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Costs and effects of strategies to improve malaria diagnosis and treatment in Nigeria

Start date: 1 Oct 2008

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[Project summary in Français / Português]

Scientific title: A cost-effectiveness analysis of provider and community interventions to improve the treatment of uncomplicated malaria in Nigeria

Latest on this research

[Français / Português]

The challenges of designing and implementing effective behaviour change interventions to support the roll out of malaria Rapid Diagnostic Tests (RDTs) should not be underestimated. Our formative research in 2009 revealed that only 13% of public facilities in Nigeria had microscopy available, and although ACTs were introduced there in 2005 only 55% of providers surveyed knew ACT was the recommended treatment. We also found that while 79% of febrile patients received an antimalarial, only 23% of patients received an ACT and two-thirds of those were in the wrong dose. Approximately 50% of patients surveyed asked for a specific medicine, and in most cases this was not an ACT. It was clear that if RDTs were to become an effective means of targeting the use of ACT in Nigeria then they needed to be supported by behaviour change interventions. This would not only mean changing the practices of providers but also changing the expectations of patients and their families.

In this trial, the primary outcome was the proportion of patients treated according to guidelines, a composite indicator requiring patients to be tested for malaria and given treatment consistent with the test result. The primary outcome was evaluated among 4946 (93%) of the 5311 patients invited to participate. A total of 40 communities (12 in control, 14 per intervention arm) were included in the analysis.

We found that although the provider arm tended to have more people treated according to guidelines (36% in provider, 23% control, 24% provider-school) there was no evidence of a statistically significant difference between the arms. With or without extensive supporting interventions, levels of testing remained critically low across all arms (34% in control; 48% provider arm; 37% provider-school arm). Our study shows that treatment of malaria based on signs and symptoms alone is an ingrained behaviour that is difficult to change in this setting. Governments and researchers must continue to explore alternative ways of encouraging providers to deliver appropriate treatment and avoid the misuse of valuable medicines especially in the private sector where testing was lowest.

Further information: 

What did we know before this research?

Private-sector providers are a major source of malaria treatment in Nigeria, and many patients in Enugu state seek treatment at pharmacies and drug stores as well as public health centres. Very few patients were tested before treatment because few facilities offer malaria testing and many patients ask for and receive antimalarials that are no longer recommended.

Revisions to malaria treatment guidelines recommended testing patient with malaria symptoms before treatment is dispensed. Rapid diagnostic tests are a relatively new innovation and can quickly confirm if someone has malaria. These tests are easy to use and do not require laboratory equipment or specialist skills. Testing patients before prescribing medication should ensure patients receive the most appropriate treatment and avoid unnecessary costs.

Limited availability of malaria testing, a lack of awareness about artemisinin combination therapy (ACT) and poor practices - by both public and private providers - were key challenges for those responsible for integrating the use of rapid diagnostic tests into malaria control.  Interventions were urgently needed to improve malaria diagnosis and treatment in routine health care settings. 

What does this study add?

Currently there is little knowledge about the cost-effectiveness of training interventions to support the large scale roll-out of rapid diagnostic tests (RDT), especially in the private sector. Working with the state, the team evaluated malaria control programme interventions in public primary health facilities, pharmacies and drug stores. The study aims to assist Nigerian policy-makers in delivering health benefits and value for money in malaria control.

This study uses a 3-arm cluster randomised design to evaluate interventions to support the roll-out of malaria rapid diagnostic tests. In the control arm, the tests were supplied and providers were shown how they should be used. In the provider intervention arm, rapid diagnostic tests were also supplied and providers received two-day training and monthly support visits. In the third arm, the provider intervention was supplemented by a school-based intervention to raise community awareness about malaria. Raising awareness in the community was important in this setting as many people go to pharmacies, drug stores and public health centres for malaria treatment, and often ask for specific medicines.

The two-day provider training sought to improve health workers’ knowledge and skills on why it is important to test for malaria and how to use rapid diagnostic tests.  The training was supplemented by monthly support visits. The school-based intervention took place at primary and secondary schools and involved training teachers and establishing peer health educators. Schools were supported to hold events in the community which used drama, songs, card games and health talks to raise awareness about diagnosing malaria using rapid diagnostic tests and about ACT being the recommended malaria drug treatment.

The REACT studies in Cameroon and Nigeria will provide an important basis for comparison across different types of health care providers (both private and public), different health care delivery and financing systems and different treatment seeking practices by ethnic and socioeconomic groups. Perhaps most interesting, these intervention trials will allow comparison between sites where currently microscopy testing is widely available (Cameroon) and where the use of any form of malaria diagnostic testing is extremely limited (Nigeria). 

The research team

Principal Investigators

  •  Dr. Virginia Wiseman, London School of Hygiene & Tropical Medicine 


  • Dr Obinna Onwujekwe, College of Medicine, University of Nigeria 



Other Investigators

  • Dr Wilfred Mbacham, University of Yaounde, Cameroon
  • Mrs Lindsay Mangham-Jefferies, London School of Hygiene & Tropical Medicine
  • Dr Clare Chandler, London School of Hygiene & Tropical Medicine
  • Ms Bonnie Cundill, London School of Hygiene & Tropical Medicine
  • Prof BSC Uzochukwu, University of Nigeria
  • Ms Ogo Ibe, University of Nigeria
  • Mr Emmanuel Nwala, University of Nigeria
  • Dr Eloka Uchegbu, University of Nigeria
  • Mrs Chinelo Enemuo, University of Nigeria

Research Themes

Related Publications

Exploring health providers’ and community perceptions and experiences with malaria tests in South-East Nigeria: a critical step towards appropriate treatment

Ogochukwu P Ezeoke, Nkoli N Ezumah, Clare CI Chandler, Lindsay J Mangham-Jefferies, Obinna E Onwujekwe, Virginia Wiseman and Benjamin S Uzochukwu  |  Published
Malaria Journal

A cost-effectiveness analysis of provider and community interventions to improve the treatment of uncomplicated malaria in Nigeria: study protocol for a randomized controlled trial

Virginia Wiseman, Ogochukwu Ezeoke, Emmanuel Nwala, Lindsay J Mangham, Bonnie Cundill, Jane Enemuo, Eloka Uchegbu, Benjamin Uzochukwu and Obinna Onwujekwe  |  Published
Trials Journal

Treatment of uncomplicated malaria at public health facilities and medicine retailers in southeastern Nigeria

Lindsay J Mangham, Bonnie Cundill, Ogochukwu Ezeoke, Emmanuel Nwala, Benjamin SC Uzochukwu, Virginia Wiseman and Obinna Onwujekwe  |  Published
Malaria Journal

What determines providers' stated preference for the treatment of uncomplicated malaria?

Lindsay Mangham-Jefferies, Kara Hanson, Wilfred Mbacham, Obinna Onwujekwe, Virginia Wiseman  |  Published
Social Science & Medicine

The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action

Joanna R, Deborah D, Lindsay M, Evelyn A, Sham L, Hilda M, Katia B, Jayne W, Lasse V, Shunmay Y, Toby L, Eleanor H, Hugh R, David L, David S, Bonnie C, Sarah S, Virginia W, Catherine G, Clare C  |  Published
Implementation Science

Economic evaluation of a cluster randomized trial of interventions to improve health workers’ practice in diagnosing and treating uncomplicated Malaria in Cameroon

Lindsay Mangham-Jefferies, Virginia Wiseman, Olivia A. Achonduh, Thomas L. Drake, Bonnie Cundill, Obinna Onwujekwe, Wilfred Mbacham  |  Published
Value in Health

Mind the gap: Knowledge and practice of providers treating uncomplicated malaria at public and mission health facilities, pharmacies and drug stores in Cameroon and Nigeria

Lindsay Mangham-Jefferies, Kara Hanson, Wilfred Mbacham, Obinna Onwujekwe, Virginia Wiseman  |  Published
Health Policy and Planning

Quality of care for the treatment for uncomplicated malaria in South-East Nigeria: how important is socioeconomic status?

Ogochukwu P Ibe, Lindsay Mangham-Jefferies, Bonnie Cundill, Virginia Wiseman, Benjamin S Uzochukwu, Obinna E Onwujekwe  |  Published
International Journal for Equity in Health

Effectiveness of provider and community interventions to improve treatment of uncomplicated malaria in Nigeria: A cluster randomized controlled trial

Obinna Onwujekwe, Lindsay Mangham-Jefferies, Bonnie Cundill, Neal Alexander, Julia Langham, Ogochukwu Ibe, Benjamin Uzochukwu, Virginia Wiseman  |  Published

Examining intervention design: lessons from the development of eight related malaria health care intervention studies

Clare I.R. Chandler*, Helen Burchett, Louise Boyle, Olivia Achonduh, Anthony Mbonye, Deborah DiLiberto, Hugh Reyburn, Obinna Onwujekwe, Ane Haaland, Arantxa Roca-Feltrer, Frank Baiden, Wilfred F. Mbacham, Richard Ndyomugyenyi, Florence Nankya, Lindsay Man  |  Published
Health Systems and Reform

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