Answering Key Questions on Malaria

"Effective health care interventions include technical, social, political and economic considerations."

This resource provides a lay person's summary of 25 research studies in 10 countries in Africa and Asia conducted from 2007-2015 by the ACT Consortium, an international research collaboration that is funded through a grant from the Bill & Melinda Gates Foundation to the London School of Hygiene & Tropical Medicine. It explains how this research collaboration fits into the wider malaria context and contributes to the goals of the World Health Organization (WHO) Global Technical Strategy (GTS) for Malaria 2016-2030 and the Roll Back Malaria Partnership's Action and Investment to Defeat Malaria (AIM) 2016-2030 - For a Malaria-Free World.

To help support these global goals, the ACT Consortium has been developing and evaluating delivery mechanisms in a series of 25 projects to improve artemesinin combination therapy (ACT) access, targeting, safety, and quality in Afghanistan, Cambodia, Cameroon, Ghana, Equatorial Guinea, Malawi, Nigeria, South Africa, Tanzania, and Uganda. Work involved multidisciplinary teams and included formative research, cluster randomised trials, cohort and descriptive studies, impact evaluations, and economic and anthropological assessments. Based on this work, the booklet explores the following questions:

• Where do patients with a fever seek care? In Uganda, for instance, they go to public health facilities, community health workers (CHWs), and private health care sectors. For example, a complex intervention improved (in small ways) malaria case management, communication between health workers and patients, and community perceptions of care offered at the intervention health centres. "To maximise the impact of investment in malaria control, we must influence not just local factors - we must also address broader systems and political issues". The question is: How can we improve the management of patients with fever in all health care sectors? While the evidence base continues to build, the ACT Consortium is part of a global conversation to answer the question: How can countries best scale up malaria RDTs in their private health care sectors? A case study in the resource (pages 14-17) provides highlights from the ACT Consortium's work to compare RDT implementation across 3 health care sectors. For example, a randomised study in Tanzania evaluated alternative approaches to RDT introduction and training with the goal of improving adherence to Tanzania's national guidelines for ACT use. Interventions ranged from basic training only for health workers, to more intensive messages and supervision for health workers, to sending additional educational messages to the community. One finding: Providing educational information for patients may improve health workers' use of RDTs and further encourage adherence to RDT results.
• What influences the uptake of rapid diagnostic tests (RDTs)? Making RDTs available does not ensure they will be used appropriately by health care providers or patients. Among the other considerations: health care provider (HCP) willingness to participate in the RDT intervention, the proportion of trained HCPs in a given setting, the relationship between HCPs and authorities, provider confidence in RDT supplies, HCP and patient familiarity with malaria testing, whether providers' workload is manageable, HCPs' priorities, and evaluation and data collection methods used.
• Do health providers prescribe according to RDT results? Not always, so malaria control programmes should identify the appropriate RDT training approach for various settings in their countries, taking into account providers' and patients' expectations of care. Authorities should also communicate with local communities about malaria diagnosis and treatment.
• What are the effects of RDTs on patients and the health care system? Effects include, for example, the fact that, compared to instances where a definitive diagnosis is unavailable, patients with a negative RDT are less likely to receive ACTs, which: reduces ACT wastage, encourages alternative diagnoses, and can increase patient referrals for further care.
• What else happens when RDTs are introduced? Consequences include, for instance: patients' treatment-seeking behaviour may change, and patient advocacy programmes need to reinforce the importance of patients receiving the correct diagnosis and subsequent treatment and thus enhance the acceptability of RDTs.
• How can we improve the management of patients with fever in all health care sectors? RDTs improve the targeting of ACTs, yet not all patients who had malaria received an ACT. RDTs can help to identify patients with non-malarial illnesses. However, where RDTs are used, health workers increase their prescription of antibiotics, which are not likely needed by most patients. So, further questions to emerge from ACT Consortium's research to date, such as: What is the overall impact on health (and health care systems) of introducing RDTs?
• If it's not malaria, what is it? The ACT Consortium and its partner institutions have developed an interactive, open-access map showing published data on causes of fever.
• How safe are ACTs in "real-world" use? ACT Consortium's data collection forms are available to anyone conducting drug safety assessments and surveillance. The forms have been developed for use by health workers with or without formal clinical training. The Consortium's drug safety database is also available for reference and use. For more information, click here.
• How safe are ACTs in vulnerable populations? The ACT Consortium conducted 4 studies, finding that repeated use of ACTs did not cause serious side effects and that the observed interactions between specific HIV and malaria medicines were not found to be clinically important.
• What is the quality of ACTs in the market? Responding to media reports suggesting that up to 1/3 of antimalarials available in malaria-endemic countries are fake, the ACT Consortium purchased and analysed the quality of over 10,000 ACT samples from 6 countries: Cambodia, Equatorial Guinea, Ghana, Nigeria, Rwanda, and Tanzania. Data from three independent laboratories showed that in these countries, falsified antimalarials are not as common as previously reported, but "[i]t is important to establish affordable systems that sample medicines in a representative way and analyse them regularly with reliable laboratory techniques."
• What did we learn from developing our projects? All public health interventions are complex, with multiple, interconnected components. The ACT Consortium encourages investigators and implementers to report the processes of designing interventions, as well as the way the intervention is finally delivered. "This promotes clear understanding of how to assess the internal validity of findings, and the potential for transferring an intervention to other contexts."

Links to further details on all of the studies cited in the resource are provided throughout.

Click here for the 24-page resource in PDF format (English).
Click here for the 24-page resource in PDF format (Portuguese).
Click here for the 24-page resource in PDF format (French).