Access

In many areas only a fraction of those who need an effective antimalarial get one. Barriers exist at every stage of the care pathway, especially for the poorest families in society. Many cannot or do not access care of any kind for children with malaria. Of those who do seek treatment a high proportion access inadequate care through the informal sector. Of those who access the informal sector the majority with malaria frequently receive no antimalarial, and of those who do the antimalarial it is often a locally ineffective drug, or is given at inadequate doses. Even where patients reach a formal healthcare facility where free antimalarials exist, only a minority may be given effective antimalarials. The net result is that if ACTs and other effective new antimalarials are deployed using current systems, they may have a very limited impact compared with their potential. The introduction of more costly and complex-to-administer ACTs could even compound these problems, especially if some part of the cost is passed on to the end user.

For maximum public health impact of ACTs, it is therefore essential that a range of potential strategies for ACT delivery are carefully evaluated to assess where ACT should be provided, how it should be delivered and who should receive it. However, the evidence base on ACT delivery strategies is currently very limited. Most countries are initially deploying ACT in formal health care facilities only, although in many settings such facilities see only a minority of febrile cases, with an equal or greater number using shop-bought drugs. There is therefore an urgent need to test interventions to improve the quality of facility care, and to extend ACT availability beyond the formal health care sector.

There is some evidence that home-based management of fever with chloroquine by community volunteers has successfully reduced mortality and progression to severe malaria. WHO now advocates the use of home-based management with effective antimalarials, and recent experiences in Ghana and Uganda with non-artemisinin combinations have demonstrated the potential of these strategies on a large scale. The major challenge now is how (or whether) to introduce ACT into home-based care. There are good reasons to do so as it undoubtedly would improve access, but there are some potential hazards. These include increasing the overuse of antimalarials, potentially exposing children to the risk of antimalarials without any possible benefit, and possibly contributing to pressures that lead to drug resistance. There is also the possibility that children who would otherwise have been taken to formal healthcare will have delay this because they have been treated with an antimalarial, with potentially serious consequences in the cases where their illness is not malaria.

Similarly, a number of pilot projects have been successful in improving malaria treatment obtained through retailers, through for example shopkeeper training, accreditation of drug stores and social marketing. In their influential report on the economics of antimalarials, the US Institutes of Medicine proposed that heavily subsidised ACT should be delivered through the retail sector, but to date no retail sector interventions in Africa have used these drugs.

It is hypothesised that the delivery of ACT through community members and/or retailers could increase substantially the coverage of prompt appropriate treatment among key target groups, and reduce incentives for leakage of public sector drugs to private providers. However, a number of important concerns have been raised. Some question the sustainability of programmes that rely heavily on volunteer staff. Others argue that widespread distribution outside facilities poses unwarranted risks due to the extent of unsupervised treatment, increase in drug pressure, and diversion of resources from other urgent public-health needs. All these issues require empirical investigation to assess the impact of a range of delivery strategies on access, utilisation, health outcomes, drug resistance and value for money. Such studies need to take place in a variety of settings to allow for variability in malaria transmission, drug resistance, socio-economic development and health systems.

Research questions to be addressed by the consortium

How can ACT delivery through health care facilities be optimised, and does this lead to increased uptake and access?
What is the appropriate role of community management in ACT delivery outside the formal healthcare sector?
What is the appropriate role of the private and non-governmental sector, including private drug retailers in ACT delivery, and how can this be best utilised to deploy ACTs and other new antimalarials?

Target outputs

To determine, in terms of healthcare systems and epidemiology, where community-based management of malaria is effective and cost-effective as a way of improving access.
To determine appropriate drugs for use within a community-based management system where ACTs are being deployed in the formal healthcare sector
To define the role of the private sector in increasing access to new antimalarials
To determine under what conditions, if any, in which rapid diagnostic tests used outside the formal healthcare sector, and especially in the private sector, can improve targeting of antimalarials to patients with malaria.