Malaria remains a public health problem in Africa. It is estimated to claim about 1 million deaths and over 400 million malaria cases worldwide each year, with 90% of these deaths occurring in sub Saharan Africa . In Tanzania malaria has been reported as the leading cause of death and account for 40% of all outpatient attendances in health facilities . Assessment of clinical symptoms is the common method of diagnosing patient’s conditions in the country, with most cases of fever being presumed to be malaria. Few health facilities are equipped with basic laboratory services or use rapid diagnostic test to provide confirmatory diagnoses of malaria; that has resulted into misdiagnosis or over diagnosis of malaria. A study conducted in Muhimbili National hospital showed 87% of patients who received antimalarial treatment with a diagnosis of severe malaria did not have detectable parasitemia, resulting in over-treatment of malaria and neglecting other potentially life threatening conditions .
Fever has been used as a major clinical symptom for malaria , Now reports show that malaria has been declining , while fever remains a major complaint in many outpatients clinical settings . This high prevalence of fever may still be presumed as malaria, hence a need to strengthen confirmation of malaria in order to target use of antimalarial drugs to confirmed cases only. The Tanzania National Guideline for diagnosis and treatment of malaria states that, “a careful assessment of a patient with suspected malaria is essential in order to differentiate between uncomplicated and severe disease. Eventually, laboratory investigations are done to complement clinical diagnosis. In health care facilities without laboratory services, diagnosis is based only on signs and symptoms” . Malaria treatment in Tanzania is mainly based on clinical judgment in the majority of health facilities, especially lower level facilities. Most of the health facilities lack laboratory diagnostic capacity for malaria and hence most of the reported malaria cases are clinically diagnosed. According to NMCP, up to early 2009, 83% of health facilities in Tanzania had no laboratory diagnostic capacity for malaria. In addition, there is a problem of inaccurate malaria microscopic diagnosis and hence misdiagnosis of patients and over use of ACT .
Microscopic examination of Giemsa-stained blood films remains a cornerstone of malaria diagnosis throughout Tanzania, but is only available at hospitals and some health centers. Historically, more than 5,000 of the lowest-level facilities (dispensaries and some health centers) had no laboratory diagnostic capacity, leaving health care workers at more than 90% of facilities to diagnose malaria on the basis of clinical signs and symptoms alone. According to the recent WHO guidelines, all suspected malaria cases should be parasitological confirmed prior to treatment, including children under five. NMCP’s policy has changed from presumptive treatment to confirmatory parasitological diagnosis. The NMCP objective is to increase the percentage of laboratory-confirmed malaria cases in public health facilities from a baseline of 20% to 80%. It is clear from numerous assessments that the quality of malaria microscopy is very poor at almost all levels of the health system. Phased rollout of RDTs began in April 2009, starting in areas of low/moderate transmission and expanded to areas of stable/high transmission. Currently, laboratory confirmation is happening in only 20% of the suspected cases and there is no system for laboratory quality assurance and quality control [8–11]. Over-diagnosis of malaria can lead to inappropriate management of other causes of fever, unnecessarily usage of antimalarials, increasing the burden of malaria treatment cost, drug resistance and unsafe treatment, or prolongation of illness and death [12–15]. Antibiotic resistance is increasingly becoming a public health problem . Improvement in antibiotics prescription will reduce chances of bacterial resistance and minimize hospital costs. In hospitals, currently the costs for antibiotics accounts for more than 30% of hospital budgets, and about one third to a half of all hospitalized patients receive an antibiotic . It is necessary, therefore, to define and assess the prescription patterns in order to address the problem of irrational prescribing habits, and understand types of drugs commonly co-prescribed with antimalarials [15, 16]. The World Health Organization (WHO) discourages the use of large number of drugs per encounter and irrational co-prescription of drugs with Artemisinin based Combination Therapy (ACT) . The assessment of drug utilisation is important for both clinical and economic reasons.
Several factors influences prescribing behaviour of clinicians, therefore, to improve prescription behaviour, it is necessary to understand predictors of those behaviours [17, 18]. This paper highlights the prescription patterns and assesses the predictors of antibiotics co-prescription with artemether-lumefantrine (AL), the first line recommended antimalarial drug in Tanzania. The study was conducted within 8 government health facilities found in two Health and Demographic Surveillance Systems sites that presented with fever or history of fever and treated with AL.