Improving quality of inpatient test-and-treat malaria case-management using joint clinical and laboratory strategy in Kano State, Nigeria

Abstract Background Quality of care and compliance with treatment guidelines supported by quality-assured parasitological diagnosis are strategic pillars of inpatient malaria case-management in Nigeria. However, scarce data, non-compliant practices, challenges in malaria microscopy, and absent linkages between clinical and laboratory quality improvement interventions are common programmatic deficiencies. We implemented and evaluated the effectiveness of a joint clinical and laboratory strategy on the quality of inpatient test-and-treat malaria case-management. Methods The innovative strategy based on annual cycles of hospital assessments and joint quarterly clinical and laboratory quality improvement interventions was implemented in 18 hospitals in Kano State, Nigeria. The effectiveness evaluation comprised two cross-sectional assessments: baseline at the beginning of the first annual cycle and endline after its completion. Data collection comprised availability audits, health worker interviews, rechecking of malaria slides, and retrospective reviews of all August 2024 and 2025 paediatric and medical ward admissions files. At each assessment, descriptive analyses included 18 hospitals, 72 health workers, and 2743 and 3198 suspected malaria admissions and 211 and 270 rechecked malaria slides, respectively. Results Minimum test-and-treat readiness, comprised of availability of malaria diagnostics, injectable artesunate and ACTs, was 94.4% at baseline and 88.9% at endline. Composite test-and-treat compliance increased by 42.4%, from 13.0% (357/2743) to 55.4% (1773/3198)—both in public [11.9% (306/2571) to 55.8% (1655/2967)] and private hospitals [29.7% (51/172) to 51.1% (118/231)], and for paediatric [12.2% (222/1825) to 64.2% (1290/2010)] and adult inpatients [14.7% (135/918) to 40.7% (483/1,188)]. Task-specific performance also improved: testing on admission from 73.7% (2022/2743) to 89.9% (2874/3198); artesunate for severe malaria from 90.2% (1028/1140) to 91.2% (1846/2025); ACT follow-on therapy from 29.8% (298/1001) to 85.6% (1572/1837); ACT for test-positive non-severe malaria admissions from 2.4% (18/754) to 7.4% (43/581); and compliance with test-negative results from 24.2% (31/128) to 57.1% (153/268). The specificity and positive predictive values of routine microscopy increased without compromising sensitivity and negative predictive values. Conclusions A single annual cycle of the joint clinical and laboratory strategy resulted in large improvements in the quality of inpatient test-and-treat malaria case-management. To maintain and further optimise performance, continuation of the intervention with repeated assessments is required. Other countries facing inpatient quality gaps may consider a joint clinical and laboratory strategy.