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Ruwanpura V, Neukom J, Grietens KP, Price RN, Thriemer K, Lynch CA. Opening the policy blackbox: unravelling the process for changing national diagnostic and treatment guidelines for vivax malaria in seven countries. Malar J 2021; 20:428. [PMID: 34717642 PMCID: PMC8556862 DOI: 10.1186/s12936-021-03959-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/18/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The changing global health landscape has highlighted the need for more proactive, efficient and transparent health policy-making. After more than 60 years of limited development, novel tools for vivax malaria are finally available, but need to be integrated into national policies. This paper maps the malaria policy-making processes in seven endemic countries, to identify areas where it can be improved to align with best practices and optimal efficiency. METHODS Data were collected during a workshop, convened by the Asia Pacific Malaria Elimination Network's Vivax Working Group in 2019, and subsequent interviews with key stakeholders from Cambodia, Ethiopia, Indonesia, Pakistan, Papua New Guinea (PNG), Sri Lanka and Vietnam. Documentation of policy processes provided by respondents was reviewed. Data analysis was guided by an analytic framework focused on three a priori defined domains: "context," "actors" and "processes". RESULTS The context of policy-making varied with available funding for malaria, population size, socio-economic status, and governance systems. There was limited documentation of the process itself or terms of reference for involved actors. In all countries, the NMP plays a critical role in initiating and informing policy change, but the involvement of other actors varied considerably. Available evidence was described as a key influencer of policy change; however, the importance of local evidence and the World Health Organization's endorsement of new treatments and diagnostics varied. The policy process itself and its complexity varied but was mostly semi-siloed from other disease specific policy processes in the wider Ministry of Health. Time taken to change and introduce a new policy guideline previously varied from 3 months to 3 years. CONCLUSIONS In the medium to long term, a better alignment of anti-malarial policy-making processes with the overall health policy-making would strengthen health governance. In the immediate term, shortening the timelines for policy change will be pivotal to meet proposed malaria elimination milestones.
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Affiliation(s)
- Varunika Ruwanpura
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia
| | | | - Koen Peeters Grietens
- Institute of Tropical Medicine, Antwerp, Belgium
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia.
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Mwendera CA, de Jager C, Longwe H, Hongoro C, Mutero CM, Phiri KS. Malaria research in Malawi from 1984 to 2016: a literature review and bibliometric analysis. Malar J 2017; 16:246. [PMID: 28606149 PMCID: PMC5469173 DOI: 10.1186/s12936-017-1895-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/06/2017] [Indexed: 11/25/2022] Open
Abstract
Background Malaria research can play a vital role in addressing the malaria burden in Malawi. An organized approach in addressing malaria in Malawi started in 1984 by the establishment of the first National Malaria Control Programme and research was recognized to be significant. This study aimed to assess the type and amount of malaria research conducted in Malawi from 1984 to 2016 and its related source of funding. Methods A systematic literature search was conducted in the Medline/PubMed database for Malawian publications and approved malaria studies from two Ethical Committees were examined. Bibliometric analysis was utilized to capture the affiliations of first and senior/last authors, funding acknowledgements, while titles, abstracts and accessed full text were examined for research type. Results A total of 483 publications and 165 approved studies were analysed. Clinical and basic research in the fields of malaria in pregnancy 105 (21.5%), severe malaria 97 (20.1%) and vector and/or agent dynamics 69 (14.3%) dominated in the publications while morbidity 33 (20%), severe malaria 28 (17%) and Health Policy and Systems Research 24 (14.5%) dominated in the approved studies. In the publications, 146 (30%) first authors and 100 (21%) senior authors, and 88 (53.3%) principal investigators in approved studies were affiliated to Malawian-based institutions. Most researchers were affiliated to the Malawi-Liverpool Wellcome Trust, College of Medicine, Blantyre Malaria Project, Ministry of Health, and Malaria Alert Centre. The major malaria research funders were the National Institute for Health/USA, Wellcome Trust and the US Agency for International Development. Only three (2.5%) out of 118 journals publishing research on malaria in Malawi were from Africa and the Malaria Journal, with 76 (15.7%) publications, published most of the research from Malawi, followed by the American Journal of Tropical Medicine and Hygiene with 57 (11.8%) in comparison to only 13 (2.7%) published in the local Malawi Medical Journal. Conclusions Clinical and basic research, which is mostly funded externally, in the fields of malaria in pregnancy, severe malaria and vector and/or agent dynamics dominated, while health policy and system research was least supported. The quantity may reflect scientific research activity but the initial primary impact is contribution to policy development.
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Affiliation(s)
- Chikondi A Mwendera
- University of Pretoria Institute for Sustainable Malaria Control (UP ISMC), School of Health Systems and Public Health, University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa
| | - Christiaan de Jager
- University of Pretoria Institute for Sustainable Malaria Control (UP ISMC), School of Health Systems and Public Health, University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.
| | - Herbert Longwe
- ICAP at Columbia University, Mailman School of Public Health, Pretoria, South Africa
| | - Charles Hongoro
- University of Pretoria Institute for Sustainable Malaria Control (UP ISMC), School of Health Systems and Public Health, University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,Population Health, Health Systems and Innovation, Human Sciences Research Council (HSRC), Pretoria, South Africa
| | - Clifford M Mutero
- University of Pretoria Institute for Sustainable Malaria Control (UP ISMC), School of Health Systems and Public Health, University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,International Centre of Insect Physiology and Ecology (ICIPE), P.O. Box 30772, Nairobi, Kenya
| | - Kamija S Phiri
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Mwendera CA, de Jager C, Longwe H, Phiri K, Hongoro C, Mutero CM. Changing the policy for intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy in Malawi. Malar J 2017; 16:84. [PMID: 28219435 PMCID: PMC5319082 DOI: 10.1186/s12936-017-1736-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 02/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background The growing resistance of Plasmodium falciparum to sulfadoxine–pyrimethamine (SP) treatment for uncomplicated malaria led to a recommendation by the World Health Organization for the use of artemisinin-based combination therapy. Inevitably, concerns were also raised surrounding the use of SP for intermittent prevention treatment of malaria during pregnancy (IPTp) amidst the lack of alternative drugs. Malawi was the first country to adopt intermittent prevention treatment with SP in 1993, and updated in 2013. This case study examines the policy updating process and the contribution of research and key stakeholders to this process. The findings support the development of a malaria research-to-policy framework in Malawi. Methods Documents and evidence published from 1993 to 2012 were systematically reviewed in addition to key informant interviews. Results The online search identified 170 potential publications, of which eight from Malawi met the inclusion criteria. Two published studies from Malawi were instrumental in the WHO policy recommendation which in turn led to the updating of national policies. The updated policy indicates that more than two SP doses, as informed by research, overcome the challenges of the first policy of two SP doses only because of ineffectiveness by P. falciparum resistance and the global lack of replacement drugs to SP for IPTp. Conclusion International WHO recommendations facilitated a smooth policy change driven by motivated local leadership with technical and financial support from development partners. Policy development and implementation should include key stakeholders and use local malaria research in a research-to-policy framework.
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Affiliation(s)
- Chikondi A Mwendera
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa
| | - Christiaan de Jager
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.
| | - Herbert Longwe
- Mailman School of Public Health, ICAP at Columbia University, Pretoria, South Africa
| | - Kamija Phiri
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Charles Hongoro
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,Population Health, Health Systems and Innovation, Human Sciences Research Council (HSRC), Pretoria, South Africa
| | - Clifford M Mutero
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,International Centre of Insect Physiology and Ecology (ICIPE), P.O. Box 30772, Nairobi, Kenya
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Mwendera C, de Jager C, Longwe H, Phiri K, Hongoro C, Mutero CM. Malaria research and its influence on anti-malarial drug policy in Malawi: a case study. Health Res Policy Syst 2016; 14:41. [PMID: 27246503 PMCID: PMC4888534 DOI: 10.1186/s12961-016-0108-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 04/28/2016] [Indexed: 11/30/2022] Open
Abstract
Background In 1993, Malawi changed its first-line anti-malarial treatment for uncomplicated malaria from chloroquine to sulfadoxine-pyrimethamine (SP), and in 2007, it changed from SP to lumefantrine-artemether. The change in 1993 raised concerns about whether it had occurred timely and whether it had potentially led to early development of Plasmodium falciparum resistance to SP. This case study examined evidence from Malawi in order to assess if the policy changes were justifiable and supported by evidence. Methods A systematic review of documents and published evidence between 1984 and 1993, when chloroquine was the first-line drug, and 1994 and 2007, when SP was the first-line drug, was conducted herein. The review was accompanied with key informant interviews. Results A total of 1287 publications related to malaria drug policy changes in sub-Saharan Africa were identified. Using the inclusion criteria, four articles from 1984 to 1993 and eight articles from 1994 to 2007 were reviewed. Between 1984 and 1993, three studies reported on chloroquine poor efficacy prompting policy change according to WHO’s recommendation. From 1994 to 2007, four studies conducted in the early years of policy change reported a high SP efficacy of above 80%, retaining it as a first-line drug. Unpublished sentinel site studies between 2005 and 2007 showed a reduced efficacy of SP, influencing policy change to lumefantrine-artemether. The views of key informants indicate that the switch from chloroquine to SP was justified based on local evidence despite unavailability of WHO’s policy recommendations, while the switch to lumefantrine-artemether was uncomplicated as the country was following the recommendations from WHO. Conclusion Ample evidence from Malawi influenced and justified the policy changes. Therefore, locally generated evidence is vital for decision making during policy change.
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Affiliation(s)
- Chikondi Mwendera
- University of Pretoria Centre for Sustainable Malaria Control (UP CSMC), School of Health Systems and Public Health (SHSPH), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa
| | - Christiaan de Jager
- University of Pretoria Centre for Sustainable Malaria Control (UP CSMC), School of Health Systems and Public Health (SHSPH), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.
| | - Herbert Longwe
- Department of Basic Medical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kamija Phiri
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Charles Hongoro
- University of Pretoria Centre for Sustainable Malaria Control (UP CSMC), School of Health Systems and Public Health (SHSPH), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,Population Health, Health Systems and Innovation, Human Sciences Research Council (HSRC), Pretoria, South Africa
| | - Clifford M Mutero
- University of Pretoria Centre for Sustainable Malaria Control (UP CSMC), School of Health Systems and Public Health (SHSPH), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,International Centre of Insect Physiology and Ecology, Nairobi, Kenya
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Martins JS, Zwi AB, Hobday K, Bonaparte F, Kelly PM. Changing the malaria treatment protocol policy in Timor-Leste: an examination of context, process, and actors' involvement. Health Res Policy Syst 2013; 11:16. [PMID: 23672371 PMCID: PMC3665480 DOI: 10.1186/1478-4505-11-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 04/30/2013] [Indexed: 11/10/2022] Open
Abstract
In 2007 Timor-Leste, a malaria endemic country, changed its Malaria Treatment Protocol for uncomplicated falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. The change in treatment policy was based on the rise in morbidity due to malaria and perception of increasing drug resistance. Despite a lack of nationally available evidence on drug resistance, the Ministry of Health decided to change the protocol. The policy process leading to this change was examined through a qualitative study on how the country developed its revised treatment protocol for malaria. This process involved many actors and was led by the Timor-Leste Ministry of Health and the WHO country office. This paper examines the challenges and opportunities identified during this period of treatment protocol change.
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Affiliation(s)
- João S Martins
- GlobalHealth@UNSW and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- Faculdade de Medicina e Ciências da Saúde, Universidade Nacional Timor Lorosae, Avenida Cidade de Lisboa, Dili, Timor-Leste
| | - Anthony B Zwi
- GlobalHealth@UNSW and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- Health, Rights and Development (HEARD@UNSW), School of Social Sciences, University of New South Wales, Sydney, Australia
- Faculdade de Medicina e Ciências da Saúde, Universidade Nacional Timor Lorosae, Avenida Cidade de Lisboa, Dili, Timor-Leste
| | - Karen Hobday
- Health, Rights and Development (HEARD@UNSW), School of Social Sciences, University of New South Wales, Sydney, Australia
| | | | - Paul M Kelly
- GlobalHealth@UNSW and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
- National Centre for Epidemiology & Population Health, College of Medicine, Biology & Environment, Australian National University, Canberra, Australia
- Population Health Division, ACT Government Health Directorate, Canberra, Australia
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Breton E, De Leeuw E. Theories of the policy process in health promotion research: a review. Health Promot Int 2010; 26:82-90. [DOI: 10.1093/heapro/daq051] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Williams HA, Vincent-Mark A, Herrera Y, Chang OJ. A retrospective analysis of the change in anti-malarial treatment policy: Peru. Malar J 2009; 8:85. [PMID: 19400953 PMCID: PMC2684118 DOI: 10.1186/1475-2875-8-85] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 04/28/2009] [Indexed: 11/12/2022] Open
Abstract
Background National malaria control programmes must deal with the complex process of changing national malaria treatment guidelines, often without guidance on the process of change. Selecting a replacement drug is only one issue in this process. There is a paucity of literature describing successful malaria treatment policy changes to help guide control programs through this process. Objectives To understand the wider context in which national malaria treatment guidelines were formulated in a specific country (Peru). Methods Using qualitative methods (individual and focus group interviews, stakeholder analysis and a review of documents), a retrospective analysis of the process of change in Peru's anti-malarial treatment policy from the early 1990's to 2003 was completed. Results The decision to change Peru's policies resulted from increasing levels of anti-malarial drug resistance, as well as complaints from providers that the drugs were no longer working. The context of the change occurred in a time in which Peru was changing national governments, which created extreme challenges in moving the change process forward. Peru utilized a number of key strategies successfully to ensure that policy change would occur. This included a) having the process directed by a group who shared a common interest in malaria and who had long-established social and professional networks among themselves, b) engaging in collaborative teamwork among nationals and between nationals and international collaborators, c) respect for and inclusion of district-level staff in all phases of the process, d) reliance on high levels of technical and scientific knowledge, e) use of standardized protocols to collect data, and f) transparency. Conclusion Although not perfectly or fully implemented by 2003, the change in malaria treatment policy in Peru occurred very quickly, as compared to other countries. They identified a problem, collected the data necessary to justify the change, utilized political will to their favor, approved the policy, and moved to improve malaria control in their country. As such, they offer an excellent example for other countries as they contemplate or embark on policy changes.
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Affiliation(s)
- Holly Ann Williams
- Malaria Branch, Centers for Disease Control and Prevention (CDC), Mail Stop F-60, 4770 Buford Hwy NE, Atlanta, Georgia 30341, USA.
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Williams HAHA, Jones COH. A critical review of behavioral issues related to malaria control in sub-Saharan Africa:. Soc Sci Med 2004; 59:501-23. [PMID: 15144761 DOI: 10.1016/j.socscimed.2003.11.010] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 1996, Social Science & Medicine published a review of treatment seeking for malaria (McCombie, 1996). Since that time, a significant amount of socio-behavioral research on the home management of malaria has been undertaken. In addition, recent initiatives such as Roll Back Malaria have emphasized the importance of social science inputs to malaria research and control. However, there has been a growing feeling that the potential contributions that social science could and should be making to malaria research and control have yet to be fully realized. To address these issues, this paper critically reviews and synthesizes the literature (published, unpublished and technical reports) pertaining to the home management of illness episodes of malaria in sub-Saharan Africa from 1996 to the end of 2000, and draws conclusions about the use of social science in malaria research and control. The results suggest that while we have amassed increasing quantities of descriptive data on treatment seeking behavior, we still have little understanding of the rationale of drug use from the patient perspective and, perhaps more importantly, barely any information on the rationale of provider behaviors. However, the results underline the dynamic and iterative nature of treatment seeking with multiple sources of care frequently being employed during a single illness episode; and highlight the importance in decision making of gender, socio-economic and cultural position of individuals within households and communities. Furthermore, the impact of political, structural and environmental factors on treatment seeking behaviors is starting to be recognised. Programs to address these issues may be beyond single sector (malaria control programme) interventions, but social science practice in malaria control needs to reflect a realistic appraisal of the complexities that govern human behavior and include critical appraisal and proposals for practical action. Major concerns arising from the review were the lack of evidence of 'social scientist' involvement (particularly few from endemic countries) in much of the published research; and concerns with methodological rigor. To increase the effective use of social science, we should focus on a new orientation for field research (including increased methodological rigor), address the gaps in research knowledge, strengthen the relationship between research, policy and practice; and concentrate on capacity strengthening and advocacy.
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Affiliation(s)
- H A Holly Ann Williams
- Malaria Epidemiology Branch, Centers for Disease Control and Prevention, Mail Stop F-22, 4770 Buford Hwy NE, Atlanta, GA 30345, USA.
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