Killing by Consensus: ACTs in Burkina Faso

Technical consensus plays a critical role in the achievement of global health objectives; for example, it is often hailed as the key driver of the TB community's success with DOTS by facilitiating financial and political support. The much more fragmented malaria world, by contrast, competes internally for money and attention across an array of treatment and prevention strategies rather than presenting a unified front, while epidemiologists can't even agree on the burden of disease. In that light, the recent convergence around artemisinin-based combination therapies (ACTs) as first-line treatment is on the whole a very welcome development. But that said, global consensus often cloaks a multitude of nuances and qualifications and the ACT case is no exception - particularly given the high costs and insufficient availability at the district level, as evidenced by a new PLoS Medicine study of malaria control in Burkina Faso.While Burkina Faso officially switched from chloroquine to ACTs (specifically, artemether-lumefantrine a.k.a. Coartem) for first-line malaria treatment in mid-2005, in reality the new medicines are still not accessible through the public sector two years later. In the town of Nouna, for example, ACTs are only available in private pharmacies at a price of $6.50 per course - no surprise, then, that of 122 fever episodes in preschoolers, not one was treated with ACTs. In this case, the poor translation from policy into practice has been blamed largely on insufficient funding, aggravated by the rejection of a Global Fund proposal seeking support for the purchase and introduction of the new products. As an interim solution, the authors advocate adopting a combination of sulfadoxine-pyrimethamine and amodiaquine. Unfortunately, a request by the National Malaria Control Program to use a portion of existing World Bank funds for this purpose was summarily rejected on the grounds that ACT is the only WHO-recommended protocol, even though AQ-SP had been proven equally effective in Burkina Faso (although this is not necessarily true elsewhere).So is this an example of "the best as the enemy of the good"? While ACTs are the ideal treatment in a broader global context, the benefits of a widespread technical consensus must also be balanced against an analysis of the specific country-level realities - particularly as new evidence demonstrates that not even all ACTs are created equal. In the case of Burkina Faso, it would seem that such a cost-benefit analysis would clearly favor the adoption of AQ-SP as first-line treatment, at least until there is a real alternative on the ground instead of just on paper. And as for the donors, this should be yet another lesson in the importance of putting their money where their mouth is.See also: Kenya's experience switching to ACTs