Regional Networks and Future Policy Implications

At present, most control policies are still organized at a national or subnational level (Kaul and Faust, 2001), but interest in regional approaches is increasing. For one thing, individual countries can no longer make drug policy decisions in isolation. Given the fluid nature of borders, they now realize that their and their neighbors’ policies affect each other. There are increasing calls for information exchanges among neighboring countries about their respective malaria situations, malaria treatment policies, and approaches used to combat drug-resistant malaria.

Recognizing that a regional approach offers a better platform for addressing malaria control problems that influence policy, several networks and initiatives have been established, most notably, the East African Network for Monitoring Antimalarial Treatments (EANMAT), the West African Networks for Monitoring Antimalarial Treatments (WANMAT I and II), the South East African Combination Antimalarial Therapy (SEACAT) Evaluation, a Central African network (Réseau d’Afrique Centrale des Thérapeutiques Antipaludiques, or RACTAP), the Amazon Malaria Initiative (AMI), and the Asian Collaborative Training Network for Malaria (ACTMalaria). These networks focus on partnership and shared goals in malaria control with a particular focus on training, research, and operational issues.

Pending full implementation of ACTs in Africa and elsewhere, one current dilemma that many malaria-endemic countries face is the practical question of when—in the face of growing antimalarial drug resistance—a change in drug policy should be implemented. Should it be initiated early, when only a small fraction of the population is at risk, or at a later stage, when risk affects a higher proportion of the susceptible population? Until recently, WHO recommended a change to more effective treatment when clinical failure rates exceeded 25 percent 14 days following treatment; now it has lowered the ceiling to >15 percent clinical and >25 percent total failure (i.e., clinical + parasitologic [WHO/HTM/RBM/2003.50]). No matter what standard threshold is selected, uniform change points fail to take into account districts where malaria is seasonal or epidemic, and local populations are therefore more vulnerable to adverse clinical outcomes from drug resistant malaria.

In addition, many authors have noted that the original WHO categories of response (grace, alert, action, and change) were developed in response to the relatively slow rate at which chloroquine resistance emerges. In contrast to chloroquine and amodiaquine, SP resistance emerges and spreads quickly in areas of high transmission (Talisuna et al., 2002). Finally, there are technical questions regarding the WHO test itself. Since it does not provide information on treatment failure beyond 14 days, many



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