Biting Back at Malaria: Assessing Health‐service Providers' Compliance with Treatment Guidelines

• Author: Arndt Reichert,Alfredo Paloyo
• Published date: 01 August 2017
• Date: 01 August 2017
• DOI: http://doi.org/10.1111/rode.12283

Biting Back at Malaria: Assessing Health-service

Providers’ Compliance with Treatment Guidelines

Alfredo Paloyo and Arndt Reichert*

Abstract

Non-compliance with established medical treatment guidelines can have dire consequences for public

health and economic well-being. Based on the Demographic and Health Surveys, we examine malaria-

treatment practices of various health-care providers in sub-Saharan Africa, where more than 90% of

malaria-induced deaths occur. We estimate each provider’s likelihood (i) to comply with guidelines to

administer (effective) antimalarial drugs and (ii) to relieve children of fever—a symptom of malaria—

after having had a fever episode within the previous two weeks. Our results indicate that, relative to self-

medication, seeking treatment at most providers is positively associated with taking an antimalarial drug

and negatively associated with using only ineffective chloroquine. Non-traditional healers are also

associated with fever relief.

1. Introduction

Evidence-based treatment guidelines for diseases are regularly provided at the

national and international levels. At the national level, these guidelines are issued

either by the Ministry or Department of Health or by the professional regulatory

associations; multilateral bodies, such as the World Health Organization (WHO), also

prescribe how diseases should be treated. These guidelines are designed to improve

health care and outcomes and to lower the cost of service provision. Deviations from

the prescribed treatment protocol could result in ineffective and inefficient treatment.

For communicable diseases, insufficient compliance will likely contribute to the

spread of drug-resistant mutations of an infectious micro-organism. As such,

compliance with mandated guidelines is one indicator for the quality of health-service

provision (Hesdorffer et al., 2002; Karbach et al., 2011; Sekhon et al., 2013).

The present paper is concerned with the compliance of health-service providers

with international and national treatment guidelines for uncomplicated malaria.

1

While these guidelines have rightfully changed over time in response to new

evidence, declining prevalence and the increasing availability of rapid diagnostic

tests (RDT), our study time frame is primarily the period during which presumptive

treatment of childhood malaria was the prescribed protocol. Under such a regime,

*Paloyo: School of Accounting, Economics, and Finance, University of Wollongong (UOW), NSW, 2522,

Australia. Tel: +61-2-4221-3687; E-mail: apaloyo@uow.edu.au. Palovo is also a member of the Centre for

Human and Social Capital Research, University of Wollongong. Reichert: Development Research Group

(Impact Evaluation Team), The World Bank, Washington, DC, 20433,USA. This article was written

when both authors were primarily employed at the Rheinisch-Westf€

alisches Institut f€

ur

Wirtschaftsforschung (RWI). The support of Christoph Helbach, J€

org Peters, Emmanuel San Andres,

Maximiliane Sievert, Christoph Strupat, and participants of the German Health Economics Association

meeting in 2013, the research seminars of the RWI and the School of Accounting, Economics, and

Finance of UOW is gratefully acknowledged, as well as the comments and suggestions of two anonymous

reviewers and the editor, Prof Andy McKay. There are no conflicts of interest to declare. All views

expressed in this paper should be considered those of the authors alone and do not necessarily represent

those of the World Bank.

Review of Development Economics, 21(3), 591–626, 2017

DOI:10.1111/rode.12283

©2016 John Wiley & Sons Ltd

antimalarial drugs should be administered to children if they present with fever

even without a clinical confirmation of malaria. The rationale behind such a regime

in regions such as sub-Saharan Africa is that malaria is endemic to the area, with

transmission rates that are quite high. This implies that the most likely underlying

cause of a fever episode in children is malaria (Cohen et al., 2015), which should be

treated immediately to improve the likelihood of being cured. Current WHO

guidelines (2010) recommend “test and treat” (i.e. confirm the presence of the

malaria parasite in a febrile child), but this is only possible where RDT kits are

available or where access to trained personnel can lead to a confirmation.

In our study, we analyze the differences in febrile-child treatment practices

between self-treatment, traditional healers, private health-care providers and the

public sector in western sub-Saharan Africa. We specifically assess the treatment

provided to children below 5 years old who had fever within the previous two

weeks by comparing the use patterns of antimalarial drugs and fever-abatement

rates. We interpret the likelihood of taking effective antimalarial drugs for febrile

children as an indicator of overall quality because such adherence to treatment

guidelines is—in the words of an anonymous reviewer—”indicative of an

understanding, appreciation and commitment to evidence-based medicine.”

We contribute to the emergent development-economics debate on the quality of

medical care in two ways. First, we present a novel way to assess the overall quality

of medical care. While actual compliance with prescribed treatment guidelines as

an indicator of overall health-care quality is not novel per se (e.g. Nshakira et al.,

2002; WHO, 2003; Tavrow et al., 2003), we propose to leverage the use of

standardized household survey data such as the Demographic and Health Surveys

(DHS), which is available in over 90 countries, as opposed to conducting costly

provider interviews (e.g. Ebong et al., 2012).

2

For policymakers and practitioners

in the field of development, our analysis can be seen as another useful way to

assess the quality of health-services providers, one that is much cheaper than

administering, for example, clinical vignettes. Second, we present further empirical

evidence on the overall quality of health care in the developing world. Generally,

more evidence is needed to uncover areas where health systems fail so that

appropriate measures to strengthen the health system may be put in place (Berman

and Bitran, 2011).

The rest of the paper is structured as follows. Section 2 provides a discussion of

related research on treatment practices and describes how we advance the

literature. Section 3 contextualizes the issue of malaria in sub-Saharan Africa as

well as the treatment regimes that are currently in place. Section 4 briefly describes

the data and the study population while section 5 presents the estimation approach

and the results. Section 6 offers an a discussion of the the heterogeneity across

countries and over time before finally concluding in section 7.

2. Related Literature

Our understanding of the treatment practices of health-care providers and treatment-

seeking behavior of malaria-infected individuals is asymmetric. While our knowledge

of the latter is informed by a large body of evidence in the medical and social

sciences’ fields (e.g. see McCombie, 1996), how providers behave—especially their

treatment practices—is insufficiently explored in the existing literature. Indeed, as

Williams and Jones (2004, p. 511) point out, “little emphasis has been given to

examining how providers prescribe antimalarials.” Quality differences between

592 Alfredo Paloyo and Arndt Reichert

©2016 John Wiley & Sons Ltd

health-care providers presumably exist, but the magnitudes of these differences—to

our knowledge—have not always been explored with methodological rigor.

A few studies on antimalarial drug provision of different health-care providers (e.g.

Onwujekwe et al., 2009; Smith et al., 2010; Ebong et al., 2012) exist, but the evidence

is restricted to single countries and—owing to a regional focus within these countries

—are usually not representative of the population. Thus, the external validity that

arise out of these estimates is limited. We use the nationally representative

Demographic and Health Surveys (DHS) for eight West African countries (Benin,

Burkina Faso, Ghana, Guinea, Liberia, Mali, Niger and Nigeria), which allow us to

assess heterogeneity in febrile-child treatment practices across countries.

Some studies examine the compliance only of health professionals without

comparing them with traditional healers (Ughasoro et al., 2013). This is a significant

gap since evidence suggests that traditional healers may, under certain conditions,

be able to provide better health services to their patients. Leonard (2003) shows

that traditional healers could be better because of the nature of the contract

between the service provider and the patient. These contracts are typically

outcome-contingent—that is, a traditional healer will not get paid unless the desired

outcome (being cured) is achieved. Both the patient and the healer, therefore, will

have an incentive to increase their effort to be cured. The contract between the

patient and a health professional, however, is not contingent on being cured. In this

paper, we explicitly compare the outcomes achieved by the formal sector relative to

those achieved both by self-medication and going to traditional healers.

Understanding these quality differences is important because “in sub-Saharan

Africa, the pragmatic choice for prompt and effective treatment (especially for

uncomplicated malaria) currently lies outside the formal health sector” (Williams

and Jones, 2004, p. 514). Based on our dataset, the share of children undergoing

self-medication is about a fifth of the population of febrile children. In Burkina

Faso, for example, it is over 50%. Over 17% of febrile children in Benin go to a

traditional healer. While these health-care providers may be prompt at delivering

some type of medication, the effectiveness of these drugs is rightly questionable.

The extent to which these providers comply with national and international

treatment guidelines is an important measure to assess their quality.

To this end, we are the first who aim to extensively control for confounding factors,

such as the educational background of the guardians. The guardian’s education, for

example, is likely to be related to both health-care provider choice and knowledge of

effective malaria treatments. Thus, we mitigate spurious correlations better than

previous studies, which abstain from employing multivariate regressions and are

based merely on regional samples within a country. We also assess whether there

exists a socioeconomic gradient in the quality of malaria treatment across different

providers. We further examine differences in treatment practices across countries and,

hence, institutional settings. Similarly, we compare Ghana and Nigeria over two years

to give an indication of how different policy implementations affect treatment

practices. Although the countries we examine all belong to western sub-Saharan

Africa, national health institutions could potentially be quite different between

countries and this should be taken into account in the analysis.

3. Background

Malaria kills about 660,000 people each year. The majority of deaths (86%) occur

in children below 5 years of age. Approximately 1500 children die as a result of

BITING BACK AT MALARIA 593

©2016 John Wiley & Sons Ltd