Improving Access to Treatment and Use of Drugs: The changes in the therapeutic regimens in the countries prompted RAVREDA-AMI to promote lines of work related to improving the availability of antimalarials and their use by prescribers and patients. Pharmaceutical management quickly emerged as one of the most important lines of work.
:: AMI - RAVREDA. Documento estratégico para la gestión del suministro y garantía de la calidad de los medicamentos e insumos para el diagnóstico y tratamiento de la malaria, 2011 (In Spanish)
The rapid changes in therapeutic regimens led to a focus on how to implement them which in turn revealed serious deficiencies in the procurement, distribution, quality, and use of antimalarials in the control programs. the RPM Plus (Rational Pharmaceutical Management) Program of the MSH (Management Science in Health) foundation, in partnership with PAHO, supported the Malaria Control Programs at the Amazon countries on assessing and strengthening the countries' pharmaceutical management systems in order to improve the availability and use of antimalarials in the region. During 2004–2006, RAVREDA also supported activities to study patients adherence to antimalarial treatments and promoted improvements in prescription an dispensation practices.
The approach developed in this component with AMI support can be broken down into four phases that overlap at some points, since the eight countries are moving forward at different speeds, see the figure below. In an initial sensitization stage, malaria programs were encouraged to review matters related to drug access and use and to put the topic on Ministry of Health agendas:
In this first phase, two international meetings were held with the participation of the CDC, PAHO, and the RPM Plus Program of Management Sciences for Health (MSH).
Identifying problems related to access to and use of antimalarials constitutes a second phase of the process. This phase began in 2004 with some preliminary studies on adherence and case management practices and further materialized in 2005 and 2006 with the implementation of a methodology developed by the RPM Plus Program/MSH to evaluate the access to and use of antimalarials. The adherence studies were important for raising interest within the control programs in this issue. They found problems of misuse of antimalarials linked to poorly prepared prescriptions. Studies with other quantitative and qualitative approaches complemented this situational diagnosis in some countries. Also as part of this situational-diagnosis phase, the use of guidelines for implementing the ACTs and a checklist of the different components of the drug management cycle were promoted.
The third phase has consisted of promoting the adoption of measures to improve access and use. Included in this phase are activities geared to strengthen the forecasting of pharmaceutical needs and the design and adoption of strategies to achieve good patient adherence to the new regimens for the treatment of uncomplicated P. falciparum malaria and the treatment of P. vivax malaria (measures such as the use of prepackaged drugs and written instructions).
Monitoring is the fourth and final phase of the process. The purpose of this phase is to encourage the adoption of systematic monitoring of drug management and compliance with prescription and dispensing procedures in health care. The proposal includes a simplified tool to make health-care network supervision more efficient (ficha_resistencia.pdf form, in Spanish), an instrument to record inventories, and measures to make the most of the malaria. information system as a management monitoring tool.
Methodology: Click on corresponding section in document.
Results (For data tables, click on corresponding section in document.)
Drug use and access studies: Between 2005 and 2006, with technical support from MSH/RPM Plus, malaria control programs in Suriname, Colombia, Bolivia and Ecuador conducted studies of availability and use of antimalarials using the methodology and corresponding tools in the PMM Manual. A pilot test was done in Venezuela. This section highlights the most notable results from those studies. Tables 1 and 2 summarize the findings.
Adherence Studies: The problem of adherence was first addressed within the AMI framework in 2004 through evaluations carried out in Bolivia, Colombia, Ecuador, and Venezuela. These early studies were important for raising interest within the control programs in this issue. They found problems of misuse of antimalarials linked to poorly prepared prescriptions (Table 3). After the meeting in Caracas, where new recommendations were made for adherence studies, between 2005 and 2006 Bolivia, Brazil, Colombia, and Ecuador made progress in carrying out new adherence evaluations. Although not all the new studies on recommendations for controlling prescription practices incorporated the new classifications, the results were nevertheless highly relevant (Table 4).
List of Measures Taken: Click on corresponding section in document.
Documentation and Links
PMM: Pharmaceutical Management for Malaria Manual (Rational Pharmaceutical Management Plus Program)
United States Pharmacopeia (USP)
Implementation Guide for a Pilot Test to Apply a Standardized Instrument for Supervising Antimalarial Drugs and Supplies (in Spanish)
Workshop on the Use of Tools to Evaluate the Management of Antimalarial Drugs (Bogotá, 19–22 July 2005) (in Spanish)
Guide for Antimalarial Adherence Studies (in Spanish)
Form from the Bolivian Ministry of Health on supervising malaria diagnostic and treatment facilities (in Spanish)