The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
RESEARCH ARTICLE

Malaria Case-Management in Urban Area: Various Challenges in Public and Private Health Facilities in Benin, West Africa



Badirou Aguemon1, Barikissou Georgia Damien1, *, Antoine Vickey Hinson2, Géraud Padonou1, Abévi Fleury Bruno Agbessinou1, Edgard Marius Ouendo3, Paul Ayélo2
1 Unit of Public health, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
2 Unit of Teaching and Research in Occupational Health and Environment, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
3 Institut Régional de Santé Publique (IRSP), Ouidah, Benin

Abstract

Background:

In Benin, malaria remains endemic and perennial throughout the year in most areas. During the last decade, a substantial increase was noticed in the procurement of Artemisinin-based combination therapies and malaria RDT. This study aimed to evaluate the quality of uncomplicated malaria cases-management in public and private health facilities.

Methods:

A cross-sectional survey was carried out in public and private health facilities in the municipality of Abomey-Calavi in southern Benin from August to September 2016. The study focused on two targets: (i) patients with uncomplicated malaria who sought care in a health facility in Abomey-Calavi during the study period; and (ii) the health care providers in public and private health facilities authorized by the Ministry of Health.

Results:

In 27 health facilities investigated, 15 in the public sector and 12 in the private sector, a total of 313 patients and 93 health care providers were included. Forty-four percent (44%) had no education. Among the patients, 60% were identified in the public health facilities. About 87% of uncomplicated malaria patients were tested in public facilities while 63% were tested in private facilities. In the same way, 54% of patients were treated in accordance with National Malaria Control Program (NMCP) guidelines.

Conclusions:

The present study showed a poor performance in uncomplicated malaria case-management in private health facilities compared to public health facilities. Strategy to improve access and utilization of malaria case-management supplies needs to be reviewed in both public and private health facilities.

Keywords: Malaria case-management, National Policy, Health facilities, Public and private, Benin, National Malaria Control Program (NMCP).


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 11
First Page: 54
Last Page: 61
Publisher Id: TOPHJ-11-54
DOI: 10.2174/1874944501811010054

Article History:

Received Date: 29/12/2017
Revision Received Date: 30/01/2018
Acceptance Date: 2/2/2018
Electronic publication date: 23/02/2018
Collection year: 2018

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© 2018 Aguemon et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Public Health, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Bénin; Tel: 97483574; Fax: 21304096; E-mail: barikiss2000@yahoo.fr




1. BACKGROUND

Malaria is a global public health issue and a significant problem in sub-Saharan Africa. Benin is not an exception, however recent reports published by the World Health Organization (WHO) indicate significant progress in control [1WHO. World malaria reportGeneva: World Health Organization 2016.http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/]. Generally, the number of malaria cases was estimated at about 212 million in 2015. By 2015, 90% of cases were recorded by the WHO in the African Region [1WHO. World malaria reportGeneva: World Health Organization 2016.http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/]. In Benin, malaria remains endemic and perennial throughout the year in most areas [2Damien GB, Djènontin A, Rogier C, et al. Malaria infection and disease in an area with pyrethroid-resistant vectors in southern Benin. Malar J 2010; 9: 380.[http://dx.doi.org/10.1186/1475-2875-9-380] [PMID: 21194470] -5Govoetchan R, Gnanguenon V, Azondékon R, et al. Evidence for perennial malaria in rural and urban areas under the Sudanian climate of Kandi, Northeastern Benin. Parasit Vectors 2014; 7: 79.[http://dx.doi.org/10.1186/1756-3305-7-79] [PMID: 24564957] ]. Over the past decade, malaria was the leading cause of consultations and hospitalization in health care facilities. In 2012, 41% of reasons for outpatient visits, 29% of reasons for hospitalization and 26% of deaths were attributed to malaria for all age groups [6Benin IN. Rapport de l’Enquête Démographique de Santé (EDS) Cotonou 2013 Available from: [wwwinsae-bjorg/enquete-demographiquehtml?file=files/enquetes/eds/] ]. Since the year 2000, a significant investment has been made in health facilities to improve the quality of care and reduce malaria indicators in a specific way. From 2000, Benin adopted the WHO recommendations of uncomplicated malaria case treatment by approving Artemisinin-based Combined Therapy (ACT) [7The African Summit on Roll Back Malaria, Abuja, Nigeria 2000.]. This new approach for uncomplicated malaria case-management was introduced by the National Malaria Control Program in Benin (NMCP) for the first time in the National Strategic Plan (NSP) 2005-2010 [8National Malaria Control Program Strategic National Plan 2006-2010 reviewed Cotonou 2007. [http://archiverbm.rollbackmalaria.org/countryaction/nsp/benin]]. The selected ACT were the Artemether-Lumefantrine (AL) as first line treatment for uncomplicated malaria and the Artesunate-Amodiaquine as the second line. In addition, over the last decade, malaria case confirmation using Rapid Diagnostic Tests (RDT) or microcopy was strongly recommended prior to any anti-malarial treatment [9 Republic of Benin National Guidelines for the Management of Malaria Cases 2015.]. There has been a substantial increase in the distribution of ACT and RDT as requested by the WHO universal access to malaria commodities policy. From 2014 to 2015, the procurement of malaria RDT packages increased from 1.3 million to almost 1.5 million [1WHO. World malaria reportGeneva: World Health Organization 2016.http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/]. Similarly, the procurement of ACT doses increased from 1.1 million in 2014 to 1.2 million in 2015. In Benin, the strategy of malaria case management varies between urban and rural area. In rural areas, the community case management is promoted by using community health workers. The private health centres are rare and the population usually goes to public health centres. In opposition, in urban areas, there is no community case management and people seek care from public and private health centers.

In order to determine the future actions to be carried out to reach the malaria elimination objectives by 2030 in Benin, it is necessary to evaluate the quality of uncomplicated malaria cases-management in public and private health facilities.

2. METHODS

2.1. Site Description

The study was carried out in public and private health facilities of the municipality of Abomey-Calavi in southern Benin. Abomey-Calavi is 12 km away from Cotonou. It extends over 650 km2 and is the second most populous commune in Benin with an estimated population of 656, 358 inhabitants [10Economic Analysis and Foresight Fourth General Census of Population and Housing INSAE Cotonou 2013. [http://www.insae.bj.org/?file=files/publications/RGPH4/Plaquette_RGPH4_fomat%20A5]]. Abomey-Calavi has several infrastructures: Two referral hospitals (Abomey-Calavi / So-Ava hospital and La Croix Hospital), 13 public health facilities and 216 private health facilities. These health facilities employ 498 health workers.

2.2. Study Design

A cross-sectional, descriptive and evaluative survey was carried out from August to September 2016. The study focused on two targets: (i) patients with uncomplicated malaria who sought care in a health facility in Abomey-Calavi during the study period; and (ii) Prescribers from public and private health facilities authorized by the Ministry of Health (MoH). Patients enrolled into the study met the following criteria: i) presence of fever with other malaria-related symptoms (chill, headache, vomiting, joint pain), and ii) patients with prescription that who had has at least one anti-malarial treatment. People who withdrew their informed consent were excluded from the study.

2.3. Sample Size

An exhaustive list of public health facilities was considered as follows: two referral hospitals and 13 health facilities. In private health facilities, the sampling method is probabilistic with a systematic sampling technique to draw 13 structures. From the list of 216 private health facilities, a sampling interval “f” was calculated: f = N / n where N is the total number of private health facilities and “n” the number of private health facilities necessary to be surveyed. A number was randomly selected between 1 and 16 and then we applied the sampling pitch to obtain the numbers corresponding to the 13 private health facilities to be investigated. Within each health facility, an exhaustive census of all patients with symptoms of uncomplicated malaria was carried out. After that the health care providers were interviewed. The content of the prescriptions for the management of uncomplicated malaria or the appropriateness of the prescriptions were also investigated.

2.4. Score of “Uncomplicated Malaria Case-Management” and the Healthcare Provider’s Adherence to the Recommendation

The main variable was the quality of uncomplicated malaria case management. It was estimated using a score. The calculation of this score was based on five components: i) the diagnostic confirmation rate, ii) the percentage of patients who received a correct treatment with the recommended anti-malarial drugs, iii) the percentage of patients who received preventive advice iv) the percentage of patients who received a follow-up appointment, and v) the percentage of patients who received good quality for overall care (Table 1).

Table 1
Sample description of patients.


For each of the first four criteria, the minimum score was 1 and the maximum was 3: i) Between 75% and 100%, the score was 3, the criterion assessment was good or high, ii) Between 50% and 75%, the score was 2, the criterion was acceptable, and iii) Between 0% and 50%, the score was 1, the criterion assessment was bad or low. As for the last indicator, the overall quality of management was of good quality if: (i) The physical examination, was conducted (ii) the diagnostic confirmation test was done, (iii) the received anti-malarial treatment was correct, (iv) the advice had been given and v) the follow-up appointment was given. The minimum score was 1 and the maximum score was 3. The assessment of the quality of care criterion was made with the same thresholds as the previous criteria. The threshold for adherence to malaria access management standards recommended by the NMCP was measured by considering the following thresholds:

  • Between 12 and 15 points: good care quality.
  • Between 9 and 11 points: Intermediate care quality.
  • Between 5 and 8 points, poor care quality.

2.5. Data Collection and Analysis

During the survey, the patients were selected over five days in the health facility and reviewed for follow-up visit. Two surveyors were employed during the study. The observation and individual interviews were conducted. For this purpose, an observation grid and a questionnaire were used.

Initially, the investigators were present in the consultation room and observed how the health worker or health providers took care of patients suffering from malaria. Data was collected from health workers by using a self-administration questionnaire procedure. The observation grids and survey forms were filled in by the investigators themselves. The data was entered in CSPro version 6.0 and then exported to SPSS version 18 for analysis. Results were presented using averages and proportions. The proportions were calculated for each indicator and their threshold was used to determine the scores. Chi-square test or Fisher's exact test to compare proportions was used to compare baseline results at a significant level of p less than 0.05.

2.6. Ethical Aspects

Ethical approval of the study was obtained from the Faculty of Health Sciences at Cotonou. Informed written consent was sought from all eligible patients and practitioners. The anonymity and confidentiality were guaranteed. All analytical work was conducted on de-identified datasets.

3. RESULTS

A total of 313 patients and 93 health care providers were included in the study. The response rate was 91.0% among the patients and the 85.3% among the health care providers. Among the 28 health facilities targeted, 27 were investigated, 15 in the public and 12 private. One private health facility refused to take part in the study.

3.1. Description of the Study Population

3.1.1. Decription of the patients

About half of the patients (48%) were aged more than 15 years. About 52% of the patients were male and 44% were not educated. Among the patients, 60% were identified in the public health facilities (Table 2). Approximately 98% of the patients reported that their hospitalization was satisfactory. In addition, 97% of the patients were cared for by paramedics (nurses and midwives) in public health facilities, while 94% were cared for by doctors in private health facilities.

Table 2
Awareness on malaria management by the health workers in public and private health facilities.


3.1.2. Description of the Health Care Providers

The mean age of the 93 health care providers was 36 ± 2 years with a minimum at 22 years and a maximum at 62 years. Three-quarters (73%) of health care providers were female and 66% were in public health facilities.

3.2. The Level of Awareness of Health Care Providers According to the Type of Health Facilities (Public or Private)

The difference between the level of awareness of the national malaria management policy was not statistically significant between public (91%) and private (75%), p = 0.0567. The rate of awareness on the new-malaria-management policy was higher in public (84%) than in private sector (34%), (p <0.0001). Finally, the therapeutic guide for malaria case-management was available for 84% of providers in public sector compared to 44% in private sector (p <0.0001), (Table 3).

Table 3
Evaluation of uncomplicated malaria case-management.


3.3. Quality of Malaria Case-Management in Public and Private Sectors

According to public and private health care providers, the availability of diagnostic tests was 67% and the recommended medicines availability was 58%.

3.3.1. Diagnosis of Uncomplicated Malaria Cases

In all health facilities, 59% of the patients were examined with 48% in public and 76% in private in search of an infectious focus. The malaria diagnostic confirmation rate was 77% with 87% in the public and 63% in the private sector (Table 4). As far as the diagnostic tests used are concerned, 58% were RDTs in the public sector compared to 2.5% in the private sector.

Table 4
Type of prescribed anti-malarial drugs.


3.3.2. Advice on Malaria Management and Prevention

Approximately, 67% of the patients received advice from a health worker on malaria with 85% in the public and 40% in the private sector (Table 4). Given that one patient received counseling more than once, the primary focus was on disease prevention (81%), return to follow-up (59%), continued treatment and good diet (52%) and rapid return to a health facility in case of severe signs (14%).

3.3.3. Follow-Up Appointments

83% of the patients received follow-up appointments after initial management. This proportion was 89% in the public and 73% in the private sector (Table 4). Among the 259 patients who received a follow-up appointment, only 54% had it within 48 hours and 51% did not show up for the appointment.

3.3.4. Good Overall Care of the Patient

Among the 313 patients surveyed, 35.5% had good overall care, while 56% and 5% respectively, were in the public and private sectors (Table 4).

3.4. Type of Treatment of Uncomplicated Malaria Cases According to National Guidelines

The type of treatment was in accordance with NMCP guidelines at 54% with 70% in public health facilities and 30% in private sector (Table 4). The most frequently used anti-malarials were AL (62.31%), quinine (25.52%) and injectable artemether (7.12%), (Table 5).

Table 5
Adherence of public and private health care facilities to the guidelines of simple malaria case-management.


To summarize, in public sector, criteria such as the diagnostic confirmation rate, follow-up appointments and counseling had a high score, adequate treatment of uncomplicated malaria with appropriate medication, and the overall management had an acceptable score. On the other hand, in private sector, criteria such as the diagnostic confirmation rate and follow-up appointments had an acceptable score. The overall quality of patient management, counseling and adequate treatment with an appropriate medication had a low score. The adherence to case-management for uncomplicated malaria cases had a good score in public health facilities (13/15) and a poor score in private health facilities (7/15), (Table 6).

Table 6
Adherence of public and private health care facilities to the guidelines of simple malaria case-management.


4. DISCUSSION

The study aimed to assess the quality of management of uncomplicated malaria cases in the public and private health facilities in the municipality of Abomey-Calavi in 2016. It gives us basic information that can be used by the Ministry of Health and the NMCP authorities. From the calculated scores according to the NMCP guidelines, the study showed that simple-malarial-access case-management is better in public than private health facilities. However, it should be noted that the presence of an interviewer in the consultation room during the direct observation of the acts of care could have induced a change in the usual behavior of the providers.

Among the 93 providers, the level of awareness of the national policy of management of uncomplicated malaria is high (86%) with 75% in the private sector. A contrary study conducted in 2013 showed a lower level of health care providers awareness (44%) in the private sector in Guinea compared to Benin [11Sow MS, Conakry G. Safiatou Diallo amadou O, Boushab BM, Savadogo M, Diawara IK. Assessment of the use of the national protocol for the management of uncomplicated malaria in Matam, Guinea Conakry. Pan Afr Med J 2016; 23.]. The present study also highlighted the problem of low qualification of health care providers in public health facilities. Indeed in the public sector, unlike private sector, care giving including medicines prescriptions are delivered by paramedics. This same observation was made during the evaluation of the implementation of the national policy of uncomplicated malaria treatment in rural Burkina Faso in 2012 [12Ouedraogo LT, Drabo KM, Zongo PS. Assessment of the implementation of the national protocol for the treatment of simple malaria cases in rural Burkina Faso. Public Health 2012; 24(4): 353-63.[PMID: 23043741] ]. The poor qualification of healthcare providers in public sector may affect the quality of care, in the case where the clinical examination of patients requires a high level of awareness of medicine. The last results were confirmed by data from this study, which shows that only 48% of patients received a physical checkup in public, compared to 76% in private sector.

According to the current study, the diagnostic confirmation of malaria cases had a high score. Indeed, more than 80% of the cases were confirmed in public health facilities compared to 63% in private sector. In addition, 58% used RDTs in the public sector, compared with 2.5% in private sector. These observations are similar to those reported by the NMCPs, which indicate that the percentage of suspected cases of malaria in public sector increased from 40% of suspected case in 2010 in the WHO African region to 76% in 2015. This increase was mainly due to increased use of RDTs, which counts for 74% of the means of detection among suspected cases of malaria in 2015 [1WHO. World malaria reportGeneva: World Health Organization 2016.http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/]. It is therefore critical to review the availability and use of RDTs in private health facilities.

In the current study, the rate of adequate treatment with an anti-malarial drug is acceptable. This proportion is lower than that observed in Burkina Faso in 2011 (82.4%) [12Ouedraogo LT, Drabo KM, Zongo PS. Assessment of the implementation of the national protocol for the treatment of simple malaria cases in rural Burkina Faso. Public Health 2012; 24(4): 353-63.[PMID: 23043741] ]. According to the importance of artemether-lumefantrine (67%), quinine (27.5%) and injectable artemether (8%), the most common anti-malarial drugs used to treat uncomplicated malaria were artemether-based regimens. These observations are almost similar to those found in Guinea, where 39.8% of anti-malarial drug prescriptions were not in line with the guidelines of the national protocol for malaria cases-management [11Sow MS, Conakry G. Safiatou Diallo amadou O, Boushab BM, Savadogo M, Diawara IK. Assessment of the use of the national protocol for the management of uncomplicated malaria in Matam, Guinea Conakry. Pan Afr Med J 2016; 23.]. According to another study carried out in Burkina Faso in 2012, 57.49% of prescriptions were compliant for all malaria cases [13Yaméogo TM, Tapsoba SP, Sombié I, Guiguemdé TR. Evaluation of application of national guidelines for the management of malaria in Bobo-Dioulasso university hospital. Sante Publique 2015; 27(2): 265-73.[PMID: 26414041] ]. Persistent use of quinine and artemisinin-based monotherapy may be explained by a failure of integration of private health facilities into the anti-malarial treatment national policy contrary to other African countries: Nigeria, Ghana, Kenya, Madagascar, Niger, Uganda, and Tanzania [14Tougher S, Ye Y, Amuasi JH, et al. Effect of the affordable medicines facility-malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet 2012; 380(9857): 1916-26.[http://dx.doi.org/10.1016/S0140-6736(12)61732-2] [PMID: 23122217] , 15Independent Evaluation of Phase 1 of the affordable medicines facility-malaria (AMFm), Multi-Country Independent Evaluation Report: Final Report Calverton, Maryland and London: ICF International and London School of Hygiene and Tropical Medicine 2012.https://www.theglobalfund.org/media/3011/terg_evaluation2013-2014thematicreviewamfm2012iephase1_report_en.pdf]. The use of non-artemisinin therapy (quinine and anti-malarial monotherapy) remains in malaria case-management behavior. It can be explained by the cost of this non-artemisinin therapy compared to ACT [16Zinsou C, Cherifath AB. The malaria testing and treatment landscape in Benin. Malar J 2017; 16(1): 174.[http://dx.doi.org/10.1186/s12936-017-1808-x] [PMID: 28446236] ].

According to the WHO, anti-malarial treatment was more likely to be ACT if children sought care from public health facilities or community health workers than if they turned to private sector [1WHO. World malaria reportGeneva: World Health Organization 2016.http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/]. A recent study conducted in Benin by ACT watch Group concluded that the public sector is typically well equipped to test and appropriately treat malaria according to national treatment guidelines. However, the private sector is responsible for most of the anti-malarial distribution, typically through general retailers, which represent informal channels of ACT distribution [16Zinsou C, Cherifath AB. The malaria testing and treatment landscape in Benin. Malar J 2017; 16(1): 174.[http://dx.doi.org/10.1186/s12936-017-1808-x] [PMID: 28446236] ]. Another national study conducted in six countries (Benin, Madagascar, Uganda, Zambia, DRC and Nigeria) showed a low availability, a low market share and high prices of ACT in the private sector [17O’Connell KA, Gatakaa H, Poyer S, et al. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malar J 2011; 10: 326.[http://dx.doi.org/10.1186/1475-2875-10-326] [PMID: 22039838] ]. Finally, a large proportion of patients received advice on malaria prevention with 85% in public health facilities and 40% in private. All these findings highlight a national issue of the actual appropriation of national malaria control policy in Benin by private health facilities. The main consequence of these observations is that adherence to case-management for uncomplicated malaria cases had a good score in public health facilities and a bad one in private ones. These results are probably due to the lack or inadequate application of quality standards (certification and accreditation) for health facilities in Benin. One of the solutions is to use public health facilities for capacity building for private ones, and induce changes of adherence of health care providers in line with the national recommended standards to treat malaria [18Argaw MD, Woldegiorgis AG, Abate DT, Abebe ME. Improved malaria case management in formal private sector through public private partnership in Ethiopia: retrospective descriptive study. Malar J 2016; 15(1): 352.[http://dx.doi.org/10.1186/s12936-016-1402-7] [PMID: 27401095] ]. A fully distributed system which allows secure sharing of all information (both medical and not) necessary for patients management can be used to improve the evaluation of the performance of health system. Patients and health care providers data be quickly and easily accessed [19].

The major limitation of this study is the presence of the investigators in the consultation room. The consequence is probably the overestimation of the adherence to case-management for uncomplicated malaria cases, the main indicator of the study.

CONCLUSION

The present study showed a poor performance in uncomplicated malaria case-management by care providers of private health facilities compared to public health facilities. Although considerable progress has been made in recent years, Benin must continue to ensure access to a good quality of care in both public and private sectors and strive to ensure that every patient is taken care of in the shortest possible time with anti-malarial of good quality.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No Animals/Humans were used for studies that are base of this research.

CONSENT FOR PUBLICATION

Written and informed consent was obtained for this study.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] WHO. World malaria reportGeneva: World Health Organization 2016.http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/
[2] Damien GB, Djènontin A, Rogier C, et al. Malaria infection and disease in an area with pyrethroid-resistant vectors in southern Benin. Malar J 2010; 9: 380.[http://dx.doi.org/10.1186/1475-2875-9-380] [PMID: 21194470]
[3] Djogbénou L, Pasteur N, Akogbéto M, Weill M, Chandre F. Insecticide resistance in the Anopheles gambiae complex in Benin: A nationwide survey. Med Vet Entomol 2011; 25(3): 256-67.[http://dx.doi.org/10.1111/j.1365-2915.2010.00925.x] [PMID: 21155858]
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[5] Govoetchan R, Gnanguenon V, Azondékon R, et al. Evidence for perennial malaria in rural and urban areas under the Sudanian climate of Kandi, Northeastern Benin. Parasit Vectors 2014; 7: 79.[http://dx.doi.org/10.1186/1756-3305-7-79] [PMID: 24564957]
[6] Benin IN. Rapport de l’Enquête Démographique de Santé (EDS) Cotonou 2013 Available from: [wwwinsae-bjorg/enquete-demographiquehtml?file=files/enquetes/eds/]
[7] The African Summit on Roll Back Malaria, Abuja, Nigeria 2000.
[8] National Malaria Control Program Strategic National Plan 2006-2010 reviewed Cotonou 2007. [http://archiverbm.rollbackmalaria.org/countryaction/nsp/benin]
[9] Republic of Benin National Guidelines for the Management of Malaria Cases 2015.
[10] Economic Analysis and Foresight Fourth General Census of Population and Housing INSAE Cotonou 2013. [http://www.insae.bj.org/?file=files/publications/RGPH4/Plaquette_RGPH4_fomat%20A5]
[11] Sow MS, Conakry G. Safiatou Diallo amadou O, Boushab BM, Savadogo M, Diawara IK. Assessment of the use of the national protocol for the management of uncomplicated malaria in Matam, Guinea Conakry. Pan Afr Med J 2016; 23.
[12] Ouedraogo LT, Drabo KM, Zongo PS. Assessment of the implementation of the national protocol for the treatment of simple malaria cases in rural Burkina Faso. Public Health 2012; 24(4): 353-63.[PMID: 23043741]
[13] Yaméogo TM, Tapsoba SP, Sombié I, Guiguemdé TR. Evaluation of application of national guidelines for the management of malaria in Bobo-Dioulasso university hospital. Sante Publique 2015; 27(2): 265-73.[PMID: 26414041]
[14] Tougher S, Ye Y, Amuasi JH, et al. Effect of the affordable medicines facility-malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet 2012; 380(9857): 1916-26.[http://dx.doi.org/10.1016/S0140-6736(12)61732-2] [PMID: 23122217]
[15] Independent Evaluation of Phase 1 of the affordable medicines facility-malaria (AMFm), Multi-Country Independent Evaluation Report: Final Report Calverton, Maryland and London: ICF International and London School of Hygiene and Tropical Medicine 2012.https://www.theglobalfund.org/media/3011/terg_evaluation2013-2014thematicreviewamfm2012iephase1_report_en.pdf
[16] Zinsou C, Cherifath AB. The malaria testing and treatment landscape in Benin. Malar J 2017; 16(1): 174.[http://dx.doi.org/10.1186/s12936-017-1808-x] [PMID: 28446236]
[17] O’Connell KA, Gatakaa H, Poyer S, et al. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malar J 2011; 10: 326.[http://dx.doi.org/10.1186/1475-2875-10-326] [PMID: 22039838]
[18] Argaw MD, Woldegiorgis AG, Abate DT, Abebe ME. Improved malaria case management in formal private sector through public private partnership in Ethiopia: retrospective descriptive study. Malar J 2016; 15(1): 352.[http://dx.doi.org/10.1186/s12936-016-1402-7] [PMID: 27401095]
[19] Castiglione A, D’Ambrosio C, De Santis A, Palmieri F. On secure data management in health-care environment IEEE, 2013.

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Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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