Matching policy with practice: effectively treating childhood fever in Kenya

Many believe that the key to reducing childhood mortality associated with malaria lies in effective, early treatment of fevers.  The kind of treatment sought, at what stage and from what service provider remains key to the effectiveness of fever treatment in young children. In Kenya, the gap between policy and practice remains. The quality and accessibility of care continues to be inconsistent across the public and private health sectors. Initiatives to promote behavioural change amongst users and improve physical access to services are a priority.

In April 2000, African Heads of Statemeeting in Abuja, Nigeria, committed themselves and their countries to ensuringthat 60% of all fever cases will be treated within 24 hours of onset with safe,effective anti-malarial drugs by 2010. What progress has been made in Kenya towards meeting this target? 

A study was conducted in December 2001 infour ecologically different districts in Kenya, in order to discover whattreatment is provided, the sources of treatment, costs and timing, for feversin children aged five years and under. Approximately 2 500 homesteads were identified in each selectedarea and interviews were conducted in all homesteads.  One child aged underfive was selected at random within each homestead as the subject of the study.The researchers and their field teams visited a total of 9 272 householdswith 18 983 resident children under five years old. 6 287 mothers orguardians were subsequently interviewed about fever in the preceding 14days. 

The study revealed significant differencesin fever prevalence between districts, which appear to correspond with theirdiffering malarial ecologies.  During theperiod of study the overall prevalence of fever in children was 42.2%,revealing fever to be a common event in children. Of the fevers reported:

• 28.1% went untreated
• 29.5% were treated at public formalfacilities
• 26.1% through the private retail sector

Differences were recorded between districtsin fever treatment rates, treatment sources, cost and medication used. Asubstantial number of fevers were treated outside the formal public sector,using mostly western pharmaceuticals. Other findings included:

• There was a median waiting period of 2 daysfrom onset of symptoms for any form of treatment across the four districts.
Less than 3% of all reported fevers weretreated within 24 hours with the nationally recognisedfirst-line anti-malarial drug (sulphur-pyrimethamine).
8.3% of western medicines dispensed wereunknown to respondents, almost all provided by government facilities.
The formal public sector was the bestsource of early anti-malarial treatment, whilst the private retail sector hadmost potential for improving access to anti-malarial drugs.

There is a need to improve prescribingpractices in private sector clinics and fever management practices at home. Inthe retail sector second-line drugs are often available, pointing to a need forimproved engagement of retailers with policy, so as to restrict theavailability of second-line drugs and promote access to first-line recommendeddrugs.

There is a huge gap between policy - as setout in the Abuja declaration - and practice.   Only 2.3% of cases were treated within 24 hours using the recommendedfirst line treatment for uncomplicated malaria in Kenya. If morbidity andmortality caused by malaria is to be halved by 2010, a major investment isneeded in improving prompt access to anti-malarial drugs through initiatives topromote behaviour change and improved physicalaccess.