A framework for stakeholder engagement in the adoption of new anti-malarial treatments in Africa: a case study of Nigeria

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Abstract

Background

Recent reports of artemisinin partial resistance from Rwanda and Uganda are worrisome and suggest a future policy change to adopt new anti-malarials. This is a case study on the evolution, adoption, and implementation of new anti-malarial treatment policies in Nigeria. The main objective is to provide perspectives to enhance the future uptake of new anti-malarials, with an emphasis on stakeholder engagement strategies.

Methods

This case study is based on an analysis of policy documents and stakeholders’ perspectives drawn from an empirical study conducted in Nigeria, 2019–2020. A mixed methods approach was adopted, including historical accounts, review of programme and policy documents, and 33 qualitative in-depth interviews and 6 focus group discussions.

Results

Based on policy documents reviewed, the adoption of artemisinin-based combination therapy (ACT) in Nigeria was swift due to political will, funding and support from global developmental partners. However, the implementation of ACT was met with resistance from suppliers, distributors, prescribers, and end-users, attributed to market dynamics, costs and inadequate stakeholder engagement. Deployment of ACT in Nigeria witnessed increased developmental partner support, robust data generation, ACT case-management strengthening and evidence on anti-malarial use in severe malaria and antenatal care management. A framework for effective stakeholder engagement for the future adoption of new anti-malarial treatment strategies was proposed. The framework covers the pathway from generating evidence on drug efficacy, safety and uptake; to making treatment accessible and affordable to end-users. It addresses which stakeholders to engage with and the content of engagement strategies with key stakeholders at different levels of the transition process.

Conclusion

Early and staged engagement of stakeholders from global bodies to community level end-users is critical to the successful adoption and uptake of new anti-malarial treatment policies. A framework for these engagements was proposed as a contribution to enhancing the uptake of future anti-malarial strategies.

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Most cited references 46

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Evidence of Artemisinin-Resistant Malaria in Africa

Betty Balikagala, Naoyuki Fukuda, Mie Ikeda … (2021)

In the six Southeast Asian countries that make up the Greater Mekong Subregion, Plasmodium falciparum has developed resistance to derivatives of artemisinin, the main component of first-line treatments for malaria. Clinical resistance to artemisinin monotherapy in other global regions, including Africa, would be problematic.

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Association of Plasmodium falciparum kelch13 R561H genotypes with delayed parasite clearance in Rwanda: an open-label, single-arm, multicentre, therapeutic efficacy study

Aline Uwimana, Noella Umulisa, Meera Venkatesan … (2021)

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The challenges of changing national malaria drug policy to artemisinin-based combinations in Kenya

Abdinasir Amin, Dejan Zurovac, Beth B Kangwana … (2007)

Backgound Sulphadoxine/sulphalene-pyrimethamine (SP) was adopted in Kenya as first line therapeutic for uncomplicated malaria in 1998. By the second half of 2003, there was convincing evidence that SP was failing and had to be replaced. Despite several descriptive investigations of policy change and implementation when countries moved from chloroquine to SP, the different constraints of moving to artemisinin-based combination therapy (ACT) in Africa are less well documented. Methods A narrative description of the process of anti-malarial drug policy change, financing and implementation in Kenya is assembled from discussions with stakeholders, reports, newspaper articles, minutes of meetings and email correspondence between actors in the policy change process. The narrative has been structured to capture the timing of events, the difficulties and hurdles faced and the resolutions reached to the final implementation of a new treatment policy. Results Following a recognition that SP was failing there was a rapid technical appraisal of available data and replacement options resulting in a decision to adopt artemether-lumefantrine (AL) as the recommended first-line therapy in Kenya, announced in April 2004. Funding requirements were approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and over 60 million US$ were agreed in principle in July 2004 to procure AL and implement the policy change. AL arrived in Kenya in May 2006, distribution to health facilities began in July 2006 coincidental with cascade in-service training in the revised national guidelines. Both training and drug distribution were almost complete by the end of 2006. The article examines why it took over 32 months from announcing a drug policy change to completing early implementation. Reasons included: lack of clarity on sustainable financing of an expensive therapeutic for a common disease, a delay in release of funding, a lack of comparative efficacy data between AL and amodiaquine-based alternatives, a poor dialogue with pharmaceutical companies with a national interest in antimalarial drug supply versus the single sourcing of AL and complex drug ordering, tendering and procurement procedures. Conclusion Decisions to abandon failing monotherapy in favour of ACT for the treatment of malaria can be achieved relatively quickly. Future policy changes in Africa should be carefully prepared for a myriad of financial, political and legislative issues that might limit the rapid translation of drug policy change into action.

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Author and article information

Contributors

Oladimeji Akeem Bolarinwa: bolarinwa.oa@unilorin.edu.ng

Journal

Journal ID (nlm-ta): Malar J

Journal ID (iso-abbrev): Malar J

Title: Malaria Journal

Publisher: BioMed Central (London )

ISSN (Electronic): 1475-2875

Publication date (Electronic): 17 June 2023

Publication date PMC-release: 17 June 2023

Publication date Collection: 2023

Volume: 22

Electronic Location Identifier: 185

Affiliations

[1 ]GRID grid.412974.d, ISNI 0000 0001 0625 9425, Department of Paediatrics, , University of Ilorin, ; Ilorin, Nigeria

[2 ]GRID grid.412974.d, ISNI 0000 0001 0625 9425, Department of Epidemiology and Community Health, , University of Ilorin, ; Ilorin, Nigeria

[3 ]Messentia Medicare, River Park Estate, Abuja, Nigeria

[4 ]GRID grid.10223.32, ISNI 0000 0004 1937 0490, Mahidol Oxford Tropical Medicine Research Unit, , Mahidol University, ; Bangkok, Thailand

[5 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, , University of Oxford, ; Oxford, UK

[6 ]GRID grid.5477.1, ISNI 0000000120346234, Copernicus Institute of Sustainable Development, , Utrecht University, ; Utrecht, the Netherlands

[7 ]GRID grid.8652.9, ISNI 0000 0004 1937 1485, Department of Health Policy, Planning and Management, School of Public Health, , College of Health Sciences, University of Ghana, ; Accra, Ghana

[8 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, The Ethox Centre, Nuffield Department of Population Health, , University of Oxford, ; Oxford, UK

Article

Publisher ID: 4622

DOI: 10.1186/s12936-023-04622-2

PMC ID: 10276382

PubMed ID: 37330469

SO-VID: 01792fe6-544f-4995-b2ab-4cfb35be565c

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 16 December 2022

Date accepted : 14 June 2023

Funding

Funded by: UK aid and the UK Government’s Foreign, Commonwealth & Development Office

Funded by: FundRef http://dx.doi.org/10.13039/501100013372, Wellcome Trust Centre for Mitochondrial Research;

Award ID: 220211

Custom metadata

ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: artemisinin resistance,stakeholder engagement,artemisinin-based combination therapy,framework,antimalarial treatment policy

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ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: artemisinin resistance, stakeholder engagement, artemisinin-based combination therapy, framework, antimalarial treatment policy

A framework for stakeholder engagement in the adoption of new anti-malarial treatments in Africa: a case study of Nigeria

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Coronaviruses, COVID-19 and SARS-CoV-2

Most cited references 46

Evidence of Artemisinin-Resistant Malaria in Africa

Association of Plasmodium falciparum kelch13 R561H genotypes with delayed parasite clearance in Rwanda: an open-label, single-arm, multicentre, therapeutic efficacy study

The challenges of changing national malaria drug policy to artemisinin-based combinations in Kenya

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