# Quality of inpatient test-and-treat malaria case-management in public and private hospitals in Kano State, Nigeria

## TL;DR

This study assesses how well hospitals in Nigeria follow malaria testing and treatment guidelines, finding significant variation in performance between public and private hospitals and among patient age groups.

## Contribution

The study provides a detailed cross-sectional assessment of inpatient malaria case-management quality in public and private hospitals in Kano State, Nigeria.

## Key findings

- Composite test-and-treat performance was 39.3%, with higher rates in children and public hospitals.
- Only 30.0% of artesunate-treated patients received ACT, with notable differences between adults and children and between hospital sectors.
- Routine microscopy showed high sensitivity but low specificity compared to expert readings.

## Abstract

Compliance with evidence-based treatment guidelines, supported by quality-assured parasitological diagnosis, is the mainstay of malaria case-management in Nigeria. However, despite increased attention, the quality of inpatient paediatric and adult, test-and-treat malaria case-management, and routine accuracy of malaria microscopy, has rarely been examined in public and private hospitals.

A cross-sectional assessment was undertaken at 18 public and private hospitals in September 2024 in Kano State, Nigeria. Data collection included hospital assessments, interviews with inpatient health workers, review of all paediatric and medical ward admission files for August 2024, and re-checking of routine malaria slides archived during the 3-month post-assessment period. Descriptive analyses included 18 hospitals, 72 health workers, 2,814 suspected malaria admissions, and 211 malaria slides.

Nearly all hospitals (94.4%) provided parasitological diagnostic services (microscopy or RDT) and stocked recommended antimalarials (injectable artesunate and ACT). Most health workers had received training on severe malaria (73.6%), but only 16.7% received supportive supervision. The composite test-and-treat performance was 39.3%, higher for children than adults (45.7% vs 26.5%) and in public compared to private hospitals (39.8% vs 30.8%). Among suspected malaria patients, 73.7% were tested on admissions and 90.2% of those with severe malaria were treated with artesunate. Children, compared to adults, were more commonly tested (79.8% vs 61.7%) and treated with artesunate (93.5% vs 80.1%). Patients in private hospitals, compared to public, were more often tested (84.3% vs 73.0%) but less frequently treated with artesunate (73.1% vs 91.2%). Only 30.0% of artesunate-treated patients were prescribed ACT—more commonly among adults than children (48.3% vs 23.0%) and in private than in public hospitals (89.2% vs 26.9%). ACT use for admitted non-severe cases was rare (2.4%), whereas non-compliance with test negative results was high (75.8%). The sensitivity, specificity, positive and negative predictive values of routine microscopy compared to expert readings were 93.2%, 42.5%, 29.9% and 95.9%, respectively.

Inpatient compliance with malaria test-and-treat guidelines varied between performance tasks, age groups, and hospital sectors. Clinicians can be confident in negative slides but should be cautious with positive results. Quality assurance of malaria diagnosis and continuous clinical and laboratory quality improvement interventions, with enhanced linkages, are needed.