Article type
Year
Abstract
Background: Ideally, malaria treatment (MT) policy-making and practice should follow the process:
Cochrane (and other) evidence --> World Health Organisation (WHO) recommendations --> National policy --> Practice (what patients receive)
WHO recommendations draw on Cochrane reviews, but large discrepancies exist between recommendations, national policies and what people receive. Many African countries still use conventional monotherapies despite high failure rates and availability of more effective replacements. As a result, malaria burden is rising.
Objectives and methods: In Africa 1. To summarise Cochrane review evidence/WHO recommendations and to compare this with policy and practice. 2. To use research evidence to highlight where further research is needed into barriers to change and how to overcome these.
Results: Evidence/WHO recommendations vs policy and practice Two Cochrane reviews [1-2] show that adding an artemisinin derivative (such as artesunate (ASU)) to existing regimens improves treatment outcome (Table 1). WHO now recommend artemisinin-based combination therapies (ACTs) for MT.
However, MT policy is still CQ in over half of Africa, and SP in 14%. Only 7% recommend ACT (2004 data)[3]. Furthermore, patients often receive MT which differs from national policy[4].
Eg, Kenya: WHO recommends/Cochrane evidence for ACT --> National policy SP (ACT expensive) --> Child given AQ at clinic (known SP resistance (policy undergoing revision)).
Some barriers and potential solutions: Evidence --> policy - Policy decisions are often based largely on local efficacy studies: Evidence made easily available to local decision makers. - ACTs 10 times more expensive than conventional drugs: WHO work with funders, patients and dispensers/prescribers to encourage consumer pressure for change. - Lengthy policy review process: Start earlier, WHO recommends when resistance reaches 5%.
Evidence --> practice - Poor treatment adherence: Community IEC (involving local media); drugs co-packaged. - Resistance to change: Disseminate evidence, train and sensitise prescribers/dispensers (opinion leaders, educational outreach etc). - Regulatory challenges: Ensure good drugs available through public sector (also as above).
Conclusions: The vast majority of African countries still have policies for failing malaria treatments, despite evidence for better alternatives. What patients receive bears little resemblance to policy, and is often inadequate.
There are many potential barriers to getting evidence into policy and practice. Qualitative research is needed to identify specific barriers in each setting and to develop targeted interventions to overcome these barriers. This work is ongoing.
References: 1. McIntosh HM, Olliaro P. Artemisinin derivatives for treating uncomplicated malaria (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd. 2. International artemisinin study group. Artesunate combinations for treatment of malaria: meta-analysis. Lancet. 2004;363:9-17. 3. WHO. Global AMDP database AFRO. 2004. [cited March 2004]; http://mosquito.who.int.amdp/amdp_afro.htm. 4. Personal communication. Talisuna A, Acting Assistant Commissioner, surveillance Ministry of Health Uganda, and Ugandan representative to EANMAT [March 2004].
Cochrane (and other) evidence --> World Health Organisation (WHO) recommendations --> National policy --> Practice (what patients receive)
WHO recommendations draw on Cochrane reviews, but large discrepancies exist between recommendations, national policies and what people receive. Many African countries still use conventional monotherapies despite high failure rates and availability of more effective replacements. As a result, malaria burden is rising.
Objectives and methods: In Africa 1. To summarise Cochrane review evidence/WHO recommendations and to compare this with policy and practice. 2. To use research evidence to highlight where further research is needed into barriers to change and how to overcome these.
Results: Evidence/WHO recommendations vs policy and practice Two Cochrane reviews [1-2] show that adding an artemisinin derivative (such as artesunate (ASU)) to existing regimens improves treatment outcome (Table 1). WHO now recommend artemisinin-based combination therapies (ACTs) for MT.
However, MT policy is still CQ in over half of Africa, and SP in 14%. Only 7% recommend ACT (2004 data)[3]. Furthermore, patients often receive MT which differs from national policy[4].
Eg, Kenya: WHO recommends/Cochrane evidence for ACT --> National policy SP (ACT expensive) --> Child given AQ at clinic (known SP resistance (policy undergoing revision)).
Some barriers and potential solutions: Evidence --> policy - Policy decisions are often based largely on local efficacy studies: Evidence made easily available to local decision makers. - ACTs 10 times more expensive than conventional drugs: WHO work with funders, patients and dispensers/prescribers to encourage consumer pressure for change. - Lengthy policy review process: Start earlier, WHO recommends when resistance reaches 5%.
Evidence --> practice - Poor treatment adherence: Community IEC (involving local media); drugs co-packaged. - Resistance to change: Disseminate evidence, train and sensitise prescribers/dispensers (opinion leaders, educational outreach etc). - Regulatory challenges: Ensure good drugs available through public sector (also as above).
Conclusions: The vast majority of African countries still have policies for failing malaria treatments, despite evidence for better alternatives. What patients receive bears little resemblance to policy, and is often inadequate.
There are many potential barriers to getting evidence into policy and practice. Qualitative research is needed to identify specific barriers in each setting and to develop targeted interventions to overcome these barriers. This work is ongoing.
References: 1. McIntosh HM, Olliaro P. Artemisinin derivatives for treating uncomplicated malaria (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd. 2. International artemisinin study group. Artesunate combinations for treatment of malaria: meta-analysis. Lancet. 2004;363:9-17. 3. WHO. Global AMDP database AFRO. 2004. [cited March 2004]; http://mosquito.who.int.amdp/amdp_afro.htm. 4. Personal communication. Talisuna A, Acting Assistant Commissioner, surveillance Ministry of Health Uganda, and Ugandan representative to EANMAT [March 2004].