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Impact of Artemisinin-Based Combination Therapy Availability on Appropriate Malaria Treatment in Nigerian Primary Healthcare Centres

Abstract

Malaria remains a major public health challenge in Nigeria and continues to contribute substantially to morbidity, healthcare utilization, and preventable deaths, particularly among children under five years, pregnant women, and populations living in malaria-endemic communities. Appropriate malaria treatment requires accurate diagnosis and prompt administration of effective antimalarial medicines according to national treatment guidelines. Artemisinin-based combination therapies (ACTs) are important medicines for the treatment of uncomplicated malaria, while appropriate case management also requires consideration of diagnostic results, patient characteristics, treatment history, and referral of severe cases. However, interruptions in the availability of recommended antimalarial medicines at primary healthcare centres may contribute to delayed treatment, inappropriate medicine selection, self-medication, or referrals that could otherwise be avoided. Ensuring consistent availability of quality-assured ACTs, together with appropriate diagnostic and treatment practices, may therefore improve malaria case management at the primary healthcare level. Against this background, this study investigates the impact of Artemisinin-based combination therapy availability on appropriate malaria treatment in Nigerian primary healthcare centres. The study will be anchored on the Donabedian Model of Healthcare Quality, Health Belief Model, and Andersen's Behavioral Model of Health Services Use. The Donabedian Model explains healthcare quality through structure, process, and outcome, with ACT availability representing an important structural component and appropriate malaria treatment serving as a measurable outcome. The Health Belief Model explains how patients' and caregivers' perceptions of malaria severity, perceived benefits of appropriate treatment, perceived barriers, and cues to action may influence treatment-seeking and medicine-use behaviours. Andersen's Behavioral Model emphasizes predisposing, enabling, and need factors affecting healthcare utilization, with the availability and accessibility of appropriate antimalarial medicines serving as important enabling factors. Collectively, these theoretical perspectives provide a suitable framework for explaining how ACT availability may influence appropriate malaria treatment in Nigerian primary healthcare centres. The study will adopt a quantitative analytical cross-sectional or quasi-experimental research design. The study population will comprise patients diagnosed with malaria and healthcare workers providing malaria treatment services in selected Nigerian primary healthcare centres. A multistage sampling technique will be used to select states, local government areas, communities, primary healthcare centres, healthcare workers, and eligible malaria cases. ACT availability will be assessed using indicators such as availability of recommended ACT formulations, frequency and duration of stock-outs, stock levels, medicine resupply frequency, stock management practices, availability of quality-assured medicines, expiry monitoring, storage conditions, accessibility to patients, and availability of national malaria treatment guidelines. Appropriate malaria treatment will be assessed using indicators such as laboratory-confirmed diagnosis where testing is available and indicated, adherence to recommended treatment guidelines, selection of appropriate antimalarial medicine, correct dosage, correct treatment duration, appropriate medicine dispensing and counselling, documentation of treatment, follow-up, recognition and referral of severe malaria, and avoidance of inappropriate antimalarial use. Data will be collected using structured questionnaires, facility assessment checklists, pharmacy and medicine registers, stock cards, malaria treatment registers, laboratory records, patient medical records, prescription records, and healthcare worker interviews. Descriptive statistics will be used to summarize healthcare facility characteristics, ACT availability, malaria case characteristics, and treatment practices. Inferential statistical techniques, including chi-square tests, t-tests, correlation analysis, and logistic or multiple regression analysis where appropriate, will be used to determine the impact of ACT availability on appropriate malaria treatment. Where a quasi-experimental design is adopted, appropriate treatment practices before and after interventions aimed at improving ACT availability may be compared, or facilities with reliable ACT supplies may be compared with similar facilities experiencing frequent stock-outs. Diagnostic tests will also be conducted to assess the reliability, validity, and robustness of the findings. The study is expected to find that consistent availability of appropriate ACTs has a significant positive impact on appropriate malaria treatment in Nigerian primary healthcare centres. Facilities with reliable supplies of recommended ACTs are expected to demonstrate higher adherence to malaria treatment guidelines and fewer instances of inappropriate antimalarial prescribing or dispensing than facilities experiencing frequent medicine stock-outs. Adequate availability may enable healthcare workers to initiate appropriate treatment promptly following diagnosis and reduce the need for patients to purchase medicines from informal sources or seek care elsewhere. Proper medicine-stock management, regular resupply, and access to updated treatment guidelines may further strengthen appropriate malaria case management. However, stock-outs of ACTs, poor supply-chain management, inadequate diagnostic capacity, insufficient healthcare worker training, high patient workload, inappropriate prescribing practices, and limited supervision may reduce the effectiveness of medicine availability. The study therefore expects reliable availability of quality-assured ACTs, combined with accurate diagnosis, adherence to treatment guidelines, and appropriate clinical supervision, to contribute significantly to improved malaria treatment practices in Nigerian primary healthcare centres. The study is expected to contribute to the literature on ACT availability, malaria treatment, malaria case management, essential medicines, primary healthcare, malaria diagnosis, antimalarial medicine supply, treatment guideline adherence, and public health in Nigeria. The findings will provide useful information to the Federal Ministry of Health and Social Welfare, National Malaria Elimination Programme, National Primary Health Care Development Agency, state ministries of health, local government health authorities, primary healthcare centres, pharmaceutical supply-chain managers, healthcare workers, development partners, and policymakers regarding strategies for improving malaria treatment services. The study will also provide evidence-based recommendations for strengthening ACT procurement and supply systems, improving stock monitoring and forecasting, reducing medicine stock-outs, strengthening healthcare worker training, ensuring availability of malaria treatment guidelines and diagnostic services, improving medicine storage and inventory management, strengthening supportive supervision, and integrating routine medicine availability monitoring into malaria control programmes across Nigerian primary healthcare centres.

Keywords: Artemisinin-based combination therapy, ACT availability, malaria treatment, appropriate malaria treatment, malaria case management, essential medicines, antimalarial medicines, primary healthcare centres, malaria control, Nigeria, public health.