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Scientific title: A cost-effectiveness analysis of provider and community interventions to improve the treatment of uncomplicated malaria in Nigeria

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?

Private-sector providers are a major source of malaria treatment in Nigeria, and many patients in Enugu state seek treatment at pharmacies and drug stores as well as public health centres. Very few patients were tested before treatment because few facilities offer malaria testing and many patients ask for and receive antimalarials that are no longer recommended.

Revisions to malaria treatment guidelines recommended testing patient with malaria symptoms before treatment is dispensed. Rapid diagnostic tests 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 should ensure patients receive the most appropriate treatment and avoid unnecessary costs.

Limited availability of malaria testing, a lack of awareness about artemisinin combination therapy (ACT) and poor practices - by both public and private providers - were key challenges for those responsible for integrating the use of rapid diagnostic tests into malaria control. Interventions were urgently needed to improve malaria diagnosis and treatment in routine health care settings.

What does this study add?
Currently there is little knowledge about the cost-effectiveness of training interventions to support the large scale roll-out of rapid diagnostic tests (RDT), especially in the private sector. Working with the state, the team evaluated malaria control programme interventions in public primary health facilities, pharmacies and drug stores. The study aims to assist Nigerian policy-makers in delivering health benefits and value for money in malaria control.

This study uses a 3-arm cluster randomised design to evaluate interventions to support the roll-out of malaria rapid diagnostic tests. In the control arm, the tests were supplied and providers were shown how they should be used. In the provider intervention arm, rapid diagnostic tests were also supplied and providers received two-day training and monthly support visits. In the third arm, the provider intervention was supplemented by a school-based intervention to raise community awareness about malaria. Raising awareness in the community was important in this setting as many people go to pharmacies, drug stores and public health centres for malaria treatment, and often ask for specific medicines.

The two-day provider training sought to improve health workers’ knowledge and skills on why it is important to test for malaria and how to use rapid diagnostic tests. The training was supplemented by monthly support visits. The school-based intervention took place at primary and secondary schools and involved training teachers and establishing peer health educators. Schools were supported to hold events in the community which used drama, songs, card games and health talks to raise awareness about diagnosing malaria using rapid diagnostic tests and about ACT being the recommended malaria drug treatment.

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 and 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 Obinna Onwujekwe, College of Medicine, University of Nigeria

Other Investigators

Dr Wilfred Mbacham, University of Yaounde, Cameroon
Mrs Lindsay Mangham-Jefferies, London School of Hygiene & Tropical Medicine
Dr Clare Chandler, London School of Hygiene & Tropical Medicine
Ms Bonnie Cundill, London School of Hygiene & Tropical Medicine
Prof BSC Uzochukwu, University of Nigeria
Ms Ogo Ibe, University of Nigeria
Mr Emmanuel Nwala, University of Nigeria
Dr Eloka Uchegbu, University of Nigeria
Mrs Chinelo Enemuo, University of Nigeria

Latest on this research
The research team has published papers that describe problems in malaria case management showing that very few health facilities in Enugu state had malaria testing available and only a quarter of patients with fever received ACTs.

Our formative research also pointed that approximately half of patients surveyed demanded a specific medicine, which in most cases was not an ACT. The provider and community interventions developed to address these problems are described in our published study protocol. These interventions have been evaluated using a cluster randomised trial design and the final results have been submitted for publication.

For training manuals from REACT study in Cameroon, please click here.