Table 1 Supporting the widespread use of artemisinin-based combination therapy to treat malaria

The Evidence-Informed Policy Networks (EVIPNet) in ten sub-Saharan African countries described the costs and consequences of three options considered viable in these countries for the support of the widespread use of artemisinin-based combination therapy to treat malaria. The impetus for these activities was the 2006 WHO guidelines on malaria treatment which endorsed artemisinin-based combination therapy (ACT) to treat uncomplicated falciparum malaria [13]. In order to support the widespread use of ACT, national governments in regions with seasonal or endemic malaria had to determine whether to confirm or change:

• Delivery arrangements: including who should dispense ACT (when, where and how), and who should be involved in surveillance, pharmacovigilance and the diagnosis and treatment of atypical cases

• Financial arrangements for patients (e.g. drug subsidies) and for prescribers (amongst others), and

• Financial arrangements for patients (e.g. drug subsidies) and for prescribers (amongst others), and

• Governance arrangements: including which ACT and other anti-malarial drugs should be registered and licensed for sale (i.e. which drugs, the dosage regimes, and the packaging required), how they could be marketed, who could prescribe them (and how), who could sell or dispense them (and how), and what safeguards should be applied to protect against counterfeit or substandard drugs

EVIPNet teams from each participating country considered options consisting of different 'bundles' of heath system arrangements. One country, for example, considered:

• Using community health workers for the presumptive treatment of uncomplicated malaria with ACT (a delivery arrangement)

• Introducing ACT subsidies within the private sector to support their use (a financial arrangement) and regulating adherence to the subsidy policy (a governance arrangement), and

• Providing incentives to prescribers (specifically nurses and doctors) for a time-limited period to encourage transition to the new treatment (a financial arrangement)

The teams, consisting of individuals such as those in involved in the second and third scenarios outlined earlier, then approached the task of describing the costs and consequences for each option using Questions 2-6 as prompts.

Type of information about each option

Examples of the nature of the research evidence sought about each option

Benefits

• People: everyone except groups other than children under five years of age (who were being treated under a separate programme) and pregnant women (whose cases of malaria were considered 'complicated' and hence beyond the remit of this element of the WHO guideline)

• Option: see above

• Comparison: status quo

• Outcomes: both process indicators (e.g. coverage rates achieved) and outcome indicators (e.g. survival)

Potential harms

• As above except for outcomes where process indicators of interest included the adherence of community health workers to non-malaria related guidelines. This was because of a fear that ACT would be provided at the expense of treating other important conditions

Costs and cost-effectiveness

• Costs collected in their own setting

• Economic evaluation conducted using a societal viewpoint given that policymakers were acting in their role as stewards for the entire health system, and not just as payers for publicly financed programmes, services and drugs

Key elements of the option (how and why it works)

• Policymakers had already invested heavily in community health workers and wanted to know whether the shared attributes of community health workers and lay health workers were sufficient to allow them to expect similar benefits to those achieved only with lay health workers [14]

Views and experiences of stakeholders

• Policymakers were aware that a large proportion of malaria treatments were dispensed by 'medicine sellers' [15] rather than health professionals or lay health workers. They therefore wanted to know more about the views and experiences of these sellers