Malaria Journal

Argaw et al. Malar J (2016) 15:352

DOI 10.1186/s12936-016-1402-7

RESEARCH Open Access

Improved malaria case management

in formal private sector through public
private partnership in Ethiopia: retrospective
descriptive study
Mesele D. Argaw*, Asfawesen GY. Woldegiorgis, Derebe T. Abate and Mesfin E. Abebe

Abstract 
Background:  Malaria is a major public health problem and still reported among the 10 top causes of morbidity and
mortality in Ethiopia. More than one-third of the people sought treatment from the private health sector. Evaluat-
ing adherences of health care providers to standards are paramount importance to determine the quality and the
effectiveness of service delivery. Therefore, the aim of this study was to evaluate the contribution of public private mix
(PPM) approach in improving quality of malaria case management among formal private providers.
Methods:  A retrospective data analysis was conducted using 2959 facility-months data collected from 110 PPM for
malaria care facilities located in Amhara, Dire Dawa, Hareri, Oromia, Southern Nation Nationalities and Peoples and
Tigray regions. Data abstraction formats were used to collect and collate the data on quarterly bases. The data were
manually cleaned and analysed using Microsoft Office Excel 2010. To claim statistical significance non-parametric
McNemar test was done and decision accepted at P < 0.05.
Results:  From April 2012–September 2015, a total of 873,707 malaria suspected patients were identified, of which
one-fourth (25.6 %) were treated as malaria cases. Among malaria suspected cases the proportion of malaria inves-
tigation improved from recorded in first quarter 87.7–100.0 % in last quarter (X2 = 66.84, P < 0.001). The majority
(96.0 %) were parasitologically-confirmed cases either by using microscopy or rapid diagnostic tests. The overall slid
positivity rate was 25.1 % of which half (50.7 %) were positive for Plasmodium falciparum and slightly lower than half
(45.2 %) for Plasmodium vivax; the remaining 8790 (4.1 %) showed mixed infections of P. falciparum and P. vivax. Adher-
ence to appropriate treatment using artemether-lumefantrine (AL) was improved from 47.8 % in the first quarter to
95.7 % in the last quarter (X2 = 12.89, P < 0.001). Similarly, proper patient management using chloroquine (CQ) was
improved from 44.1 % in the first quarter to 98.12 % in the last quarter (X2 = 11.62, P < 0.001).
Conclusions:  This study documented the chronological changes of adherence of health care providers with the
national recommended standards to treat malaria. The PPM for malaria care services significantly improved the
malaria case management practice of health care providers at the formal private health facilities. Therefore, regional
health bureaus and partners shall closely work to scale up the initiated PPM for malaria care service.
Keywords:  Malaria, Case management, Public private partnership, Formal private sector

*Correspondence: [email protected]
Private Health Sector Project, Abt Associates Inc. In Ethiopia, P. O.
Box 2372, 1250 Addis Ababa, Ethiopia

© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Argaw et al. Malar J (2016) 15:352 Page 2 of 11

Background [17]. This strategy was developed in line with the roll
Malaria is caused by the protozoan parasite of the genus back malaria (RBM) partnership’s Action and investment
Plasmodium and transmitted by Anopheles mosqui- to defeat malaria, to ensure shard goals and complemen-
toes. Globally, it is an important public health problem. tarity. The strategy has three main building blocks. The
According to the World Health Organization (WHO) first pillar is to ensure universal access to malaria pre-
global malaria report 2015, there were an estimated vention, diagnosis and treatment. The second pillar is
214 million in 2015 (range 194–303 million) cases. Most to accelerate efforts towards elimination of malaria and
of the estimated cases (88 %) occurred in WHO African the third pillar is to transform malaria surveillance into a
Region. In the same year, an estimated 438,000 deaths core intervention [17, 18].
were reported, mostly (90 %) in the African Region [1]. In many developing countries the private health sec-
In Ethiopia, malaria is a major public health problem. tor provides public health care and services for about one
Approximately over 50  million (60  %) of the population half of their population [1, 19, 20]. The situation in Ethio-
live in malaria endemic area, mainly at altitudes below pia is quite similar with other SSA countries [19]. How-
2000 m above sea level [2]. According to Ethiopian Fed- ever, very few studies were documented on the role of
eral Ministry of Health (EFMOH 2013/2014), there were private health facilities on malaria control and the quality
57,503 public sector malaria hospitalizations, 4.9 million of care in Ethiopia [21–23]. Jerne et  al. state that out of
malaria outpatient cases, and the majority 2.9  million 102 survey facilities in Oromia Regional State of Ethiopia,
were laboratory-confirmed Plasmodium falciparum out- 86.0  % were providing malaria diagnosis and treatment
patient malaria cases, and 1.2  million were Plasmodium services [21]. They also stated that the private health sec-
vivax cases [3]. tor were not part of malaria case management training
Malaria is a significant impediment to social and eco- and didn’t get opportunity to be familiar with the most
nomic development in Ethiopia. In endemic areas, resent recommendations [21, 22]. Moreover, there was no
malaria has affected the population during planting and strong established system to ensure the efficacy of drug

cost of full dose of artemether-lumefantrine (Coartem®)

harvesting seasons, cutting down productive capacity at a accessed through private sector [17]. On top of these, the
time when there is the greatest need for agricultural work.
The disease has also been associated with loss of earnings, available through the private sector was found to be high
low school attendance, and high treatment cost [3–5]. and challenges the affordability of services to the general
In the last 5  decades, Ethiopia has executed all three population.
WHO recommended malaria prevention and control Public Private Partnership (PPP) for malaria care ser-
strategies i.e. early diagnosis and prompt treatment, vec- vice in Ethiopia has been implemented by six Regional
tor control and epidemic prevention and control [4, 6]. State Health Bureaus and United State Agency for Inter-
Currently, malaria care services in public health facilities national Development (USAID) Funded Private Health
are offered free of charge at all three levels of the health Sector Programme (PHSP) (2009–2015). PHSP provided
care tier system. Despite the effort made by the govern- technical support for Regional Health Bureaus to take the
ment to improve access and quality of services in public leadership and stewardship on PPP and private facilities
health facilities, significant numbers of the community to be committed for the success of the national vision
members sought treatment from the private health sector ‘seeing malaria free Ethiopia’. One hundred ten private
[7–9]. health facilities engaged in the implementation of the
On one hand, evidences from countries with different malaria care services through initiated partnerships [19,
modality working with private health sector on malaria 24, 25].
case management revealed improved quality of services This retrospective study was conducted to analyse
[10–14]. On the other hand, there are reported challenges forty-two months’ health facility quarterly reports on
facing the health system due to unregulated private sec- malaria service delivery to assesses magnitude of cases
tor through poor adherence to the nationally recom- and adherence of health care workers on the national
mended standards for malaria case management [15, 16]. standards. The result of this study will be useful for
In the context of malaria elimination, working with the policy-makers, programme managers and health care
private health sector is essential to ensure complete and workers for evidence based decision for quality service
timely reporting of all malaria cases and ensuring access delivery.
to effective case management for people seeking treat-
ment from private providers [1]. WHO developed the Methods
Global technical strategy for malaria 2016–2030, which Study area
sets the most ambitious targets for reduction in malaria Ethiopia is located in the horn of Africa with an area
cases and deaths since the malaria eradication era began of estimated 1.1  million sq. km [26]. This data analysis
Argaw et al. Malar J (2016) 15:352 Page 3 of 11

covers five regional state and one city administration based organization) and the third group were work place
where over 54.5 million people live at risk of malaria [3]. facilities; with the goal of establishing effective public
private partnership for improving access to and demand
Process of establishing PPP for malaria care for quality public health services with affordable costs.
Private Health Sector Programme (PHSP) was a 6  years The malaria programme was implemented in 110 private
project (September 2009–September 2015), funded health facilities (Fig. 1) [24].
by United States Agency for International Develop-
ment (USAID). PHSP was the successor of Private Sec- Foundation
tor Project (PSP), which has piloted Public Private Mix PHSP has implemented its project using its programme
Directly Observed Therapy Short Course (PPM_DOTS) implementation strategies [24] with step ladder fashion
and Human Immuno-deficiency Virus (HIV) programs (Fig. 2). The first phase of the implementation strategy is
in Ethiopia and concluded with recommendation to scale dedicated to construct the foundation of PPP approaches.
up the approach to maximize the health impact of the PHSP has conducted preliminary discussions with all
partnership [19, 24, 25]. Regional State Health Bureaus (RHBs). Then, consensus
PHSP provided its technical support in the implemen- building workshops were held with delegates of public
tation of PPM for human immuno-deficiency virus (HIV) sector, private sector and other relevant stakeholders.
acquired immune deficiency syndrome (AIDS), tubercu- PHSP in collaboration with RSHBs conducted facility
losis (TB), malaria, family planning (FP), sexually trans- readiness assessment from January through September
mitted infections (STI) programmes for five regional 2012. Using a predetermined objective criteria like ser-
states and two city administrations namely: Amhara, vice integration, malaria case load, human resources,
Oromia, Tigray, Southern Nations Nationalities and Peo- willingness and commitment of private health facilities
ples (SNNP), Hareri Regions and Dire Dawa and Addis owners, 110 health facilities i.e. seven Primary (Lower
Ababa City Administration. Moreover, PHSP built the Clinics), 10 Hospitals, 37 Higher Clinics and 56 Medium
capacity of 342 private health facilities, primarily private Clinics were selected [24]. Moreover, Referral directory
for profit, followed by private not for the profit (faith were developed and distributed to all actors for smooth

Fig. 1  Map of location of Ethiopia in Africa and distribution of PPP for malaria care facilities. Map of study area with distribution of Public Private
partnership for malaria care health facilities in Ethiopia
Argaw et al. Malar J (2016) 15:352 Page 4 of 11

Fig. 2  Private health sector programme implementation strategies. Figure depicting the step ladder fashion implementation strategies followed by
the project which includes foundation, capacity building, service delivery, exit and continuous quality improvement cycles

networking. Therefore, this was the time which builds the Service delivery
capacity of public sector leadership and governance in The third and final steps are service delivery which
owning the partnerships at regional health bureaus and includes service initiation, advocacy, demand creation
its line structures. supervision and mentoring. On a quarterly basis, tech-
nical assistances for all facilities was provided by a team
Capacity building of malaria expert from Woreda health office, laboratory
Before commencing the PPP for malaria care services, quality officer, pharmacy mentor and programme offic-
PHSP provided a team based trainings for case, labora- ers. In addition, demands were created using 347 spot
tory and supply chain managers. The staff underwent health radio messages in five local languages i.e. Amharic,
4 days of malaria case management and malaria diagnosis Hareri, Oromiffa, Somali and Tigrigna, distribution of
methods trainings. The third person attended nationally 168,500 patient brochures and 29,000 posters [24].
recommended 3  day training on supply chain manage-
ment using standard operating procedure (SOP) for inte- Quality assurance
grated pharmaceutical logistics system (IPLS). PHSP adopt, print and distribute a set of malaria morbid-
In the implementation strategy after working on foun- ity and mortality register, comprehensive laboratory reg-
dation, capacity building would resume in the parameter ister, weekly reporting forms, national malaria guidelines
of clinical and non-clinical areas which include: training and job aids. Furthermore, joint supportive supervisions
for private health facility owners on business manage- were conducted on quarterly bases by a team of malaria
ment, signing of memorandum of understandings, link- experts from public sector, clinical officer, laboratory
ing facilities to public health supplies system and site quality officer and pharmacy mentor.
preparation. During the study periods 344 malaria case The established partnerships need commitment of pri-
managers were trained in twelve sessions. One hundred vate health facilities to serve the community only with
eighty five laboratory personnel were trained on malaria consultation and laboratory service fees. As per the signed
diagnosis, internal quality control (IQC), and external Memorandum of Understanding (MOU) with or between
quality assurance (EQA) furthermore 140 supply chain RHB, confirmed P. falciparum cases should get AL (Coar-
mangers were trained in five sessions. tem) for free of charge while P. vivax cases should be
Argaw et al. Malar J (2016) 15:352 Page 5 of 11

treated with chloroquine. In addition, the health facili- project activity permission to use the data were sought
ties are expected to document the result of IQC and EQA and obtained from Private Health Sector Project, Abt
results. Finally, the overall implementation of malaria case Associated Inc. in Ethiopia. Patient identifier information
detection and management is verified through continuous was not collected. As per the requirement of the public
quality improvement approaches [24]. health system summarized information’s were submitted
to six Regional Health Bureaus (RHBs) on quarterly and
Data collection methods and data quality annual bases.
This retrospective descriptive study [27] was conducted
to determine malaria prevalence and adherence of Results
health care providers to national standards using forty- Descriptive information
two months or 2959 facility-months data i.e. from April A complete set of 2959 months-facility malaria morbidity
2012–September 2015. The data were collected from 110 data were collected on quarterly bases from 110 malaria
Public Private Partnership (PPP) for malaria care facilities care services facilities located in six regional states of
located in six regional states of Ethiopia. Data were col- Ethiopia. Between the initiation of PPP for malaria care
lected using the pretested data abstraction form through services and September 2015, a total of 873,707 malaria
reviewing primary source from comprehensive labora- suspected patients were identified, of which 223,293
tory and malaria morbidity registers which consists of (25.6 %) were treated as malaria cases. Almost all 214,259
age, sex, date seen at health facility, diagnosis, treatment, (96.0  %) were parasitological confirmed either using
history of admission, referral and outcome of admitted microscopy or malaria RDTs. The rest 9034 (4.0 %) were
malaria patients. The tool has facility identifiers, data col- diagnosed by clinical signs or symptoms as presumed
lection period and detail malaria case information. malaria cases (Table 1).
In all PHSP supported private health facilities, malaria The majority (63.7 %) of malaria suspected cases were
was diagnosed using standard operating procedure either served at medium clinics, followed by higher clinics
using Giemsa (3 or 10 %) stained blood film or multi spe- (18.7 %). The third largest group of patients (13.8 %) was
cies malaria rapid diagnostic test kits (RDT). Only pri- served in lower clinics and the rest of malaria suspected
mary clinics (lower clinics) were expected to use RDTs to cases (3.8 %) were served in Hospitals.
diagnose malaria. The data were collected by nine team The majority 133,876 (60.0 %) of malaria patients were
composed of trained twenty four public health profes- males. However, this gender difference in utilization of
sionals (regional programme coordinators and program the service among malaria patient increased when the
officers) and the data quality were ensured through reg- age group increased from lower to next higher age cate-
ularly conducted data quality assessment by continuous gory. Two-third (68.9 %) were patients in the age category
quality improvement experts. The teams found margins 15  years old or more, followed by 15.8  % were children
of errors of less than 3 % [20]. 5–14  years old and the rest 15.2  % were under 5  years
old children (Table  2). The majority 87.1  % of malaria
Data analysis suspected cases was serviced in private for profit facili-
The summaries of quarterly reports were transferred ties, followed by 9.7 % of malaria suspected patients were
to continuous quality improvement team through served in workplace facilities (Fig. 3).
Open Data Kit (ODK) using smart phones. For statisti-
cal analysis the data were exported to Microsoft Excel Malaria diagnosis
2010. The data were cleaned and checked for consisten- The malaria microscopy slide positivity rate was 24.5  %
cies. Descriptive statistical analysis [27] (Frequency dis- (198,066/807,275). Almost half of confirmed cases
tribution and line graphs for trend analysis) were made. (50.4  %) were P. falciparum, 45.6  % were P. vivax (and
Botma et  al. [28] recommended a non-parametric sta- the rest (4.1 %) were mixed species P. falciparum/P. vivax
tistical analysis, McNemar Chi square test for paired or infections (Table 3). The malaria RDT positivity rate was
dependent proportions. For this retrospective descriptive 36.2  %. The Plasmodium species identified using RDT:
study, McNemar’s test is selected, where each nominal 55.0 % were P. falciparum, 40.2 % were P. vivax, and 4.7 %
data in the first quarter was paired with the last quarter were mixed infections (Table 4). The overall malaria para-
data. Statistically significant relationship was claimed at site detection rate (either using microscopy or RDT) was
P < 0.05 [28]. 25.1 % (214,259/851,994). And the proportion of Plasmo-
dium species confirmed in PPP facilities consists of 50.7 %
Ethical clearance were P. falciparum, 45.2  % were P. vivax and 4.1  % were
The research protocol of this retrospective study was not mixed infections (Table  3). Making malaria diagnosis
reviewed by research ethics committee. As one of the according to the national standards with parasitological
Argaw et al. Malar J (2016) 15:352 Page 6 of 11

Table 1  Malaria suspected, parasitological confirmed and clinically identified malaria cases in Ethiopia, April 2012–Sep-
tember 2015
Years Malaria suspected Investigated % Malaria cases (con- % Confirmed malaria % Clinical malaria %
cases for malaria firmed + clinical)a cases cases

2012 (1) 71,800 62,455 87.0 26,817 37.3 24,698 92.1 2119 7.9
2013 (2) 292,986 288,225 98.4 89,985 30.7 84,080 93.4 5905 6.6
2014 (3) 336,250 328,760 97.8 74,566 22.2 73,673 98.8 893 1.2
2015 (4) 172,671 172,554 99.9 31,925 18.5 31,808 99.6 117 0.4
Grand total 873,707 851,994 97.5 223,293 25.6 214,259 96.0 9034 4.0
a 2 2 2
 χ  = 14.061, df = 3, χ /df = 4.69, P (χ  >14.061) = 0.0028

Table 2  Distribution of malaria by age, sex and pregnancy status in Ethiopia, April 2012–September 2015
Year 0–4 years 5–14 years 15 + years Males Females
M F M F M F Freq. % Freq. %

2012 (1) 2495 1813 2361 1862 10,490 7796 15,346 57.2 11,471 42.8
2013 (2) 8207 6282 8910 6434 35,987 24,165 53,104 59.0 36,881 41.0
2014 (3) 6145 4685 6260 4832 32,830 19,814 45,235 60.6 29,331 39.3
2015 (4) 2296 1708 2468 1918 15,427 8108 20,191 63.2 11,734 36.7
Grand total 19,143 14,488 19,999 15,046 94,734 59,883 133,876 60.0 89,417 40.0

workers to the standards of P. falciparum (AL) infec-

tion treatment was improved from 47.8 % (2501/5223) to
95.7  % (3417/3567) in the last quarter (July–September
2015) with wide range from 56.0 to 95.1 % achievements
for the rest of the quarters (Fig.  5). Similarly, adherence
to P. vivax treatment (CQ) was 44.1 % (1425/3225) in the
first quarter and 98.1  % (3295/3358) in the last quarter
with range 76.3–100.0  % of performance was recorded
within the study period (Fig.  6), respectively. The tem-
poral changes of improvements in treatment adherence
with the national recommended standards were evalu-
ated using with non- parametric statistics McNemar’s
test. Computing the changes in improvement of malaria
management of the first against the last quarter for AL
and CQ was found statistically significant at P  <  0.001
(Table 4).
Fig. 3  Pie chart depicted proportion of malaria care services
beneficiaries by ownership of facilities, April 2012–September 2015 Discussion
(n = 223, 293) This study determined the magnitude of malaria among
self-reported suspected cases in PPP for malaria care
facilities from April 2012 through September 2015 in
confirmation was significantly improved from 87.7  % six regional states of Ethiopia. The study describes the
during the first 3  months to almost 100.0  % in the last prevalence of Plasmodium species, service beneficiar-
3  months, and PPP for malaria care facilities showed up ies by age category, sex and years. In addition, the study
their commitment with sustaining the results (Fig. 4). documented the significant improvement in adherence
of health care providers with national standards recom-
Malaria case management mended for diagnosis and treatment.
In this study, at the time of initiation of PPP for malaria The majority 96.0  % of malaria patients treated
care service (April–June 2012) adherence of health in selected 110 PPP for malaria care facilities were
Argaw et al. Malar J (2016) 15:352 Page 7 of 11

Table 3  Malaria parasite detection rates using either Microscopy or RDT in PPP facilities Ethiopia, April 2012–September
2015
Year Test type Test done Positive Prevalence % Pf Pf % Pv Pv % Mixed Pf/Pv Mixed %

2012 (1) BF 60,727 23,925 39.4 12,825 53.6 9503 39.7 1597 6.7
RDT 1728 773 44.7 415 53.7 291 37.6 67 8.7
BF and RDT 62,455 24,698 39.5 13,240 53.6 9794 39.7 1664 6.7
2013 (2) BF 271,680 77,404 28.5 38,936 50.3 34,362 44.4 4106 5.3
RDT 16,545 6676 40.4 3955 59.2 2558 38.3 163 2.4
BF and RDT 288,225 84,080 29.2 42,891 51.0 36,920 43.9 4269 5.1
2014 (3) BF 307,573 66,407 21.6 34,264 51.6 30,385 45.8 1758 2.6
RDT 21,187 7266 34.3 4185 57.6 2673 36.8 408 5.6
BF and RDT 328,760 73,673 22.4 38,449 52.2 33,058 44.9 2166 2.9
2015 (4) BF 167,295 30,330 18.1 13,768 45.4 15,998 52.7 564 1.9
RDT 5259 1478 28.1 356 24.1 995 67.3 127 8.6
BF and RDT 172,554 31,808 18.4 14,124 44.4 16,993 53.4 691 2.2
Sub total BF 807,275 198,066 24.5 99,793 50.4 90,248 45.6 8025 4.1
Sub total RDT 44,719 16,193 36.2 8911 55.0 6517 40.2 765 4.7
Grand total 851,994 214,259 25.1 108,704 50.7 96,765 45.2 8790 4.1
Annual summary are presented with italics font

parasitological confirmed either using microscopy or whole country [32], and might be ascribed to the imple-
RDT. This finding is a little higher than the national mented twelve steps PHSP strategies which ensure the
estimated 60.0 and 84.1  % confirmed malaria patient quality of services [24]. The average SPR was 25.1 %. This
treated in private and public health facilities in Ethiopia, finding was a little higher than the national estimated
respectively [3, 22]. This successful achievement could slide positivity rate 19.0  % [3]. However, Chala and Per-
be related to the effective intervention (technical sup- tos [5] for the period ranges from 2001 to 2005 reported
port, joint supportive supervisions, team trainings, men- overall SPR was 30.9  % in Finchaa Sugar Plantation and
torships and access to supplies) made by the RHBs and Factory site in Ethiopia [5].
PHSP. In Ethiopia, the two dominant Plasmodium species
This study revealed that 60  % of malaria patients sur- known for causes of malaria infection with annual preva-
veyed in PPP for malaria facilities were males. But this lence were 60–70 % P. falciparum and 30–40 % P. vivax
difference significantly reduced when the age of patients [2, 4]. Whereas, in this study, almost one half (50.0  %)
falls in the lower age category. This finding is in line with were found to be for P. falciparum and 46.0 % were con-
Yukich et  al. [29] and Regassa [30] describe the pres- firmed P. vivax. This research documented a significant
ence of higher risk of malaria infection among adults and difference in proportion of Plasmodium species identi-
males in Ethiopia. On the other hand adult males might fied using RDT compared to microscopy. The magni-
have better economic position and decision power in tude of P. falciparum among patients diagnosed using
seeking medical care than females [5]. In Kenya, a result RDT groups was much higher than patients identified
of large national survey documented females are 1.4 using microscopy. Studies reported wide range of differ-
times more likely acquire to malaria than males [31]. ence in prevalence of Plasmodium species for example
The majority of service beneficiary were accessed in North Western Ethiopia 90.0  % P. falciparum were
malaria care services from private for profit health facili- documented in 10 years data from Metema Hospital [33],
ties. In addition, close to one out of ten patients were while Regassa (2014) found 64 % P. falciparum and 25 %
served in Private not for the profit; workplace health P. vivax in SNNP, Arbamich hospital [29].
facilities. This result could be due to the fact that the Figures  4 and 5 depicted the trends of appropriate
larger groups of PHSP supported facilities are Private for malaria case management to presumed diagnosis, P. fal-
Profit facilities [24]. ciparum or mixed, and P. vivax infections, respectively.
The trend of SPR significantly decreases from 39.4 % in The temporal changes in adherence to recommended
the first quarter to 18.4 % in the last quarter (X2 = 4.69, treatment for presumed diagnosis, P. falciparum or
P < 0.001). This significant level of result might be attrib- mixed infection was improved from 47.8  % in the first
uted to the reduction in burden of malaria across the quarter to 95.7 % in the last quarter. Similarly, adherence
Argaw et al. Malar J (2016) 15:352 Page 8 of 11

Table 4  Number of regions, health facilities, adherence to laboratory investigation and recommended treatment (April
2012–September 2015)
Time/quarter Number Malaria lab test % Positive labo- % Appropriate % Appropriate %
of active done ratory test AL (Coarterm) CQ (Chloro-
regions quine)
Private health Malaria sus- Malaria lab AL illegible CQ illegible
facilities pected test done

Apr–Jun 2012 2 17,984 87.77 7220 40.15  2501 47.88  1425 44.19 
39 20,489 17,984 5223 3225
Jul–Sep 2012 3 44,471 86.67 17,478 39.30  9648 81.76  6569 100.00 
57 51,311 44,471 11,800 6569
Oct–Dec 2012 3 67,511 96.67 24,569 36.39  10,750 68.22  7293 76.36 
57 69,834 67,511 15,758 9551
Jan–Mar 2013 4 69,091 98.61 18,037 26.11  6982 56.08  6483 70.40 
77 70,062 69,091 12,449 9209
Apr–Jun 2013 4 78,297 99.61  20,216 25.82  9825 86.25  6706 71.01 
78 78,606 78,297 11,391 9444
Jul–Sep 2013 5 73,326 98.44  21,258 28.99  10,076 74.82  5727 65.71 
88 74,485 73,326 13,467 8716
Oct–Dec 2013 6 96,721 93.40  27,901 28.85  14,373 85.65  9507 83.81 
100 103,551 96,721 16,781 11,344
Jan–Mar 2014 6 85,498 99.83  17,357 20.30  8897 99.02  8421 98.84 
110 85,645 85,498 8985 8520
Apr–Jun 2014 6 72,869 99.79  12,552 17.23  6108 97.43  6320 98.11 
110 73,019 72,869 6269 6442
Jul–Sep 2014 6 73,673 99.51  15,863 21.53  9082 95.87  6699 99.22 
99 74,035 73,673 9473 6752
Oct–Dec 2014 4 51,875 99.91  12,255 23.62  5402 81.99  5354 93.68 
41 51,924 51,875 6589 5715
Jan–Mar 2015 4 42,766 99.96  6526 15.26  2167 98.10  4264 98.41 
43 42,782 42,766 2209 4333
Apr–Jun 2015 4 37,546 99.86  6103 16.25  2442 95.13  3587 100.00 
43 37,597 37,546 2567 3587
Jul–Sep 2015 4 40,367 100.00  6924 17.15  3417 95.79  3295 98.12 
43 40,368 40,367 3567 3358
Total 851,995 97.51  214,259 25.15  101,670 80.35  81,735 84.47 
873,708 851,995 126,528 96,765
McNemar’s test 66.84 P < 0.001 26.67 P < 0.001 12.89 P < 0.001 11.62 P < 0.001

to P, vivax infection was improved from 44.1  % in the Limitations

first quarter and 98.1  % in the last quarter. This finding This retrospective descriptive study was made based on
was much higher than the baseline survey conducted collected data for Health Information System. This study
by Argaw (2015) in Ethiopia. However, there are several unable to determine and analyse other socio demographic
studies documented improvements in adherence to the characteristics of the clients and other aspects of quality
standards [10–14, 34–36]. service delivery such as provider client interaction.
Argaw et al. Malar J (2016) 15:352 Page 9 of 11

Fig. 4  Line chart showing the proportion of confirmed malaria cases treated by region, 2012–2015

Fig. 5  Trends of appropriate treatment using AL (Coartem®) in PPP malaria facilities, Ethiopia, 2012–2015. Line graphs showing adherence of health
care providers to the nationally recommended treatment for Plasmodium falciparum malaria, mixed malaria and clinical diagnosis malaria
Argaw et al. Malar J (2016) 15:352 Page 10 of 11

Fig. 6  Trends of appropriate treatment using chloroquine (CQ) in PPP malaria facilities, Ethiopia, 2012–2015

Conclusions 663-A-00-09-00434-00. The authors are grateful to the USAID funded Private
Health Sector Program for the permission given to this research. We are
This study documented the chronological changes of indebted to all health facilities, data collectors and program managers for their
adherence of health care providers with the national quality of work to the standards. The finding and opinions expressed by the
recommended standards to treat malaria. Scaling up of authors may not reflect the views of the employing or funding organizations.
PPP for malaria care services is recommended through Competing interests
partners and the national malaria prevention control The authors declare that they have no competing interests.
programme.
Availability of data and materials
The data is available and can be shared up on request.
Abbreviations
Consent for publication
AIDS: acquired immune deficiency syndrome; AL: artemether-lumefantrine;
Agreed to publish our article on BMC Malaria Journal.
CQ: chloroquine; EFMOH: Ethiopian Federal Ministry of Health; EQA: external
quality assurance; FP: family planning; HIV: human immune deficiency virus;
Ethics approval and consent to participate
IPLS: integrated pharmaceutical logistics management system; IQC: internal
Permission to conduct the retrospective data analysis was sought and
quality control; MOU: memorandum of understanding; ODK: open data kit;
obtained from Abt Associates Inc.
PHSP: Private Health Sector Programme; PPM: public private mix; PPM- DOTS:
public private mix direct observed therapy short course; PPP: public private
Funding
partnerships; PSP: private sector project; RBM: roll back malaria; RDT: rapid
Private Health Sector Porgramme was funded by USAID. However, for this
diagnostic test; RHB: regional health bureau; SNNP: Southern Nation Nationali-
study no special fund was used.
ties People; STI: sexually transmitted infections; TB: tuberculosis; USAID: United
State Agency for International Development; WHO: World Health Organization.
Received: 8 March 2016 Accepted: 17 June 2016
Authors’ contributions
MDA has made substantial contribution to conception and design the study,
clean the data, analyze the data, interpreted the analysis and draft the manu-
script. AGW has been involved in revising it critically for intellectual content.
DTA has been involved in collecting, collating the data, and critically review References
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