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Policy brief on improving access to artemisinin-based combination therapies for malaria in Burkina Faso

Published online by Cambridge University Press:  15 April 2010

Bocar Kouyaté  and
Victor Nana
Bocar Kouyaté
Affiliation:
Ministry of Health, Ouagadougou, Burkina Faso
Victor Nana
Affiliation:
Ministry of Health, Ouagadougou, Burkina Faso
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Extract

Malaria is a major public health problem in Burkina Faso. Statistics from health facilities in 2006 show that 40.1 percent of medical consultations, 53.4 percent of hospital admissions, and 45.8 percent of deaths are malaria related (2). Malaria among children under 5 years of age accounted for 46 percent of all cases in 2004, 49 percent in 2005 and 48 percent in 2006. In the same age group, malaria was the cause of 66.4 percent of deaths in 2004, 62.0 percent in 2005 and 62.7 percent in 2006.

Keywords

AntimalarialsCare accessHealth policyBurkina Faso
Type
THEME SECTION: OPTIONS FOR IMPROVING MALARIA TREATMENT
Information
International Journal of Technology Assessment in Health Care , Volume 26 , Issue 2 , April 2010 , pp. 233 - 236
Copyright
Copyright © Cambridge University Press 2010

THE PROBLEM

Malaria is a major public health problem in Burkina Faso. Statistics from health facilities in 2006 show that 40.1 percent of medical consultations, 53.4 percent of hospital admissions, and 45.8 percent of deaths are malaria related (2). Malaria among children under 5 years of age accounted for 46 percent of all cases in 2004, 49 percent in 2005 and 48 percent in 2006. In the same age group, malaria was the cause of 66.4 percent of deaths in 2004, 62.0 percent in 2005 and 62.7 percent in 2006.

In addition, data on the therapeutic efficacy of antimalarials at six sentinel sites in 2003 indicated treatment failure rates varying between 26.9 percent and 63.3 percent for chloroquine and 10 percent for sulfadoxine-pyrimethamine, thereby prompting Burkina Faso to adopt a new malaria treatment policy in February 2005 (3). The first-line drugs now recommended for the treatment of uncomplicated malaria are the artemisinin-based combination therapies (ACTs) artemether + lumefantrine and amodiaquine + artesunate (4–6;15;Reference Zongo, Dorsey and Rouamba16).

A core strategy for malaria control is early and appropriate management of malaria cases at all levels of the health pyramid (3;5;6). The home-management strategy for treatment of uncomplicated malaria was adopted by the National Malaria Control Programme (PNLP) in 1997 and has been implemented in all health districts in partnership with community groups and associations (Reference Kouyaté, Somé and Jahn9;Reference Pagnoni, Convelbo, Tiendrebeogo, Cousens and Esposito11;Reference Sirima, Cotte and Konaté14). Thus, in addition to fulfilling their traditional role in the referral process, community intermediaries will also be supplied with ACTs to enhance the home management of uncomplicated malaria (3;5;6). However, it should be noted that the majority of community health workers are no longer practicing because there is little or no financial incentive for them to do so (Reference Lewin, Dick and Pond10;Reference Sauerborn, Nougtara and Diesfeld13). The strength of their commitment to providing community-based services is undermined by the absence of a continuous and effective motivational strategy on the part of communities, the Ministry of Health, and other partners.

ACTs are available at subsidized rates in public health facilities only, despite the fact that private facilities are important dispensers of medication, particularly in urban areas. This leads to deficiencies in early treatment of uncomplicated malaria, given that private facilities dispense ACTs at prices in excess of CFAF 4,000 (US$9) (i.e., forty times more expensive than ACTs for children under 5 years of age and four times more expensive than ACTs intended for adults).

With the introduction of ACTs and the scaling up of their use in treating uncomplicated malaria, single-drug therapy, especially chloroquine, should be removed from the list of essential drugs. Single-drug therapy should be strictly reserved for specific pathologies.

The following key points emerge from analysis of the malaria control situation: (i) Motivating community intermediaries to ensure the long-term future of community-based interventions remains a challenge; (ii) It has been decided to subsidize ACTs dispensed by public health services but not private facilities because of concerns that the latter might not respect pricing guidelines; and (iii) Single-drug therapy hinders scaling up the use of ACTs for treating uncomplicated malaria

POLICY OPTIONS

Universal and equitable access to ACTs for treating uncomplicated malaria is needed urgently. Three policy options that could improve access are changes in Delivery arrangements: motivate community health workers responsible for home management of uncomplicated malaria; Financial arrangements: ensure that private-sector stakeholders (pharmacies, clinics, nursing practices) comply with national guidelines on subsidized pricing of ACTs; and Governance arrangements: ban antimalarial drugs used in single-drug therapy for uncomplicated malaria and remove these drugs from the national list of essential drugs. These three options are described in Table 1.

Table 1. Policy Options

aUS$22.8 million.

bUS&11.4 million.

CUS$0.1 million.

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

The policy brief summarized here was discussed in a 2-day policy dialogue in May 2008. A consensus was reached in support of all three policy options. The three policy options were subsequently incorporated in the proposal to the 7th round of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM). The implementation process for lay health worker activities has been started as a pilot in three districts. Because of the short time span between the policy dialogue and submission of the 7th GFATM proposal, it was decided to propose a large scale implementation of lay health worker activities in the 8th GFATM proposal. The other two options are currently being implemented.

CONTACT INFORMATION

Bocar Kouyaté, MD, PhD (), Director, National Malaria Research and Training Centre (CNRFP), Victor Nana, MD (), DU/Malaria Case Management Officer, National Malaria Control Programme (PNLP), Ministry of Health, 01 BP 7009, Ouagadougou, Burkina Faso

References

REFERENCES

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Table 1. Policy Options

Figure 1

Table 2. Implementation of the Policy Options