A Rapid Assessment of Severe Malaria Case Management Practices and Constraints in Angola

Malaria is the leading cause of death, hospitalization and school and work absenteeism in Angola. In 2018, the death toll in Angola represented 4% of total deaths attributable to malaria worldwide. Poor case management for uncomplicated and severe malaria may be significantly contributing to these results.

This study aimed to identify existing gaps in knowledge about severe malaria case management in Angola by collecting information at different health service levels and through different study populations. A mixed method cross sectional study was implemented in six districts, distributed evenly across three provinces, namely Cuando Cubango, Luanda and Uíge. Different tools were used to collect data about health facility conditions, health worker knowledge and training on severe malaria, and current practices for diagnosing
and treating severe malaria patients. Data from patients and caregivers was also collected alongside qualitative information from focus group discussions held in communities.

Results showed critical gaps in the ability of the Angolan health system to effectively manage severe malaria cases. First and foremost, health worker training on severe malaria case management has been scarce, and where evident has been mainly supported by partners. The impact of this was reflected in the non-uniform use of artesunate as a first line malaria drug. There was a lack of knowledge regarding the preparation of injectable artesunate, and a clear preference for the administration of artemether as first line severe malaria treatment. Gaps related to guidance as to by whom, where and when rectal artesunate can and should be administered were also identified. The lack of training was also evident in the documented failure by some health workers to adhere to treatment guidelines.

This study also identified drug stock outs, inaccurate and/or missing malaria reporting data, and delays in health-seeking behaviour by patients as factors negatively affecting severe malaria case management in Angola. Drug stock outs were frequent both for uncomplicated and severe malaria drugs, mostly attributable to ineffective quantification mechanisms and poor supply systems. Malaria data was found to be prone to mistakes that may result in both under and over reporting of malaria, including severe malaria cases and malaria deaths. Data from private facilities is not integrated into national reporting systems, which is also contributing to inaccurate malaria burden reporting. Delays in health care seeking
for logistical, financial, social and cultural reasons were identified through focus group discussions and interviews with key informants.