Adherence – last step but not the least

The process that ensures people in malaria endemic countries get appropriate and timely life saving treatment starts far away from the individual sufferers. Researchers determine safe and efficacious medicines, international agencies issue guidance, national governments develop treatment policies, guidelines and standards, pharmaceutical companies scale up production, funds to purchase drugs are mobilized, orders for medicines are placed and shipped … and after all these steps treatment has still not reached those in need.

Once the medicines are in the country (either produced there or imported) the supply/distribution chain continues through both public and private warehouses and medical stores. In the public sector the debate over who delivers or collects the medicines start – do states, regions, and districts collect from the national stores or are the medical stores responsible for shipping supplies out to the regions and districts. The debate begins again at the district level when individual facilities contemplate how to get their own supplies.

dscn0254a.JPGAssuming the appropriate medicines reach the shelves of the frontline clinic or medicine shop, the next step is for clients to obtain these for themselves and their children.  Eligibilty questions come up – are free medicines only for children or everyone.  Finally the medicines reach the home.  Success of malaria control ultimately rests on the last step, taking the full, correct dose of the medicines.  So what do we know about adherence to malaria drug regimes?

In Senegal Souares and colleagues looked at adherence to a regimen of SP-amodiaquine, in use then, as a proxy for adherence to ACTs at the point when this would be introduced, since both had a 3-day regimen. They found that, “35.3% of children did not comply with the recommended doses and 62.3% did not exactly adhere to the drug schedule. Despite the good efficacy of the drugs, adherence to the therapeutic scheme was poor.” Even though efficacy was good, they foresaw a time when poor adherence could lead to drug resistance and recommended training of health workers to improve patient-provider communication about adherence.

We cannot wait for haphazard adherence to lead to ACT failure. ACT performance standards are needed and should be part of the roll out of any government or donor funded malaria treatment program.  Importantly, training on these standards must reach the private and informal sector, too.

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