Hostname: page-component-745bb68f8f-lrblm Total loading time: 0 Render date: 2025-02-11T20:40:42.278Z Has data issue: false hasContentIssue false
  • English
  • Français

Policy brief on improving access to artemisinin-based combination therapies for malaria in the East African community

Published online by Cambridge University Press:  15 April 2010

Harriet Nabudere ,
Gabriel L. Upunda  and
Malick Juma
Harriet Nabudere
Affiliation:
Makerere University
Gabriel L. Upunda
Affiliation:
East African Community
Malick Juma
Affiliation:
Ministry of Health, Zanzibar
Rights & Permissions [Opens in a new window]

Extract

The World Health Organization (WHO) since June 1998 has advocated for the use of artemisinin-based combination therapies (ACTs) in countries where Plasmodium falciparum malaria is resistant to traditional antimalarial therapies such as chloroquine, sulfadoxine-pyrimethamine, and amodiaquine (19;22). In 2006, WHO released evidence-based guidelines for the treatment of malaria backed by findings from various scientific studies (21). During the period between 2002 and 2006, all the five East African states Tanzania, Kenya, Uganda, Rwanda, and Burundi changed their national antimalarial treatment policies to use ACTs as first-line treatments for uncomplicated falciparum malaria and commenced with deployment of the drugs in the state-managed health facilities (12–15). To scale up the use of ACTs in the East African region to combat malaria and speed up progress toward the sixth Millennium Development Goal, a combination of delivery, financial, and governance arrangements tailored to national or subnational contexts needs to be considered.

Keywords

AntimalarialsCare accessHealth policyEast African CommunityTanzaniaKenyaUgandaRwandaBurundi
Type
THEME SECTION: OPTIONS FOR IMPROVING MALARIA TREATMENT
Information
International Journal of Technology Assessment in Health Care , Volume 26 , Issue 2 , April 2010 , pp. 255 - 259
Copyright
Copyright © Cambridge University Press 2010

THE PROBLEM

The World Health Organization (WHO) since June 1998 has advocated for the use of artemisinin-based combination therapies (ACTs) in countries where Plasmodium falciparum malaria is resistant to traditional antimalarial therapies such as chloroquine, sulfadoxine-pyrimethamine, and amodiaquine (19;22). In 2006, WHO released evidence-based guidelines for the treatment of malaria backed by findings from various scientific studies (21). During the period between 2002 and 2006, all the five East African states Tanzania, Kenya, Uganda, Rwanda, and Burundi changed their national antimalarial treatment policies to use ACTs as first-line treatments for uncomplicated falciparum malaria and commenced with deployment of the drugs in the state-managed health facilities (12–15). To scale up the use of ACTs in the East African region to combat malaria and speed up progress toward the sixth Millennium Development Goal, a combination of delivery, financial, and governance arrangements tailored to national or subnational contexts needs to be considered.

WHO reports show that more than 90 percent of the annual global malaria cases and deaths are reported from the African region (20). Children under the age of 5 years and pregnant mothers are the most vulnerable groups affected by the disease. Malarias’ annual contribution to deaths in under-5 year olds is as high as 39,000 in Uganda, 31,000 in Tanzania and 18,000 in Kenya (23).

Community health workers (CHWs) have successfully contributed to public health services in the fight against malaria. The CHW kits for home-based management of fever at present still contain older antimalarials in Uganda and Tanzania. Rwanda does not have a CHW network, whereas Kenya has incorporated ACTs to be used at community level by CHWs.

The private sector provides health services to a large proportion of the population in East Africa through faith-based organizations and other not-for-profit organizations, as well as for-profit facilities (Reference Goodman6). The cost of ACTs at these outlets is still quite high (between US$5 and US$15 per adult treatment course) compared with the free ACTs provided by public facilities. Samarasekera highlights the need for a stronger regulatory framework by government to oversee the private sector in provision of health-related services and products (Reference Samarasekera17).

POLICY OPTIONS

The policy options described in this policy brief are not mutually exclusive interventions; they are complementary strategies in the fight against malaria. The policy brief does not recommend any one option over another, but highlights existing research evidence in support of the included interventions. The three options are the following: (i) Include ACTs in the home-based management provided by Community Health Workers (CHWs). CHWs are normally recruited from members of the community, such as mothers, farmers, teachers, and others. CHWs are much more accessible than healthcare professionals, particularly in rural areas where there are fewer and poorly equipped healthcare facilities; (ii) Engage the private sector in distributing ACTs in accordance with standard treatment guidelines, and ban importation and prescribing of artemisinin monotherapies; (iii) Improve health sector financing and universal access to healthcare by shifting from out-of-pocket payments to prepayment and pooling of funds using a combination of social health insurance and community-based health insurance. These three options are described in Table 1.

Table 1. Policy Options

IMPLEMENTATION OF THE POLICY OPTIONS

Obstacles to implementing the three policy options and strategies for addressing these are described in Table 2.

Table 2. Implementation of the Policy Options

DISCUSSION

A half-day policy dialogue meeting was held by the Uganda country office of the Regional East African Community Health Policy Initiative in April 2008. Participation included researchers, policy makers, health managers, and civil society. There was general agreement about the feasibility of two of the policy options in the Ugandan context. Some delegates advocated for the inclusion of Rapid Diagnostic Kits to support use of ACTs by CHWs. It was believed that there was need for more evidence to support social health insurance. A key output was the decision by a senior policy maker to include the policy brief as one of the resource documents to develop the new National Health Policy document (2009), which provides direction for the health sector for the next 10 years.

CONTACT INFORMATION

Harriet Nabudere, MD, MPH (), Project Coordinator, SURE Project, Office of the Principal, College of Health Sciences, Makerere University, Administration Building, 2nd floor, New Mulago Hospital Complex, Kampala, Uganda

Gabriel L. Upunda, MD, MMED, MPH (), Executive Director, Regional East African Community Health Policy Initiative, East African Community, Arusha International Conference Centre, Arusha, United Republic of Tanzania

Malick Juma, MD, MMED (), Director, General Health Services, Ministry of Health, Zanzibar, P.O Box 236, Zanzibar, United Republic of Tanzania

References

REFERENCES

1. Bennett, S. The role of community-based health insurance within the health care financing system: A framework for analysis. Health Policy Plan. 2004;19:147–158.CrossRefGoogle ScholarPubMed
2. Carrin, G, Waelkens, MP, Criel, B. Community-based health insurance in developing countries: A study of its contribution to the performance of health financing systems. Trop Med Int Health. 2005;10:799–811.CrossRefGoogle Scholar
3. Clinton Foundation. Distribution of artemisinin-based combination therapies through private sector channels: Lessons from four country case studies. New York: Clinton Foundation; 2008.Google Scholar
4. Ekman, B. Community-based health insurance in low-income countries: A systematic review of the evidence. Health Policy Plann. 2004;19:249–270.CrossRefGoogle ScholarPubMed
5. Fapohunda, BM, Beth, AP, Robert, A, et al. Home-based management of fever strategy in Uganda: A report of the 2003 survey. Arlington, VA: MOH, WHO and BASICS II; 2004.Google Scholar
6. Goodman, CA. An economic analysis of the retail market for fever and malaria treatment in rural Tanzania. Thesis submitted to the University of London for the Degree of Doctor of Philosophy. London: London School of Hygiene and Tropical Medicine, Health Policy Unit; 2004.Google Scholar
7. Grilli, R, Ramsay, C, Minozzi, S. Mass media interventions: Effects on health services utilisation. Cochrane Database Syst Rev. 2002;(1);1:CD000389.Google Scholar
8. Ikeoluwapo, OA, Browne, EN, Garshong, B, et al. Feasibility and acceptability of artemisinin-based combination therapy for the home management of malaria in four African sites. Malaria J. 2008;7:6.Google Scholar
9. Kutzin, J, Barnum, H. How health insurance affects the delivery of health care in developing countries. World Bank technical paper. Washington DC: World Bank; 1992.Google Scholar
10. Lagaarde, M, Palmer, N. Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence-Informed Action to Achieve Health Goals in Developing Countries (IDEAHealth). Geneva: Alliance for Health Policy and Systems Research; 2006. http://www.who.int/rpc/meetings/HealthFinancingBrief.pdf. (accessed February 28, 2008)Google Scholar
11. Lewin, SA, Babigumira, SM, Bosch-Capblanch, X, et al. Lay health workers in primary and community health care: A systematic review of trials. Geneva: Alliance for Health Policy and Systems Research; 2006. www.who.int/rpc/meetings/LHW_review.pdf. (accessed December 24, 2009)Google Scholar
12. Ministry of Health. Antimalarial treatment policy change to ACTs. Kampala, Uganda: Ministry of Health; 2005.Google Scholar
13. Ministry of Health. Management of uncomplicated malaria. A practical guide for health workers. 3rd ed. Kampala, Uganda: Ministry of Health Malaria Control Programme; 2005.Google Scholar
14. Ministry of Health. National guidelines for treatment. Diagnosis and prevention of malaria in Kenya. Nairobi, Kenya: Ministry of Health; 2006.Google Scholar
15. Ministry of Health. The guidelines for malaria diagnosis and treatment. Zanzibar: United Republic of Tanzania: Ministry of Health; 2007.Google Scholar
16. Ranson, MK. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: Current experiences and challenges. Bull World Health Organ. 2002;80:613–621.Google Scholar
17. Samarasekera, U. Drug subsidy could help Tanzania tackle malaria. Lancet. 2008;371:1403–1406.CrossRefGoogle ScholarPubMed
18. Waters, H, Hatt, L, Peters, D. Working with the private sector for child health. Health Policy Plan. 2003;18:127–137.CrossRefGoogle ScholarPubMed
19. World Health Organization. Antimalarial drug combination therapy. Report of a WHO technical consultation. Geneva, Switzerland: World Health Organization; 2001.Google Scholar
20. World Health Organization. Burden of disease project. http://www.who.int/healthinfo/bodproject/en/index.html (accessed April 7, 2008).Google Scholar
21. World Health Organization. Guidelines for the treatment of malaria. Geneva, Switzerland: World Health Organization; 2006.Google Scholar
22. World Health Organization. The use of artemisinin and its derivatives as antimalarial drugs: A report of a joint CTD/DMP/TDR Informal Consultation. Geneva: World Health Organization; 1998. WHO/MAL/98.1086Google Scholar
23. World Health Organization. World malaria report 2008. Geneva: Global Malaria Programme; 2008. WHO/HTM/GMP/2008.Google Scholar
24. Yeboah-Antwi, K, Gyapong, JO, Asare, IK, et al. Impact of prepackaging antimalarial drugs on cost to patients and compliance with treatment. Bull World Health Organ. 2001;79:394–399.Google ScholarPubMed
Figure 0

Table 1. Policy Options

Figure 1

Table 2. Implementation of the Policy Options