THE PROBLEM
In the Central African Republic (CAR) malaria is a major public health problem and hampers socioeconomic development. It accounts for 40 percent of complaints and 10 percent of deaths in health facilities (15;17). Pregnant women, who make up 4 percent of the population, and children under 5 years of age, who represent 17.3 percent, are the groups most vulnerable to malaria owing to their low levels of immunity.
For many years, uncomplicated malaria was treated with chloroquine, amodiaquine, and a sulfadoxine-pyrimethamine combination. Resistance to these drugs has developed since 1986, as several studies have documented (Reference Belec, Delmont and Vesters3;Reference Menard, Djalle and Manirakiza8;Reference Menard, Madji and Manirakiza9). Between 2002 and 2004, there was a steady increase in resistance to 40.9 percent in the case of chloroquine and 22.8 percent in the case of sulfadoxine-pyrimethamine. Following the recommendation of the World Health Organization, the national health authorities reviewed the national malaria management guidelines and opted for the use of artemisinin-based combination therapies (ACTs) as the front-line drug instead of the formerly recommended sulfadoxine-pyrimethamine combination (10–14).
Several factors limit implementation of the revised national malaria management guidelines, including (i) unavailability of ACTs in CAR owing to high cost and supply problems; (ii) nonadherence of health professionals, community health workers, and licensed dispensers (private-sector and community-based pharmacies); and (iii) continued availability of antimalarials formerly used in single-drug therapy.
Any strategy designed to facilitate access to treatment must take account of the rural poor who are particularly ill served by the health system. It is this problem of accessibility that is being addressed by the home management of malaria (PECADOM) strategy. This is a community-based strategy that enlists the participation of community health workers, mothers, and traditional practitioners in the home management of uncomplicated malaria. It relies on the services provided by the private, formal, and informal health sectors. Home management complements and extends the outreach of public health services (Reference Ajayi, Browne and Garshong1;Reference Amin, Zurovac and Kangwana2;Reference Hopkins, Talisuna and Whitty5).
POLICY OPTIONS
Scaling up the treatment of uncomplicated malaria through the use of ACTs could be achieved through three policy options (described in Table 1): (i) Make ACTs available at all levels of health system; (ii) Involve all healthcare providers in prescribing ACTs and motivating them appropriately; and (iii) Regulate the registration import and local production of antimalarials.
Table 1. Policy Options
aUS$11.4 million.
bUS&450,000.
CUS$46.000.
Make ACTs Available Nationally
The government, supported by its development partners, could tap funds to ensure national availability of ACTs and subsidize ACTs provided by private health facilities. Funding is currently provided by the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The major challenges are geographical accessibility due to poor road access during rainy season and security factors in the north of the country and ensuring that the private sector follows national guidelines designed to make ACTs affordable at all levels of health system.
The role of private healthcare providers in malaria control is now widely recognized. If private-sector facilities can provide subsidized ACTs at low cost, this will facilitate access to them and deliver rapid, effective treatment for uncomplicated malaria. This policy option takes account of the distribution of private facilities and patients’ health-seeking behavior. To guarantee the long-term future of free treatment, the government could establish a solidarity fund for drugs to control malaria, tuberculosis and HIV/AIDS. Exemption from user fees would make ACTs affordable but is not a sustainable long-term option (Reference Lagaarde and Palmer6;Reference Patouillard, Goodman, Hanson and Mills16).
Involve All Healthcare Providers in Prescribing ACTs and Motivating Them Appropriately
To ensure early case management, all healthcare providers could be involved in prescribing ACTs. Several initiatives have already been explored as part of home management of malaria, including (i) capacity-building with a view to applying norms and standards in the areas of case management and drug administration through training for health professionals,; and (ii) national training for community health workers, traditional practitioners, and mothers
Providing training for all categories of providers—including health professionals in public and private health facilities, community health workers, and traditional practitioners—would help to ensure that all healthcare providers are knowledgeable about the use of ACTs. To enable these providers and ensure that they manage malaria cases appropriately, it is also necessary to (i) ensure that health facilities are regularly supplied with ACTs, (ii) make malaria management tools available, (iii) introduce appropriate sustainable incentives, and (iv) monitor and evaluate performance of those who have received training.
This option could help to reduce malaria-related morbidity and mortality by improving early case management of uncomplicated malaria at the community level (Reference Ajayi, Browne and Garshong1;Reference Forsetlund, Bjørndal and Rashidian4;Reference Lewin, Babigumira and Bosch-Capblanch7). Education of the population through awareness-raising campaigns in the mass media would be an essential component of this option.
Regulate the Import and Local Production of Antimalarials
The existence of various informal sources of antimalarials fosters continuing inappropriate management of malaria. Regulation of the importation of antimalarials into CAR could reduce this problem by removing from the national drug list and banning drugs used in single-drug therapy for uncomplicated malaria from the market. However, important obstacles that would need to be addressed include the potential of (i) parallel supply routes for unlicensed antimalarials emerging and (ii) healthcare providers failing to adhere to national guidelines.
Implementation of the Policy Options
Barriers to implementing the three policy options and strategies for addressing these are described in Table 2.
Table 2. Implementation of the Policy Options
DISCUSSION
The policy brief summarized here was discussed in a 1-day policy dialogue in June 2009. Several priority actions were proposed and discussed by the participants. During the discussion, a consensus was obtained that the first priority action is to ensure the availability of ACTs at all levels of the health system. To do this the government, with the help of development partners, needs a budget of more than 5 billion CFAF (US$11.4 million) for the next 5 years to secure ACTs in public and private health facilities. The second priority action is related to the involvement and the motivation of healthcare providers in the prescription of ACTs. The involvement of traditional healers in prescribing ACTs was hardly discussed. Their involvement was obtained because of their high impact on health care in rural areas. Finally, the regulation of the importation of antimalarials was retained as the third priority action. This action will reduce or eliminate the availability of unwanted medicines used in single-drug therapy.
CONTACT INFORMATION
Gérard Gresenguet, MD, PhD (gerardgres@yahoo.fr), Professeur, Santé Publique, Université de Bangui, Avenue des martyrs, BP 1383 Bangui, RCA; Coordonnateur de recherche, Lutte contre SIDA, MST Tuberculose, Centre Référence MST-SIDA, Avenue Gamal Abdel Nasser, BP 2229 Bangui, RCA
Méthode Moyen, MD (methodemoyen@yahoo.fr), Chef du Programme Paludisme, Programme de lutte contre Paludisme, Direction de lutte contre la maladie, Ministère de la Santé Publique, BP 883, Bangui, RCA
Boniface Koffi, MD (dockkoffi@yahoo.fr), Maitre de Conférence, Sciences Biomedicales, Université de Bangui, Avenue des martyrs, BP 1383 Bangui (RCA); Anatomo pathologiste, Anatomie et cytopathologie, Laboratoire National de Biologie Clinique et de Santé Publique, BP 1426 Bangui (RCA)
Jean Pierre Bangamingo, MD (bangamingo@yahoo.fr), Chargé de mission, Cabinet du Ministre de la Santé Ministère de la Santé Publique, Avenue Gamal Abdel Nasser, BP 883 Bangui
