Table 1 Clarifying the problem underpinning the lack of widespread use of the recommended malaria treatment

   ◊ Cure rates for, and drug resistance (or reduced drug sensitivity) to, ACT and other anti-malarial drugs, as well as the side effects and costs of the drugs

   ◊ The views and experiences of patients about particular anti-malarial drugs

• Does the problem relate to the current health system arrangements within which programmes, services and drugs are provided?

   ◊ Governance arrangements

–        Regulations about which ACT and other anti-malarial drugs (i.e. drugs, dosage regimes, and packaging) can be registered/licensed for sale, how counterfeit or substandard drugs are safeguarded against, how patents for them and profits arising from them are handled, how they can be marketed, who can prescribe them and how, and who can sell or dispense them and how

–        National treatment guidelines and/or the national malaria control policy about the first-line (and second-line) drug therapy recommended for uncomplicated falciparum malaria, as well as their dosage regimes/packaging, targeting for particular populations, and targeting for areas with particular characteristics

–        National essential drugs list, particularly the list of anti-malarial drugs

   ◊ Financial arrangements

–        Drug and dispensing fees for first-line drug therapy (and for ACT if this is not the first-line therapy) for uncomplicated falciparum malaria, including any subsidies for particular populations, remuneration arrangements for health works prescribing and dispensing ACT

–        The views and experiences of patients about fees and subsidies and about financial incentives to promote adherence

   ◊ Delivery arrangements

–        Access rates for first-line drug therapy (and for ACT if this is not first-line therapy) for uncomplicated falciparum malaria (i.e. who has access to someone who can dispense drug therapy)

–        Coverage rates for first-line drug therapy (and for ACT if this is not first-line therapy) for uncomplicated falciparum malaria (i.e. who is dispensed which drug)

–        Treatment patterns for uncomplicated falciparum malaria (i.e. who dispenses what, when, where and how, including whether treatment is part of the Integrated Management of Childhood Illness or other ‘horizontal’ programmes)

–        Adherence patterns for the treatment of uncomplicated falciparum malaria (i.e. who takes what, when, where and how)

–        Arrangements for surveillance, pharmacovigilance and the diagnosis and treatment of atypical cases

–        The views and experiences of patients about particular providers (or delivery arrangements more generally)

• Does the problem relate to the current degree of implementation of an agreed-upon course of action?

   ◊ For example, regulations can only help to address a problem if they are acted upon throughout the health system. Regulations may exist about the registration/licensure, marketing, prescribing and dispending of ACT and other anti-malarial drugs. However, if the regulations are not enforced, there may be many counterfeit or substandard drugs in circulation, false statements may be made in drug advertisements, and untrained individuals may be prescribing or dispending ACT

The EVIPNet teams all concluded that the problem could be related to a risk factor, disease or condition, the programmes, services or drugs currently being used, the current health system arrangements and, in some cases, the current degree of implementation of an agreed-upon course of action. This had important implications for which options were considered appropriate to address this multi-faceted problem.