MANAGER. Addressing Barriers in Malaria Control through Pharmaceutical and Commodity Management THE

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1 THE MANAGER MANAGEMENT STRATEGIES FOR IMPROVING HEALTH SERVICES 2003 Volume 12 Number 1 I This Issue Promotig Effective Strategies While Esurig Good Maagemet... 2 Why Does Malaria Cotiue to Spread?... 4 Recogizig Barriers to Malaria Cotrol Efforts... 5 Layig the Groudwork for Stroger Malaria Cotrol... 8 Advacig Prevetive Measures to Protect agaist Malaria Supportig the Distributio of Isecticide- Treated Nets ad Isecticides...11 Protectig Pregat Wome through Prevetive Treatmet...13 Stregtheig Treatmet for Malaria Procurig Effective Pharmaceuticals...14 Makig Appropriately Packaged Products Available...15 Itegratig Malaria Cotrol with Child Survival Services...15 Improvig Home-Based Treatmet...16 Advocatig for Natioal Policies That Support Effective Pharmaceuticals...16 Usig Resources to Pla for Malaria Cotrol...17 Global Strategies ad Resources for Malaria Cotrol...17 Applyig Tools to Support Plaig for Malaria Cotrol...18 Takig Charge to Improve Malaria Cotrol Glossary...20 Case A Malaria Task Force Works to Improve Supply ad Demad for Appropriate Atimalarials Addressig Barriers i Malaria Cotrol through Pharmaceutical ad Commodity Maagemet Editors Note MALARIA IS A SERIOUS, sometimes fatal disease caused by a parasite that is spread to humas through the bite of ifected mosquitoes. For more tha 50 years, chloroquie, a iexpesive ad widely available medicie, has bee used to cure malaria. Today, however, the world is faced with a resurgece of malaria, fueled i part by the spread of strais of the parasite that are resistat to chloroquie ad other atimalarial medicies. Malaria is a problem i every regio of the developig world. The problem is greatest i Africa, where over 80 percet of malaria cases ad deaths occur. The disease affects all ages ad ecoomic groups with a devastatig impact o pregat wome ad childre less tha five years of age. I 1992, the Global Miisterial Coferece o Malaria released a world declaratio i Amsterdam stressig, the urget eed for commitmet to malaria cotrol by all govermets, all health ad developmet workers ad the world commuity.... The Coferece wet o to say, We have leart that the key to success [for malaria cotrol] is to apply the right strategies i the right place at the right time, ad to apply the appropriate strategies o a sustaied basis. The 2000 Summit o Roll Back Malaria reiterated commitmet to malaria cotrol through a ambitious five-year strategy to improve treatmet ad prevetio. THIS ISSUE OF THE MANAGER focuses o both the barriers that impede the cotrol of malaria ad promisig strategies for addressig them through pharmaceutical ad commodity maagemet. Policymakers ad health maagers ca apply some of these strategies to esure a supply of effective atimalarial medicies ad promote their correct use. They ca use other strategies to promote the wide distributio of isecticide-treated ets ad isecticides for re-treatig these ets.

2 THE MANAGER Editorial Review Board Dr. Med Bouzidi, Iteratioal Plaed Parethood Federatio, Lodo Abu Sayeed, TAI, Bagladesh Celicia Sereata, Departmet of Health, South Africa Dr. Erique Suárez, The Mexica Federatio of Private Health ad Commuity Developmet Associatios Dr. A. B. Sulaima, Plaed Parethood Federatio of Nigeria Sixte Zigirumugabe, USAID, Mali Field Advisor Dr. Eléoore Rabelahasa, PRISM, Guiea Subscriptios to The Maager are $15 per year i North America, Wester Europe, Japa, ad Australia; i all other areas the publicatio is distributed free of charge. Postmaster: Sed address chages to: 165 Alladale Road, Bosto, MA USA. Editorial Director Jaice Miller Editors Robert Grigle Claire Bahamo Case Studies Laura Lorez Web Editios Alex Bermudez Foudig Editor James Wolff Cosultig Editors Susaa Bize A Buxbaum Saul Helfebei Desktop Publishig Ceallaigh Reddy Distributio Sherry Cotaco Eri Molloy The Maager (ISSN ) is published quarterly by Maagemet Scieces for Health with support from USAID. This publicatio does ot represet official statemets of policy by MSH, USAID, or the Bill & Melida Gates Foudatio. Copyright 2003 Maagemet Scieces for Health. All rights reserved. Recommeded citatio: Maagemet Scieces for Health. Addressig Barriers i Malaria Cotrol through Pharmaceutical ad Commodity Maagemet The Maager (Bosto), vol. 12, o. 1 (2003): pp MSH Publicatios Maagemet Scieces for Health 165 Alladale Road Bosto, Massachusetts USA Phoe: Fax: bookstore@msh.org Web site: This issue was published with support from the US Agecy for Iteratioal Developmet through the Ratioal Pharmaceutical Maagemet Plus (RPM Plus) Program uder cooperative agreemet HRN-A Additioal support was provided by the Bill & Melida Gates Foudatio through the MSH Strategies for Ehacig Access to Medicies (SEAM) Program. Promotig Effective Atimalarial Strategies While Esurig Good Pharmaceutical ad Commodity Maagemet Betwee 300 millio ad 500 millio ew cases of malaria occur every year, resultig i 1.5 to 1.7 millio deaths aually. Those most vulerable to malarial ifectio iclude childre less tha five years of age (particularly i Africa), pregat wome, ad idividuals with little or o atural resistace to malaria (oimmue persos). I some areas, malaria is the leadig cause of death of childre uder five. Complicatios from ifectio iclude aemia ad icreased susceptibility to other diseases. Malaria represets a major public health challege, particularly i may of the poorest coutries. Well over three-quarters of the malaria cases ad deaths occur i Africa. The disease also iflicts severe ecoomic loss o societies i the form of lost school days, low ecoomic productivity, ad log-term disability from severe illess. I some areas, as much as 25 percet of aual household icome is spet o malaria-related costs. The total cost of malaria i sub-sahara Africa has bee estimated to be US$12 billio per year with 40 percet of public health expeditures i high-burde coutries goig to malaria cotrol ad maagemet. I some areas, gross domestic productivity is estimated to be 32 percet lower tha it would be if malaria had bee eradicated from Africa by The magitude of malaria s effects prompted reewed global commitmet to eradicatig the disease. The 1992 Global Miisterial Coferece o Malaria i Amsterdam, atteded by represetatives from 102 coutries, released the World Declaratio o the Cotrol of Malaria, which urges early diagosis of malaria, prompt treatmet, ad sustaiable prevetive measures. At the 2000 Summit o Roll Back Malaria i Abuja, Nigeria, Africa heads of state reaffirmed this commitmet ad called for stregtheed health systems to esure that by the year 2005, at least 60 percet of those sufferig from malaria will have prompt access to correct, affordable treatmet ad those at risk of malaria, particularly pregat wome ad childre uder five years of age, will beefit from the most suitable combiatio of persoal ad commuity measures such as isecticide-treated mosquito ets ad other materials to prevet ifectio ad sufferig. Today, oe of the biggest challeges i cotrollig malaria is combatig drug resistace. Icreasigly, oe of the parasites that cause malaria (Plasmodium falciparum) is becomig resistat to chloroquie, the most widely used malaria treatmet sice the 1940s. The most commo replacemet for chloroquie i Africa, sulfadoxie-pyrimethamie (SP), is also rapidly losig effectiveess agaist this parasite. Cotiued use of ieffective pharmaceuticals ot oly cotributes to the spread of drug resistace but also causes a disturbig icrease i malaria-related morbidity ad mortality. A shift to effective first-lie treatmet could prevet a substatial percetage of the deaths each year from malaria. Haltig the spread of drug-resistat malaria eeds to be a global priority, ad resources must be focused o those areas of the world where the burde from the disease is greatest. 2 THE MANAGER Vol. 12, No. 1, 2003

3 This issue of The Maager was writte to support the goals of the Global Malaria Cotrol Strategy. It outlies the curret barriers to malaria cotrol ad offers policymakers ad health maagers at the district ad provicial levels some ways to promote widespread access to safe, effective, high-quality, affordable atimalarial medicies ad isecticide-treated ets for populatios at risk, while developig systems for ratioal pharmaceutical use. It stresses that ratioal pharmaceutical use must be promoted to preserve the useful therapeutic life of effective atimalarial medicies ad to reduce morbidity ad mortality due to ieffective maagemet of the disease. This issue was writte by Rima Shretta ad Grace Adeya. Ms. Shretta is a pharmacist ad Seior Program Associate at the Ceter for Pharmaceutical Maagemet (CPM) of Maagemet Scieces for Health (MSH). She has extesive experiece i malaria programs ad maages the pharmaceutical maagemet activities that the USAID-fuded Ratioal Pharmaceutical Maagemet Plus Program (RPM Plus) udertakes to support the Roll Back Malaria iitiative. Dr. Adeya, a physicia with widespread commuity health experiece, is a Seior Program Associate also workig with CPM s RPM Plus Program. Located i the Washigto, DC area, CPM provides techical assistace ad traiig i pharmaceutical maagemet worldwide to support the key role that pharmaceuticals play i the delivery of high-quality health care. Uderstadig Malaria ad Malaria Cotrol Efforts Malaria is a ifectio caused by parasites of the geus Plasmodium. Huma malaria is caused by four species: P. falciparum, P. vivax, P. malariae, ad P. ovale. The first two species have the widest distributio, with P. falciparum causig the most serious illess ad the majority of deaths associated with malaria, particularly i Africa. P. vivax is the most prevalet species i Asia. TRANSMISSION OF MALARIA EFFORTS TO CONTROL MALARIA Malaria is ormally trasmitted through the bite of a ifected female mosquito of the geus Aopheles. The female mosquitoes acquire the parasite whe they feed o the blood of a idividual ifected with malaria, maily betwee dusk ad daw. Malaria ca also be trasmitted through the trasfusio of ifected blood to a oimmue idividual. I the 1880s, oe of the Plasmodium parasites was first idetified i red blood cells, ad mosquitoes were subsequetly idetified as the vector for this parasite. Early malaria cotrol efforts focused o avoidig ad killig mosquitoes. Later developmets occurred i: 1955 evirometal itervetios were iitiated aimed at eradicatig mosquitoes with dichlor-dipheyl-trichloroethae (DDT) ad sythetic isecticides. 1970s as eradicatio efforts failed, particularly i Africa, ew strategies focused o cotrollig malaria as part of primary health care, icludig promotig widespread use of chloroquie to prevet malaria. 1980s failures of the malaria cotrol efforts resulted i malaria ceasig to be a priority. 1990s to preset the World Health Orgaizatio (WHO) has fostered efforts to stimulate global malaria cotrol through the Amsterdam coferece s adoptio of a global strategy for malaria ad the establishmet of the Roll Back Malaria partership. Iterest i attempts to develop a malaria vaccie is also growig. Source: Techical Notes o Malaria Cotrol, Malaria Cosortium, Addressig Barriers i Malaria Cotrol 3

4 Why Does Malaria Cotiue to Spread? With worldwide focus o malaria over decades, why does this disease cotiue to spread? Malaria disproportioately affects populatios with few resources ad vulerable groups, such as pregat wome ad youg childre. Its spread will cotiue util effective itervetios are widely used ad access to health services ad prevetive measures icreases. The developmet of a vaccie to prevet malaria would greatly reduce the burde of this disease, but util researchers develop oe, health services must rely o atimalarial medicies ad isecticide-treated ets. If you are a district or provicial health maager, you eed to review local or regioal surveillace data, if available, to aswer questios about critical evirometal factors that may be fuelig malaria s spread i your geographic area: What are the patters of drug resistace i your geographic area? What other ifectios are preset that will ifluece the regioal effects of malaria? What are the local patters of malaria trasmissio ad the risks to pregat wome ad childre? Idetifyig Patters of Drug Resistace Researchers have foud drug resistace i P. vivax (chloroquie resistace) ad to a greater extet i P. falciparum. I fact, P. falciparum has bee foud resistat to almost all the atimalarials. Surveillace systems ca help you determie if such drug resistace exists i your area. Drug resistace for malaria was defied by WHO i 1973 as the ability of a parasite strai to survive ad/or multiply despite the admiistratio ad absorptio of a medicie give i doses equal to or higher tha those usually recommeded but withi tolerace of the subject. Resistace to a medicie usually occurs as a result of chages i the gee structure of a parasite so that its sesitivity to the medicie is reduced. Whe a medicie is used to treat malaria, the parasite with the altered gees survives while other parasites die. This survivig parasite ca cotiue to reproduce ad be spread to other people. Whe health care providers uderdose patiets or patiets do ot adhere to treatmet regimes, they cotribute to the spread of resistat parasites i the populatio. Recogizig Other Ifectios That Ifluece the Severity of Malaria Malaria iteracts with other ifectios to icrease geeral morbidity i ifected people. A major cause of aemia i pregat wome ad childre, malaria destroys red blood cells or worses aemia caused by malutritio ad other parasites. Idividuals with HIV ifectio are at icreased risk of developig malaria, ad more severe malaria, probably because of their compromised immuity. HIV-ifected pregat wome who are also ifected with placetal malaria are more likely to trasmit the HIV virus to their fetus. Your populatio is more at risk if such ifectios are preset i your area. Uderstadig Patters of Malaria Trasmissio ad Risks to Pregat Wome ad Youg Childre There are two types of malaria trasmissio, edemic ad epidemic, usually occurrig i differet areas of a coutry or group of coutries. Both types of trasmissio pose sigificat risks to pregat wome. Areas of edemic trasmissio are cosidered highor stable-trasmissio areas. Edemic trasmissio occurs year-roud, ad most adult wome who live i these areas have developed some degree of immuity. Whe they become pregat, they may have silet attacks of malaria, without experiecig the commo symptoms. Despite the lack of overt symptoms, pregat wome i edemic areas are at high risk of severe aemia ad ofte have logstadig placetal malaria. These coditios ca lead to aemic ad low-birthweight babies, with icreased risk of ifat mortality. Areas of epidemic trasmissio are viewed as lowtrasmissio areas, where malaria occurs durig certai seasos of the year. I these areas, adult wome have geerally ot developed ay immuity. Whe they become pregat, they are two to three times more likely to get cliical malaria tha opregat wome livig i the same regio. Cliical malaria marks the poit at which ifectio with malaria turs ito a disease with symptoms. The symptoms make it 4 THE MANAGER Vol. 12, No. 1, 2003

5 more likely that pregat wome will seek help or be diagosed durig preatal visits. If utreated, their ifectio ca result i severe aemia, miscarriage, premature delivery, stillbirth, or eve materal death. Regardless of the type of trasmissio, malaria i childre uder five causes fever ad aemia ad icreases their susceptibility to other diseases. Recogizig Barriers to Malaria Cotrol Efforts While geographic areas may have differet local patters of drug resistace ad of ifectios, all health maagers face may of the same barriers i treatig ad prevetig malaria. After lookig at disease surveillace data for your area, you eed to recogize local barriers to pharmaceutical ad commodity maagemet. Barriers reduce your ability to provide ifected idividuals with the prompt, effective treatmet ecessary to reduce death ad illess from malaria. For example, low-icome people frequetly lack access to effective health services ad therapy, thus hiderig their treatmet, ad their referral if their ifectio is severe. Other barriers you may face iclude: uecessary treatmet of adults; limited availability ad high cost of diagostic tests; risig costs of atimalarial treatmet; substadard or poor-quality pharmaceuticals; iadequate regulatory systems to cotrol of the quality of atimalarial medicies; difficulties i chagig first-lie pharmaceutical therapies; populatios over-reliace o sources of ieffective medicies; providers ocompliace with pharmaceutical guidelies ad dosages; patiets oadherece to medical advice ad istructios; limited availability ad cost of isecticide-treated ets. Uecessary Treatmet of Adults Where the diagosis of malaria depeds primarily o the cliical skills of the providers, as it does i most parts of Africa, providers ofte diagose malaria i adults who do ot have malaria. This results i widespread overtreatmet ad extra costs for the health care system. It ca cotribute to icreased resistace if treated adults are exposed to the malaria parasite whe they have subtherapeutic or ieffective medicies i their systems. Stadard criteria exist for the cliical diagosis of malaria, but they are ot highly accurate because other diseases commoly cause fevers i the populatios at risk for malaria. Give the difficulty of diagosis, as reliable medicies become more expesive, providers will eed to improve their diagostic skills or weigh the effects of ot treatig a ifected idividual agaist the costs of treatig a oifected idividual. Where malaria is commo i childre uder five years of age, particularly i high trasmissio areas i Africa, treatig childre is ever a problem. There, it is geerally cosidered prudet to treat fever i all childre uder five as malaria i order to prevet death. Limited Availability ad High Cost of Diagostic Tests I areas with low trasmissio of malaria, biological tests ca improve diagosis. However, i areas of high or stable trasmissio, amog semi-immue, opregat adults, tests are ot very useful because these populatios ormally carry malaria parasites i their blood without the appearace of symptoms. Basic microscopy ca differetiate species of malaria parasites ad estimate the desity levels of these parasites, but health care facilities i coutries with few resources ofte lack the ecessary materials, equipmet, ad traied persoel to perform these tests. I additio, the absece of parasites i blood draw for testig does ot ecessarily mea that ifectio is abset. Specialized dipsticks are highly effective i idetifyig P. falciparum i Southeast Asia, but they are ot useful for detectig treatmet failures or other malaria parasites. These dipsticks are expesive ad sigificatly drive up the cost of treatmet. As a result, i areas of Addressig Barriers i Malaria Cotrol 5

6 high trasmissio, cliical diagosis is ofte used. Efforts to brig dow the cost of diagostic tests could help decrease uecessary treatmet. Risig Costs of Atimalarial Treatmet Because of drug resistace, the limited possibilities for affordable treatmet alteratives for malaria may soo be depleted. If this happes, commuities may eed to rely o ewer, alterative pharmaceutical treatmets. Curretly, the most promisig of these are the artemisii combiatios. However, treatmet with these is 20 to 400 times more expesive tha with the older medicies ad would be out of reach for most households at risk. Natioal pharmaceutical committees may fid it difficult to select a replacemet therapy because the ewer replacemet pharmaceuticals may ot have chloroquie s useful therapeutic life of 50 years, ad atioal treatmet policies may eed to be chaged more ofte. Substadard or Poor-Quality Pharmaceuticals A sigificat percetage of atimalarial pharmaceuticals are ieffective agaist the disease either because of developed resistace or because they have low levels of active igrediets. The quality of atimalarial pharmaceuticals o the market varies widely. For example, a 2001 assessmet of access to essetial medicies prepared for the MSH/CPM Strategies for Ehacig Access to Medicies (SEAM) Program idicated that the active igrediet i sulfadoxie-pyrimethamie (SP) tablets i oe Africa coutry varied from 28 to 108 percet of the stated dose amout. Oly five out of 11 geeric products tested coformed to the labels, ad oe met the required criteria for disitegratio. Other studies have show that high percetages of pharmaceuticals o the market lack all the active igrediets they claim to cotai. For example, i Asia where artemisii combiatios are expesive, icreasig umbers of couterfeit atimalarials are beig itroduced i packages that mimic a existig brad yet cotai o active igrediet. Iadequate Regulatory Systems to Cotrol Pharmaceutical Quality If your coutry s regulatory system for cotrollig pharmaceutical quality is iadequate, it will cotribute to irratioal prescribig ad use of pharmaceuticals, distributio of poor-quality products, ad itesified drug resistace. Reasos for differeces i the quality of pharmaceuticals iclude gaps i regulatory capacity, lack of implemetatio of guidelies for geeric pharmaceuticals, little or o quality cotrol over imported products, lack of skilled workers to provide ispectios, ad fiacial icetives to sell iexpesively produced low-quality pharmaceuticals for large profits. Oly 20 percet of WHO s 191 member states have a well developed pharmaceutical regulatio system, ad aother 50 percet have regulatory systems at varyig levels of developmet (Kapp 2002). To improve the quality of pharmaceuticals requires testig for quality prior to pharmaceutical registratio, a effective post-marketig surveillace system, ad cotrols at coutry borders. Ispectios are ecessary to eforce quality stadards. Difficulties i Chagig First-Lie Pharmaceuticals If the pharmaceuticals specified for your regio are ieffective because of drug resistace, efforts may be uderway to chage first-lie pharmaceuticals. Makig this chage requires chagig etreched practices of providers by ifluecig the decisios of may sectors ad stakeholders. Ifluecig the decisio makers is ot easy. Despite resistace to chloroquie i most of Africa, the WHO Regioal Office for Africa idicates that oly four of the 17 coutries with a malaria-ipregacy policy are actually implemetig it. Oppositio to desired chages is largely the result of past success. Chloroquie has bee used for more tha 50 years, is widely available ad relatively safe, ad has few side effects. Ay ew policy addressig the use of atimalarial pharmaceuticals eeds to iclude logterm objectives to esure safe, effective, high-quality pharmaceuticals while also beig sesitive to emergig strais of resistat parasites. 6 THE MANAGER Vol. 12, No. 1, 2003

7 Populatios' Over-Reliace o Sources of Ieffective Medicies Rather tha seeig a health care provider whe symptoms of malaria occur, may idividuals (betwee 12 ad 89 percet i sub-sahara Africa [McCombie 1996]) treat themselves with ieffective medicies from private drugstores or the black market. If these medicies do ot seem to work, idividuals may evetually visit a provider i the formal sector, but ofte after their coditio has deteriorated. Practical access to affordable, essetial atimalarial pharmaceuticals should be available ot oly through the public sector but also through formal ad iformal private-sector outlets where people go for treatmet. To esure appropriate dispesig of essetial pharmaceuticals will require differet strategies tailored to outlets ad providers situatios. Providers Nocompliace with Pharmaceutical Guidelies ad Dosages Eve if health care facilities ad private outlets have a reliable supply of high-quality atimalarial pharmaceuticals ad patiets obtai treatmet early i their illess, effective treatmet depeds o provider compliace with up-to-date treatmet guidelies. Providers perceptios of specific treatmets ifluece their compliace with treatmet guidelies. I the private sector, providers ofte dispese small quatities of pharmaceuticals because they believe that may patiets are ot able to afford a full treatmet ad thik of this as the simplest solutio. Providers may ot cosistetly educate patiets about the correct way to take the treatmet ad the importace of completig a full course of treatmet. This is partly because may providers dispesig pharmaceuticals either kow eough about the illess ad recommeded treatmet, or are closely moitored. I the public sector, may providers have o way of stayig curret about ew developmets i guidelies ad treatmet policies. Poor salaries ad competitio from private providers may sap their motivatio to seek iformatio ad provide good service. Excessive patiet loads may prevet them from spedig eough time with each patiet. Patiets Noadherece to Medical Advice ad Istructios Patiet adherece ca be defied as the degree to which patiets follow medical advice ad take medicies as directed. For malaria treatmet to be effective, patiets must uderstad their role i treatig their disease ad be willig ad able to carry out istructios for correct use. May barriers ca keep patiets from takig their atimalarial medicies correctly: isufficiet iformatio about the severity ad potetial cosequeces of the disease; iability to afford effective medicie or complete doses of a medicie; lack of uderstadig of istructios ad discomfort about askig questios; cofusio about the umber of daily doses eeded; iability to take the doses as required for various reasos, icludig the frequecy of doses or upleasat side-effects of the medicies; lack of uderstadig about how quickly or slowly the medicie begis to work; lack of uderstadig about the legth of time eeded to complete treatmet; discotiuatio of medicatio whe symptoms disappear, due to a lack of uderstadig of the importace of completig treatmet; cofusio caused by varied pharmaceutical packagig ad by variatios i a medicie s taste, color, tablet size, or dosage volume. Addressig Barriers i Malaria Cotrol 7

8 Improvig Patiet Adherece: What a Provider Ca Do The provider must first have accurate, up-to-date iformatio to give to patiets from the coutry s curret stadard treatmet guidelies. The provider must gai patiets trust ad persuade them that treatmet is worthwhile. To improve patiets adherece, providers eed to: be sympathetic ad reassurig; discuss the disease, symptoms, ad treatmet i a culturally appropriate way; ask ojudgmetal questios to uderstad each patiet s perspective o malaria, its causes ad effects, ad why adherece might be difficult; carefully explai the medicie s possible side-effects ad why it is importat to cotiue with the treatmet despite ay side-effects; discuss with each patiet his or her cocers i takig the medicie; explai the umber of doses, whe to take them, ad for how log; iclude istructios, i writig or pictures, o takig the medicie; arrage subsidies to cover the costs of low-icome patiets, especially those from vulerable groups. Limited Availability ad Cost of Isecticide- Treated Nets Isecticide-treated ets are very effective i prevetig malaria, yet curretly require some public support before they become commercially sustaiable. Their cost, though low, still remais beyod the reach of the most vulerable populatios. A recet Roll Back Malaria aalysis estimated that a et with a useful life of about five years is US$3.50, while the cost of treatig the et oce is a additioal US$0.50. The ets eed to be retreated every six to 12 moths i order to stay effective, ad while utreated ets are available i may regios, the isecticide for treatig the ets is ot yet widely available. Sustaiig cotiual retreatmet will remai a challege util it becomes a local custom. For ways to overcome this barrier, please see Supportig the Distributio of Isecticide-Treated Nets ad Isecticides o pages Layig the Groudwork for Stroger Malaria Cotrol Though the barriers to malaria cotrol are umerous, you ad other health maagers ca address them through a umber of very effective prevetive ad curative measures. First, you eed to lay the groudwork that will help to esure the success of these measures by: establishig up-to-date stadard treatmet ad prevetio guidelies; workig toward itersectoral collaboratio; likig public commuicatio ad patiet icetives to supply strategies; cosiderig possible itervetios i the cotext of the pharmaceutical ad commodity maagemet cycle. 8 THE MANAGER Vol. 12, No. 1, 2003

9 Establishig Up-to-Date Stadard Treatmet ad Prevetio Guidelies As a maager, you should establish stadard treatmet ad prevetio guidelies at the provicial or local level to promote the ratioal use of effective atimalarial treatmet ad treated ets. First, familiarize yourself with your coutry s atioal guidelies for treatig ad prevetig malaria. Make sure they are up to date ad resposive to the situatio of your provice or area, based o your review of local disease surveillace data ad drug resistace data. Check the date o the guidelies ad see if they iclude a discussio about whether they were developed to address risig levels of drug resistace. Natioal guidelies eed to be cotiually updated as the malaria parasites develop resistace to commoly used medicies. If you work at the provicial or local level, you ca alert the atioal level if treatmet failures to particular pharmaceuticals icrease, so that the appropriate authorities ca modify the guidelies. Ay chages to the atioal guidelies eed to be distributed widely throughout the public ad private sectors ad amog NGOs. Some versios of the guidelies eed to be adapted for use by ophysicias at health care facilities. Your distributio strategy should address the fact that, i some areas, the private sector has rarely had ew guidelies, so persoel i that sector are either uaware that the guidelies exist or are oly aware of older atioal guidelies that may o loger be i effect. You ca also advocate for updated provicial or local guidelies if they are out of date. These will eed to be i lie with the atioal guidelies ad based o local disease patters. It is importat that the local guidelies complemet guidelies for other programs, such as those for the itegrated maagemet of childhood illesses (IMCI) ad for reproductive health. Oce the local guidelies are curret, you ca oversee their distributio i your area ad make them available at all health care facilities. Workig toward Itersectoral Collaboratio Throughout the world, atimalarial treatmet is frequetly offered through formal ad iformal outlets i the private sector as well as through the public sector ad ogovermetal orgaizatios (NGOs). People usig public-sector cliics may be referred to shops that sell isecticide-treated ets. It is therefore critical that you collaborate with maagers of other sectors to esure that effective treatmet ad prevetio measures are delivered appropriately. If you are a district or provicial maager, you ca take the followig steps to ecourage a coordiated approach: trai ad support providers, dispesers, ad shopkeepers i all three sectors; ivestigate frachisig ad accreditatio of drug shops; develop collaborative itervetios; offer icetives to providers. Trai ad support health care providers, dispesers, ad shopkeepers. Oce the guidelies are widely distributed, you eed to esure they are implemeted i all sectors. To do this requires traiig public, private, ad NGO providers ad dispesers who provide atimalarial medicatios, icludig traditioal healers, public health physicias, ad atioal malaria cotrol program maagers. Also cosider orgaizig traiig i prevetive measures for shopkeepers who are willig to stock mosquito ets ad for commuity health workers who ca help treat the ets with isecticide. Oce these groups have bee traied, you will eed to provide maagemet support for them, their helpers, ad other staff. You should set up or stregthe systems for commuicatio, supplies, supervisio, moitorig, ad evaluatio. Commuicate with private dispesers ad other orgaizatios workig o malaria cotrol to dissemiate ew iformatio, assist i problem solvig, ad speak o behalf of your program. Provide directio ad motivate your ow staff to carry out their atimalarial tasks well. Allocate your resources effectively, egotiate agreemets with your staff ad parters, ad implemet chages to keep your program focused ad curret. Ivestigate frachisig ad accreditatio of drug shops. To esure the quality of drug shops, you ca ivestigate atioal or regioal approaches for establishig accredited drug-dispesig outlets. Accredited approaches for dispesig pharmaceuticals foster the de- Addressig Barriers i Malaria Cotrol 9

10 velopmet of alterative suppliers for public, private, ad church missio health care services. Workig with pharmacy boards, these accredited outlets help to assure the quality ad affordability of pharmaceuticals dispesed. Whether part of a frachise or idepedet, such outlets eed to be moitored through a combiatio of govermet accreditatio (with the threat of losig their licese to sell pharmaceuticals if their quality declies) ad commuity oversight through local govermet ad commuity istitutios. Develop collaborative itervetios. Parterships betwee various sectors of the Miistry of Health greatly improve the quality of services. For example, you may wat to ivestigate a partership betwee your malaria cotrol program ad the reproductive health departmet i the Miistry of Health to improve implemetatio of your itervetios to cotrol malaria durig pregacy. Offer icetives for providers. Well thought-out icetives ca motivate providers to prescribe appropriately. You may wat to cosider istitutig moetary bouses for accurately providig the most curret treatmet ad care, or travel vouchers to cover the cost to providers of travelig for commuity outreach. Likig Public Commuicatio ad Patiet Icetives to Supply Strategies To create demad for appropriate medicatios ad treated ets, you will eed to establish systems through which you ca commuicate with commuities about the policies you are implemetig ad the ratioale behid these policies. Your cotact should take ito accout curret patters of commuicatio betwee providers ad cosumers ad their various perceptios about treatmets ad services for malaria ad other diseases. Icetives ca ecourage patiets to resposibly take the medicies you promote or to purchase treated ets. You may wat to use travel vouchers that cover patiets trasportatio costs to a cliic to ecourage timely treatmet. The followig box provides a example of a itervetio i Keya desiged to commuicate appropriate treatmet iformatio to both providers ad patiets. Workig Solutios Keya VENDOR-TO-VENDOR TRAINING AND PUBLIC INFORMATION EXCHANGE The Africa Medical & Research Foudatio (AM- REF) i Keya developed a district-wide strategy to improve malaria treatmet practices i the Bugoma district. The strategy icluded havig vedors trai other vedors ad distribute simple job aids produced by the foudatio. At the same time, the foudatio iitiated a eighbor-to-eighbor iformatio exchage system where five persos i each commuity receive iformatio o the appropriate treatmet for malaria ad relay this iformatio to at least five others, who the pass the iformatio o to aother five, ad so o. This two-proged itervetio has improved the rates of appropriate prescriptio to over 50 percet, compared to 21 percet i outlets ot participatig i the itervetio. The program still eeds to stregthe the public/private partership, maitai retailers motivatio, address the uregulated market for atimalarial pharmaceuticals, ad secure sufficiet log-term fudig. 10 THE MANAGER Vol. 12, No. 1, 2003

11 Cosiderig Strategies withi the Pharmaceutical ad Commodity Maagemet Cycle As you desig prevetio ad treatmet strategies for your malaria cotrol program, it will be helpful for you to view your strategies withi the cotext of good maagemet for atimalarial pharmaceuticals ad commodities such as isecticide-treated ets. The pharmaceutical ad commodity maagemet cycle provides a useful, systematic approach to the maagemet of these supplies. The Pharmaceutical ad Commodity Maagemet Cycle The pharmaceutical ad commodity maagemet cycle ca help you thik about the distributio ad use of atimalarial products ad the procuremet of these, if that is a resposibility of your provice. For more iformatio o the pharmaceutical ad commodity maagemet cycle, please refer to Maagemet Scieces for Health ad the World Health Orgaizatio, Maagig Drug Supply, secod editio, Advacig Prevetive Measures to Protect agaist Malaria Sprayig to reduce mosquito populatios has teded ot to be cost-effective except i places where mosquitoes have permaet breedig places or ted to rest i houses. However, there are two highly effective prevetive measures you should advace: isecticide-treated ets that keep mosquitoes from bitig people as they sleep; itermittet prevetive therapy that protects pregat wome from malaria. Supportig the Distributio of Isecticide- Treated Nets ad Isecticides Isecticide-treated ets, commoly used aroud beds, help protect both the populatio at large ad the highrisk groups (pregat wome ad youg childre). Treated ets are oe of the most effective, low-cost itervetios you ca promote. They decrease the risk of malaria by keepig malaria-ifected mosquitoes from physically cotactig people, ad, ulike utreated ets, ca repel or kill the mosquitoes. Whe used appropriately, the treated ets decrease the risk of death i childre uder five by 20 percet ad reduce cases of malaria by 50 percet. Net treatmet. The ets eed to be iitially treated ad the re-treated every six moths to a year depedig o how ofte they are washed. You ca iclude et treatmet, istallatio, ad periodic retreatmet as oe of the tasks of commuity health workers. Fiacig ad collaboratio for local distributio. Oe of the Abuja summit goals is to esure that 60 percet of pregat wome ad of childre less tha five years of age i Africa have a treated et by the year To achieve this coverage, you ca icrease the access of low-icome ad high-risk groups to low-cost, treated ets through public-private collaboratio. To make certai that ets are provided i a equitable way to those most i eed, you may wat to: Provide vouchers. Health care providers ca give vouchers to patiets to purchase the ets ad isecticide from retail stores i the private sector at a discouted price. The vouchers eed to be desiged so they ca oly be redeemed for these ets ad treatmet kits, ad the private sector eeds to offer both the ets ad kits i the same geographic areas as the voucher programs. Vouchers foster the sustaiable distributio of the ets, because health care facilities avoid the costs of stockig the ets ad do ot compete with private vedors. Addressig Barriers i Malaria Cotrol 11

12 Sell ets at a subsidized price. Your health care facilities ca sell treated ets to patiets or exempt patiets from charges for these supplies. Sice public-sector distributio is more difficult to sustai tha privatesector distributio, ay distributio through public cliics or NGOs should be limited to the most vulerable patiets, such as impoverished pregat wome, who might ot ormally purchase the ets from stores. I Chia ad Vietam, people buy their ets from vedors, while the govermet offers free isecticide treatmet for the ets because it has bee harder to stimulate public demad for ad commercial supply of this isecticide. Positive busiess eviromet. To esure widespread availability of treated ets, your regio eeds a busiess eviromet that favors private-sector ivolvemet i sellig the ets ad isecticides. Roll Back Malaria suggests that at the atioal level, govermets take three steps to expad the distributio of these supplies i the private sector: develop a favorable fiscal ad regulatory eviromet by removig tax ad tariff barriers to reduce the cost of the materials used i maufacturig the ets ad ultimately the cosumer price; streamlie the registratio process for appropriate isecticides so that isecticides that are chemically safe for use i homes ad effective agaist mosquitoes are available; provide iformatio, educatio, commuicatio (IEC), ad appropriate advertisig for treated ets ad create demad for the isecticide for treatig ets, as 10 to 30 millio utreated ets exist i Africa. If you are a provicial or district maager, you ca promote local demad for treated ets by ecouragig social marketig strategies i your area. You ca also ecourage cooperatives that sew ad sell treated ets. Log-lastig isecticidal ets. Log-lastig ets may overcome some difficulties i re-treatig the ets. Log-lastig ets retai a effective amout of isecticide over time because the fibers used i maufacturig the ettig have isecticide icorporated i them rather havig the isecticide applied after the ets are made. If you ecourage supply ad demad for such ets, recogize that they are more expesive ad that the people who use these ets will still eed the same iformatio as users of other treated ets: the effects of differet soaps o the isecticide, how to retur the isecticide to full stregth after washig, ad the useful life of ets uder home coditios. Workig Solutios Africa PROVIDING INSECTICIDE-TREATED NETS TO HIGH-RISK GROUPS Tazaia will soo implemet a system i materal ad child health cliics to provide vouchers for highrisk groups to redeem with retailers for isecticidetreated ets. The retailers will, i tur, be able to redeem the vouchers through baks. Through this approach, the govermet is expectig to stimulate the private sector s distributio of the treated ets ad icrease their use i rural areas without placig a admiistrative burde o health care staff. Potetial problems with this iitiative iclude fraud (vouchers are highly valued items), retailers refusal to accept the vouchers, ad lack of cooperatio from baks. The Ugada miistry of health is proposig a similar scheme. Pregat wome visitig public ad private preatal cliics ad parets or caretakers of childre uder five receivig services through the Expaded Programme o Immuizatios (EPI) will receive vouchers that they ca exchage for subsidized treated ets at retail outlets. Coupos redeemable for oly oe brad of treated et are beig tested i four districts. The Ghaa miistry of health is distributig treated ets to families as part of its EPI services. Caretakers will receive traiig i the treatmet ad retreatmet of ets with appropriate isecticides. 12 THE MANAGER Vol. 12, No. 1, 2003

13 Protectig Pregat Wome through Prevetive Treatmet As a district or provicial maager, oe of your highest priorities is to protect pregat wome from malaria. I additio to makig sure these wome have treated ets, you eed to parter with family plaig ad reproductive health programs to offer treatmet through preatal services. I this way, you ca quickly expad malaria cotrol for pregat wome wherever large umbers of wome atted preatal cliics at least oce durig their pregacy, such as happes i may Africa coutries. If your area has edemic (year-roud) trasmissio, wome may ot show symptoms, so you will wat preatal cliics to offer Itermittet Prevetive Treatmet (IPT). Itermittet Prevetive Treatmet for Pregat Wome The health care facilities that offer preatal ad reproductive health services i areas of edemic trasmissio should offer Itermittet Prevetive Treatmet (IPT) for pregat wome. IPT clears malaria parasites from the blood of pregat wome so their babies ca be bor healthier. WHAT IS IPT? HOW OFTEN? WITH WHAT MEDICINE? IPT provides for full curative treatmet doses of a effective atimalarial at predefied itervals durig pregacy, begiig i the secod trimester after the first oted movemet of the fetus (quickeig). WHO advises that all pregat wome i areas of edemic trasmissio receive the recommeded atimalarial pharmaceutical at the first preatal visit after quickeig ad at each regularly scheduled visit after that, for a miimum of two IPT doses. Sice the preatal schedule recommeded by WHO requires three visits i the secod ad third trimesters, the ideal schedule would result i three doses of the recommeded atimalarial. A sigle-dose atimalarial pharmaceutical is the preferred medicie for IPT because it improves adherece by allowig the treatmet to be directly observed. The curretly recommeded pharmaceutical is sulfadoxie-pyrimethamie (SP) (500mg/25mg); a sigle dose is three tablets. Extesive research has show that IPT usig SP sigificatly reduces placetal malaria, low birthweight i ifats, ad severe materal aemia. Due to icreasig resistace to SP, particularly i East Africa, however, studies are uderway to idetify medicies that could replace SP for the IPT strategy. Source: WHO/AFRO, Strategic Framework for Malaria Cotrol durig Pregacy i the Africa Regio, Stregtheig Treatmet for Malaria Cotrollig malaria through treatmet meas providig prompt access to effective treatmet, prevetig progressio to severe disease, ad dealig effectively with malaria durig emergecies ad outbreaks. Your approach eeds to combie a strategy ad a pharmaceutical, for example, reachig agreemet with the Expaded Programme o Immuizatios to use a artesuate/sulfadoxie/pyrimethamie combiatio pharmaceutical for childre uder five. To stregthe treatmet for malaria, you eed improve the diagosis ad referral of severe cases, makig sure that secodlie medicies are available at referral ceters for severe cases. Other strategies you may wat to cosider iclude: procurig effective pharmaceuticals; makig appropriately packaged products available; itegratig malaria cotrol with child survival services; improvig home-based treatmet; advocatig for atioal policies that support effective pharmaceuticals. Addressig Barriers i Malaria Cotrol 13

14 Procurig Effective Pharmaceuticals Good pharmaceutical procuremet ivolves purchasig pharmaceuticals i ways that cotribute to their availability ad quality, promote effective treatmet, ad preserve scarce resources by cotrollig costs. If your program procures atimalarial pharmaceuticals at the provicial level, the based o your up-to-date stadard treatmet guidelies, you should: procure the most cost-effective atimalarial pharmaceuticals i the right quatities; select reliable suppliers of high-quality products; esure timely delivery; achieve the lowest possible cost for all pharmaceuticals. If the malarial parasite i your area is resistat to chloroquie, your malaria guidelies may require that you procure a alterative therapy. While this ca be expesive, several iitiatives are uderway to develop low-cost therapies. Covertig to a more effective pharmaceutical ca reduce malaria mortality ad morbidity, as well as improve the quality of care ad help reduce health care costs from retur visits ad ipatiet admissios. For more iformatio o how to procure effective pharmaceuticals, see Maagig Drug Supply, secod editio, Stayig Ahead of Resistace with Combiatio Therapies SUCCESS OF CTS CURRENT RESEARCH ISSUES IN INTRODUC- ING CTS I may regios, mootherapy, or the use of a sigle atimalarial pharmaceutical, is still widely used to treat malaria. Yet experts believe that icreasig resistace to atimalarial medicies ca be slowed by the use of a combiatio of two or more pharmaceuticals at the same time. Combiatio therapies (CTs) usig artemisii-based pharmaceuticals, also kow as ACTs, have bee successfully used i Southeast Asia, especially i border areas with frequet migratio, where multidrug resistace teds to flourish. This approach has improved the success rate of treatmet ad appears to have slowed the developmet of resistace while reducig malaria s trasmissio. It is still uclear whether a combiatio is less effective if it icludes oe pharmaceutical to which a malaria parasite is resistat. Several studies i Africa are evaluatig the effectiveess of ACTs there ad assessig which combiatio should be used. To address the urgecy of malaria i their coutries, some Africa govermets have already adopted ACTs without waitig for the studies results. For example, Zambia has decided to use a combiatio of artemether/ lumefatrie; Zazibar is usig artemether/amodiaquie; ad Burudi ad the KwaZulu-Natal provice i South Africa, are usig a artesuate/sulfadoxie/pyrimethamie combiatio. I order for CTs to reduce resistace i a regio, all mootherapy pharmaceuticals must be replaced with CTs i both the private ad public sectors. Poor prescribig practices ad oadherece to guidelies i either sector could pose challeges to the effectiveess of CTs. Itroducig CTs also requires chages i atioal pharmaceutical policy ad strategies for their implemetatio. Some coutries are choosig to move to other treatmets while they try to sort out all the issues that policymakers eed to cosider: challeges i marketig the ew combiatios; the icreased cost of ACTs; equity issues ad delivery issues arisig because most CTs are curretly available oly as separate pharmaceuticals with shorter shelf lives; chages i both provider ad user behavior to esure availability ad ratioal use of the combiatios; the possibility of replacig the cliical diagosis of malaria with a more defiitive biological diagosis based o laboratory tests so that ACTs are ot prescribed uecessarily. 14 THE MANAGER Vol. 12, No. 1, 2003

15 Makig Appropriately Packaged Products Available To make it easier for providers ad patiets to effectively use atimalarial treatmets, you ca support makig available prepackaged products that meet your coutry s ad your area s most effective treatmet regime. With their premeasured doses of daily medicies, blister packs are easy for providers to prescribe ad for patiets to use with proper istructio. These packs also make tamperig with the medicies difficult to coceal. Workig Solutios Cambodia INTRODUCING PREPACKAGED FIRST-LINE TREATMENTS IN THE PUBLIC AND PRIVATE SECTORS I Cambodia durig the mid- to late 1990s, patiets i areas of edemic trasmissio obtaied malaria treatmet i their commuities, most ofte from private providers. Iappropriate medicies ad dosages were commo, ad fake or substadard pharmaceuticals were widely available from pharmacies ad other vedors. As a result, i 1999 the Cambodia Natioal Malaria Ceter implemeted a approach with three compoets to improve early diagosis ad use of effective atimalarial medicies: covetioal public-sector chaels to trai ad use a etwork of village malaria workers i the most remote, iaccessible, highly edemic areas; social marketig usig IEC techiques to iform ad persuade cosumers ad to advertise the availability of effective first-lie pharmaceuticals through the private sector; program efforts to improve cliical diagostic skills ad provide a prepackaged combiatio therapy (artesuate/mefloquie) i the public sector as the first-lie pharmaceutical for P. falciparum. To facilitate distributio of a effective first-lie therapy i the private sector, its strategy also called for a equivalet artesuate/mefloquie combiatio therapy i that sector. With the support of WHO ad the Europea Uio ad usig research i the private sector, the Natioal Malaria Ceter offered a attractive brad of combiatio therapy that could be easily promoted through social marketig. It was amed Malarie, because tests foud the ame to be uiversally liked ad remembered. To ecourage ratioal use, the public-sector product was repackaged i blister packs, sealed to discourage tamperig, ad distributed oly to specific commuity providers who were traied to dispese them correctly. This approach is beig scaled up for coutrywide use, although distributig the products to remote areas, particularly alog the Cambodia- Thailad border, will remai a challege. Itegratig Malaria Cotrol with Child Survival Services For youg childre, it is importat to combie malaria cotrol with child survival services, such as the itegrated maagemet of childhood illess (IMCI) strategy. Child survival strategies geerally icorporate case maagemet ad prevetio to improve the health ad well beig of childre uder five by focusig o treatig major childhood illesses, icludig malaria, peumoia, diarrhea, ad malutritio. The IMCI strategy has three atioal compoets that ca be adapted for use i malaria programs: Addressig Barriers i Malaria Cotrol 15