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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