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Background: The World Health Organization (WHO) recommends injectable artesunate given either intravenously or by the intramuscular route for definitive treatment for severe malaria and recommends a single intramuscular dose of intramuscular artesunate or intramuscular artemether or intramuscular quinine, in that order of preference as pre-referral treatment when definitive treatment is not possible. Where intramuscular injections are not available, children under 6 years may be administered a single dose of rectal artesunate. Although the current malaria treatment guidelines in Ethiopia recommend intra-rectal artesunate or alternatively intramuscular artemether or intramuscular quinine as pre-referral treatment for severe malaria at the health posts, there are currently no WHO prequalified suppliers of intra-rectal artesunate and when available, its use is limited to children under 6 years of age leaving a gap for the older age groups. Intramuscular artesunate is not part of the drugs recommended for pre-referral treatment in Ethiopia. This study assessed the perspectives of health workers, and policy-makers on the use of intramuscular artesunate as a pre-referral and definitive treatment for severe malaria at the health post level. Methods: In-depth interviews were held with 101 individuals including health workers, malaria focal persons, and Regional Health Bureaus from Oromia and southern nations, nationalities, and peoples’ region, as well as participants from the Federal Ministry of Health and development partners. An interview guide was used in the data collection and thematic content analysis was employed for analysis. Results: Key findings from this study are: (1) provision of intramuscular artesunate as pre-referral and definitive treatment for severe malaria at health posts could be lifesaving; (2) with adequate training, and provision of facilities including beds, health posts can provide definitive treatment for severe malaria using intramuscular artesunate where referral is delayed or not possible; (3) health workers at health centres and hospitals frequently use the intravenous route because it allows for co-administration of other drugs, but they find the intramuscular route easier to use at the health post level; (4) the reasons commonly cited against the management of severe malaria using intramuscular artesunate at health post level were: lack of capacity to manage complications and fear of irrational drug use; (5) use of intramuscular artesunate at health post level will require evidence on safety and feasibility before policy shift. Conclusion: From the perspective of health workers, use of intramuscular artesunate as pre-referral treatment of severe malaria cases at the health post is possible but dependent on training and availability of skilled workers. Use of intramuscular artesunate as definitive treatment at health posts was not supported, however, operational research to establish its feasibility, safety and efficacy was recommended to guide any implementation of such an intervention.
The study was conducted in two regions of Ethiopia, southern nations, nationalities, and peoples’ region (SNNPR), and Oromia from January to March, 2015. Participants were identified from health facilities serving nine malarious areas of the regions, Zonal offices, Regional Health Bureaus, Federal Ministry of Health and partners. Oromia is the most populous region in Ethiopia with a total population of 32 million. SNNPR is the 3rd largest regional state with a total population of 18 million [6]. SNNPR and Oromia regions have the highest malaria burden in Ethiopia [23]. The major health problems of SNNPR and Oromia remain largely preventable communicable diseases and nutritional disorders. The health system priorities are health service delivery at household, community and facility level to improve maternal, neonatal, child, adolescent and youth health, nutrition, hygiene and environmental health, and to reduce/combat HIV/AIDS, tuberculosis and malaria and other communicable and non-communicable diseases [15]. Access to care remains a problem especially in rural areas where the population is characterized by poverty and poor health indicators. The Ethiopian government has endeavored to improve access to care by providing a community based service provided by health extension workers who after a year’s training provide comprehensive preventive and curative services to these remote populations and by equipping health centres with ambulances to provide care for obstetric and other emergencies but referral from health post could be delayed due to poor infrastructure or other emergencies. The Ethiopia health care tiers are presented in Fig. 1. This was a qualitative exploratory study that used in-depth interviews to collect data on the perspectives of health workers, and policy-makers on the use of intramuscular artesunate as a pre-referral and definitive treatment for severe malaria at health posts. A total of 101 respondents were interviewed. A list of all zones from the two regions regarded high burden by the Federal Ministry of Health was used and from this list nine zones with the highest burden were selected. The selected zones were the following: East Shoa, South west Shoa and Jima zone from Oromia region, and Gomgofa, Silti, Kembata Tembaro, Halaba, Wolayita and Hadiya zones from SNNPR. A zone is an administrative area below the region, and includes several districts or woredas. Thirty health facilities from each of the two states (Oromia and SNNPR) were purposively selected to be included in the study if they had large numbers of severe malaria cases reported (according to the routine health facility data reports) and if were easily accessible by the study team. A maximum of two health workers, one health worker involved in management of malaria on the day of the interview and one manager in the selected health facilities were included in the study. In Oromia state, given the busy schedules of the health workers, it was impossible to interview more than one staff at the selected facilities, and two of the selected facilities were not open on the survey day. In SNNPR, all selected facilities were functional and two health workers were interviewed at each of the facilities. At two of the facilities in SNNPR, the team was able to interview both the severe malaria ward manager and well as the health facility manager. In addition, the malaria focal persons from the Zonal health departments, Regional Health Bureau, Federal Ministry of Health, and development partners were also included in the study. The number of respondents interviewed within the different categories are presented in Table 1. Respondents selected by category and region An interview guide was used to collect data from respondents. In-depth interviews were conducted by twenty research assistants with research experience and trained in data collection specifically for this study. The interviews were conducted in the local languages. The research assistants working in pairs approached the managers and asked permission to conduct the study in the health facilities and for guidance on the health workers to be interviewed. Informed consent was then sought from the health workers to participate in the study. Appointments were made for interviews with all other participants at zonal, regional, Federal Ministry of Health and development partners. The research assistants took notes and audio recordings during the interviews. Supervision and guidance to the field teams was provided by two co-investigators with experience conducting qualitative research. Daily supervision of interviewers and checking of completed interviews was done to ensure collection of accurate and complete data. Audio-recorded data were transcribed and then translated from the local languages to Amharic and then into English. Senior researchers read the transcripts and identified emerging themes, and codes. The transcripts were then coded using Atlas.ti7 (Atlas.ti GmbH, Berlin) during the coding process; more codes were identified and discussed by the research team. These codes were merged into categories and then into themes reflecting the study objectives and other emerging issues. Thematic content analysis was employed.
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