SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Prompt access to diagnosis and treatment with effective antimalarial drugs is a central component of malaria control. Home- or community-based programmes for managing malaria are one strategy that has been proposed to overcome the geographical barrier to malaria treatment. In these programmes people living in rural settings, such as mothers, volunteers, or community health workers, are trained to recognise fever and provide antimalarial medicines at a low cost or for free.
Key messages
Home- or community-based programmes for treating malaria
− probably increase the number of children who are treated promptly with an effective antimalaria medicine
− probably reduce all-cause mortality
− may have little or no effect on the prevalence of anaemia
The effects of home- or community-based programmes for treating malaria on hospitalisations, severe malaria, the prevalence of parasitaemia, and adverse effects are uncertain.
The use of rapid diagnostic tests in home- or community-based programmes for treating malaria, compared to clinical diagnosis
− probably reduces the number of children treated with antimalarials
− may have little or no effect on all-cause mortality and hospitalisations
The effects of using rapid diagnostic tests in home- or community-based programmes for treating malaria on treatment failures, severe malaria, the prevalence of parasitaemia, anaemia, and adverse effects are uncertain.
Okwundu CI, Nagpal S, Musekiwa A, Sinclair D. Home- or community-based programmes for treating malaria. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009527. DOI: 10.1002/14651858.CD009527.pub2.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Malaria is a major public health problem, especially in Africa where an estimated 400 to 900 million episodes of fever occur each year. Prompt treatment using effective antimalarial therapy is essential to reduce malaria morbidity and mortality. However, the effectiveness of malaria treatment is limited by the lack of adequate healthcare infrastructure in parts of Africa. For this reason, home- or community-based management of malaria has been promoted as a key strategy for delivering more timely – and therefore more effective – malaria treatment. The strategy has been adopted by the World Health Organization as a cornerstone of its efforts to control malaria in African countries.
| Review objectives: To evaluate home- and community-based management strategies for treating malaria | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effects of a home- or community-based programme for treating malaria |
7 randomised trials and 3 controlled before-after studies. In all 10 studies, the intervention involved training low-level health workers or mothers to give antimalarials provided free or at a highly-subsidised cost. 8 studies compared presumptive treatment of all episodes of fever to standard (facility-based) care. 2 studies compared home- or community-based programmes using rapid diagnostic tests to confirm malaria with programmes using presumptive treatment. |
| Participants | People living in a malaria endemic setting |
7 studies targeted children aged less than six years, and 3 studies treated all age groups. |
| Settings | Malaria endemic settings |
Kenya (2 studies), Tanzania (2), Uganda (2); Burkina Faso, DR Congo, Ethiopia, Zambia (1 study in each country) |
| Outcomes |
Primary: all-cause mortality Secondary: malaria-specific mortality, hospitalisations, severe malaria, recommended treatment within 24 hours, any antimalarial treatment, parasitaemia, anaemia, adverse events |
For home- or community-based programmes versus facility-based care: all-cause mortality (1 study), hospitalisations (1), prompt treatment (2), parasitaemia (2), anaemia (3) For using rapid diagnostic tests versus clinical diagnosis: all-cause mortality (2), hospitalisations (1), treatment with an antimalarial (2), treatment failure at day 7 (2) |
| Date of most recent search: September 2012 | ||
| Limitations: This was a well-conducted systematic review with only minor limitations. | ||
Okwundu CI, Nagpal S, Musekiwa A, Sinclair D. Home- or community-based programmes for treating malaria. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009527. DOI: 10.1002/14651858.CD009527.pub2.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Eight studies compared home- or community-based management of malaria to standard (facility-based) care. The intervention in all eight studies included training low-level health workers or mothers to give antimalarials, providing antimalarials free or at a highly-subsidised cost, and presumptive treatment of all episodes of fever.
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Home- or community-based programmes for treating malaria versus facility-based care |
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People Children with fever or malaria symptoms Settings Malaria endemic areas Intervention Home- or community-based programmes Comparison Standard care |
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Outcomes |
Absolute effect* |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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|
Without |
With based programmes |
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|
50 per 1000 |
29 per 1000 |
RR 0.58 (0.44 to 0.77) |
Moderate |
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Difference: 21 fewer deaths per 1000 children (Margin of error: 11 to 28 fewer) |
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|
Hospitalisations |
230 per 1000 |
145 per 1000 |
RR 0.63 (0.35 to 1.17) |
Very low |
|
|
Difference: 85 fewer hospitalizations per 1000 children (Margin of error: 149 fewer to 39 more) |
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Prompt treatment with an effective antimalarial |
100 per 1000 |
469 per 1000 |
RR 4.69 (1.00 to 22.07) |
Moderate |
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Difference: 369 more treated promptly per 1000 children (Margin of error: 0 to 900 more) |
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Prevalence of parasitaemia |
Mixed results |
Mixed results |
Very low |
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Prevalence of anaemia |
44 per 1000 |
59 per 1000 |
RR 1.33 (0.70 to 2.51) |
Low |
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Difference: 15 more children with anaemia per 1000 (Margin of error: 13 fewer to 66 more) |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) * The risk WITHOUT the intervention is based on the median or mean control group risk across studies. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval). |
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Home- or community-based programmes for treating malaria that use rapid diagnostic tests compared to ones that do not:
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Home- or community-based programmes using rapid diagnostic tests versus clinical diagnosis |
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People Children with fever or malaria symptoms Settings Malaria endemic areas Intervention Home- or community-based programmes using rapid diagnostic tests Comparison Home- or community-based programmes using clinical diagnosis |
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Outcomes |
Absolute effect* |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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|
Without |
With |
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All-cause mortality |
1 per 1000 |
2 per 1000 |
RR 3.51 (0.68 to 18.22) |
Low |
|
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Difference: 1 more death per 1000 children (Margin of error: 1 less to 10 more) |
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Hospitalisations |
7 per 1000 |
2 per 1000 |
RR 0.25 (0.04 to 1.50) |
Low |
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Difference: 5 fewer hospitalizations per 1000 children (Margin of error: 7 fewer to 4 more) |
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Treatment with an antimalarial |
980 per 1000 |
382 per 1000 |
RR 0.39 (0.18to 0.84) |
Moderate |
|
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Difference: 598 fewer treated per 1000 children (Margin of error: 804 fewer to 157 fewer) |
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Treatment failure at day 7 |
Mixed results |
Mixed results |
Very low |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) * The risk WITHOUT the intervention is based on the median control group risk across studies. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval). |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| All of the studies were conducted in malaria-endemic African countries. |
The findings of the review are applicable to low-income countries. |
| EQUITY | |
| No data regarding the differential effect of the intervention for disadvantaged populations was provided. |
Home- and community-based programmes for treating malaria probably reduce inequities when implemented in underserved rural areas. |
| ECONOMIC CONSIDERATIONS | |
| The included studies did not provide any data on the costs of home- and community-based programmes for treating malaria. |
Local costing studies should be considered prior to implementing home- and community-based programmes for treating malaria. Costs include training costs, antimalarial costs, the cost of rapid diagnostic tests if used, and lay health worker time. |
| MONITORING & EVALUATION | |
| The certainty of the evidence varies from very low to moderate. |
Consideration should be given to evaluating the effects of planned home- and community-based programmes for treating malaria before scaling them up. Adverse events, severe malaria, malaria-specific mortality, and costs should be monitored and evaluated, in addition to all-cause mortality and prompt access to antimalarials. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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World Health Organization. Global Fund – funding proposal development – WHO policy brief 2016. Geneva: World Health Organization, 2016. http://www.who.int/malaria/publications/atoz/who-policy-brief-2016/en/
World Health Organization. Guidelines for the treatment of malaria. Third edition. Geneva: World Health Organization, 2015. http://www.who.int/malaria/publications/atoz/9789241549127/en/
Andrea Basagoitia. EVIPNet Unit at the Strategic Development Department in the Ministry of Health, Santiago, Chile
None known. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Tomas Pantoja, Atif Riaz, and Newton Opiyo.
Basagoitia A. Do home- or community-based programmes for treating malaria improve health outcomes? A SUPPORT Summary of a systematic review. March 2017. www.supportsummaries.org
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, home management, community-based programmes, malaria
