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Background The ongoing COVID-19 pandemic has placed an unprecedented health and economic burden on countries at all levels of socioeconomic development, emphasizing the need to evaluate the most effective vaccination strategy in multiple, diverse environments. The high reported efficacy, low cost, and long shelf-life of the ChAdOx1 nCoV-19 vaccine positions it well for evaluation in different settings. Methods Using data from the ongoing ChAdOx1 nCoV-19 clinical trials, an individual-based model was constructed to predict the 6-month population-level impact of vaccine deployment. A detailed probabilistic sensitivity analysis (PSA) was developed to evaluate the importance of epidemiological, demographic, immunological, and logistical factors in determining vaccine effectiveness. Using representative countries, logistical plans for vaccination rollout at various levels of vaccine availability and delivery speed, conditional on vaccine efficacy profiles (efficacy of the booster dose, time interval between doses, and relative efficacy of the first dose) were explored.Findings and Interpretation Our results highlight how expedient vaccine delivery to high-risk groups is critical in mitigating COVID-19 disease and mortality. In scenarios where the number of vaccine doses available is insufficient for high-risk groups (those aged more than 65 years) to receive two vaccine doses, administration of a single dose of vaccine is optimal. This effect is consistent even when vaccine efficacy after one dose is just 75% of the levels achieved after two doses. These findings offer a nuanced perspective of the critical drivers of COVID-19 vaccination effectiveness and can inform optimal allocation strategies. These are relevant to high-income countries with a large high-risk group population as well as to low-income countries with younger populations, where the cost and logistical challenges of procuring and delivering two doses for each citizen represent a significant challenge.

Dexamethasone has been shown to reduce mortality in hospitalised COVID-19 patients needing oxygen and ventilation by 18% and 36%, respectively. Here, we estimate the potential number of lives saved and life years gained if this treatment would be rolled out in the UK and globally, as well as its cost-effectiveness of implementing this intervention. We estimate that, for the UK, approximately 12,000 [4,250 - 27,000] lives could be saved by January 2021. Assuming that dexamethasone has a similar effect size in settings where access to oxygen therapies is limited, this would translate into approximately 650,000 [240,000 - 1,400,000] lives saved globally. If dexamethasone acts differently in these settings, the impact could be less than half of this value. To estimate the full potential of dexamethasone in the global fight against COVID-19, it is essential to perform clinical research in settings with limited access to oxygen and/or ventilators, e.g. in low and middle-income countries.

Background Ghana has made impressive progress against malaria, decreasing mortality and morbidity by over 50% between 2005 and 2015. These gains have been facilitated in part, due to increased financial commitment from government and donors. Total resources for malaria increased from less than USD 25 million in 2006 to over USD 100 million in 2011. However, the country still faces a high burden of disease and is at risk of declining external financing due to its strong economic growth and the consequential donor requirements for increased government contributions. The resulting financial gap will need to be met domestically. The purpose of this study was to provide economic evidence of the potential risks of withdrawing financing to shape an advocacy strategy for resource mobilization. Methods A compartmental transmission model was developed to estimate the impact of a range of malaria interventions on the transmission of Plasmodium falciparum malaria between 2018 and 2030. The model projected scenarios of common interventions that allowed the attainment of elimination and those that predicted transmission if interventions were withheld. The outputs of this model were used to generate costs and economic benefits of each option. Results Elimination was predicted using the package of interventions outlined in the national strategy, particularly increased net usage and improved case management. Malaria elimination in Ghana is predicted to cost USD 961 million between 2020 and 2029. Compared to the baseline, elimination is estimated to prevent 85.5 million cases, save 4468 lives, and avert USD 2.2 billion in health system expenditures. The economic gain was estimated at USD 32 billion in reduced health system expenditure, increased household prosperity and productivity gains. Through malaria elimination, Ghana can expect to see a 32-fold return on their investment. Reducing interventions, predicted an additional 38.2 clinical cases, 2500 deaths and additional economic losses of USD 14.1 billion. Conclusions Malaria elimination provides robust epidemiological and economic benefits, however, sustained financing is need to accelerate the gains in Ghana. Although government financing has increased in the past decade, the amount is less than 25% of the total malaria financing. The evidence generated by this study can be used to develop a robust domestic strategy to overcome the financial barriers to achieving malaria elimination in Ghana.

The world has made tremendous progress in the fight against malaria in the past 15 years. According to the World Malaria Report, malaria case incidence was reduced by 41 percent and malaria mortality rates were reduced by 62 percent between 2000 and 2015 (WHO 2016c). At the beginning of 2016, malaria was considered to be endemic in 91 countries and territories, down from 108 in 2000.Despite this progress, malaria continues to place a heavy toll on the world. In 2015, 212 million cases occurred globally, leading to 429,000 deaths, most of which occurred in children under age five years in Africa. These estimates are likely to be conservative, as adult deaths from malaria might well be underestimated in Africa and India (Adjuik and others 2006; Bawah and Binka 2007; Dhingra and others 2010; Gupta and Chowdhury 2014).More than 100 countries have eliminated malaria in the past century. Of the 106 countries with ongoing transmission in 2000, 57 reduced malaria incidence more than 75 percent by 2015, in line with the World Health Assembly target for 2015 of reducing the malaria burden by 75 percent. An additional 18 countries reduced incidence by more than 50 percent (WHO 2015e), also achieving target 6C of the Millennium Development Goals, which called for halting and beginning to reverse the global incidence of malaria by 2015.An increasing number of countries are moving toward the elimination of malaria. Since 2000, 12 countries have eliminated malaria; 4 were certified as malaria free by the World Health Organization (WHO) between 2007 and 2013 (Armenia, Morocco, Turkmenistan, and the United Arab Emirates); an additional 8 moved into the WHO’s prevention-of-reintroduction phase after sustaining at least three years of zero local malaria transmission (Argentina, the Arab Republic of Egypt, Iraq, Georgia, the Kyrgyz Republic, Oman, the Syrian Arab Republic, and Uzbekistan); and 5 interrupted local transmission (Azerbaijan, Costa Rica, Paraguay, Sri Lanka, and Turkey). The WHO European Region reported zero indigenous cases for the first time in 2015, in line with the goal of the Tashkent Declaration to eliminate malaria from the region by 2015.According to the WHO (2016a), an additional 21 countries are in a position to achieve at least one year of zero indigenous cases of malaria by 2020. These dramatic declines can be attributed to the scale-up of effective malaria control tools and technologies coupled with renewed political leadership and financial commitment.Bolstered by these successes, most national malaria programs now consider elimination to be an attainable goal, and the idea of eradication is once again on the global health agenda. Many countries have developed national elimination goals, and regional networks have been formed to facilitate collaboration (Newby and others 2016). Leaders from the Asia Pacific Leaders Malaria Alliance and the African Leaders Malaria Alliance endorsed regional goals for malaria elimination by 2030 in November 2014 and January 2015, respectively, galvanizing support for elimination and eradication (APLMA 2015; United Nations 2015).In this context, two new global malaria policy and advocacy documents supporting elimination and eradication were released in 2015: the Roll Back Malaria (RBM) Partnership’s Action and Investment to Defeat Malaria 2016–2030 and the WHO’s Global Technical Strategy for Malaria 2016–2030. The Global Technical Strategy (GTS), which the WHO ratified in May 2015, calls for at least another 40 percent reduction in malaria-related mortality and morbidity between 2015 and 2020. Other goals and targets are illustrated in table 12.1. A third document, launched in September 2015, From Aspiration to Action: What Will It Take to End Malaria?, outlines the resources and strategies needed for global eradication by 2040, calling by 2020 commit to eradication in the next five years (Gates and Chambers 2015).Despite these advances, malaria elimination and eradication face significant technical, operational, and financial challenges. About 3.2 billion people remain at risk of malaria; in 2015 alone, there were an estimated 214 million new cases of malaria and more than 400,000 malaria-related deaths. Global progress in malaria control and elimination is marked by vast disparities between and within countries, with vulnerable groups that have poor access to health services continuing to be marginalized. The Sub-Saharan Africa region shoulders the heaviest burden, with two countries—the Democratic Republic of Congo and Nigeria—accounting for more than 35 percent of global malaria deaths. In these areas, malaria control programs aim to maximize the reduction of malaria cases and deaths; elimination will likely require more potent tools and stronger health systems.A few countries that have successfully reduced malaria transmission are struggling to maintain their gains. An increased number of cases has recently been reported from a number of countries, including Cambodia, Djibouti, Madagascar, Uganda, and Republica Bolivariana de Venezuela (WHO 2015e). Furthermore, as the global malaria burden declines, emerging biological threats have the potential to critically weaken malaria responses in several parts of the world. In 2014, 60 countries reported resistance of mosquitoes to at least one insecticide used in vector control strategies; resistance of parasites to artemisinin, the cornerstone of malaria chemotherapy, has been detected in five countries in the Greater Mekong subregion, posing a serious threat to global health security.This chapter summarizes the literature on malaria elimination; describes the progress made; and discusses malaria epidemiology, interventions, and challenges. In addition, it presents empirical information on financing and economics, including cost information from various settings. It concludes with a discussion of the economic basis for eradication and recommendations for research.

Background Reactive case detection (RACD) is an active case finding strategy where households and neighbours of a passively identified case (index case) are screened to identify and treat additional malaria infections with the goal of gathering surveillance information and potentially reducing further transmission. Although it is widely considered a key strategy in low burden settings, little is known about the costs and the cost-effectiveness of different diagnostic methods used for RACD. The aims of this study were to measure the cost of conducting RACD and compare the cost-effectiveness of microscopy to the more sensitive diagnostic method loop-mediated isothermal amplification (LAMP). Methods The study was conducted in RACD surveillance sites in five sub-districts in Aceh Besar, Indonesia. The cost inputs and yield of implementing RACD with microscopy and/or LAMP were collected prospectively over a 20 months study period between May 2014 and December 2015. Costs and cost-effectiveness (USD) of the different strategies were examined. The main cost measures were cost per RACD event, per person screened, per population at risk (PAR); defined as total population in each sub-district, and per infection found. The main cost-effectiveness measure was incremental cost-effectiveness ratio (ICER), expressed as cost per malaria infection detected by LAMP versus microscopy. The effects of varying test positivity rate or diagnostic yield on cost per infection identified and ICER were also assessed. Results Among 1495 household members and neighbours screened in 36 RACD events, two infections were detected by microscopy and confirmed by LAMP, and four infections were missed by microscopy but detected by LAMP. The average total cost of conducting RACD using microscopy and LAMP was $1178 per event with LAMP-specific consumables and personnel being the main cost drivers. The average cost of screening one individual during RACD was $11, with an additional cost of diagnostics at $0.62 and $16 per person for microscopy and LAMP, respectively. As a public health intervention, RACD using both diagnostics cost an average of $0.42 per PAR per year. Comparing RACD using microscopy only versus RACD using LAMP only, the cost per infection found was $8930 and $6915, respectively. To add LAMP as an additional intervention accompanying RACD would cost $9 per individual screened annually in this setting. The ICER was estimated to be $5907 per additional malaria infection detected by LAMP versus microscopy. Cost per infection identified and ICER declined with increasing test positivity rate and increasing diagnostic yield. Conclusions This study provides the first estimates on the cost and cost-effectiveness of RACD from a low transmission setting. Costs per individual screened were high, though costs per PAR were low. Compared to microscopy, the use of LAMP in RACD was more costly but more cost-effective for the detection of infections, with diminishing returns observed when findings were extrapolated to scenarios with higher prevalence of infection using more sensitive diagnostics. As malaria programmes consider active case detection and the integration of more sensitive diagnostics, these findings may inform strategic and budgetary planning. Electronic supplementary material The online version of this article (10.1186/s12936-018-2361-y) contains supplementary material, which is available to authorized users.

Summary points Country programs and international donors are increasingly focused on regional approaches to malaria elimination; regional initiatives have been established in southern Africa, the Arabian Peninsula, Asia Pacific, Eastern Europe, and Latin America. Despite this growing attention, there is limited information and guidance on both key activities and organizational components of regional initiatives. In a review conducted for this policy forum, common characteristics across existing regional initiatives emerged: building a region-specific evidence base, leveraging expertise and resources, shifting commodities or pooling procurement, developing data-sharing systems, mobilizing resources, promoting high-level accountability, and strengthening advocacy. Regional initiatives share key structural elements: a strategic unit, technical forums, mechanisms to distribute financing, a high-level political body, and a regional champion or envoy. Monitoring and evaluating the impact of regional initiatives is weak, and reporting of funding is very limited. A suitable set of indicators to better evaluate the impact of regional initiatives is needed. Finally, the established aid architecture should adapt to improve proposal and grant management processes for regional initiatives in comparison to national and bilateral grants.

Background: The Asia-Pacific region has made significant progress in combatting malaria since 2000 and a regional goal for a malaria-free Asia Pacific by 2030 has been recognised at the highest levels. External financing has recently plateaued and with competing health risks, countries face the risk of withdrawal of funding as malaria is perceived as less of a threat. An investment case was developed to provide economic evidence to inform policy and increase sustainable financing. Methods: A dynamic epidemiological-economic model was developed to project rates of decline to elimination by 2030 and determine the costs for elimination in the Asia-Pacific region. The compartmental model was used to capture the dynamics of Plasmodium falciparum and Plasmodium vivax malaria for the 22 countries in the region in a metapopulation framework. This paper presents the model development and epidemiological results of the simulation exercise. Results: The model predicted that all 22 countries could achieve Plasmodium falciparum and Plasmodium vivax elimination by 2030, with the People’s Democratic Republic of China, Sri Lanka and the Republic of Korea predicted to do so without scaling up current interventions. Elimination was predicted to be possible in Bangladesh, Bhutan, Malaysia, Nepal, Philippines, Timor-Leste and Vietnam through an increase in long-lasting insecticidal nets (and/or indoor residual spraying) and health system strengthening, and in the Democratic People’s Republic of Korea, India and Thailand with the addition of innovations in drug therapy and vector control. Elimination was predicted to occur by 2030 in all other countries only through the addition of mass drug administration to scale-up and/or innovative activities. Conclusions: This study predicts that it is possible to have a malaria-free region by 2030. When computed into benefits and costs, the investment case can be used to advocate for sustained financing to realise the goal of malaria elimination in Asia-Pacific by 2030.

Over the past decade, the countries of the Asia-Pacific region have made significant progress towards the goal of malaria elimination by the year 2030. It is widely accepted that for the region to meet this goal, an intensification of efforts supported by sustained funding is required. However, robust estimates are needed for the optimal coverage and components of malaria elimination packages and the resources required to implement them. In this collection, a multispecies mathematical and economic modelling approach supported by the estimated burden of disease is used to make preliminary estimates for the cost of elimination and develop an evidence-based investment case for the region.

Leaders in the Asia-Pacific have endorsed an ambitious target to eliminate malaria in the region by 2030. The emergence and spread of artemisinin drug resistance in the Greater Mekong Subregion makes elimination urgent and strategic for the global goal of malaria eradication. Mathematical modelling is a useful tool for assessing and comparing different elimination strategies and scenarios to inform policymakers. Mathematical models are especially relevant in this context because of the wide heterogeneity of regional, country and local settings, which means that different strategies are needed to eliminate malaria. However, models and their predictions can be seen as highly technical, limiting their use for decision making. Simplified applications of models are needed to allow policy makers to benefit from these valuable tools. This paper describes a method for communicating complex model results with a user-friendly and intuitive framework. Using open-source technologies, we designed and developed an interactive application to disseminate the modelling results for malaria elimination. The design was iteratively improved while the application was being piloted and extensively tested by a diverse range of researchers and decision makers. This application allows several target audiences to explore, navigate and visualise complex datasets and models generated in the context of malaria elimination. It allows widespread access, use of and interpretation of models, generated at great effort and expense as well as enabling them to remain relevant for a longer period of time. It has long been acknowledged that scientific results need to be repackaged for larger audiences. We demonstrate that modellers can include applications as part of the dissemination strategy of their findings. We highlight that there is a need for additional research in order to provide guidelines and direction for designing and developing effective applications for disseminating models.

Background Declining donor funding and competing health priorities threaten the sustainability of malaria programmes. Elucidating the cost and benefits of continued investments in malaria could encourage sustained political and financial commitments. The evidence, although available, remains disparate. This paper reviews the existing literature on the economic and financial cost and return of malaria control, elimination and eradication. Methods A review of articles that were published on or before September 2014 on the cost and benefits of malaria control and elimination was performed. Studies were classified based on their scope and were analysed according to two major categories: cost of malaria control and elimination to a health system, and cost-benefit studies. Only studies involving more than two control or elimination interventions were included. Outcomes of interest were total programmatic cost, cost per capita, and benefit-cost ratios (BCRs). All costs were converted to 2013 US$ for standardization. Results Of the 6425 articles identified, 54 studies were included in this review. Twenty-two were focused on elimination or eradication while 32 focused on intensive control. Forty-eight per cent of studies included in this review were published on or after 2000. Overall, the annual per capita cost of malaria control to a health system ranged from $0.11 to $39.06 (median: $2.21) while that for malaria elimination ranged from $0.18 to $27 (median: $3.00). BCRs of investing in malaria control and elimination ranged from 2.4 to over 145. Conclusion Overall, investments needed for malaria control and elimination varied greatly amongst the various countries and contexts. In most cases, the cost of elimination was greater than the cost of control. At the same time, the benefits of investing in malaria greatly outweighed the costs. While the cost of elimination in most cases was greater than the cost of control, the benefits greatly outweighed the cost. Information from this review provides guidance to national malaria programmes on the cost and benefits of malaria elimination in the absence of data. Importantly, the review highlights the need for more robust economic analyses using standard inputs and methods to strengthen the evidence needed for sustained financing for malaria elimination. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1635-5) contains supplementary material, which is available to authorized users.

Summary In the past several years, as worldwide morbidity and mortality due to malaria have continued to decrease, the global malaria community has grown increasingly supportive of the idea of malaria eradication. In 2015, three noteworthy global documents were released—the WHO's Global Technical Strategy for Malaria 2016–2030, the Roll Back Malaria Partnership's Action and Investment to defeat Malaria 2016–2030, and From Aspiration to Action: What Will It Take to End Malaria?—that collectively advocate for malaria elimination and eradication and outline key operational, technical, and financial strategies to achieve progress toward malaria eradication. In light of this remarkable change in global attitudes toward malaria elimination and eradication, and as the malaria community debates how and when to embark on this ambitious goal, it is important to assess current progress along the path to eradication. Although low-income, high-burden countries are often the focus when discussing the substantial challenges of eradication, the progress toward elimination in middle-income, low-burden countries is a major driver of global progress and deserves better recognition. Additionally, although global support and guidance is essential for success, malaria elimination and eradication efforts will ultimately be driven at the country level and achieved in a collaborative manner, region by region. In this Review, we examine the present status of the 35 malaria-eliminating countries, summarise existing national and regional elimination goals and the regional frameworks that support them, and identify the most crucial enabling factors and potential barriers to achieving eradication by a theoretical end date of 2040.

Background The Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) has been the largest financial supporter of malaria since 2002. In 2011, the GFATM transitioned to a new funding model (NFM), which prioritizes grants to high burden, lower income countries. This shift raises concerns that some low endemic countries, dependent on GFATM financing to achieve their malaria elimination goals, would receive less funding under the NFM. This study aims to understand the projected increase or decrease in national and regional funding from the GFATM’s NFM to the 34 malaria-eliminating countries. Methods Average annual disbursements under the old funding model were compared to average annual national allocations for all eligible 34 malaria-eliminating countries for the period of 2014–2017. Regional grant funding to countries that are due to receive additional support was then included in the comparison and analysed. Estimated funding ranges for the countries under the NFM were calculated using the proposed national allocation plus the possible adjustments and additional funding. Finally, the minimum and maximum funding estimates were compared to average annual disbursements under the old funding model. Results A cumulative 31 % decrease in national financing from the GFATM is expected for the countries included in this analysis. Regional grants augment funding for almost half of the eliminating countries, and increase the cumulative percent change in GTFAM funding to 32 %, though proposed activities may not be funded directly through national malaria programmes. However, if countries receive the maximum possible funding, 46 % of the countries included in this analysis would receive less than they received under the previous funding model. Conclusions Many malaria-eliminating countries have projected national declines in funding from the GFATM under the NFM. While regional grants enhance funding for eliminating countries, they may not be able to fill country-level funding gaps for local commodities and implementation. If the GFATM is able to nuance its allocation methodology to mitigate drastic funding declines for malaria investments in low transmission countries, the GFATM can ensure previous investments are not lost. By aligning with WHO’s Global Technical Strategy for Malaria and investing in both high- and low-endemic countries, the Global Fund can tip the scale on a global health threat and contribute toward the goal of eventual malaria eradication.

Background Studies have shown that supply chain costs are a significant proportion of total programme costs. Nevertheless, the costs of delivering specific products are poorly understood and ballpark estimates are often used to inadequately plan for the budgetary implications of supply chain expenses. The purpose of this research was to estimate the country level costs of the public sector supply chain for artemisinin-based combination therapy (ACT) and rapid diagnostic tests (RDTs) from the central to the peripheral levels in Benin and Kenya. Methods A micro-costing approach was used and primary data on the various cost components of the supply chain was collected at the central, intermediate, and facility levels between September and November 2013. Information sources included central warehouse databases, health facility records, transport schedules, and expenditure reports. Data from document reviews and semi-structured interviews were used to identify cost inputs and estimate actual costs. Sampling was purposive to isolate key variables of interest. Survey guides were developed and administered electronically. Data were extracted into Microsoft Excel®, and the supply chain cost per unit of ACT and RDT distributed by function and level of system was calculated. Results In Benin, supply chain costs added USD 0.2011 to the initial acquisition cost of ACT and USD 0.3375 to RDTs (normalized to USD 1). In Kenya, they added USD 0.2443 to the acquisition cost of ACT and USD 0.1895 to RDTs (normalized to USD 1). Total supply chain costs accounted for more than 30% of the initial acquisition cost of the products in some cases and these costs were highly sensitive to product volumes. The major cost drivers were found to be labour, transport, and utilities with health facilities carrying the majority of the cost per unit of product. Conclusions Accurate cost estimates are needed to ensure adequate resources are available for supply chain activities. Product volumes should be considered when costing supply chain functions rather than dollar value. Further work is needed to develop extrapolative costing models that can be applied at country level without extensive micro-costing exercises. This will allow other countries to generate more accurate estimates in the future. Electronic supplementary material The online version of this article (doi:10.1186/s12936-014-0530-1) contains supplementary material, which is available to authorized users.

Must balance bold aspiration with technical feasibility In the year 2000, 193 countries adopted the millennium development goals (MDGs), a milestone in global development. The eight goals were simple to grasp, measurable, and time bound, ending in 2015. Goals 4, 5, and 6 focused on reducing child, maternal, and infectious disease mortality, respectively, raising health to the top of the global agenda and mobilising new health financing.1 Although the three health related goals are unlikely to be met, there has been substantial progress towards their achievement, particularly for infectious diseases.2 As the MDGs come to an end, a new set of sustainable development goals (SDGs) will be debated during the UN General Assembly that starts on 24 September 2014. These goals will have a 2030 end date. They could catalyse further transformations in global health. An intergovernmental open working group is writing the new goals and has just published its first draft.3 Whereas the MDGs were “‘top-down goals’ formulated by policy elites,”4 the working group deserves credit for drafting the new goals using a bottom-up approach, based on wide ranging consultations. There is much to like in the draft: …

The global demand for artemisinin-based combination therapy (ACT) has grown sharply since its recommendation by the World Health Organization in 2002. However, a combination of financing and programmatic uncertainties, limited suppliers of finished products, information opacity across the different tiers in the supply chain, and widespread fluctuations in raw material prices have together contributed to a market fraught with demand and supply uncertainties and price volatility. Various short-term solutions have been deployed to alleviate supply shortages caused by these challenges; however, new mechanisms are required to build resilience into the supply chain. This review concludes that a mix of strategies is required to stabilize the artemisinin and ACT market. First, better and more effective pooling of demand and supply risks and better contracting to allow risk sharing among the stakeholders are needed. Physical and financial buffer stocks will enable better matching of demand and supply in the short and medium term. Secondly, physical buffers will allow stable supplies when there are procurement and supply management challenges while financial buffer funds will address issues around funding disruptions. Finally, in the medium to long term, significant investments in country level system strengthening will be required to minimize national level demand uncertainties. In addition a voluntary standard for extractors to ensure appropriate purchasing and sales practices as well as minimum quality and ethical standards could help stabilize the artemisinin market in the long term.

Background Globally, the monitoring of prompt and effective treatment for malaria with artemisinin combination therapy (ACT) is conducted largely through household surveys. This measure; however, provides no information on case management processes at the health facility level. The aim of this review was to assess evidence from health facility surveys on malaria prescribing practices using ACT, in the presence and absence of ACT stock, at time and place where treatment was sought. Methods A systematic search of published literature was conducted. Findings were collated and data extracted on proportion of patients prescribed ACT and alternative anti-malarials in the presence and absence of ACT stock. Results Of the 14 studies identified in which ACT prescription for uncomplicated malaria in the public sector was evaluated, just six, from three countries (Kenya, Uganda and Zambia), reported this in the context of ACT stock. Comparing facilities with ACT stock to facilities without stock (i) ACT prescribing was significantly higher in all six studies, increasing by a range of 21.3% in children < 5 yrs weighing ≥ 5 kg (p < 0.001; Kenya 2006) to 51.7% in children ≥ 10 kg (p < 0.001; Zambia 2006); (ii) SP prescribing decreased significantly in five studies, by a range of 14.4% (p < 0.001; Kenya 2006), to 46.3% (p < 0.001; Zambia 2006); (iii) Where quinine was a reported alternative, prescriptions decreased in five of the six studies by 0.1% (p = 1.0, Kenya 2010) to 10.2% (p < 0.001; Zambia 2006). At facilities with no ACT stock on the survey day, the proportion of febrile patients prescribed ACT was < 10% in five of the nine target groups included in the six studies, with the proportion prescribed ACT ranging from 0 to 28.4% (Uganda 2007). Conclusions Prescriber practices vary based on ACT availability. Although ACT prescriptions increased and alternative anti-malarials prescriptions decreased in the presence of ACT stock, ACT was prescribed in the absence, and alternative anti-malarials were prescribed in the presence of, ACT. Presence of stock alone does not ensure that treatment guidelines are followed. More health facility surveys, together with qualitative research, are needed to understand the role of ACT stock-outs on provider prescribing behaviours and preferences.

Background Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment. In Kenya, the Division of Malaria Control is committed to ensuring that 80 percent of childhood fevers are treated with effective anti-malarial medicines within 24 hours of fever onset, but this target is largely unmet. This review aimed to document evidence on access to effective malaria treatment in Kenya, identify factors that influence access, and make recommendations on how to improve prompt access to effective malaria treatment. Since treatment-seeking patterns for malaria are similar in many settings in sub-Saharan Africa, the findings presented in this review have important lessons for other malaria endemic countries. Methods Internet searches were conducted in PUBMED (MEDLINE) and HINARI databases using specific search terms and strategies. Grey literature was obtained by soliciting reports from individual researchers working in the treatment-seeking field, from websites of major organizations involved in malaria control and from international reports. Results The review indicated that malaria treatment-seeking occurs mostly in the informal sector; that most fevers are treated, but treatment is often ineffective. Irrational drug use was identified as a problem in most studies, but determinants of this behaviour were not documented. Availability of non-recommended medicines over-the-counter and the presence of substandard anti-malarials in the market are well documented. Demand side determinants of access include perception of illness causes, severity and timing of treatment, perceptions of treatment efficacy, simplicity of regimens and ability to pay. Supply side determinants include distance to health facilities, availability of medicines, prescribing and dispensing practices and quality of medicines. Policy level factors are around the complexity and unclear messages regarding drug policy changes. Conclusion Kenya, like many other African countries, is still far from achieving the Abuja targets. The government, with support from donors, should invest adequately in mechanisms that promote access to effective treatment. Such approaches should focus on factors influencing multiple dimensions of access and will require the cooperation of all stakeholders working in malaria control.

Widespread resistance of Plasmodium falciparum parasites to commonly used antimalarials, such as chloroquine, has resulted in many endemic countries considering changing their malaria treatment policy. Identifying and understanding the key influences that affect decision-making, and factors that facilitate or undermine policy implementation, is critical for improving the policy process and guiding resource allocation during this process. A historical review of archival documents from Mala ˆ wi and data obtained from in-depth policy studies in four countries (Tanzania, South Africa, Kenya and Peru) that have changed malaria treatment policy provides important lessons about decision-making, the policy cycle and complex policy environment, while specifically identifying strategies successfully employed to facilitate policy-making and implementation. Findings from these country-level studies indicate that the process of malaria drug policy review should be institutionalized in endemic countries and based on systematically collected data. Key stakeholders need to be identified early and engaged in the process, while improved communication is needed on all levels. Although malaria drug policy change is often perceived to be a daunting task, using these and other proven strategies should assist endemic countries to tackle this challenge in a systematic fashion that ensures the development and implementation of the rational malaria drug policy.

This paper describes the introduction of the Malarone Donation Programme in KENYA: Using a policy analysis approach it illustrates the political nature of donation programmes and how they are affected by a large and varied group of national, regional and international stakeholders, with different levels of influence and experience. The paper shows that interaction between these different groups may affect the development and implementation of the donation programme. It ends by raising some more general questions about public/private partnerships and corporate donation programmes, and their potential impact on national drug policies.