More than eight years have elapsed since the introduction of ACT for malaria in Sudan. However, proper case management for patients with malaria remains a challenge. In this large study of prescribing practices among healthcare workers in Gezira State, the recommended first-line drug was prescribed in most patients, which would seem to indicate confidence among heath care providers in this approach to treatment. Nevertheless, misuse of ACTs was widespread. Artemether injections were prescribed inappropriately, patients were not diagnosed according to standard guidelines, patients received inadequate education regarding their therapy, and treatment packages were poorly labeled. Overall, a minority of patients were diagnosed and treated according to the nationally recommended guidelines. A previous study in Ghana showed similar results [20].

A variety of factors may explain the findings in this study. For instance, poor supervision of health care providers, coupled with inadequate training and few opportunities for continuing education, could be a contributing cause of irrational ACT prescribing. Patient-related factors may also play a large role. Self-treatment of malaria is a common practice in Sudan [21], as well as in other countries [22]. Patient demand for treatment may influence the prescribing behaviors of health care providers. This may be especially true at the primary health care level whereworking conditions are sometimes unfavorable due to heavy workloads and low salaries. Additionally, it is not infrequent that such facilities encounter medication stock outs, which can lead by necessity to haphazard prescribing of other anti-malarial drugs (e.g., prescribing artemether injections for uncomplicated malaria despite the fact that this is not recommended therapy).

The majority of health care providers in this study requested a laboratory confirmation for malaria before prescribing treatment. However, among those who were prescribed ASP, only half were smear positive. Higher rates were reported in a Kenyan study where nearly 80% of patients with negative blood smears were prescribed malaria treatment [23]. This may raise concerns about Sudanese healthcare worker’s acceptance of laboratory results. Lack of trust of health care providers in laboratory diagnosis could be a factor in overreliance on clinical diagnosis of malaria. In the past, when laboratory facilities were largely unavailable in rural and remote areas, presumptive treatment of malaria was widely accepted. In recent years, however, with the expansion of health services across the country including the introduction of rapid diagnostic tests, presumptive treatment is no longer recommended as long as laboratory facilities are available. Moreover, requesting a laboratory investigation without utilizing its result is a waste of resources and poses unnecessary cost for patients. Most importantly, prescribing ACT for malaria negative patients increases the risk of developing drug resistance in the future, and should therefore be restricted. Unless all efforts come together to ensure accurate and safe diagnosis of malaria patients, barriers to effective clinical practices are likely to remain.

According to the national malaria treatment policy, the first-line treatment is made available free of charge in primary health care facilities. Overall, prescribing ACT using the generic name was widely neglected. Prescribers tend to use the term “Rajimat” to refer to the first–line therapy instead of prescribing it generically. It appears that the system for reviewing written prescriptions is either lacking or ineffective. Furthermore, the rate of antibiotic co-prescribing is evidently high. In some cases the healthcare provider may be uncertain about the diagnosis and therefore prescribe an antibiotic along with the anti-malarial. Haphazard antibiotic prescribing promotes the development of drug resistance and puts patients at risk of adverse drug effects. Our investigation also showed that the ACT dosage form was incorrectly written in the majority of prescriptions. For a prescription to be considered correctly written it should at minimum contain the medication’s dose (written in milligrams), quantity, and schedule. That information was incorrect, incomplete, or not written in the vast majority of prescriptions reviewed in our study. This practice has serious implications related to patient safety, including increasing the potential for treatment failure, promoting drug resistance, and increasing the risk of complications either due to the disease itself or to the administering of an inappropriate dose.

Interestingly, the availability of ACT in the study sites was high during the study period. Most ACT prescriptions were fully dispensed. This is a positive finding, since reliable availability of first-line therapies at primary health facilities would be expected to promote their rational use. However, labeling of dispensed drug packages was grossly inadequate. Moreover, information given to patients about their prescribed treatment was insufficient in most cases. Patient education and information enhance their adherence to prescribed therapies, leading to better treatment outcomes [24-26]. Heavy patient load in primary health facilities could be a main contributory factor.

Given that a multifactorial etiology is likely the cause for poor ACT prescribing patterns among health workers in Sudan, it would seem difficult to significantly improve the situation unless collaborative efforts take place by many different stakeholders. Examples of potentially important interventions include targeted training programmes for health workers, strategies for providing clear ACT information to patients and to the general public, strict policies focused on ACT deployment, and continuous monitoring of existing practices. Clear regulations relating to ACT use should be institutionalized, and more support is needed to encourage health care providers to adhere to the recommended guidelines. Evidence-based interventions such as implementing a self-administered checklist have proven to be effective for improving the performance of health care providers in disciplines such as surgery and childbirth [27,28]. Perhaps similar checklist-based interventions could promote the rational use of ACTs in Sudan.

This study has a several limitations. Prescribing data in this study were collected prospectively over a limited period of time and the fact that healthcare providers were aware that their practices were being observed could be a source of bias via the Hawthorne effect. However, retrospective collection of information was not feasible in this setting since records in most health facilities are severely incomplete. Interruptions in the anti-malarial drug supply chain or seasonality were also possible sources of bias. Another limitation of this study is the cluster sampling method used. While it is a well-accepted statistical method for increasing efficiency of data capture, similarities between individuals within clusters could result in the study sample being less representative of the study population. Nevertheless, Gezira state covers a huge geographical area and random sampling was impractical.