Unwilling or unable? understanding healthcare providers’ perspectives on guideline compliance for malaria testing in Ghana

The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.

globalsymposium_logosBelow is an abstract by Nana Yaa Boadu (IDRC), John Amuasi (University of Minnesota), Daniel Ansong KATH Kumasi), Edna Einsedel (University of Calgary), and Stephanie Yanow, (University of Alberta) on malaria/febrile illness testing in Ghana. Other abstracts will appear subsequently.

“The test-based malaria management guideline in Ghana reflects a 2009 recommendation by the World Health Organization, to confirm suspected cases before providing treatment. The guideline aims to limit inappropriate antimalarial use, which contributes to emerging drug resistance. Rapid diagnostic tests (RDTs) enable confirmatory malaria diagnosis in peripheral settings without microscopy.

“Yet healthcare providers frequently prescribe antimalarials without a test, or despite negative test results. This study investigated poor providers’ compliance with the malaria testing guideline. The findings are useful to streamline antimalarial prescribing practices, to improve malaria management, and to limit drug resistance development in Ghana.

“A focused ethnography conducted between November 2011 and October 2012 involved 50 providers at six different primary healthcare settings in the Atwima-Nwabiagya district. Observations, semi-structured interviews and focus groups involving providers revealed reasons for poor compliance. Consultations with local and national policy representatives identified system-wide factors affecting providers’ compliance, including national health insurance.

“Poor availability and quality of RDTs, heavy workloads, and insufficient guideline knowledge limited providers’ readiness to test before treating suspected malaria. Knowing the risks and consequences of delayed treatment, providers were unwilling to withhold antimalarials from suspected cases. Due to frequent RDT stock outs testing was sporadic, often conducted after treated patients returned with unyielding signs and symptoms.

“Limited healthcare delivery capacity created tension for providers between recommended and achievable practice standards, which restricted effective guideline implementation. Perceived patient risk and poor RDT quality undermined providers’ willingness to test, leading to precautionary treatment practices. These factors interdependently influenced guideline compliance.

“Training should enhance providers’ knowledge of policy, practice, and technology for diagnosing malaria. However, health system capacity-building is critical to bolster providers’ confidence in RDT and guideline utility for managing malaria.”

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