The three most prevalent diagnoses in this study, were ARI, malaria and diarrhoea. URTI and diarrhoea diagnoses and treatments adhered least to STG. These findings coincide with studies that seem to suggest that low adherence to STG, especially for the management of childhood diseases such as diarrhoea and respiratory tract infections, is common not only in LMICs but worldwide [21–23]. Partial adherence to STG for URTI was mainly due to the high prescription of antibiotics for bronchitis which is generally caused by a virus and would therefore not benefit from them. In accordance with STG, antibiotics were indicated for the treatment of pneumonia, they were not, however, indicated for URTIs and GI problems. Fifty-six percent of diarrhoea cases, 25% of malaria cases and 21% of worm cases also received an antibiotic. However, in rural areas diagnosis is complicated by the scarcity of diagnostic tools and facilities which can lead to prescribing antibiotics presumptively when rapid decisions are a matter of mortality. This was observed, at least, for malaria treatment in rural areas, in Tanzania, where patients presenting with fever were more likely to receive co-prescription of antibiotics and antimalarial when diagnosis was clinical and not backed by malaria rapid testing [24]. Nevertheless, the fact that 61% of patients, in this study, received an antibiotic, disregarding the diagnoses, is of grave concern. It is also a far cry from the WHO prescribing indicator that recommends use in less than 30% of cases [2, 25]. Tanzania has a history of overprescribing antibiotics and according to an assessment conducted in four regions of Tanzania in 2014 it does not appear to have improved [3].
The total of all malaria diagnoses in all districts in this study was 18%. It is interesting to note the lower prevalence of malaria, 1.8% of all diagnoses, in the Dodoma Municipal which is a more urban district. Complete adherence to STG for malaria for primary diagnoses was 65%, partial 28% and non-adherence 7.5%. Budimu et al. reported, from a study conducted in the Meatu district of Tanzania in 2017, 54.6% of all 196 healthcare workers there strictly adhered to the STG for malaria case management. Ten (5.1%) healthcare workers partially adhered when they chose antimalarials without confirmed cases of malaria and 79 (40.3%) health workers did not adhere [17]. Although the study in the Meatu district was on a much smaller scale and in a different region, comparing these studies, the adherence to STG seems to have regressed. In a study in the Kilosa district of Tanzania back in 2010, concerns were raised, however, that the STG for administering the malaria treatment, artemisinin combination therapy, were not clear enough and thereby probably contributed to the prescribers’ non-conformity with STG [26].
Complete adherence to diarrhoea STG was extremely low. Partial adherence was mainly due to prescribing oral rehydration solution (ORS) plus antibiotics and the lack of prescribed Zinc. Extremely low adherence to STG for the management of acute diarrhoea in children under 12 was also found in a study in Ujjain, Madhya Pradesh, India and the high rate of prescribing non-recommended medication was discussed [21]. The duration and volume of diarrhoea is not lessened with ORS, therefore, many practitioners look for alternative therapies to shorten its time span [27]. As vomiting can be caused and aggravated by incorrectly prepared ORS, parents and caregivers may be discouraged to continue the therapy leading to a failure in oral hydration [28]. Thus, the perceived ineffectiveness of ORS therapy may have then led to an increase in prescribing other non-recommended medications such as antibiotics. Pathak et al. also considered that accompanying symptoms like the presence of fever, pain, blood in the stool and vomiting significantly increased antibiotic prescribing even though most diarrhoeal episodes are of a viral origin [21].
Another matter of interest in the present study was the low number of diagnoses of NCDs with just 51 cases (2%) despite NCDs, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes being the leading cause of mortality in the world today. In fact, recent data shows that NCDs are estimated to account for 33% of all deaths in Tanzania [29]. Thus, the low number of diagnoses in the present study may be explained with either actual low prevalence in the Dodoma region at the time or, what is more likely, low awareness and insufficient diagnostic skills of what are often, initially, silent diseases. Similarly, mental disease appears not to have been a problem in Dodoma region. This again may be due to low prevalence but more likely to be an unawareness and underdiagnoses of mental conditions.
The implementation of STG provides a point of reference by which practitioners can review, compare and advance the quality of care that they deliver. They are packaged so as to contain statements that provide expected standards of practice in order to diminish variations in clinical practice and to reduce costly and avoidable mistakes and adverse events [30]. It is of concern then that, approximately, only a third of primary diagnoses in this study were prescribed and treated completely in accordance with the national STG. A little over a third (38.7%) of primary diagnoses prescriptions partially adhered to them, thus, in these cases patients at least received the correct medicine but also further unnecessary or incorrect medicines, which is a waste of limited resources. In addition, approximately a third of prescribers diagnosed and treated patients incorrectly and not in accordance with STG; therefore the quality of care and patient outcome may have been seriously compromised.
As printed materials alone seem to have little effect in changing the prescribing behaviour of clinical health workers, STG need to be accompanied by reminders, educational outreach and feedback in order to be effective [6, 12–14]. Notwithstanding implementing ineffective training and supportive supervision, the shortage of healthcare workers, together with high clinical and administrative workloads, negatively impacts the quality of patient care delivered. In Tanzania, between the period 2007 and 2013 the physician to population ratio per 10,000 was 0.3, this was far lower than the WHO African Region average of 2.7 and the global average of 13.9. During the same period the nursing and midwifery personnel to population ratio per 10,000 was 4.4, again this was far lower than the WHO African region average of 12.4 per 10,000 and the global average of 28.6 [31]. The overall performance of health service delivery at all levels is severely impeded by a variety of complex factors and the heavy demands on the health system has led to an overwhelmed workforce that is consequently challenged to adhere to STG [16].