A Ghanaian study¹ has shown that treatment of malaria is more costeffective, in terms of both time and money when antimalarials are pre-packed in daily doses. Preliminary observations in six districts indicated that some of the major problems in malaria control programmes are: high cost of treatment; high chloroquine consumption (in syrup form); long waiting times at dispensaries; and a large number of untrained/unqualified dispensers who are unable to give advice.

¹ The study was part of a project to improve malaria control in Ghana, co-sponsored by the UK’s Department for International Health, Liverpool School of Tropical Medicine (UK), the Ministry of Health in Ghana and WHO’s Special Programme for Research and Training in Tropical Diseases (TDR).

Two types of pre-packaging were used in the study - plastic bottles for chloro-quine syrup and sealed plastic bags for chloroquine tablets. The advantages of pre-packaged antimalarials were found to include:

Reduced cost because of: reduction in the number of drugs prescribed; smaller volumes of syrup consumed; reduction in the number of injections given; reduction in excess chloroquine consumption.

Improved drug management - easier to balance books; easier to monitor drugs issued; reduced contamination; less wastage.

Improved case management - doses given according to weight.

Improved compliance - easy to understand and easy to remember instructions; more effective counselling.

Reduced waiting times in dispensaries.

Sustainability - cheap, readily available materials.

Acceptability - to both staff and patients.

Because of the clear advantages of pre-packaged antimalarials, Ghana’s district medical officers are eager to extend the practice to other commonly used drugs.

The Ghanaian study adds to the evidence from similar research on pre packaging in South-East Asia. For example, in China, blister packaging of antimalarials produced 97% adherence to treatment compared to 83% in the control group, whose drugs were handed out in envelopes (which are often lost or disintegrate in the rainy season associated with malaria).

Why patients need information

Other Ghanaian studies have shown how much greater the effect of prepackaging antimalarials is when better information is provided to patients by prescribers and dispensers. These studies were part of the series being carried out by district medical teams in collaboration with the Health Ministry’s Health Research Unit, in the context of Ghana’s health sector reforms. A Phase 1 study had indicated that many patients who receive chloroquine are not given any information about how many tablets to take or how often to take them. They may also be given either more or less chloroquine than they need. This is important because failure to comply with the full course of treatment affects both the patient’s cure and the drug resistance of parasites.

The packaging process for antimalarials, seen here at the National Institute of Medical Research, Lagos, Nigeria. Pills are bagged, heat sealed and labelled with dosage instructions

Photo: WHO/TDR/A. Crump

The follow-up intervention ensured that prescribers and dispensers provided full information to patients about the duration of therapy and the quantity of chloroquine to take each day. As well as verbal instructions patients were given a diagrammatic explanation to take home.

Following the intervention there was a significant increase in adherence to treatment - from 25% to 50% - in the number of patients strictly complying with these instructions. The proportion of people obtaining at least enough chloroquine on each of the three days of treatment increased from 29% to 54%. The proportion of children who obtained at least the recommended minimum dose of chloroquine syrup on each of the three days increased from 59% to 85%. Sample sizes used in the study were between 55 and 75 patients.

This work shows that a little time invested in providing appropriate information to the user at primary health care facilities will, in the long run, pay dividends in terms of increased patient adherence to treatment.

For further information contact: World Health Organization, Special Programme for Research and Training in Tropical Diseases, 1211 Geneva 27, Switzerland.

Source: TDR Newsletter No. 54, October 1997.