This paper has been selected by an expert panel as one of eight of the most outstanding articles to address critical issues of global health research and policy and will be presented at the launch of the global theme issue at the US National Institutes of Health in Washington on Monday 22 October 2007.
The study was conducted on the children's ward at the national hospital in Guinea-Bisaau with poor conditions, no direct access to medical drugs, and poorly paid, unmotivated workers. In 2004, 12% of deaths (case fatalities) on the ward were due to malaria.
Staff training alone is not a solution, so researchers evaluated whether training, together with availability of drugs and small financial incentives, could save lives.
Before the study began, all personnel were trained in the use of standardised malaria case management guidelines. Both nurses and physicians were randomised to work on the intervention or the control ward. Personnel working on the intervention ward received a small financial incentive ($50/month) and their compliance with the guidelines was closely monitored.
At the start of the study, 951 children aged three months to five years who were admitted to hospital with a diagnosis of malaria were randomised to the intervention or control wards and a 28 day follow-up visit was arranged.
Case fatality was 5% for the intervention group and 10% in the control group, so effectively the intervention halved the case fatality among children.
These findings show that the quality of care in the paediatric ward depends not only on training and availability of drugs, but also on financial incentives adequate to allow staff to work fully and efficiently in the hospital, say the authors.
The results of this study are likely to be directly relevant in other national and district hospitals in developing countries facing the same conditions and problems. Although it is against the policy of most donors to give salary top-ups, this study provides powerful evidence that that policy should change, they conclude.