Testing Before Counseling

How might we make complying with clinical protocols practically and psychologically easier for providers?

Country: Nigeria

Health Area: Malaria

Context and Insights

National guidelines in Nigeria require all fever cases be tested for malaria before prescribing anti-malarial medication. However, many healthcare providers often do not follow this protocol, sometimes skipping tests or ignoring negative results. The high prevalence of malaria in the region leads providers to assume most fevers are malaria, causing them to discount negative test results and prescribe medication anyway. Providers also face time pressures and logistical challenges that tempt them to skip testing. Additionally, limited training and resources make it difficult for providers to diagnose other illnesses, reinforcing their reliance on treating fevers as malaria despite negative test results.

The Solution

Instead of testing clients for malaria after an initial consultation with a provider, facilities offer malaria testing during client intake or triage. This change saves time: clients do not have to see the provider twice, and it also ensures clients have test results when they consult with a provider. A facilitated group discussion among providers, called “Why Rapid Diagnostic Tests (RDTs) are Reliable,” addresses their concerns about RDTs by refuting common misconceptions about the reliability of RDTs and the prevalence of malaria. The session provides the Testing Before Counseling (TBC) solution set, a simplified tool for diagnosing non-malaria causes of fever based on national and World Health Organization guidelines. This solution set removes the decision of whether to test for malaria from the provider, increases their confidence in negative RDT results, and gives them the ability to diagnose fevers where malaria has been ruled out.

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“We don’t gamble with human life up here […] You know the main killer in Africa is this malaria.” — Doctor, Akwa Ibom State, Nigeria

“It’s a process to help both the provider and the patients […] The idea will reduce the time that patients will spend at the health center.” — Community Health Extension Worker, Nigeria

The Innovation

The TBC solution set addresses underlying challenges such as providers’ inability to diagnose and treat something other than malaria. It reduces the complexity of diagnostic processes and addresses widespread misconceptions about RDTs in the medical community. TBC improves adherence to the testing standards by making it easier (practically and psychologically) to treat the source of fever correctly.

The Evidence

Facilities participating in a pilot test of the solution set approached 100% adherence to the protocol throughout the pilot. Providers’ responses to a post-pilot knowledge and attitude test also demonstrated improvements in knowledge and trust in RDTs compared to pre-pilot tests. When deployed at scale, the number of clients inappropriately diagnosed with malaria decreased from 84 per 1,000 to 4 per 1,000.

Scale-Up & Adapt

The solution set easily integrates into routine service delivery and leverages existing practices and guidelines such as supportive supervision. As of 2023, the project has scaled solutions to nearly 800 health facilities across seven states, with plans to expand to two additional states.

Who can I speak with about this solution?

Eno’bong Idiong, Senior Technical Advisor

Shittu Abdu-Aguye, Chief of Party, Nigeria

Angela Acosta, Senior Program Officer

Faraz Haqqi, Principal Behavioral Designer, ideas42

Other resources

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