11
Maximizing the Effective Use of Antimalarial Drugs

INTRODUCTION

The success or failure of any public health program is largely determined by the public’s effective use of the services offered. This principle is especially relevant in treating malaria because prompt use of efficacious drugs greatly reduces the incidence of severe and complicated disease (Salako et al., 2001). Merely making an efficacious treatment available is not enough to reduce malaria mortality, however—the treatment also must be used optimally. Even the most highly efficacious treatment, if not used correctly, can fail to cure the illness, and may facilitate the development of drug resistance.

In real life, many human factors thwart access and use of curative medications in resource-poor settings, including traditional beliefs, illiteracy, mistrust and fatalistic attitudes. In the case of malaria, economic barriers to the purchase of drugs; complex treatment and dosing regimens; limited understanding of how or why to adhere to recommended regimens; and adverse side effects compound the problem (Fungladda et al., 1998; Bloland et al., 2000; Yepez et al., 2000). A false sense of security also affects choice and use of antimalarial treatments, particularly in sub-Saharan Africa. Most residents in malaria-endemic areas of Africa do not appreciate the rising toll of chloroquine-resistant P. falciparum because, for many years, chloroquine worked so well. In some cases, chloroquine’s loss of activity is also obscured by its partial antipyretic effects, which suggest to



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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance 11 Maximizing the Effective Use of Antimalarial Drugs INTRODUCTION The success or failure of any public health program is largely determined by the public’s effective use of the services offered. This principle is especially relevant in treating malaria because prompt use of efficacious drugs greatly reduces the incidence of severe and complicated disease (Salako et al., 2001). Merely making an efficacious treatment available is not enough to reduce malaria mortality, however—the treatment also must be used optimally. Even the most highly efficacious treatment, if not used correctly, can fail to cure the illness, and may facilitate the development of drug resistance. In real life, many human factors thwart access and use of curative medications in resource-poor settings, including traditional beliefs, illiteracy, mistrust and fatalistic attitudes. In the case of malaria, economic barriers to the purchase of drugs; complex treatment and dosing regimens; limited understanding of how or why to adhere to recommended regimens; and adverse side effects compound the problem (Fungladda et al., 1998; Bloland et al., 2000; Yepez et al., 2000). A false sense of security also affects choice and use of antimalarial treatments, particularly in sub-Saharan Africa. Most residents in malaria-endemic areas of Africa do not appreciate the rising toll of chloroquine-resistant P. falciparum because, for many years, chloroquine worked so well. In some cases, chloroquine’s loss of activity is also obscured by its partial antipyretic effects, which suggest to

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance some patients that the drug is curing them as opposed to merely relieving symptoms. There’s a tremendous confidence in the public in the old drug [chloroquine], even though the old drug is failing. That’s part of the problem. Don DeSavigny, Tanzania Essential Health Interventions Project Another major problem is the inadequacy of public health infrastructure to serve basic health care needs in Africa and other resource-poor settings (Kager, 2002; Moerman et al., 2003). This inadequacy is reflected in a lack of electricity, clean water, or reliable medicines in many public health facilities (Gilson et al., 1994; Israr et al., 2000) as well as poorly trained and poorly motivated staff, leakage of drugs for private resale, unauthorized patient charges, mismanagement of patient user fees, distance to facilities, lack of drugs and other desired services, and lengthy waiting times (Bloland et al., 2003). As a result, private-sector sources—ranging from licensed pharmacies to informal drug kiosks and itinerant drug sellers—have assumed an increasingly important role. In some studies, as many as 60 percent or more of patients seeking help for febrile illness received their medicines from the private sector (McCombie, 1996; WHO/UNICEF, 2003). This chapter reviews specific barriers to access and use of antimalarial drugs in falciparum-endemic areas, as well as promising strategies to enhance appropriate drug use in the future. When negative and positive factors are added together, the net approximates the ultimate goal of “programmatic effectiveness” (Box 11-1). OVERCOMING ECONOMIC BARRIERS The high cost of treatment—real or perceived—is a major barrier to accessing malaria drugs and treatment (Ndyomugyenyi et al., 1998). In addition to direct drug costs, indirect costs such as transportation and time affect utilization. When chloroquine was still effective, many mothers in Ghana who believed in its efficacy failed to use it simply because they lacked access to health services, pharmacies, or urban markets where they could buy the product (Glik et al., 1989). Similarly, in Papua New Guinea, patients’ willingness to seek malaria care at primary health facilities was strongly influenced by the distance they had to travel to reach those facilities (Muller et al., 1998). In another study from Ghana, the cost of treatment influenced where

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance BOX 11-1 What Is Programmatic Effectiveness? Development of rational malaria treatment policies in endemic countries relies on consideration of a variety of data, including economic, behavioral, biomedical, and political (Bloland and Ettling, 1999). Among the relevant biomedical data, evidence from carefully conducted in vivo assessments of malaria therapy efficacy using established methodologies are critical for guiding appropriate drug choice, and for timing policy change (WHO, 2003). Ultimately, however, the central purpose of formulating rational malaria treatment policies is to reduce malaria mortality. Making an appropriate drug available is merely the first step. The optimal use of that drug involves many additional steps. The patient (or their parent) must also: recognize the need for treatment with Western medicine; believe that the recommended treatment is useful, choose to use it, and know where to get it; perceive that treatment is safe, of reasonable quality, available, and affordable; at the time of dispensing, receive an appropriate amount of medicine from the provider—whether public sector- or private sector-based—along with adequate information on how to take the treatment correctly; and actually take the medicine completely and correctly. This more holistic view of malaria therapy, i.e., one that takes into account all of the factors that determine treatment success in practice, underlies the concept of “programmatic effectiveness.” Programmatic effectiveness recognizes that even the most highly efficacious treatment, if not used correctly, can fail to cure the illness, and possibly contribute to the development of resistance. In one of the few studies that have tried to measure programmatic effectiveness of malaria therapy, the authors identified a series of 7 critical factors leading to successful treatment (Krause and Sauerborn, 2000). They then measured the frequency with which each factor was satisfied in an actual health setting in Burkina Faso and found that the overall programmatic effectiveness of malaria treatment was only about 3% (i.e., only 3% of patients were successfully treated, according to their definitions). More important, increasing the efficacy of the malaria treatment from 85% to 100% increased overall programmatic effectiveness by less than 1%. This example illustrates that optimizing a single factor while ignoring other factors may yield minimal improvements overall. In the case of malaria, simply optimizing drug efficacy by providing ACTs without attempting to optimize the environment in which treatment occurs may result in far less influence on overall morbidity and mortality rates than expected. Infusing ACTs in the same environment in which chloroquine, sulfadoxine/pyrimethamine, and other drugs have failed could even be counterproductive. An unprecedented investment in highly efficacious ACTs must be accompanied by investments aimed at improving the environment in which they will be used in order to maximize their benefits minimize the potential for harm resulting from misuse. Peter Bloland, U.S. Centers for Disease Control and Prevention

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance malaria care was sought. Interestingly, individuals with higher incomes were more likely to purchase drugs privately and self-medicate for malaria; users acknowledged that the convenience of local purchase and the option of taking a partial course of medication affected their decision to self-treat. This study also found that patients were more likely to visit private or mission facilities (where overall quality was perceived to be higher) when user fees rose at local government clinics (Asenso-Okyere et al., 1997). Other studies have shown that it is not necessarily the price paid for treatment that is most important but how it is paid. In Tanzania, for example, many subjects who reported they could not afford Western medicines (including antimalarials) still bought relatively costly traditional medicines. The inconsistency was partly explained by healers’ willingness to accept credit or payment in kind as opposed to requiring cash for their products and services. While some public and mission hospitals also extend credit, they do so less frequently than traditional healers (Muela et al., 2000). Price is an important factor in choosing both a treatment and a treater, but it interacts with a host of other variables. Even when drugs are free through public-sector sources, they are not necessarily accessible. Patients and their families may seek malaria treatment outside the public sector because private outlets are easier to reach, and their products are perceived to be of higher quality. Consumers also may obtain drugs from private facilities for the simple reason that antimalarial drugs are frequently out of stock at public clinics. A global subsidy to flood the public and private marketplace with highly effective artemisinin combination therapies (ACTs) in even the most peripheral areas where drug resistant P. falciparum is being transmitted would circumvent these economic barriers, as discussed in detail in Chapter 3. MAKING ANTIMALARIALS SAFER AND MORE USER-FRIENDLY Packaging That Promotes Appropriate Use In many parts of the world, especially sub-Saharan Africa, antimalarial pills are still dispensed in unmarked paper envelopes, and syrups constitute the major form of treatment for children under five. Prepackaged tablets are one means by which to ensure proper dosing and adherence to a full course of antimalarial treatment. The Special Programme for Research and Training in Tropical Diseases (TDR) advocates a simple, dose-wise packaging of antimalarials to help patients take the correct drug dosage at the correct time (TDR/RBM, 2002). Well designed drug packages increase adult compliance, on average, 20 percent (Yeboah-Antwi et al., 2001), and the

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance effect in children (Pagnoni et al., 1997) may be even greater. In Ghana, a 91 percent adherence rate was found in children aged 0-5 years who were given prepacked tablets compared with a 42 percent adherence rate in users of antimalarial syrup. The tablets, in contrast to the syrup, did not require measuring, and the daily dose was clearly indicated. Most important, the cost of treating children with tablets was roughly 25 percent that of treating them with syrup (Ansah et al., 2001). Prepackaged tablets also have been associated with reduced drug wastage at health facilities and reduced patient waiting times at dispensaries (Yeboah-Antwi et al., 2001). The adherence is actually better to tablets in children. With syrups the mothers get confused. To a mother … a spoon is a spoon is a spoon. So you get anything from a one ml spoon to nine ml spoon being used to administer the drug. But if you package it … people value it. Irene Agyepong, Ghana Health Service Similar results have been reported elsewhere. In a comparison of blister packaging of antimalarials with other interventions (including public information campaigns and drug quality assessment), blister packaging was most effective at improving adherence (Gomes et al., 1998). Studies in Burma (Shwe et al., 1998) and China (Qingjun et al., 1998) also suggest that blister packs are an effective way to improve adherence to short-course and combination treatments. A recent qualitative study among urban and rural women in western Uganda found prepacked, unit-dosed malaria treatment for children widely accepted by mothers (Kilian et al., 2003). Ninety-one percent of women said they preferred the prepacked to the conventional type of treatment, and 94 percent were willing to pay between US$0.17 (rural women) and US$0.29 (urban women) more for this treatment. The main reasons for preferring prepacks were safety and cleanliness; ease of application, dosing, and compliance were additional perceived benefits. In Burkina Faso, mothers who received training and packaged drugs recognized and treated malaria promptly and correctly (Sirima et al., 2003). In sum, evidence that better packaging technology improves adherence is timely and relevant to the introduction of more efficacious antimalarial treatments such as ACTs, particularly in Africa. An emphasis on convenient dosing schedules as well as forms (for example, rectocaps and blister packs) developed in partnership with private industry will be essential to enhanced penetration of new-generation antimalarial drugs.

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Poor-Quality and Counterfeit Drugs The quality of medicines in less developed countries is often poor due to a lack of quality assurance during manufacture, excessive decomposition of active ingredients under hot and humid conditions, and/or counterfeiting. Nonetheless, substandard and expired drugs continue to circulate because of simple economics, lack of adequate drug information, and weak country-level drug regulatory systems. In one study conducted by the Department of Pharmacy of the University of Nairobi, 46 percent of locally manufactured products were substandard when their active ingredient was measured by compendial methods (Kibwage et al., 1992). In another study, almost half of nearly 600 antimalarial, antibacterial, and antituberculosis drugs purchased in Lagos or Abuja, Nigeria did not comply with set pharmacopoeial limits. The sample included chloroquine, sulfadoxine/pyrimethamine (SP), and quinine tablets, and chloroquine and SP syrups, some of which had less than 25 percent active ingredient (Taylor et al., 2001). Failure to dissolve was found in 44 and 13 percent respectively of SP and amodiaquine tablets sold by private wholesale pharmacies in Dar es Salaam, Tanzania (Minzi et al., 2003). These findings validate consumers’ concerns about antimalarial drug quality in many malaria-endemic countries. In contrast to a substandard drug, a counterfeit drug is one that has been incorrectly packaged or constituted in a deliberate attempt to dupe sellers and consumers (Wondemagegnehu, 1995). Among cases in which pharmaceutical preparations contain no active ingredient, a drug other than that stated on the label, or consistently low concentrations of drug, fraud is the most likely cause (Wan Po, 2001). Counterfeit artesunate and mefloquine preparations are widely sold in Cambodia (Rozendaal, 2001). Another recent study from Southeast Asia found that more than a third of tablets labeled “artesunate” purchased from shops in Cambodia, Laos, Burma, Thailand, and Vietnam contained no drug (Newton et al., 2001). Recognizable packaging is one means of increasing the likelihood that drugs are authentic, although it does not eliminate the need to verify quality using, for example, drug testing kits. In Southeast Asia where counterfeit packaging changes frequently, this type of testing must be conducted on a regular basis (Newton et al., 2001). Labeling and Instructions Labeling of pharmaceuticals, malaria drugs included, is woefully inadequate in many malaria-endemic settings. When drugs are accompanied by printed information, the information is often written in complicated or technical language, or, in some cases, a language entirely unknown to the

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance consumer. And in many cases, the printed information is of no use whatsoever because the consumer is illiterate. Difficulties reading antimalarial instructions are well documented (Ansah et al., 2001; Okonkwo et al., 2001; TDR/RBM, 2002). In addition, verbal instructions are often inadequate. In Zambia, many children suffering from malaria did not receive the appropriate 3-day course of chloroquine because their caregivers did not receive adequate instruction on how to administer the drug (Baume et al., 2000). In Uganda, only 38 percent of children received chloroquine in compliance with instructions given by health workers or drug shop attendants (Nshakira et al., 2002). Obviously, consumers can only use antimalarials correctly if they receive a full explanation from a health care provider or drug seller, or appropriate written and graphic labeling accompanies the drug. Good labeling, in fact, is a minor added expense for producers that yields an excellent return on investment. In a three-armed Nigerian study of antimalarial treatment with chloroquine syrup, the addition of a pictorial insert plus good verbal instructions doubled adherence with the correct dosing regimen (Okonkwo et al., 2001). The pictorial insert added only US$0.01 per patient to the base cost of US$.30 for the syrup. Close-to-Home Treatment At the Abuja Summit in April 2000, African heads of state agreed that, by 2005, 60 percent of malaria sufferers should have prompt access to affordable, appropriate treatment within 24 hours of the onset of symptoms (WHO, 2000). This recommendation coincided with increasing interest in extending malaria treatment closer to home, or even within the home. Although there is, at present, no single accepted definition of home-based malaria therapy, the general idea is to greatly improve access to efficacious medicines at the most peripheral levels, and to increase community members’ knowledge about how to use antimalarial medicines properly (Bloland et al., 2003). In fact, unsupervised home treatment with antimalarials has been a common practice in certain African countries and settings for many years (Breman and Campbell, 1988; Deming et al., 1989; Ahorlu et al., 1997; Nshakira et al., 2002), especially where local residents are dissatisfied with formal health services. In a recent study in Kenya, home treatment with an antimalarial drug was given to 47 percent of children under 5 years (for 32 percent, this was their only antimalarial treament), 43 percent were taken to a health facility, and 25 percent had no antimalarial treatment (Hamel et al., 2001). In Mali and Nigeria, 76 and 71 percent of mothers, respectively, managed their child’s illness at home with antimalarial drugs (Thera et al.,

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance 2000; Fawole and Onadeko, 2001). Urban settings (where population density creates markets responsive to consumer demand) also promote home treatment (Glik et al., 1989; Brinkmann and Brinkmann, 1991; Agyepong and Manderson, 1994). In rural Gambia, in contrast, low rates of home treatment with chloroquine (<10 percent) have been documented in several studies (Menon et al., 1988; von Seidlein et al., 2002; Clarke et al., 2003), possibly due to the restricted availability of antimalarials as well as lower costs for treatment at government health centers. A similar pattern has been reported from Zambia, where private providers also are few, and treatment at government facilities free (Baume et al., 2000). If the availability of effective antimalarials increased in rural African communities along with stakeholder education, many experts believe that residents could use drugs effectively. One community-based intervention in northern Ethiopia in which mother coordinators provided home treatment reduced under-5 malaria mortality by 40 percent (Kidane and Morrow, 2000). A smaller study in Guinea Bissau found similar treatment outcomes and day 7 chloroquine blood levels in children with symptomatic malaria whose treatment was either supervised in a health center or given at home following adequate caregiver education by health staff (Kofoed et al., 2003). The main disadvantage of self-treatment is the lack of clinical evaluation of patients by trained health professionals, which can result in missed diagnoses and delays in appropriate treatment (Hamel et al., 2001). In addition, presumptive treatment of febrile episodes at home is likely to result in overuse of antimalarial drugs and the attendant risk of escalating drug resistance. Malaria is a serious problem. About 95 percent of people in the village get sick with malaria … Because health care is very far from the village, most deaths occur at home. Village official, Mkuranga, Tanzania (2002) I think household based treatment is inevitable, it’s what people have been doing down the centuries, and they are continuing to do it. And then you have really poor people. They are always doing economic calculations … they [calculate] the difference between fish in the soup today or [taking] him to the clinic. Irene Agyepong, Ghana Health Service (2002)

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance EDUCATING STAKEHOLDERS Health Education Messages Health education messages can provide information and address a variety of misconceptions regarding the use of antimalarials. Common formats include posters, video clips, radio, and other forms of mass media. Other methods include peer education, mothers’ clubs, and school-based programs. In Tanzania, popular misconceptions about SP were undermining adherence to treatment. The Tanzanian health service responded by creating health education messages to counter the belief that SP is ineffective because it lacks chloroquine’s immediate antipyretic plus anti-inflammatory effects. Other messages in Tanzania and elsewhere have focused on malaria’s symptoms and complications, correct dosing of antimalarial drugs, the use of oral versus injectable antimalarials, and persistent or recurrent symptoms following treatment (Ruebush et al., 1995; Foster, 1995). As with many health education messages (Engleman and Forbes, 1986; Helitzer-Allen et al., 1993; Denis, 1998) however, the Tanzanian malaria campaign was never formally evaluated. One exception to the dearth of educational evaluations is a study conducted in Cambodia in which posters combined with video clips improved antimalarial adherence rates as much as 20 percent (Denis, 1998). The influence of posters alone was much more modest. Educational benefits were mainly reported among those who visited public and private health practitioners as opposed to consumers who purchased their drugs from vendors. While posters have been used widely in malaria education, this is the only study that has compared their effect on adherence with another form of mass media; namely video. Training Shopkeepers Many consumers in Africa, Asia and Latin America seek medical treatment outside the formal heath care sector (Foster, 1995). Although close-to-home treatment is desirable in theory, in practice, private sector vendors are frequently unable to provide appropriate advice, complete doses, or even the correct category of drug for a specific complaint (Bloland et al., 2003). One way of improving quality of private-sector treatment is to train drug sellers and shopkeepers. In western Nigeria, primary health care training of patent medicine vendors improved knowledge about malaria as well as other infectious disorders and malnutrition (Oshiname and Brieger, 1992). In Kenya, 500 private drug sellers were enrolled in a 2-4 day training workshop mounted by the Ministry of Health in conjunction with a public

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance information campaign. The effort resulted in a short-term increase in the appropriate use of over-the-counter chloroquine of 62 percent (Marsh et al., 1999). One year later, however, there was a 20 percent turnover in outlets and/or trained staff (Marsh et al., 2004). A promising new trend for improving the quality of private-sector malaria prescribing is networks of licensed or franchised drug shops that can dispense quality treatment advice and medications with a high degree of oversight (for examples, see http://msh.org/features/gates/kenya-release.html or http://www.cfwshops.org/about.html). Educating Health Professionals It should not be assumed that community-based health care providers—in particular midwives, traditional birth attendants, and health workers—are well informed about malaria. However, with regular training and updates, they can serve as potent advocates for proper case management and adherence to treatment guidelines (Ndyomugyenyi et al., 1998). Medical assistants working in health posts are another target group for ongoing education and auditing. In Ghana, one study found a surprising discrepancy among clinic providers between knowledge and practice of malaria treatment (evidenced by over- and under-dosing of chloroquine) as well as a tendency to yield to patient demands for injections and polypharmacy (Ofori-Adjei and Arhinful, 1996). In-service training did not alter these poor prescribing practices over the long term despite medical assistants’ knowledge of correct treatment paradigms. The authors argue for an increased awareness of the sociocultural context of antimalarial drug use when designing educational programs for health providers and patients. Targeting Family Decision Makers and Traditional Healers Understanding local knowledge, perceptions, and practices of malaria management has become an increasing focus of research during the last decade. In a recent study based on semi-structured interviews with community members in Mbarara, Uganda, causes of malaria—in addition to “fever due to mosquitoes”—were reported to be drinking of dirty or unboiled water, breathing bad air, staying near somebody with malaria, witchcraft, avenging spirits, and eating fresh maize or sweet fruit such as mangoes, pineapples, and passion fruit. Even those who said that mosquitoes cause or transmit malaria had erroneous ideas about the route of transmission. Most believed that malaria was acquired by drinking mosquito eggs or larvae in dirty water as opposed to a mosquito bite (Nuwaha, 2002). Despite misconceptions about its cause, many people know malaria’s common clinical features. Kenyan and Ghanaian mothers had sufficiently

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance good knowledge to recognize mild to moderate malaria (Ruebush et al., 1995; Ahorlu et al., 1997). In Uganda, not only were convulsions, anemia, and splenomegaly linked to malaria, interviewees also discussed complications of malaria in pregnancy, in particular abortions (Nuwaha, 2002). However, many caregivers in Africa still blame convulsions—a prominent finding in severe malaria—on supernatural causes (Mwenesi et al., 1995; Ahorlu et al., 1997; Nuwaha, 2002). When spiritual causes are invoked, traditional healers, as opposed to medical professionals, are frequently consulted. Educating traditional healers about febrile convulsions and severe malaria is a particularly important means of rerouting children with seizures and impaired consciousness to effective antimalarials. Another ethnographic study conducted in Tanzania found parents and traditional healers unanimous in their belief that febrile seizures require traditional treatments, at least initially, and that these treatments are effective (Makemba et al., 1996). While traditional healers did refer some patients who were not improving to the District Hospital, the referral typically came late in the course of illness. In Uganda, traditional medicine also was endorsed for treatment of convulsions and splenomegaly (Nuwaha, 2002). Squeezing juice from herbs into the nose and mouth was a common way of treating a convulsing or unconscious child, while splenomegaly was often treated with therapeutic marks and herbs squeezed into cuts overlying the splenic area. Let’s imagine that we are in a remote area in Africa and a mother has a sick child, and this child has severe malaria, convulsions, etc. that really scares the person. Very often, she doesn’t decide immediately or alone [if she will take the child for treatment]. She will either consult the mother-in-law, the neighbor, or the father. The other important element that comes into the decision is whether or not she is financially able to pay for the transport. So there are several steps in the decision-making process that require a back and forth for the woman and the child that delay the treatment. Magda Robalo, WHO AFRO (2002) In focus group discussions, health workers and mothers in Tanzania were clear about the signs and symptoms of homa ya malaria, a Swahili term consistent with mild malaria. However mothers also believed that cerebral malaria was a childhood convulsive disorder called degedege caused by evil spirits. According to discussants from urban, suburban, and

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance rural settings, effective treatments for degedege included urinating on affected children, or fuming them with elephant dung. Injections, on the other hand, were thought to have the power to kill some degedege sufferers. The role of grandmothers and mothers-in-law as key decision makers regarding cases of degedege was an important finding of the study, suggesting that these individuals be specifically targeted with information and teaching regarding severe malaria (Comoro et al., 2003). School-Based Education The education sector already knows the importance of health to schoolchildren as evidenced by the child-friendly schools of UNICEF (United Nations Children’s Fund), the health promoting schools of the World Health Organization (WHO), and the International School Health Initiative of the World Bank. Malaria is a disease particularly well suited to public health partnerships with teachers, principals, and designers of school curricula. Although malaria in areas of stable transmission is most common and severe in children who are not yet attending school, it still remains an important cause of mortality (10-20 percent of all cases) and morbidity in schoolchildren (Bundy et al., 2000). In addition, malaria can significantly influence educational outcomes, accounting for roughly three to eight percent of all reasons for absenteeism (Colbourne, 1955; Trape et al., 1987, 1993), 13 to 50 percent of school days missed per year due to preventable medical causes (Bundy et al., 2000), as well as residual neurologic sequelae impairing cognitive and developmental potential in one to five percent of children infected early in life (Snow et al., 1999). Children in rural African households assume significant responsibility at a young age—for example, looking after siblings, fetching water or firewood, and cooking (van der Geest and Geissler, 2003). They also participate in the collection and preparation of herbal medicines and are sent to buy pharmaceuticals (Sternberg et al., 2000; Prince and Geissler, 2001; Prince et al., 2001). Primary schoolchildren’s knowledge of medicines and self-treatment were investigated between 1996 and 1998 among the Luo of western Kenya and the Iteso of eastern Uganda. These studies showed that children of primary school age possess knowledge of both herbal remedies and “hospital” medicines and that they use medicines to treat themselves as well as their younger siblings. However, few children questioned knew the correct dosage of chloroquine for the treatment of malaria or the difference between antimalarials, antipyretics, and analgesics (Geissler et al., 2001). Children can be important agents for change for themselves and their families. Similarly, school health education can have a significant yield in terms of community-wide understanding of malaria control and treatment. It has been suggested that school-based teaching of medicine could start

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance from standard four (age 10 to 12), focusing on treatments for simple malaria, cough and cold, diarrhea, eye disorders, and pain (van der Geest and Geissler, 2003). Medicine use should be taught in a participatory manner didactically connected with children’s everyday experience—this, in turn, requires modification of educational curricula and teacher training. Recognition that the educational system could be used to target messages about antimalarials is now receiving broader acceptance (Bloland et al., 2003). Other Points of Contact Integrated management of childhood illness (IMCI) is an algorithm that assists health care workers with minimal training and little or no access to diagnostic aids to treat certain childhood illnesses based on clinical signs and symptoms alone (Perkins et al., 1997). Although IMCI protocols may result in considerable misdiagnosis, and unnecessary treatment of malaria, the program offers another point of contact for malaria education for patients, families, and providers. Intermittent preventive treatment (IPT) (reviewed in Chapter 8) is a WHO-endorsed strategy that aims to provide full treatment doses of antimalarial drugs to pregnant women at least once each during the second and third trimesters of pregnancy (WHO, 2002). IPTi is a new program for infants designed to reduce malaria-related morbidity and mortality by the use of periodic antimalarial treatment doses of antimalarial drugs during infancy. If IPT and IPTi become standard in large areas of sub-Saharan Africa, they also will expedite malaria education of stakeholders. Similarly, linking routine childhood immunization to IPTi has the potential to reduce the clinical effect of malaria (Schellenberg et al., 2001) while facilitating the education of stakeholders about malaria control and treatment. REFERENCES Agyepong IA, Manderson L. 1994. The diagnosis and management of fever at household level in the greater Accra region, Ghana. Acta Tropica 58(3-4):317-330. Ahorlu CK, Dunyo SK, Afari EA, Koram KA, Nkrumah FK. 1997. Malaria-related beliefs and behaviour in southern Ghana: Implications for treatment, prevention and control. Tropical Medicine and International Health 2(5):488-499. Ansah EK, Gyapong JO, Agyepong IA, Evans DB. 2001. Improving adherence to malaria treatment for children: The use of pre-packed chloroquine tablets vs. chloroquine syrup. Tropical Medicine and International Health 6(7):496-504. Asenso-Okyere WK, Osei-Akoto I, Anum A, Appiah EN. 1997. Willingness to pay for health insurance in a developing economy. A pilot study of the informal sector of Ghana using contingent valuation. Health Policy 42(3):223-237. Baume C, Helitzer D, Kachur SP. 2000. Patterns of care for childhood malaria in Zambia. Social Science and Medicine 51(10):1491-1503.

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