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Sierra Leone and Madagascar Enhance the Quality of Malaria Service Delivery Through a Standardized Approach

“I have proudly shown my colleagues how to carry out these procedures”, Lahai Swarray shared after receiving training that improves the technical skills of the growing base of microscopists in Sierra Leone. 

Lahai is a laboratory technician who examines patient blood samples for the presence of malaria at a district hospital. Laboratory technicians play a critical role in diagnosing cases of malaria, examining blood sample slides from suspected malaria patients with microscopes. 

Malaria is preventable and treatable, and yet every year it kills more than 400,000 people around the world – primarily children under five.  

Quick diagnosis and appropriate treatment of malaria is essential to avoid the potentially deadly toll. The quality of malaria services delivered to those that need it most is dependent on health care providers properly diagnosing and treating malaria. Health care providers need training on the most up-to-date malaria diagnosis and treatment guidelines and support in putting that training into action when delivering services in their workplace.  

To help make this happen, PMI Impact Malaria, the flagship global service delivery project of the President’s Malaria Initiative (PMI), uses a quality improvement approach called Outreach, Training, and Supportive Supervision (OTSS+)

The OTSS+ approach deploys supportive supervision agents to work side-by-side with malaria service delivery providers in the health facilities where they work, like Lahai in Sierra Leone, and Gabriel, a nurse who treats malaria patients at a military hospital in Madagascar. Supervisors use standardized quality checklists based on global and national malaria diagnosis and treatment guidelines to observe the work of providers like Lahai and Gabriel and help them build their skills with on-the-job support and training.  

Boosting Microscopy Skills in Sierra Leone 

In Sierra Leone, technicians were having trouble preparing the slides, determining the presence of the malaria parasite in the blood sample, and identifying the malaria parasite species. These are all critical elements used by health providers in determining appropriate treatment. 

With PMI support through the PMI Impact Malaria project, Sierra Leone’s NMCP conducted its first round of OTSS+, reaching 53 health facilities from all regions of the country and a total of 202 laboratory technicians.  

An OTSS+ supervisor in Sierra Leone observes laboratory technicians conducting malaria microscopies and provides on-the-job training. Photo Credit: Salieu Timbo, PMI Impact Malaria Sierra Leone.  

Lahai has worked at the Bonth District Government Hospital for the past four years. Through OTSS+ he received supervision and training to improve his malaria microscopy skills. “This is my first-time being part of such training,” says Lahai, “procedures I didn’t do competently, like preparing Giemsa stains, can now be done.” 

Treating Severe Malaria in Madagascar 

In Madagascar, supportive supervision agents held OTSS+ visits to the military hospital in Antisiranana I in the far north. While there, they found that the hospital treated severe malaria patients with quinine, rather than injectable artesunate recommended by the National Malaria Control Program (NMCP) and WHO.  

They also found that the latest treatment guidelines were not in use and there was no injectable artesunate in stock. Using a set of standardized checklists, the OTSS+ supervisors offered a path for the hospital to immediately and effectively improve severe malaria management.   

When two teenage patients were admitted to the hospital in a coma due to cerebral malaria, a severe neurological complication of malaria infection, Gabriel administered injectable artesunate with the help of OTSS+ supervisors. Preparing for this scenario, they had brought the WHO-recommended injectable artesunate with them to provide for hospitals. Within four hours both patients emerged from their comas.  

Over several months of repeat OTSS+ visits, health workers at the hospital received on-the-job training and supportive supervision on the new treatment guidelines and how to prevent stockouts. 

Today, Gabriel is a champion for injectable artesunate and trains his peers on best practices to treat severe malaria.  

A recent OTSS+ visit found that the hospital’s severe malaria management score increased dramatically from 15% on the initial visit to 73%. 

After receiving training and supportive supervision through OTSS+, Gabriel teaches his colleagues about injectable artesunate and how best to treat severe malaria. Photo Credit: Emeraldon Ratsiahimarizafy, PMI Impact Malaria Madagascar.

With continued support and training through OTSS+, more laboratory staff like Lahai will improve their malaria microscopy skills. More nurses like Gabriel will learn to treat malaria using the most up to date guidelines. Through these efforts, a pool of experienced malaria health providers will continue to grow in their respective countries. 

Through PMI Impact Malaria, PMI supports NMCPs in 13 countries to conduct OTSS+ and empower providers and health facility staff at all levels of the health system to improve provider competencies and to deliver quality malaria services in adherence with national guidelines and policies. 


PMI Impact Malaria is funded and technically assisted by the U.S. President's Malaria Initiative (PMI) and is led by Population Services International (PSI) in partnership with JhpiegoMedical Care Development International (MCDI), and UCSF.

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