Research

Why don't health workers prescribe ACT? A qualitative study of factors affecting the prescription of artemether-lumefantrine

Beatrice Wasunna^1,2 , Dejan Zurovac^2,3,4 , Catherine A Goodman^2,5 and Robert W Snow^2,3

¹  Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC)/KEMRI, P.O. Box 54840-00200, Nairobi, Kenya

²  Malaria Public Health & Epidemiology Group, Centre for Geographic Medicine Research-Coast, Kenya Medical Research Institute/Wellcome Trust Research Programme, P.O. Box 43640, 00100 GPO, Nairobi, Kenya

³  Centre for Tropical Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK

⁴  Department of International Health, School of Public Health and Center for International Health and Development, 5^th Floor, Boston University School of Public Health, 85 East Concord Street, Boston, MA 02118, USA

⁵  London School of Hygiene and Tropical Medicine, Health Policy Unit, Keppel Street, London, WC1E 7HT, UK

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Malaria Journal 2008, 7:29doi:10.1186/1475-2875-7-29

Published:	5 February 2008

Abstract

Background

Kenya recently changed its antimalarial drug policy to a specific artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). New national guidelines on the diagnosis, treatment and prevention were developed and disseminated to health workers together with in-service training.

Methods

Between January and March 2007, 36 in-depth interviews were conducted in five rural districts with health workers who attended in-service training and were non-adherent to the new guidelines. A further 20 interviews were undertaken with training facilitators and members of District Health Management Teams (DHMTs) to explore reasons underlying health workers' non-adherence.

Results

Health workers generally perceived AL as being tolerable and efficacious as compared to amodiaquine and sulphadoxine-pyremethamine. However, a number of key reasons for non-adherence were identified. Insufficient supply of AL was a major issue and hence fears of stock outs and concern about AL costs was an impediment to AL prescription. Training messages that contradicted the recommended guidelines also led to health worker non-adherence, compounded by a lack of follow-up supervision. In addition, the availability of non-recommended antimalarials such as amodiaquine caused prescription confusion. Some health workers and DHMT members maintained that shortage of staff had resulted in increased patient caseload affecting the delivery of the desirable quality of care and adherence to guidelines.

Conclusion

The introduction of free efficacious ACTs in the public health sector in Kenya and other countries has major potential public health benefits for Africa. These may not be realized if provider prescription practices do not conform to the recommended treatment guidelines. It is essential that high quality training, drug supply and supervision work synergistically to ensure appropriate case management.