The role of private health facilities in the provision of malaria case management and prevention services in four zones of Oromia Regional State, Ethiopia

Article Outline

• Summary
• 1. Introduction
• 2. Materials and methods
• 3. Results
• 4. Discussion
• Authors’ contributions
• Authors’ disclaimer
• Funding
• Competing interests
• Ethical approval
• Acknowledgements
• References
• Copyright

Summary 

Little is known about the contribution of the private health sector in managing malaria cases and contributing to malaria prevention and control efforts in Ethiopia. We assessed 102 private health facilities and 92 drug outlets in 20 districts of Oromia Regional State, Ethiopia, for their provision of malaria-specific services. Of the assessed health facilities 86% provided such services. Diagnosis was largely clinical, with only 31% and 15% of all health facilities seen using rapid diagnostic tests and microscopy, respectively. Facilities had chloroquine, artemether-lumefantrine, quinine and sulfadoxine-pyremethamine. Gaps were seen in provision of guidelines and other malaria-related materials, training of facility staff and supervision. Inclusion of the private health sector in malaria control program is crucial to expand current malaria prevention and control efforts in Ethiopia.

Keywords: Malaria, Ethiopia, Case management, Private sector

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1. Introduction 

Malaria is the leading cause of outpatient consultations, the fourth highest cause of health facility admissions and the eighth highest cause of in-patient deaths in Ethiopia.¹ As per national malaria diagnosis and treatment guidelines malaria patients are treated with either artemether-lumefantrine (AL) for Plasmodium falciparum or chloroquine for P. vivax infections; severe malaria cases are treated with quinine.²

Although malaria patients access diagnosis and treatment at public health facilities free of charge, anecdotal reports and isolated surveys indicate that a considerable proportion of patients also access private sector facilities for the same services. Thus, Deressa et al. showed that 439 (21.0%) of 2087 women surveyed sought malaria treatment from private health providers,³ and the Malaria Indicator Survey in 2007 showed that, of the 92 children aged <5 years with a fever, 21 (36.4% [weighted proportion]) and 41 (34% [weighted proportion]) received antimalarial drugs from private and public health providers, respectively.⁴ In both studies no information was given with regards to the type of service patients received from private sector facilities.

The objective of this study was to assess the role of private sector health facilities and drug outlets in providing malaria case management and prevention services in four administrative zones of Oromia Regional State.

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2. Materials and methods 

A survey was carried out in 20 randomly-selected districts of four administrative zones (Arsi, East Shoa, Jimma, and West Arsi) in Oromia from September–October 2009; the zones were priority geographical areas of the USA's President's Malaria Initiative at that time. Probability proportional to size sampling was used when selecting from the 389 private health facilities and 385 drug outlets operating in these districts; a total of 102 private health facilities and 92 drug outlets were included in the study.

We deployed a team of 16 data collectors, four supervisors, and four zonal coordinators, all of whom had been trained for three days in the survey's methodology. Quantitative approaches were used to assess the provision of malaria diagnosis, treatment, prevention and control services using separate health facility and drug outlet assessment questionnaires.

CSpro version 4.0 (U.S. Census Bureau, Washington DC, USA) was used to enter and clean the data; data was analyzed using SPSS 16.0 (SPSS Inc, Chicago, USA). Descriptive statistics were used to analyze the data.

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3. Results 

Of the 102 private health facilities surveyed, 100 (98.0%) and all drug outlets were private for-profit institutions. A public sector health facility existed within a 5km radius for 96 (94%) health facilities and 79 (86%) drug outlets. Surveyed facilities and drug outlets had been operating for a median of 5 years in their catchment areas (Table 1, Table 2).

Table 1. Characteristics of 102 private facilities surveyed in Oromia, Ethiopia

	Health Facilities					Total (%)
	Small clinic	Medium clinic	Higher clinic	Higher specialized	Hospital
Number of facilities surveyed (%)	73 (71.6)	17 (16.7)	8 (6.9)	3 (2.9)	1	102
Health personnel at the facility						287
Specialist physicians	0	1	8	2	2	13 (4.5)
General practitioner	1	7	16	0	4	28 (9.7)
Nurse	92	26	24	6	8	156 (54.4)
Midwife	2	1	3	2	2	10 (3.4)
Health officer	4	9	10	0	0	23 (8.0)
Laboratory technician	1	21	15	4	4	45 (15.7)
Environmental health officer	0	0	1	0	0	1 (0.3)
Pharmacy personnel	6	1	3	0	1	11 (3.8)
Distance from public sector facility
≤5 km	68	17	7	3	1	96 (94.1)
>5 km	5	0	1	0	0	6 (5.9)
Availability of in-patient department	NA	8	7	2	1	18 (17.6)
In-patients admitted in previous 12 months, median [IQR]	NA	72	300	45	480	138 [60–480]
Outpatients consulted in previous 12 months, median [IQR]	1348	1740	3956	2500	15642	1500 [600–3000]
Duration of service in the study area, median [IQR]	4	5	4.5	1	2	5 [1–9] years

NA: Not applicable.

Table 2. Characteristics of drug outlets surveyed in Oromia, Ethiopia

	Drug outlets
	Rural drug vendor	Drug shop	Pharmacy	Total (%)
Number of facilities surveyed	51	35	6	92
Personnel at the facility				92
Pharmacist	0	3	1	4 (4.3)
Pharmacy technician	5	27	5	37 (40.2)
Other health worker	43	3	0	46 (50)
Non health workers	3	2	0	5 (5.4)
Median distance from public sector facility
≤5 km	42	31	6	79 (86)
>5 km	1	0	0	1 (1)
No government facility	8	4	0	12 (13)
Duration of service in the study area, median (in years)	7	3	4	5

Of the private sector health facilities, 88 (86%) provided case management services and 73 (71.6%) were small clinics. As most facilities were small clinics only 18 (18%) had in-patient services; nurses were the major health care provider (156 out of 287 health professionals; 54.4%) in facilities surveyed (Table 1). Among the 88 facilities providing malaria case management services, 40 (45%) used only clinical signs and symptoms for malaria diagnosis. Although 38 (43%) and 16 (18%) facilities reportedly provided malaria diagnosis by microscopy and rapid diagnostic tests (RDTs), only 27 (31%) and 12 (14%) were seen by the survey team to actually use microscopy and RDTs, respectively.

Of 92 surveyed drug outlets, only 13 (14%) stated that they would prescribe drugs based on clinical signs; no microscopy or RDT was performed at drug outlets. Of surveyed outlets, 78 (85%) stated that they request a prescription from customers prior to dispensing malaria drugs, with 49 (53%) stating that they would, however, not need evidence of a positive parasitological diagnosis. Pharmacy technicians were the major health provider (37; 40%) in drug outlets surveyed (Table 2).

With regards to availability of antimalarial drugs, chloroquine was found to be available in 34 (39%) health facilities, followed by sulfadoxine pyrimethamine (SP) in 16 (18%), AL in 13 (15%), and quinine in 12 (14%). Similarly, chloroquine was found in 88 (98%) followed by SP in 32 (36%), quinine in 14 (16%) and AL in 6 (7%) of drug outlets surveyed. Further investigation in 13 health facilities and six drug outlets which reported AL availability showed that AL was stored at room temperature (i.e. <30°C) in eight health facilities and one drug outlet. One health facility had expired AL. The reported suppliers of AL for private health facilities were private distributors (6, 46%), government (4, 31%) and charitable organizations (3, 23%); and all drug outlets claimed that their providers were private pharmaceutical companies. Flow charts for malaria diagnosis and treatment were available in 6 (7%) of surveyed health facilities; however, upon inspection only two had charts consistent with the national malaria diagnosis and treatment guidelines.² A treatment schedule was available in 6 (7%) of the health facilities’ examination rooms as a reference for health personnel. Clinical job aids including the Glasgow and Blantyre Coma Scales were being used in 6 (7%) and 7 (8%) of the health facilities surveyed, respectively.

Of 71 private health facilities surveyed, 15 (21%) provided malaria-specific information, education, communication (IEC) to patients. Only three facilities reported receiving print and audio IEC materials from non-governmental organizations (NGOs) operating in the area, one received materials from the local government health office, and one from other sources. Of the 56 health facilities reportedly not disseminating malaria IEC messages, the main reasons given included lack of IEC materials 10 (18%), being beyond facilities’ scope of activity 9 (16%), or lack of funds to produce IEC materials on malaria 6 (11%). With regards to drug outlets only 4 (4.3%) had distributed IEC materials.

Of the 88 private health facilities providing malaria services and 92 drug outlets, 77 (88%) and 40 (43%) were visited by government health staff at least twice per year, respectively. For 86 (98%) of health facilities and 83 (90%) of the drug outlets, visits focused on assessing whether the facility complied with the government's standard service requirements. Communicating updates on the national technical guidelines as a reason for supervision was reported only by one health facility and two drug outlets; in fact, only 4 (5%) health facilities received diagnosis and treatment guidelines from the government health authorities. None of the surveyed facilities’ staff had attended training on malaria diagnosis and treatment by either government or NGOs operating in the facilities’ catchment area; in fact training is organized for public health facilities only.

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4. Discussion 

Here we show that malaria-specific services provided by private sector facilities and drug outlets in four zones of Oromia are variable, with only a proportion of facilities providing comprehensive diagnostic or treatment services, and even less facilities disseminating IEC materials or other supportive services. As shown here, a range of antimalarial drugs are available at private sector facilities and drug outlets. The current operational framework prevents private facilities having branded AL (CoArtem®, Novartis, Basel, Switzerland) in Ethiopia. However, our study shows that besides generic AL, branded AL is available in some facilities and drug outlets, suggesting leakage from the public sector. Although SP has been dropped as a malaria treatment approach in Ethiopia since 2004² it is still being prescribed for malaria treatment by some private health providers. Clearly such practice could be prevented by providing private facilities with up-to-date national malaria guidelines.

To sustain current malaria prevention and control efforts in Ethiopia, it will be crucial to include the private sector in malaria service delivery. This will require the public health sector to collaborate with the private sector to be engaged in the implementation of malaria activities, supporting the sector in terms of provision of guidelines and IEC materials, training of human resources, and strengthening the sector's monitoring and evaluation.

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Authors’ contributions 

DJ designed the survey, trained the research team, oversaw the fieldwork, and led the data analysis. MT contributed to designing the survey. GF and SG reviewed the study design and questionnaires and oversaw the fieldwork. HT, SC, and RR contributed to data analysis. HT drafted the manuscript, SC and RR critically reviewed the manuscript. All authors reviewed and approved the final version of the manuscript. HT is guarantor of the paper.

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Authors’ disclaimer 

The opinions expressed are those of the authors and may not reflect the position of their employing or funding organizations.

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Funding 

This work was carried out under the U.S. Agency for International Development C-Change Cooperative Agreement to the Academy for Educational Development (Agreement 663-A-00-08-00432-00) funded by the U.S. President's Malaria Initiative.

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Competing interests 

None declared.

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Ethical approval 

Ethical clearance was obtained from the Oromia Regional Health Bureau, Addis Ababa, Ethiopia, to carry out the study.

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Acknowledgements 

We thank Eftu Ahmed for commenting on the study questionnaire, Abiy Tsegaye for assisting in the data analysis and thank all field supervisors for conducting the field work.

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References 

1. Federal Ministry of Health. Health and health related indicators 2008-2009. Addis Ababa: Federal Ministry of Health; 2010.
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2. Federal Ministry of Health. Malaria diagnosis and treatment guidelines for health workers in Ethiopia. Addis Ababa: Federal Ministry of Health; 2004.
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3. Deressa W, Ali A. Malaria-related perceptions and practices of women with children under the age of five years in rural Ethiopia. BMC Public Health. 2009;9:259
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4. Jimma D, Getachew A, Bilak H, Stekeetee RW, Emerson PM, Graves PM, et al. Malaria Indicator Survey 2007, Ethiopia: coverage and use of major malaria prevention and control interventions. Malaria Journal. 2010;9:58
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