Today, prompt and effective treatment is the key to reducing drug-resistant malaria’s increasing morbidity and mortality. Rational antimalarial drug policies are therefore essential elements of any national malaria control program. Because many countries with growing resistance to first-, second-, and even third-line antimalarial drugs are burdened with debt and poorly financed health budgets, a change in antimalarial drug policy is economically daunting. The process of policy change can also be time consuming and involved.
A detailed analysis of Kenya’s change from chloroquine to SP emphasizes the complexity of the decision-making and implementation process even when two drugs are similar in cost (Shretta et al., 2000). Chloroquine resistance was first acknowledged at a meeting organized by the Kenya Medical Research Institute in January 1989. In 1991, the Ministry of Health requested a review of the scientific evidence in support of a revision. In October 1997, draft guidelines were finally issued, reflecting more than 20 independent studies over 14 years documenting chloroquine failure.
Even after consensus has been reached, multiple factors can delay country-level implementation for another 18 months or more: political and financial support, training of health care providers, and sensitization of the general population, which is crucial for ultimate success of the antimalarial changeover (WHO/UNICEF, 2003). In the future, a culture in which changes in malaria treatment, based on sound evidence, can occur on a fairly regular basis will be crucial. This is happening to some extent now (e.g., in Kenya, and Tanzania) but far more flexibility, and rapid response is needed in most malaria endemic countries.
In 1993, Malawi was the first sub-Saharan country to switch from chloroquine to SP as first-line therapy for P. falciparum. Between 1998 and 2001, Kenya, Uganda, Tanzania, Zanzibar, Rwanda, and Burundi followed suit (like Malawi, they either chose SP monotherapy or a combination of SP plus chloroquine or amodiaquine). Countries that have now adopted and (more recently) implemented ACTs include Tanzania (Zanzibar) (2001), Zambia (2001), and Burundi (2002). In South Africa, the provinces where ACTs have been fully implemented are KwaZulu Natal (Coartem), and Mpumalanga (artesunate+SP) (WHO/UNICEF, 2003). First-line antimalarial drug policies for selected countries in Africa, Asia, and South America, as of March 2003, are listed in Table 8-4.