Lessons on malaria treatment from Ghana’s education sector

Poor, underserved and rural communities in sub-Saharan Africa have higher rates of illness and death from malaria than other areas. How can governments improve malaria control in these communities? A study in Nzema East district in the western region of Ghana assessed schools as a possible channel for better access to diagnosis and treatment.

Key strategies for reducingdeath from malaria are early detection and prompt effective treatment of cases.Health services in Ghana treat about 65 percent of the population but thisfigure is much lower in most rural and hard-to-reach parts of the country.However, basic schools are available in most rural communities. The two phasesof the study, which involved the UK Liverpool School of Tropical Medicine andthe Ghana Ministry of Health, addressed different questions:

• Phase one: Can trained primary teachers act as careproviders in the early detection and management of malaria?
• Phase two: When the number of schools is increased andpre-packaged antimalarials are used, can the teachersimprove their rates of correct diagnosis and treatment, and maintain theserates when supportive visits are reduced?

The main treatment formalaria in Ghana is now artemisinin and amodiaquine but at the time of the study, chloroquine wasused. Key results of the study include:

• In phase one, 59 trained teachers in 12 schools diagnosed 570fever cases as malaria. Of these, 93 percent were correct diagnoses accordingto the study guidelines.
• The teacherscorrectly treated three quarters of these presumed malaria cases.
• In phase two, 241teachers in 82 schools were either trained or retrained. Accuracy of diagnosisfell to 79 percent (317 out of 402 fever cases), but almost all of these weretreated correctly using pre-packaged drugs.
• However, whenparents supervised students (at weekends) using pre-packed antimalarials, this did notimprove their treatment rates compared to non-packed treatment.
• When thefrequency of teacher supervision was reduced, the rate of correct diagnosisdeclined but there was no change in the level of correct treatment.

Both parents and teacherswere happy with the programme. However, teachers pointed out that it wasdifficult to get good information from the younger children and that somechildren stopped taking chloroquine after the first dose made them itch.

Although less frequentsupervision gave a higher risk of misdiagnosis, pre-packaging of chloroquineensured that no-one was under-dosed, limiting the development of drug-resistantmalaria strains. The researchers conclude that it is feasible for the healthand education sectors to work together to deliver malaria treatment inunderserved regions. Governments wishing to implement this strategy should:

• review policy toallow the participation of school teachers in this effort
• legislate for mandatory commercial pre-packaging of anti-malarials in suitable doses for different ages for use byschools and the general public.