Dangme West District, Greater Accra Region, Ghana

Dr. Evelyn Korkor Ansah MB ChB, MPH, PhD

District Director of Health Services,

Dangme West District Health Directorate

P.O.Box DD1, Dodowa, Ghana.

Email: Ansahekdr@yahoo.co.uk

• Prof Christopher Whitty, London School of Hygiene and Tropical Medicine
• Dr. Clare Chandler, London School of Hygiene and Tropical Medicine
• Dr. Kristian Hansen, London School of Hygiene and Tropical Medicine
• Dr. Shunmay Yeung, London School of Hygiene and Tropical Medicine

There is good evidence from multiple sites, including Ghana, that malaria is massively over-diagnosed. It could be argued that where microscopy is not available it can be introduced, and elsewhere it can be improved, but high-quality microscopy is not easy to sustain. Furthermore, syndromic diagnosis in Ghana, as elsewhere, is not accurate, with no reliable way of distinguishing between malaria and bacterial disease. The introduction of rapid diagnostic tests (RDTs) has the potential to provide a way of more accurately directing ACTs to those that need them. They may also encourage clinicians to consider alternative diagnoses in test-negative cases, reducing the risk of missing treatable, and potentially fatal, alternative causes of febrile illness.

Introduction of RDTs has the potential to more accurately direct ACT use. It may also encourage clinicians to consider alternative diagnosis in test negative cases. RDTs to direct ACT use can be very cost-effective but only if clinicians prescribe based on test results. Cost effectiveness however falls away rapidly when test results are ignored

Rapid Diagnostic Tests for malaria were introduced into two settings in the Dangme West district of Ghana: the microscopy setting where blood testing for malaria using microscopy is available and the clinical setting where there are no laboratory services. The study was a Randomized Controlled Trial (RCT) and was carried out in 4 health facilities i.e Dodowa Health Centre, Prampram Health Centre, Agomeda Community Clinic and Ebenezer Private Clinic.

Initial data from Tanzania suggests that providing RDTs in the context of formal healthcare settings may have little impact on clinician behaviour, but the health system in Ghana is very different, and both clinician and patient beliefs about malaria are likely to be different. Additionally, this has not been properly tested in areas with little or no access to microscopy, nor where ACTs are currently available, which may influence clinician behaviour. The main trial aims to test the impact of RDT use on clinician behaviour directly by means of a randomised controlled trial (RCT) whilst the qualitative study aims to explore the reason behind clinician prescribing behaviour with a view to influencing it positively.

The objectives of the exploratory study are:

• To understand why health workers prescribe antimalarials as frequently with RDTs as microscopy in the microscopy setting
• To understand how health workers decide to follow the test result or not in the clinical setting
• To evaluate the feasibility of using RDTs in practice (how they were used and whether they would continue to use them)
• To evaluate the training given with the introduction of RDTs
• To evaluate the acceptability of RDTs to patients
• To evaluate the acceptability of restricting antimalarials to RDT positives amongst patients

If RDTs are found to be effective, either compared to microscopy where it is available, or compared to clinical diagnosis, the key question will be- are they cost-effective for Ghana? Current cost-effectiveness models on ACT and RDT are very optimistic but need to be tested directly.

The cost-effectiveness of the whole intervention is of great importance if this is to be moved into policy.

The objectives of the cost-effectiveness study are therefore as follows:

• To document the socio-economic status of patients receiving primary care for malaria in two settings where RDTs have been introduced: where there is microscopy and where there is none
• To document both the direct and indirect household costs of care in both settings
• To document the incremental cost-effectiveness of RDTs compared to malaria microscopy diagnosis and presumptive diagnosis respectively
• To use already existing models to determine under what conditions RDTs might be cost-effective in these settings