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Table 1 Outline of a policy brief about supporting the widespread use of a new, highly effective treatment for malaria in an African country

From: SUPPORT Tools for evidence-informed health Policymaking (STP) 13: Preparing and using policy briefs to support evidence-informed policymaking

What problem has been identified?

• The overarching problem is one of low coverage rates for artemisinin-based combination therapies (ACT) to treat uncomplicated falciparum malaria in sub-Saharan Africa. Key features of the problem include:

   • A high incidence of, and death rates from, malaria

   • Existing treatments have much lower cure rates than ACT. However, patients often favour existing treatments because of their past experiences and the higher price of ACT

   • The national malaria control policy, treatment guidelines, and drug formulary in many countries do not all support the prescription, dispensing and use of ACT

   • Delivery arrangements for ACT often rely primarily on physicians but not everyone has regular access to them and many are comfortable receiving care from community health workers. Financial arrangements favour existing treatments over ACT (which is much more expensive) yet some patients are sceptical about heavily subsidised medication. Governance arrangements often do not allow community health workers to prescribe ACT and do not protect against counterfeit or substandard drugs

What information do systematic reviews provide about three viable options to address the problem?

• Each of the following three options was assessed in terms of the likely benefits, harms, costs (and cost-effectiveness), key elements of the policy option if it was tried elsewhere, and the views and experiences of relevant stakeholders:

   • Enlarge the scope of practice for community health workers to include the diagnosis of malaria and prescription of ACT (governance arrangements), introduce target payments for achieving a defined coverage rate for ACT treatment (financial arrangements), and provide them with training and supervision for the use of both rapid diagnostic tests and prescribing (delivery arrangements)

   • Introduce partial subsidies for both rapid diagnostic tests and ACT within the private sector where much care is provided in urban areas (financial arrangements)

   • Restrict the types of anti-malaria drugs that can be imported and introduce penalties for those found dispensing counterfeit or substandard drugs (governance arrangements) and make changes to the national malaria control policy and drug formulary to ensure that ACT is the recommended first-line treatment

• Important uncertainties about each option's benefits and potential harms were flagged in order to give them particular attention as part of any monitoring and evaluation plan put into place

What key implementation considerations need to be borne in mind?

• A number of barriers to implementation were identified, among which were the familiarity of some patients and healthcare providers with existing treatment options and their resistance to change. Systematic reviews about the effects of mass media campaigns, the effects of strategies for changing healthcare provider behaviour generally, and for influencing prescribing and dispensing specifically, all proved helpful in deciding how to address these barriers

Notes about the supporting evidence base:

• Six systematic reviews about anti-malarial drugs had been published since the release of the World Health Organization guidelines in 2006, all of which lent further support to ACT as the recommended first-line treatment

• Of the systematic reviews identified: two addressed relevant governance arrangements, six addressed financial arrangements, five addressed specific configurations of human resources for health, and fifteen addressed implementation strategies, many of which could be supplemented by local studies