Monitoring Outpatient Malaria Case Management Policy in Kenya

- Baseline Results-
This report presents results of the first survey planned as a biannual monitoring exercise aiming to timely inform national policy makers, and donor organizations, on the case management progress of the new NMS.

Effective malaria case management based on confirmed parasitological diagnosis and artemisinin based combination therapy (ACT) is one of the cornerstones of the recently launched National Malaria Strategy (NMS) in Kenya.

By 2009, all 42 African malaria endemic countries had changed their policies to support ACT use for uncomplicated malaria. Furthermore, 20 countries had adopted policies promoting all-age group parasitological diagnosis using malaria microscopy and rapid diagnostic tests (RDTs) (WHO 2009). Policies in other African countries are under the revision to support parasitological diagnosis. These changes in malaria case management policy represent some of the most significant public health
developments in malaria control for decades.

Prior to the large scale implementation activities aiming at universal availability of ACTs and diagnostics, universal coverage of health facilities and health workers with health systems support activities and universal health worker's adherence to the new malaria case management guidelines, the baseline survey was undertaken at public health facilities nationwide.

The main objectives of the survey were assessment of the availability of malaria case management commodities and the quality of outpatient case management practices in accordance with new national guidelines for uncomplicated malaria recommending parasitological testing of febrile patients, treatment of only test positive results with a recommended ACT - artemether-lumefantrine (AL), and the provision of dispensing and counseling tasks for patients treated with AL.

CONCLUSIONS AND RECOMMENDATIONS
The findings of this national survey reveal that most of the key indicators measured in this study are well below the 2013 optimistic targets aiming at universal availability of malaria case management commodities, universal coverage of health facilities and health workers with malaria related health systems support activities and universal health worker's adherence to national outpatient guidelines for malaria diagnosis, treatment, counseling, and drug dispensing. These findings should be primarily viewed as the baseline information identifying major gaps prior to the forthcoming implementation activities under the new National Malaria Strategy.

In addition to providing baseline information for the new NMS, the findings highlight a series of lessons learned during the past policy implementation that should inform the future case management activities to improve upon the quality of the implementation process.

Recommendations:
Alongside the implementation of parasite based diagnosis the following case management messages should be emphasized during the in-service trainings and reinforced during the supervisory visits:
1) All febrile patients should be tested,
2) Test positive patients should not be treated with combined AL and quinine treatment but only with AL,
3) Test negative patients should not be treated for malaria,
4) Weighing of all patients, and in particular children, should be systematically performed,
5) The first AL dose should be administered at facilities even in the absence of food, and
6) Patients and caretakers should be advised to return for replacement dose to complete full treatment course in case of vomiting.

Memusi D, Nyandigisi A, Mbithi A, Shieshia M, Muturi A, Zurovac D, Juma E. Monitoring outpatient malaria case management under the 2010 diagnostic and treatment policy in Kenya-baseline results. Division of Malaria Control, Ministry of Public Health and Sanitation, June 2010.

Authors
Dorothy Memusi, Agneta Mbithi, Andrew Nyandigisi, Mildred Shieshia, Alex Muturi,
Dejan Zurovac, Elizabeth Juma