Changing of antimalarial treatment policy

A change of policy on the first-line drug for malaria is a major challenge to endemic countries, malaria being a ‘high-burden’ disease, and particularly, as in the case of chloroquine or S/P, when it entails changing from a low cost, and easy-to-administer drug with a known safety prophile. This was evident in the all too delayed response from countries all over the world in replacing chloroquine and S/P, often at the cost of a high morbidity and mortality.

Although several indicatorsⁱ may signal the need for a policy review, failing therapeutic efficacy of the first-line antimalarial drug is the single most important guide to drug policy review. Currently, countries are advised to be on high alert for policy review when clinical failure ratesⁱⁱ exceeds 6%, and to change the antimalarial treatment when failure rates reach 15%.

ⁱ Framework for developing, implementing and updating national treatment policy: a guide for country malaria control programmes. Brazzaville, WHO Regional Office for Africa, 2002

ⁱⁱ As defined by the WHO Protocol for Assessment and Monitoring of Antimalarial Drug Efficacy for the Treatment of Uncomplicated Falciparum Malaria. WHO unpublished document. WHO/HTM/RBM/2003.50

Delivering antimalarials to the community

Health facilities are most often not able to meet all treatment needs especially in remote and rural areas and among marginalised populations, ethnic minorities and forest dwellers in Africa, Asia and Latin America. This coupled with scarce transport facilities make the likelihood of reaching a functional health facility in time very low. These constraints can only be surmounted by making treatment available as near the home as possible, be that in the community or in the home itself. This strategy is referred to as “Home Management of Malaria”.

Malaria treatment requires accessing effective treatment within 24 hours of the onset of illness especially for non-immune persons and this is critical to saving child lives in Africa and for reducing child and adult mortality in other endemic regions of the world. Therefore, one of the most important strategies to reduce child mortality due to malaria is home management of malaria. The strategy entails educating mothers, community health workers, volunteers and/or drug vendors to recognise symptoms suggestive of malaria and deliver appropriate preferably pre-packed antimalarial drugs. Home management of malaria is very much embodied within the principles of primary health care (PHC) to improve access to care and to ensure equity, and it widely implemented in the Indian subcontinent. Providing FDC antimalarial products could simplify the home management of malaria.

Delivering antimalarials through public sector

Home management of malaria involves engaging communities, changing treatment seeking behaviour, educating mothers and training community health workers, pre-packaging drugs and putting in place supervisory and simple monitoring systems. It requires intensive support from the public health services, particularly from the peripheral health facilities. The most important components are the Community Owned Resource Persons, be they community volunteers, shop keepers or mother co-ordinators who frequently function on a voluntary basis. Governments need to consider how these persons can be remunerated to prevent the currently high attrition of trained personnel within these programmes.

In many Asian countries village level workers, such asmidwives and public health inspectors (in Sri Lanka) and multi-purpose community health workers (in India) are on a government payroll. In Africa, community health nurses in Ghana show the importance of government investment in the community level of health care. In Uganda, the government is promoting community drug distributors to ensure access to pre-packed antimalarial drugs (chloroquine plus S/P) within the communities. A similar programme is under way in Madagascar.

Delivering antimalarials through the private sector

In endemic countries where malaria is a major health problem today, the private sector plays a significant role in delivering antimalarial treatment, and in some affected communities it may be the sole provider of life-saving medicines. When governments have been slow to review national treatment policy and replace failing drugs with effective ones, populations have turned to this poorly regulated private sector market in order to buy newer drugs that are perceived to be effective. While their motive is profit, they may offer the best option for accessing treatment to those communities who would otherwise have to travel long distances to reach health facilities only to find them functioning poorly, often being out-of-stock of antimalarial drugs and offering no more than a clinical diagnosis before referring them back to the drug sellers for purchasing treatment.

However, the informal private sector is also a source of major challenges in malaria treatment delivery. This sector is represented inmany countries by a network of small-scale traders, unregulated and unregistered peddlers or drug sellers that sells a variety of goods from food to household items and drugs with questionable quality, including counterfeits. More importantly, regulation of drug quality and price is difficult to impose leaving a chaotic antimalarial drug market.

It is imperative to engage and train local drug vendors in the basics of disease recognition as well as proper prescription and referral practices, which form an integral component of home management of malaria in Africa today. Experiences in Kenya, Nigeria and Uganda have shown that training of shopkeepers and chemical sellers may lead to significant improvement in treatment practives with antimalarial drugs. Investment in their training would need to be continued as new traders continuously enter the market. The public sector’s stewardship role is critically important to ensure the quality of drugs sold and proper patient counselling delivered in the informal private sector.

Delivering antimalarial through partnership with NGOs

In many malaria endemic countries, non-governmental organizations (NGOs) are governments’ most reliable partners in the delivery of health care in hard to reach populations. National and district level health administrations working with these organisations should actively be encouraged by principal financing sources such as bilateral agencies and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). NGOs are usually at the grass root and committed workforce that is able to function efficiently without the constraints of bureaucratic organizations

Given the findings presented above, it can be concluded that:

• The majority of “malaria” cases is being treated at home, with home remedies or drugs bought directly from the informal private sector. Distance to, frequent stock-outs, and poor services are the main reasons for non-use of public health facilities for malaria treatment;

• In many countries there is a common practice to consider and treat all cases of fever as being malaria;

• Malaria treatment practices are frequently inappropriate, especially in the private sector, and this may contribute significantly to the problems of drug resistance;

• There are serious quality problems with antimalarial products circulating in countries;

• Costs of malaria treatment for households are considerable, and may be a major contributor to poverty in some countries. Cost of malaria drugs affect disproportionately poor households. Costs of new ACTs may significantly add to this.

• Poor practices with malaria treatment may be continued with the use of new FDC ACT preparations, especially if prices to the consumers of these drugs will be high. New and effective approaches will be necessary to promote the appropriate deployment of ACTs.