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Scientific title: A cost-effectiveness analysis of provider interventions to improve health worker practice in providing treatment for uncomplicated malaria in Cameroon

Cost and effects of strategies to improve malaria diagnosis and treatment in Cameroon and Nigeria from ACT Consortium on Vimeo.

What did we know before this research?

Rapid diagnostic tests (RDT) are a relatively new innovation and can quickly confirm if someone has malaria. These tests are easy to use and do not require laboratory equipment or specialist skills.

Testing patients before prescribing medication is important, and should ensure patients receive the most appropriate treatment. This is important because unnecessary and inappropriate treatment has costs –incurred by patients, but also governments and donors working to control malaria. The cost-effectiveness of rapid diagnostic tests critically depends on health workers prescribing treatment based on the test result.

Background research on malaria case management in Cameroon found that malaria testing was available but under-used, and many health workers prefer to prescribe an antimalarial even when the malaria test has a negative result.

What does this study add?
We designed a cluster randomised trial to compare the introduction of malaria rapid diagnostic tests (RDT) accompanied by either basic training or enhanced training with routine care (in which microscopy was available to identify the presence of malaria parasites in the blood).

Working with the Ministry of Health, one-day basic and three-day enhanced training courses were designed to support the roll-out of malaria rapid diagnostic tests. These training courses are suitable for implementation on a large-scale.

Both training courses show health workers how to use the rapid diagnostic tests and explain which antimalarials are used to treat confirmed cases of uncomplicated malaria. The enhanced course contains additional activities and uses interactive methods – such as drama, games and problem solving exercises – to encourage health workers to use malaria testing and prescribe treatment based on the test results.

This is the first study of a randomised controlled trial that compares different interventions to support the uptake of rapid diagnostic tests and adherence to their results in Cameroon.

The REACT studies in Cameroon and Nigeria will provide an important basis for comparison across different types of health care providers (both private and public), different health care delivery and financing systems, as well as different treatment seeking practices by ethnic and socioeconomic groups. Perhaps most interesting, these intervention trials will allow comparison between sites where currently microscopy testing is widely available (Cameroon) and where the use of any form of malaria diagnostic testing is extremely limited (Nigeria).

The research team
Principal Investigators

Dr. Virginia Wiseman, London School of Hygiene & Tropical Medicine

Dr Wilfred Mbacham, University of Yaoundé, Cameroon

Other Investigators

Mrs Lindsay Mangham-Jefferies, London School of Hygiene & Tropical Medicine

Dr Obinna Onwujekwe, College of Medicine, University of Nigeria

Ms Bonnie Cundill, London School of Hygiene & Tropical Medicine

Dr Clare Chandler, London School of Hygiene & Tropical Medicine

Ms Olivia Achonduh, University of Yaoundé

Akindeh Mbuh Nji, University of Yaoundé

Latest on this research
We have found that interactive training programmes for health workers reduced malaria over diagnosis by half, helping to prevent the wastage of antimalarials on patients who don't need them.

The study compared the use of RDTs when packaged with either a basic or a comprehensive training programme for clinicians. Our results showed that those undertaking the comprehensive programme were much less likely to overuse antimalarials. Only 31% of patients in this group received a malaria drug that they didn’t need, compared to 52% in the group undertaking the basic programme and 84% in the control group which represented the standard practice.

The more effective training package lasted three days and was designed to change prescribing practices. In addition to the content of the basic package, which only provided conventional training on RDTs, malaria diagnosis and treatment, the comprehensive package had smaller groups and longer discussions about clinical guidelines, real-life scenarios and effective communication with patients. It was also more interactive, using card games, drama and problem solving exercises. These training materials are available through the ACT Consortium along with the study protocol and papers that describe problems in malaria case management in Cameroon identified in formative research for this study.

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