Credit: Brant Stewart/RTI
Malaria is a leading health threat in Ethiopia, where more than two-thirds of the population lives in high-risk areas. It is the leading cause of outpatient visits and is a particularly deadly disease for children under five years of age and pregnant women. Hospitals and health centers in Ethiopia primarily use microscopy to diagnose malaria; however, assuring the quality of this testing has been a longstanding challenge. As a result, clinicians have largely treated patients with suspected malaria empirically, even when laboratory tests show a negative test result for malaria. This has lead to overuse of antimalarial drugs in some situations and delays in specific treatment for other causes of fever.
To meet Ethiopia’s ambitious goal of reducing malaria deaths by 70 percent, PMI and the Federal Ministry of Health (FMOH) have worked with implementing partners over the past 6 years in Ethiopia to strengthen laboratory diagnostic capacity and malaria case management at the national, regional, and health facility levels. An initial survey of the national program, health centers, and specialized laboratories revealed that most lacked adequate microscopes and supplies and had no standardized training programs for laboratory technicians. Only 24 percent of laboratory staff at these health facilities had received training in the previous year, and none of the laboratories surveyed had formal quality assurance or quality control protocols. In addition, there were no standard national malaria diagnostic guidelines or national malaria laboratory quality assurance guidelines.
Starting with Oromia Region, the President’s Malaria Initiative (PMI) supported training and capacity building in malaria diagnosis for laboratory professionals working in hospitals, health centers, clinics, and laboratories. A national training manual for malaria microscopy was developed, as well as an external quality assurance guideline for malaria laboratory diagnosis. Mr. Gemechis Mesfin, who directs laboratory services at Nedjo Hospital in Oromia, acknowledges, “We never knew anything about EQA [external quality assurance] activities before the training.”
In 2011, the program expanded its reach to three additional regions (Amhara, Tigray, and Southern Nations, Nationalities, and Peoples’ Region), thus increasing support from 57 to 371 health facilities. Of these, eight regional laboratories were strengthened through training in malaria microscopy and equipped with new microscopes, reagents, standardized microscopic slides, and other essential laboratory commodities. More than 150 professionals from regional and national reference laboratories took part in the initial training-of-trainers program in malaria microscopy and quality assurance. Further in-service training was then rolled out to an additional 1,400 laboratory personnel by the end of March 2014. This included a basic introduction to malaria-HIV laboratory diagnosis and practical skills, such as blood sample collection, smear preparation, staining, blood film examination, microscope maintenance, and HIV testing methods. A package of program-developed resources, including the malaria quality assurance guidelines, standard operating procedures, job aides, bench aides, and log sheets were provided to help standardize the quality of services and improve information management.
In addition to building laboratory capacity, the program developed an algorithm for managing fever and malaria patients and trained more 1,300 clinicians and program managers in its use, advancing one of the goals of Ethiopia’s National Strategic Plan for Malaria – to treat all confirmed malaria cases with appropriate antimalarial drugs and manage all severe cases according to the new treatment guidelines. With this intensive investment of resources to improve case management of malaria, 80 percent of all clinically suspected malaria cases are now laboratory confirmed in Ethiopia. In Oromia, where the intervention began, substantial gains have been made in reducing presumptive treatment of malaria from 99 percent in 2007 to 23 percent in 2013. Stronger national standards for quality control also have led to improved test accuracy, which reduces the misdiagnosis of malaria and unnecessary use of antimalarial drugs.