Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial

Abstract

Objective: To test whether strict implementation of a standardised protocol for the management of malaria and provision of a financial incentive for health workers reduced mortality.

Design: Randomised controlled intervention trial.

Setting: Paediatric ward at the national hospital in Guinea-Bissau. All children admitted to hospital with severe malaria received free drug kits.

Participants: 951 children aged 3 months to 5 years admitted to hospital with a diagnosis of malaria randomised to normal or intervention wards.

Interventions: Before the start of the study, all personnel were trained in the use of the standardised guidelines for the management of malaria, including strict follow-up procedures. Nurses and doctors were randomised to work on intervention or control wards. Personnel in the intervention ward received a small financial incentive ($50 (25 pounds sterling; 35 euros)/month for nurses and $160 for doctors) and their compliance with standard case management was closely monitored.

Main outcome measures: In-hospital mortality and cumulative mortality within 4 weeks of hospital admission.

Results: In-hospital mortality was 5% for the intervention group and 10% in the control group (risk ratio 0.48, 95% confidence interval 0.29 to 0.79). The effect may have been stronger in patients with positive malaria slides (0.36, 0.16 to 0.80). Cumulative mortality 4 weeks after discharge was also lower in the intervention group (0.61, 0.40 to 0.95).

Conclusions: Supervising healthcare workers to adhere to a standardised treatment protocol was associated with greatly reduced in-hospital mortality. Financial incentives may be important for the dedication and compliance of staff members.

Trial registration: Clinical Trials NCT00465777 [ClinicalTrials.gov].

Conflict of interest statement

Competing interests: None declared.

Figures

Study flowchart