Facility readiness and determinants of malaria test-before-treat implementation in public health facilities in Kaduna and Kano States, Nigeria.

BACKGROUND

Prompt diagnosis and treatment of malaria remain central to malaria control strategies. The World Health Organization recommends testing suspected malaria cases before treatment using rapid diagnostic tests (RDTs) or microscopy. However, evidence on the readiness of health facilities to implement this policy in high-burden Nigerian states remains limited. This study assessed facility readiness, testing-before-treatment (TBT) coverage, and facility-level determinants of malaria diagnostic readiness among public health facilities in Kaduna and Kano States, Nigeria.

METHODS

A cross-sectional health facility assessment was conducted across 418 public health facilities in Kaduna and Kano States between August 5 and 28, 2025. A stratified two-stage sampling approach was used, with primary health facilities randomly selected proportionally across all 67 Local Government Areas and all secondary facilities purposively included. Data were collected using a structured Health Facility Assessment questionnaire. Facility readiness was assessed using five indicators: availability of RDTs, availability of microscopy services, trained staff on malaria case management, availability of standard operating procedures, and absence of stock-outs of RDTs or artemisinin-based combination therapy within the previous three months. A composite readiness index (0-5) was constructed and facilities were classified as having full or partial readiness. Associations between facility characteristics and readiness were examined using multivariable logistic regression.

RESULTS

All facilities had RDTs and trained staff on malaria case management, and none reported commodity stock-outs during the three-month reference period. Overall, 381 facilities (91.1%) demonstrated full readiness, with a mean readiness score of 4.91 ± 0.29. Microscopy services were available in 23.0% of facilities. Most facilities reported high TBT coverage, with 90.4% reporting ≥ 85% testing coverage. Secondary facilities (aOR = 2.15, 95% CI:1.06-4.36), urban location (aOR = 1.78, 95% CI:1.01-3.12), supportive supervision (aOR = 2.54, 95% CI:1.28-5.02), malaria focal persons (aOR = 2.92, 95% CI:1.63-5.23), and availability of free malaria commodities (aOR = 1.98, 95% CI:1.07-3.68) were significantly associated with full readiness.

CONCLUSION

Public health facilities assessed in Kaduna and Kano States demonstrated high structural readiness for malaria diagnosis. Study limitations include the cross-sectional design, reliance on facility records which may be subject to reporting bias, and the exclusion of private health facilities, limiting generalizability. These findings highlight the need for sustained commodity security, regular supportive supervision, and targeted investments in rural facilities to maintain and strengthen diagnostic readiness.