1% (17). This difference might be used as unequal tracer items for malaria service readiness and instability of the country to improve malaria service through the implementation of malaria prevention and controlling strategy. Availability of trained health workers, antimalaria drug and paracetamol tab in each level of health facility was mandatory. In the current study, 65% and 72% of the facilities have had the availability of ACT and Paracetamol tab in the facilities which is lower than different studies in Tanzania and . Nearly 30% of the facilities were had availability at least one trained health worker/Staff for malaria diagnosis and treatment service which is lower than the study connected in Tanzania 59% (18) but higher than the previous study conducted in Ethiopia (17%) and Nigeria (24%) (16,22).
Overall, 52% of the facilities were ready to provide malaria service which is more likely to compared with study in Somalia (42%) and less likely compare with Tanzania (64%) (17,18). Facilities which are managed by other than public authority had lower mean score readiness of trace item by 7% compared with those facility managed by public authority. The significant regional difference was observed on the mean score readiness of the tracer item. This study revealed that facilities found in Addis Ababa, SNNP, Oromia, Somali and Amhara region were had lower the mean score readiness of trace item for malaria service by 17%, 13%, 12%, 12%, 10%, and 9% compared with Tigray region respectively. In addition to this, there is a significant association between facility types on the mean score readiness of tracer items. Thus, the current study indicates that the mean score readiness of tracer items in the lower clinic, health post, and Higher & Medium clinic were negatively associated with Hospitals. This might be the availability of well-trained health workers in hospitals and also hospitals were able to availed malaria service-