Abstract:
Background: Change of severe malaria treatment policy from quinine to artesunate, a
major malaria control advance in Africa, is compromised by scarce data to monitor
policy translation into practice. In Kenya, hospital surveys were implemented to monitor
health systems readiness and inpatient malaria case-management.
Methods: All 47 county referral hospitals were surveyed in February and October 2016.
Data collection included hospital assessments, interviews with inpatient health workers
and retrospective review of patients' admission files. Analysis included 185 and 182
health workers, and 1162 and 1224 patients admitted with suspected malaria,
respectively, in all 47 hospitals. Cluster-adjusted comparisons of the performance
indicators with exploratory stratifications were performed.
Results: Malaria microscopy was universal during both surveys. Artesunate availability
increased (63.8-85.1%), while retrospective stock-outs declined (46.8-19.2%). No
significant changes were observed in the coverage of artesunate trained (42.2% vs
40.7%) and supervised health workers (8.7% vs 12.8%). The knowledge about treatment
policy improved (73.5-85.7%; p = 0.002) while correct artesunate dosing knowledge
increased for patients < 20 kg (42.7-64.6%; p < 0.001) and > 20 kg (70.3-80.8%; p =
0.052). Most patients were tested on admission (88.6% vs 92.1%; p = 0.080) while
repeated malaria testing was low (5.2% vs 8.1%; p = 0.034). Artesunate treatment for
confirmed severe malaria patients significantly increased (69.9-78.7%; p = 0.030). No
changes were observed in artemether-lumefantrine treatment for non-severe test positive
patients (8.0% vs 8.8%; p = 0.796). Among test negative patients, increased adherence to
test results was observed for non-severe (68.6-78.0%; p = 0.063) but not for severe
patients (59.1-62.1%; p = 0.673). Overall quality of malaria case-management improved
(48.6-56.3%; p = 0.004), both for children (54.1-61.5%; p = 0.019) and adults (43.0-
51.0%; p = 0.041), and in both high (51.1-58.1%; p = 0.024) and low malaria risk areas
(47.5-56.0%; p = 0.029).
Conclusion: Most health systems and malaria case-management indicators improved
during 2016. Gaps, often specific to different inpatient populations and risk areas,
however remain and further programmatic interventions including close monitoring is
needed to optimize policy translation.