Adopting ACTs for Malaria: Kenya's Experience

Artemisinin-based combination therapies (ACTs) for malaria are the textbook case of demand forecasting gone wrong, in part because of wildly optimistic assumptions about uptake in developing countries. While the recent CGD report A Risky Business: Saving Money and Improving Global Health through Better Demand Forecasts discusses the underlying incentives - and the resulting health and financial consequences - it does not not explain why it took so long for countries to switch to Coartem in the first place. Now, a new article in the Malaria Journal addresses this critical question head-on by providing a detailed look at Kenya's experience changing and implementing their national malaria drug policy, which highlights the need for more and better evidence to inform decision-making at every level and draws out key lessons for the future.I strongly recommend reading the paper in its entirety, as it makes far too many excellent points and historical facts to summarize here. But the big takeaway is that the poor availability and quality of data delayed a decision of which product to use in place of the former first-line drug treatment protocol, sulphadoxine/sulphalene-pyrimethamine, and that even after settling on artemether-lumefantrine (AL) - under the Coartem fixed dose brand - it took over two and half years before it was actually available to patients:

The factors that resulted in a paralysis from policy decision to policy implementation included: (1) concerns and government procurement difficulties with a single-sourced product; (2) timely access to external funds provided by the [Global Fund to Fight AIDS, Tuberculosis and Malaria]; (3) lack of agreement on whether there was a long-term, sustainable financing plan; and (4) competing local and international interests for alternatives to AL. The GFATM was in its nascent stages and experience needed to be built in putting up structures that would ensure its monies were spent in a transparent way. Nonetheless, alternative mechanisms of financing drug procurement require further attention and the issue of long-term financing remains unresolved.

The paper also addresses the opposition from local manufacturers, who were left holding huge stocks of the old products, and the legislative implications of allowing over-the-counter access in the future. Finally, the authors point towards the "complexities of harmonizing various national treatment guidelines, developing effective in-service training, ensuring adequate drug supply and educating the patient population" inherent in any change of national drug policies:

Each of these activities consume huge amounts of ministry staff time and demand inputs from many other partners [and] must be carefully managed to avoid health workers being confronted with new drugs without information on how to prescribe and dispense them, trained health workers without the resources to implement the new policy or a patient population told that old medicines don't work but who cannot access new medicines.

There are many more hurdles ahead, as Kenya seeks to sustain regular drug supplies and manage the new systems in place. While better demand forecasts will both contribute to and result from these ongoing efforts, there is much more that needs to be done, and like the authors, I hope that the government, donors and others will continue to support the uptake of ACTs - both in Kenya and elsewhere - as well as the credible operational research that should inform each of the steps along the way.