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

International Journal of Technology Assessment in Health Care, 26:2 (2010), 255–259.
Policy brief on improving access
to artemisinin-based combination
therapies for malaria in the East
African community

Harriet Nabudere
Makerere University
Gabriel L. Upunda
East African Community
Malick Juma
Ministry of Health, Zanzibar
Keywords: Antimalarials, Care access, Health policy, East African Community, Tanzania,
Kenya, Uganda, Rwanda, Burundi
WHO reports show that more than 90 percent of the annual global malaria cases and deaths are reported from the The World Health Organization (WHO) since June 1998 African region (20). Children under the age of 5 years and has advocated for the use of artemisinin-based combination pregnant mothers are the most vulnerable groups affected therapies (ACTs) in countries where Plasmodium falciparum by the disease. Malarias’ annual contribution to deaths in malaria is resistant to traditional antimalarial therapies such under-5 year olds is as high as 39,000 in Uganda, 31,000 in as chloroquine, sulfadoxine-pyrimethamine, and amodi- aquine (19;22). In 2006, WHO released evidence-based Community health workers (CHWs) have successfully guidelines for the treatment of malaria backed by findings contributed to public health services in the fight against from various scientific studies (21). During the period malaria. The CHW kits for home-based management of fever between 2002 and 2006, all the five East African states at present still contain older antimalarials in Uganda and Tanzania, Kenya, Uganda, Rwanda, and Burundi changed Tanzania. Rwanda does not have a CHW network, whereas their national antimalarial treatment policies to use ACTs as Kenya has incorporated ACTs to be used at community level first-line treatments for uncomplicated falciparum malaria and commenced with deployment of the drugs in the The private sector provides health services to a large state-managed health facilities (12–15). To scale up the use proportion of the population in East Africa through faith- of ACTs in the East African region to combat malaria and based organizations and other not-for-profit organizations, speed up progress toward the sixth Millennium Development as well as for-profit facilities (6). The cost of ACTs at these Goal, a combination of delivery, financial, and governance outlets is still quite high (between US$5 and US$15 per adult arrangements tailored to national or subnational contexts treatment course) compared with the free ACTs provided by public facilities. Samarasekera highlights the need fora stronger regulatory framework by government to oversee The authors thank the Swiss Agency for Development through the Research the private sector in provision of health-related services and Table 1. Policy Options
protect against catastrophichealth expenditures (2;4;10;16) would subscribe making thescheme financially untenable (10) POLICY OPTIONS
nity Health Workers (CHWs). CHWs are normally recruitedfrom members of the community, such as mothers, farmers, The policy options described in this policy brief are not teachers, and others. CHWs are much more accessible than mutually exclusive interventions; they are complementary healthcare professionals, particularly in rural areas where strategies in the fight against malaria. The policy brief does there are fewer and poorly equipped healthcare facilities; (ii) not recommend any one option over another, but highlights Engage the private sector in distributing ACTs in accordance existing research evidence in support of the included inter- with standard treatment guidelines, and ban importation ventions. The three options are the following: (i) Include and prescribing of artemisinin monotherapies; (iii) Improve ACTs in the home-based management provided by Commu- health sector financing and universal access to healthcare by INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 26:2, 2010 Malaria treatment policy brief for the East African community Table 2. Implementation of the Policy Options
mandatory, therefore, the sick aremore likely to subscribe, makingthe schemes untenable •Use of mass media for public awareness and education for all three options • Use of a “suggested retail price” bicycles for transportation, smallcommissions on each ACT packdispensed, small sustainableallowances for CHWs In a high quality systematic review, Grilli and colleagues (7) found that health messages in the mass media can promote desirable health behaviors among healthcare practitioners as well as the general public. Higher incomegroups have better access to media such as television, radio, and the Internet, and are more likely to benefit fromthis exposure than lower income groups. This could increase inequities. This strategy is well accepted, but theremay be considerable financial cost for sustained campaigns INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 26:2, 2010 Table 2. Continued
shifting from out-of-pocket payments to prepayment and tration Building, 2nd floor, New Mulago Hospital Complex, pooling of funds using a combination of social health in- surance and community-based health insurance. These three Gabriel L. Upunda, MD, MMED, MPH (glupunda@gmail.
com), Executive Director, Regional East African CommunityHealth Policy Initiative, East African Community, ArushaInternational Conference Centre, Arusha, United Republic IMPLEMENTATION OF THE POLICY
Malick Juma, MD, MMED (,
Director, General Health Services, Ministry of Health, Zanz-
Obstacles to implementing the three policy options and ibar, P.O Box 236, Zanzibar, United Republic of Tanzania strategies for addressing these are described in Table 2.
1. Bennett S. The role of community-based health insurance within the health care financing system: A framework for anal- A half-day policy dialogue meeting was held by the Uganda ysis. Health Policy Plan. 2004;19:147-158.
country office of the Regional East African Community 2. Carrin G, Waelkens MP, Criel B. Community-based health in- Health Policy Initiative in April 2008. Participation included surance in developing countries: A study of its contribution researchers, policy makers, health managers, and civil soci- to the performance of health financing systems. Trop Med Int ety. There was general agreement about the feasibility of two of the policy options in the Ugandan context. Some delegates 3. Clinton Foundation. Distribution of artemisinin-based combi- advocated for the inclusion of Rapid Diagnostic Kits to sup- nation therapies through private sector channels: Lessons from port use of ACTs by CHWs. It was believed that there was four country case studies. New York: Clinton Foundation; 2008.
need for more evidence to support social health insurance.
4. Ekman B. Community-based health insurance in low-income countries: A systematic review of the evidence. Health Policy A key output was the decision by a senior policy maker to include the policy brief as one of the resource documents to 5. Fapohunda BM, Beth AP, Robert A, et al. Home-based man- develop the new National Health Policy document (2009), agement of fever strategy in Uganda: A report of the 2003 which provides direction for the health sector for the next 10 survey. Arlington, VA: MOH, WHO and BASICS II; 2004.
6. Goodman CA. An economic analysis of the retail market for fever and malaria treatment in rural Tanzania. Thesis submit-ted to the University of London for the Degree of Doctor of CONTACT INFORMATION
Philosophy. London: London School of Hygiene and TropicalMedicine, Health Policy Unit; 2004.
Harriet Nabudere, MD, MPH (,
7. Grilli R, Ramsay C, Minozzi S. Mass media interventions: Project Coordinator, SURE Project, Office of the Principal, Effects on health services utilisation. Cochrane Database Syst College of Health Sciences, Makerere University, Adminis- INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 26:2, 2010 Malaria treatment policy brief for the East African community 8. Ikeoluwapo OA, Browne EN, Garshong B, et al. Feasibility and treatment. Zanzibar: United Republic of Tanzania: Ministry of acceptability of artemisinin-based combination therapy for the home management of malaria in four African sites. Malaria J.
16. Ranson MK. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, 9. Kutzin J, Barnum H. How health insurance affects the delivery India: Current experiences and challenges. Bull World Health of health care in developing countries. World Bank technical paper. Washington DC: World Bank; 1992.
17. Samarasekera U. Drug subsidy could help Tanzania tackle 10. Lagaarde M, Palmer N. Evidence from systematic reviews to malaria. Lancet. 2008;371:1403-1406.
inform decision making regarding financing mechanisms that 18. Waters H, Hatt L, Peters D. Working with the private sector for improve access to health services for poor people. A policy child health. Health Policy Plan. 2003;18:127-137.
brief prepared for the International Dialogue on Evidence- 19. World Health Organization. Antimalarial drug combination Informed Action to Achieve Health Goals in Developing Coun- therapy. Report of a WHO technical consultation. Geneva, tries (IDEAHealth). Geneva: Alliance for Health Policy and Switzerland: World Health Organization; 2001.
Systems Research; 2006. 20. World Health Organization. Burden of disease project. http:// HealthFinancingBrief.pdf. (accessed February 28, 2008) 11. Lewin SA, Babigumira SM, Bosch-Capblanch X, et al. Lay health workers in primary and community health care: A 21. World Health Organization. Guidelines for the treatment of systematic review of trials. Geneva: Alliance for Health Pol- malaria. Geneva, Switzerland: World Health Organization; icy and Systems Research; 2006. LHW_review.pdf. (accessed December 24, 2009) 22. World Health Organization. The use of artemisinin and its 12. Ministry of Health. Antimalarial treatment policy change to derivatives as antimalarial drugs: A report of a joint CTD/ ACTs. Kampala, Uganda: Ministry of Health; 2005.
DMP/TDR Informal Consultation. Geneva: World Health Or- 13. Ministry of Health. Management of uncomplicated malaria. A practical guide for health workers. 3rd ed. Kampala, 23. World Health Organization. World malaria report 2008.
Uganda: Ministry of Health Malaria Control Programme; Geneva: Global Malaria Programme; 2008. WHO/HTM/GMP/ 14. Ministry of Health. National guidelines for treatment. Diag- 24. Yeboah-Antwi K, Gyapong JO, Asare IK, et al. Impact of nosis and prevention of malaria in Kenya. Nairobi, Kenya: prepackaging antimalarial drugs on cost to patients and compli- ance with treatment. Bull World Health Organ. 2001;79:394- 15. Ministry of Health. The guidelines for malaria diagnosis and INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 26:2, 2010


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