Shocking Gaps in Malaria Treatment: How Poor Dispensing Practices in Ghana Are Undermining Global Fight Against a Deadly Disease
Imagine a world where millions battle malaria, a preventable killer that claims lives daily, especially among vulnerable children and pregnant women in Africa. Despite advances in antimalarial drugs, the way these medicines are handed out at health facilities could be sabotaging our progress—and that's exactly what a groundbreaking study from Ghana reveals. But here's where it gets controversial: are we really doing enough to ensure these life-saving treatments are dispensed correctly, or are outdated practices and resource shortages fueling resistance and worse outcomes? Stick around, because this is the part most people miss—the hidden flaws in a system meant to save lives.
Key Details of the Study
Published in Malaria Journal on November 11, 2025 (volume 24, article 394), this research delves into antimalarial dispensing habits in Ghana from 2018 to 2022. It's an open-access piece, freely available thanks to Springer's commitment to transparent science.
Authors: Esenam Mawufemor Tagboto (Accra Metropolitan Health Directorate), Michael Opoku-Mireku (Atebubu-Amantin Municipal Health Directorate), Jocelyn Laryea (Regional Health Directorate, Greater Accra), Timothy Agandah (Department of Epidemiology and Disease Control, University of Ghana), Paul Boateng (National Malaria Elimination Programme), Joel Jeffrey Idun-Acquah (National Malaria Elimination Programme), Keziah Laurencia Malm (National Malaria Elimination Programme), and Harriet Affran Bonful (Department of Epidemiology and Disease Control, University of Ghana).
Abstract
Overview
Malaria continues to pose a significant public health challenge worldwide, even though it's both preventable and treatable. It's a leading cause of death for pregnant women and young children, particularly across Africa. In 2023, global malaria cases surged to 60.4 per 1,000 people at risk, with nearly all (94%) occurring in sub-Saharan Africa. That same year, production of artemisinin-based therapies skyrocketed to 4.4 billion doses, mostly funneled through national programs in the region. Yet, this surge raises alarms due to emerging partial resistance to artemisinin. To combat this, effective stewardship of these drugs is essential. The Outreach Training and Supportive Supervision (OTSS) initiative offers a solid quality assurance approach to promote responsible use. OTSS data has already been leveraged to enhance various malaria care elements, but dispensing practices have gone largely unexamined. This investigation aims to outline these practices and track their changes over time in Ghana from 2018 to 2022.
Approach
We conducted an analytical observational study using secondary data from Ghana's yearly OTSS visits across all 16 regions. The assessments targeted selected health centers. Data came from the Electronic Data System, a digital tool for OTSS. Key indicators included location, service level, facility details, and pharmacy metrics—specifically, 3 related to labeling and 12 to adherence. Dispensing practice was evaluated as a median-split composite of labeling and adherence. After cleaning, we analyzed 7,193 valid entries from 4,471 facilities, including 2,722 repeat visits. We summarized practices by region and service level annually, and employed mixed-effects logistic regression to forecast the likelihood of good dispensing based on year and trends over time.
Findings
Peak adequate dispensing rates by region each year were 85.7% in 2018, 70.8% in 2019, 58.8% in 2020, and 66.0% in 2022. For service levels, peaks reached 57.7% in 2018, 56.3% in 2019, 57.8% in 2020, and 45.8% in 2022. Eight regions matched Greater Accra's standards, three fell below, and four exceeded them. Dispensing excelled in Community-based Health Planning and Services (CHPS) zones compared to hospitals (Adjusted Odds Ratio [AOR] = 0.48), clinics (AOR = 0.37), and maternity homes (AOR = 0.33).
Conclusion
Dispensing practices stayed stubbornly low nationwide and across service tiers during the period. Nonetheless, CHPS zones and health centers fared better than advanced facilities. Ongoing investments in training, oversight, and supplies are vital for fair improvements in dispensing.
Background
Malaria isn't just a health issue—it's a relentless threat that, despite our best efforts, remains a top global killer, especially in Africa where it disproportionately affects pregnant moms and kids under five. For instance, in 2023, infections hit 60.4 cases per 1,000 at-risk individuals worldwide, with a staggering 94% in sub-Saharan Africa. And while artemisinin-based combination therapies (ACTs) saw a massive boost in production that year—reaching 4.4 billion doses, mostly in these African programs—this boom comes with a dark side: growing partial resistance to artemisinin itself. This resistance could render our strongest weapons ineffective, highlighting the urgent need for careful management of these drugs through deliberate stewardship.
Enter the Outreach Training and Supportive Supervision (OTSS), a Ghanaian program since 2009 that's proven effective in boosting ACT use, adherence to guidelines, and outcomes in prevention, diagnosis, and treatment. OTSS merges on-site training with supportive oversight to build facility skills and expertise. During visits, skilled supervisors use standardized, competency-focused digital checklists to observe provider actions and review records. Nine checklists cover six areas: two for case management, one for pregnancy-related malaria, two for lab checks, one for pharmacy, two for data handling, and one for general reviews. They capture real-time procedures, develop plans to fix issues, and track progress.
Growing evidence shows OTSS's power in improving care. For example, data from it has sparked research and practical changes in many areas. In Zambia, Worges and colleagues showed how OTSS sharpened malaria diagnostic skills and treatment decisions. Similarly, it has enhanced provider abilities in rapid diagnostic tests (RDTs), microscopy, pregnancy malaria management, clinical care, guideline following, and preventive treatments for expectant mothers.
But with ACT production soaring, stewardship must go beyond just diagnosing and prescribing—it must include proper dispensing. Alarmingly, antimalarial dispensing in Ghana is understudied, with only a handful of localized studies. These pharmacy checklists in OTSS offer a great chance to improve quality, covering dispensing, infrastructure, stock control, and supply availability. Building on OTSS's successes in diagnostics and treatment, it's logical to extend it to dispensing. Without this, poor practices rampant in sub-Saharan Africa could lead to resistance, counterproductive results, and even death.
This marks the first nationwide look at Ghana's dispensing habits using OTSS data, filling a knowledge gap on facility-level practices by region and service type. It seeks to detail these habits and map their shifts from 2018 to 2022.
Methods
Study Design
This was a retrospective observational analysis of secondary data from Ghana's OTSS rounds from 2018 to 2022. Using a repeated cross-sectional setup, we evaluated facility-level antimalarial dispensing yearly. We pulled data from the Electronic Data System (EDS) application in June to July 2023. EDS digitizes OTSS, improving malaria care through real-time collection, checklist-based reviews, trend monitoring, and optimized oversight. We analyzed data from 2018 to 2022 to spot patterns and changes in dispensing, noting that 2021 visits happened in 2022 due to COVID-19 disruptions.
Study Setting
Ghana, a lower-middle-income West African nation, had a 2021 population of 31 million across 238,537 square kilometers. It consists of 16 regions: Ahafo, Ashanti, Bono, Bono East, Central, Eastern, Greater Accra, North East, Northern, Oti, Savannah, Upper East, Upper West, Volta, Western, and Western North.
Ghana's health system blends public and private sectors, offering services at primary, secondary, and tertiary levels. Primary care starts with CHPS compounds, maternity homes, clinics, health centers, and polyclinics—focusing on initial patient contact. Secondary includes district and regional hospitals for specialized care, while tertiary provides advanced services. Care spans urban, rural, and peri-urban areas, with public, private, mission, and community providers.
Facility Selection
Yearly OTSS targets facilities with weak performance, chosen via composite scores from routine indicators like test rates, ACT treatment shares, third-dose IPTp for pregnant women, and LLIN distributions. Ghana's OTSS covers diverse facilities across regions, but logistical limits mean not every district gets visited annually. To maximize coverage, previously visited sites are skipped, implicitly favoring unvisited or underserved ones.
Data Sources
The OTSS dataset, managed by Ghana Health Service's National Malaria Elimination Programme via EDS, includes secondary info on malaria treatments at selected sites. It spans six categories: case management, pregnancy malaria, labs, pharmacy, data management, and general oversight. We zeroed in on pharmacy, broken into dispensing, infrastructure, supplies, and stock management. We also gathered details on service levels and regions.
Data Gathering
Downloaded in Excel in June 2023, the data covered all pharmacy category indicators—3 on labeling, 12 on adherence, 4 on infrastructure, and 3 on stock. Individual observations from assessing 3 workers per facility per visit were included. We created composite scores for facility variables, outlined in Table 1 (reproduced in the original for reference).
Key Variables
Tables 1 and 2 summarize our variables. The main outcome was dispensing practice, measured by labeling and counseling adherence composites. Scores were skewed, so we split at the median per Iacobucci et al.'s advice when no standard cutoffs exist. We adjusted for region, service level, and time trends.
Data Handling and Analysis
Our unit was an OTSS-visited facility in Ghana from 2018 to 2022. Starting with 7,834 entries, we removed those with over 10% missing data, leaving 7,732. We cleaned duplicates, yielding 7,193 records—4,471 unique, with 2,722 repeats (42.2%). We described summaries by region, year, and dispensing. Chi-square tests checked links between dispensing and variables yearly. Mixed-effects logistic regression predicted dispensing odds by year and trends, accounting for repeated visits via random facility effects. Fixed effects covered region, service level, and time; interactions for region-time and level-time trends. A null model started us, with intraclass correlation at 0.159 indicating clustering. We added variables, comparing models via likelihood ratio tests; the full model (with interactions) fit best (p=0.009), with AUC=0.85. We reported main effect adjusted odds ratios and interaction predicted probabilities.
Ethical Aspects
Approval came from Ghana Health Service Ethics Review Committee (GHS-ERC:044/01/24). Administrative clearance from the National Malaria Elimination Programme allowed data use, all anonymized to protect identities.
Results
Table 3 details 7,193 facility entries, broken by dispensing sub-metrics. Greater Accra (14.8%) and Ashanti (14.2%) dominated, while North East (1.1%) and Savannah (1.8%) had the least. CHPS compounds (42.9%) were most assessed, maternity homes (4.2%) least. A third of data was from 2019 (31.3%), then 2022 (34.9%).
Patients got clear prescription info in 63.1% of cases; 57.8% had proper labels. But only 40.7% grasped instructions, 35.2% of under-5s had DOT for first ACT, and 31.5% learned about side effects.
Table 4 shows bivariate links between dispensing and geography/service level. Rates varied yearly and by level. In 2018, Central region had 6/7 (85.7%) adequate; North East and Savannah 0/3 (0%). Regions with low rates had tiny samples (≤3 facilities). Highs included Central (85.7%), Upper West (70.8%), Northern (75.0%), North East (66.0%). Health centers topped in 2019 (56.3%), 2020 (57.8%), 2022 (45.8%), except 2018 when CHPS led (57.7%). Peak adequate was 50.1% in 2020, low 41.2% in 2022.
Table 5 gives main effects: Bono (AOR=4.33), Bono East (3.83), Savannah (2.14), Upper West (2.41) higher than Greater Accra; Ashanti (0.57), Northern (0.03), Upper East (0.26) lower; odds dipped in 2019 (0.51), 2022 (0.49) vs. 2018; CHPS better than hospitals (0.48), clinics (0.37), maternity homes (0.33).
Figure 2 plots regional trends: Northern/Ahafo rising; Bono/Bono East/Central/North East/Oti/Upper East/Upper West falling; others steady.
Figure 3 shows level trends: CHPS/health centers stable-high; clinics/maternity homes declining/volatile; hospitals moderate gains.
Discussion
Our OTSS data review uncovers ongoing deficiencies in Ghana's antimalarial dispensing. Adequate practices peaked at 85.7% in 2018, dropped to 58.8% in 2020, then rose to 66.0% in 2022. By level: 57.7% in 2018, 56.3% in 2019, 57.8% in 2020, 45.8% in 2022. Four regions (Bono/Bono East/Savannah/Upper West) equaled Greater Accra, three lagged (Ashanti/Northern/Upper East), four excelled. Odds fell post-2018; CHPS outperformed hospitals/clinics/maternity homes.
These lows align with Pakistan's unsatisfactory practices and Ethiopia's poor labeling/counseling/errors. Critical misses include side-effect info (31.5%) and DOT for kids (35.2%). Reasons? Staff knowledge gaps, untrained dispensers, weak supervision. Ghana's 1:10,000 pharmacist ratio (vs. WHO's 1:2,000) forces non-professionals to rely on uneven guideline use.
While OTSS helps, more frequent visits and action follow-ups are needed. Studies show up to 73% misunderstand hospital instructions, risking misuse/resistance. Gaps reflect resource disparities; CHPS/health centers excel via personalized, community-focused care, unlike overburdened hospitals/clinics/maternity homes prioritizing speed.
Trends show stagnant or worsening practices, questioning OTSS's long-term impact. Sampling by performance might hinder steady gains. Future efforts could shift to patient-centered care, test Lean Six Sigma, tailored education, or multifaceted strategies.
First national OTSS-based study; limitations: small samples in low-rate regions skew reliability. Tools/median-split need validation; no standard metrics. But this provides initial insights.
Conclusion
This work outlines Ghana's dispensing habits and trends from 2018-2022. Rates stayed low regionally and by level. Eight regions mirrored Greater Accra (most facilities/workforce); three underperformed, four better. Practices worsened after 2018; CHPS/health centers bested higher-level sites.
Sustained training/oversight/resource boosts are key for fair gains. Target poor performers with skill-building, more visits, action tracking. Recruit pros for hospitals. Build monitoring systems. Diversify sampling; test interventions like education.
Data Availability: Accessible at Mendeley Data: https://data.mendeley.com/datasets/87js77z43z/1.
Abbreviations: ACT: Artemisinin-based combination therapy; AIC: Akaike information criteria; AUC: Area under receiver operating characteristic curve; CHPS: Community-based health planning and services; DOT: Directly observed therapy; EDS: Electronic data system; LLIN: Long-lasting insecticidal nets; OTSS: Outreach training and supportive supervision; RDT: Rapid diagnostic testing.
References: [Full list from original, unchanged for accuracy.]
Acknowledgements: Thanks to National Malaria Elimination Programme for data access.
Funding: Data by NMEP; other costs by EMT.
Authors and Affiliations: As listed.
Contributions: EMT/HAB conceived; MMO/JL analyzed; EMT/JL/MMO drafted; HAB/TAA/JJI/KLM reviewed; all approved.
Ethics: Approved as above.
Competing Interests: None.
What do you think—should governments prioritize pharmacist training over quick fixes like digital apps? Or is the real issue deeper, like funding gaps that leave clinics understaffed? Share your views in the comments; let's debate how to fix this global health puzzle!
