Quality Improvement and Malaria

Sheila Leatherman and colleagues have written this month that …

Despite … acknowledgment of the critical role of quality of care in  strengthening health systems, there are few descriptions of how to insure high-quality health care in developing countries. While modern  approaches to improving quality are increasingly used globally, their appropriateness for resource poor settings has received little attention and their adoption remains sporadic.

These authors have put together a reference list of 22 quality improvement research study publications in developing countries in the following areas:

  • Emergency obstetric care
  • Acute child illness care
  • Primary care
  • Health system (microsystem level)
  • Prescribing practices

Unfortunately, “Many if not most QI interventions are never published.”

Though these studies do not address malaria issues directly, all are areas that affect malaria services.

The WHO health systems strengthening action framework (2007) does mention malaria is several instances.  For example, the report recommends “working more directly with other international partners (e.g. The Global Fund to fight AIDS, TB and Malaria) on their support for health systems strengthening.” The report also recognizes that an integrated approach is needed because, “One cannot advise on health systems financing from the perspective of malaria or child health alone.”

There are some recent articles that do address malaria service quality issues. Concerning malaria case management in Angola, Rowe et al. found problems in maintaining drug stocks, clinical supervision, use of malaria tests, and health worker knowledge.

Specifically addressing testing/parasitological diagnosis in Tanzania, Mosha and colleagues were concerned about over-diagnosis of malaria. They concluded that, “The introduction of RDTs is likely to lead to financial savings. However, improving diagnosis to one disease may lead to over diagnosis of another illness. Quality improvement is complex but introducing RDTs for the diagnosis of malaria is a good start.”

In Cambodia, Yasuoka and co-researchers studied village malaria workers and found that, “VMWs were effective in conducting diagnosis with Rapid Diagnostic Tests (RDTs) and prescribing anti-malarials to those who had positive RDT results, skills that they had acquired through their training programmes. However, most other services, such as active detection, explanations about compliance, and follow-up of patients, were carried out by only a small proportion of VMWs.”

100_0517.jpgJhpiego has a system of performance quality improvement known as Standards Based Management and Recognition (SBM-R). Jhpiego’s malaria in pregnancy (MIP) work is based on WHO’s guidance that MIP services should be integrated into antenatal care (ANC).

In each country where Jhpiego works a set of appropriate performance standards are developed – for example, 16 basic standards for ANC in Nigeria and 18 in Angola. Malaria in pregnancy interventions in both countries have linked improvements in ANC standards, which include MIP services, to increased use of these MIP services. [picture shows recognition ceremony for health workers and facilities achieving 80% of the standards.]

Quality improvement for malaria services is crucial at the next stage for highly endemic countries on their pathway to elimination. This year all are scaling up for impact. Moving forward this scale up must be sustained. Sustained effort can only happen if there is high performance quality among malaria service providers.

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