Malaria-treatment policies: when and how should they be changed?

There appears to be a large a gap in the literature between primary work on malaria control and policy on the one hand and the interpretation of such work in making real policy decisions on the other. The focus of the present review is policy formulation for treatment of uncomplicated falciparum malaria, rather than prophylaxis in travellers or the treatment of severe disease. The World Health Organization has formulated guidelines addressing the issue of changing from one recommended drug for treating malaria to another, but there does not appear to have been a comprehensive attempt to describe how and when such a decision on drug policy should be made. Issues of drug availability, both to countries and to communities within them, are discussed, as well as the acceptability of drug regimens and compliance with them. It emerges that the cost of treatment has a disproportionate influence on the decision-making process, and that the indirect costs of drug failure are often not considered properly. Brief mention is made of the indicators of overall disease burden. There is some discussion about the usefulness of one recently introduced economic indicator: the disability-adjusted life-year (DALY). Also examined are the difficulties that arise within the context of drug-policy changes, such as a regimen's appropriateness to all target groups, and the strong influence of the private sector on decision-making that affects its own financing. The consensus seems to be that a policy change is urgent when high-level resistance occurs in 40% or more of treated cases, when parasitological response is poor, and when the costs of treatment failures are higher than those of treatments with a newer drug. It also emerges that much remains to be done regarding co-operation between public and private sectors; considering the importance of private-sector provision of health care, this needs to be addressed.