Category Archives: Policy

Policy reform and aid must go together

Last month the philanthropic community – government, international, corporate, donor, non-governmental and media partners – met in New York to promote “health among the world’s poorest populations.” Global Health Progress explained that this event was held to “discuss ways to strengthen partnerships toward achieving the Millennium Development Goals (MDGs), especially in areas where progress has been slow and stronger multi-stakeholder participation would be beneficial.”

With the billions of dollars now available annually for health/development aid from multinational, bilateral and philanthropic sources, this group appears to have something to celebrate. But is aid and money the main answer? Paul Collier explains that this is only half of the story:

Poverty in the developing world will decline by about one-half by 2015 if the trends of the 1990s persist. Most of this poverty reduction will occur in Asia, however, while poverty will decline only slightly in Africa. Effective aid could make a contribution to greater poverty reduction in lagging regions. Even more potent would be significant policy reform in these countries. We develop a model of efficient aid in which flows respond to policy improvements that create a better environment for poverty reduction and effective aid. We investigate scenarios of policy reform and efficient aid that point the way to how the world can cut poverty in half in every major region.

In a New York Times review of Paul Collier’s new book, WARS, GUNS, AND VOTES, Kenneth Roth highlights the following:

Collier’s primary conclusion: democracy, in the superficial, election-focused form that tends to prevail in these (pseudo-democracies), “has increased political violence instead of reducing it.” Without rules, traditions, and checks and balances to protect minorities, distribute resources fairly and subject officials to the law, these governments lack the accountability and legitimacy to discourage rebellion. The quest for power becomes a “life-and-death struggle” in which “the contestants are driven to extremes.” Collier’s data show that before an election, warring parties may channel their antagonisms into politics, but that violence tends to flare up once the voting is over. What’s more, when elections are won by threats, bribery, fraud and bloodshed, such so-called democracies tend to promote bad governance, since the policies needed to retain power are quite different from those needed to serve the common good.

The common good of course includes effective and equitable programs against AIDS, malaria, TB and the neglected diseases. In violent environments that often lead to displacement of populations these diseases thrive.

Until the structures of government are geared to the common good and not to helping powerful parties retain power, we may never see the end of malaria and other devastating diseases.  International donors and philanthropists need to ask themselves what they are doing to promote good governance along with their financial aid.

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Readers may have noticed that we have not been using many photos in our recent entries.  We could add previously uploaded photos to new stories, but not upload new photos.  This problem relates to storage space and hopefully will be resolved soon.

Health research and research for health: the Mali example

bamako2.JPGDuring the first day of the 2008 Global Ministerial Forum on Research for Health in Bamako we were told that while not every country needs a national airline, all need indigenous health research capacity. How else could the unique ecological, cultural and administrative context for providing appropriate health services be discerned? The objectives for the forum follow:

  • Strengthening leadership for health, development and equity
  • Engage all relevant constituencies in research and innovation for health
  • Increase accountability of research systems

While the forum is featuring improtant processes such as capacity building research ethics, civil society involvement, operations research application, among others, specific health issues like malaria are a subtext running throughout.  Mali itself has been developing strong malaria research capacity, and not surprisingly Ogobara Doumbo, the Director of the Malaria Research and Training Center (MRTC), University of Bamako, is a member of the program committee.

This month in The Lancet Stephen Pincock presents a short biography of Ogobara Doumbo, which starts with a childhood commitment to health care from someone clearly rooted in his culture and thus, able to ground his future health research in his country’s needs.

“One day towards in the late 1960s, a doctor came to visit a small village in eastern Mali where the young Ogobara Doumbo and his family lived. He asked the 10-year-old what he wanted to be when he grew up. “I said, ‘I am planning to be a doctor like you’”, Doumbo recalls. “He was very surprised for a small child to be so convinced he wanted to be a doctor.” Considering Doumbo’s father and grandfather were both traditional healers, perhaps his response was not really so surprising. From that year, Doumbo began travelling with his grandfather to other mountain villages, absorbing his strongly ethical approach to treating ailments ranging from infectious diseases to breast inflammation. “I spent enough time to see his practice and follow him carefully.”

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According to US National Institutes for Health, which is one of the supporter the MRTC, “The MRTC is viewed by many as a model for research centers in developing countries, as its research is planned, directed, and executed by African scientists.” Thus the MRTC can certainly hold pride of place equal to if not greater than a national airline. A small sample of findings from recent MRTC publications include –

  • Artesunate-mefloquine is well-tolerated and is as effective as artemether-lumefantrine for the treatment of P. falciparum malaria. Artesunate-mefloquine also prevented more new infections (AMJMH).
  • Maps provide valuable information for selective vector control in Mali (insecticide resistance management) and may serve as a decision support tool for the basis for future malaria control strategies including genetically manipulated mosquitoes (Malaria Journal).
  • The magnitude of antibody response against Plasmodium falciparum may not be as important as it is believed to be. Instead, the fine specificity or function of the response might be more critical in protection against malaria disease (Acta Tropika)
  • Given the delay in the time to first malaria episode associated with HbAS, it would be advisable for clinical trials and observational studies that use this end point to include Hb typing in the design of studies conducted in areas where HbAS is prevalent. (J Infect Dis)
  • Altogether, these results suggest that indoor mating is an alternative mating strategy of the M molecular form of An. gambiae. Because naturally occurring mating couples have not yet been observed indoors, this conclusion awaits validation. (J Med Entomol)

Keep track of the Bamako Forum via TropIKA.net and learn more about health systems research, the challenges of eHealth and other health research issues that will affect the future of malaria research.

Artemisinin – supply & demand

The Clinton Foundation is tackling a challenge that faces the world market for artemisinin-based combination therapy (ACT) medicines – the supply, demand and ultimately the price of the basic ingredient. The move by malaria control partners to get countries to switch to ACTS and save lives amid the failing efficacy of chloroquine and sulfadozine-pyrimethamine was relative swift and did not account for the normal market forces involved in introducing new pharmaceutical products, especially when these are provided free or at cost to the end user.

tdr9300523.jpgIn addressing Kenya’s rapid policy change to ACTs, Zurovac and colleagues concluded that, “Changes in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa.” They also said that policy makers 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.”

According to news reports, “In 2002, Clinton established an HIV/AIDS initiative that sought to negotiate lower prices for anti-retroviral treatments, and he since has expanded his focus to include malaria treatments such as artemisinin-based combination therapies, or ACTs. One of the factors making the price of artemisinin so volatile – fluctuating from $155 to $1,100 per kilogram in recent years – has been a wildly erratic cycle of shortage and excess of the extract.”

Earlier this year, one of the major producers of ACTs, Novartis, announced, “a 20% average reduction in the price of Coartem® tablets (artemether/lumefantrine 20 mg/120 mg), the state-of-the-art artemisinin-based combination treatment (ACT) for malaria. Starting this Friday, which is World Malaria Day, this price reduction will increase access to Coartem for millions of malaria patients, especially children in low income regions of Africa.”

Of course Novartis, like other producers must not only rely on supplies of this natural product which is subject to the normal risks of agricultural production, but also to the fact that countries who need ACTs do not always order their supplies in a timely and coordinated manner. This is despite the fact that Novartis has had an edge on other ACT manufacturers by being the first WHO prequalified drug, guaranteeing its priority purchase through Global Fund grants.

The AP story goes on to explain that, “Clinton said he has negotiated with six suppliers involved in producing ACTs that have agreed to certain price ceilings that the foundation says will help keep prices constant and not so dependent on the fluctuating cycles.The agreements are with two suppliers at three levels of the supply chain — raw material, processing and final formulation — and the foundation hopes to add more suppliers.”

Previously we have addressed the potential for synthetic artemisinin production as well as the need for continued research into new and alternative malaria drugs. Stabilizing the price of the raw product will certainly have short term benefits. The long term requires increasing the scope of our malaria treatment arsenal.

G8 Documents Health Commitments

On July 8th the G8 issued a series of documents and declarations on issues under discussion, particularly a declaration on energy security and climate change, which some have seen as progress and others as a hollow acceptance of the status quo. The document on ‘Development and Africa‘ addresses a long series of policy and financial commitments of these rich nations over several summits. The health section of that document is produced below in full, and builds on the summit’s health experts’ report, the Toyako Framework for Action on Global Health, and a progress report on G8 support for Africa. One can think about the difference between a ‘declaration’ and a ‘document.’

Health

45. As a result of its growing political and financial commitment to fight infectious diseases, the G8 has raised international awareness on global health issues and contributed to remarkable improvements on health in partner countries, notably access to HIV/AIDS prevention, treatment and care; stabilization of tuberculosis incidence; increased coverage of innovative tools such as insecticide-treated nets against malaria; impressive falls in measles deaths; and considerable progress on polio which is closer to eradication than ever before. Investment through the Global Fund to Fight AIDS, Tuberculosis and Malaria together with national efforts, bilateral and other multilateral programs has enabled recipient countries to save more than 2.5 million lives to date. The Second Voluntary Replenishment Conference held in Berlin in 2007 raised US$ 9.7 billion for expanded activities during the period 2008-2010. But many challenges remain toward reaching the health-related MDGs. G8 members are determined to honor in full their specific commitments to fight infectious diseases, namely malaria, tuberculosis, polio and working towards the goal of universal access to HIV/AIDS prevention, treatment and care by 2010. In this regard, we welcome the report submitted by our health experts along with its attached matrices, showing G8 implementation of past commitments to ensure accountability. Building on the Saint Petersburg commitments to fight infectious diseases, the experts’ report sets forth the ‘Toyako Framework for Action’, which includes the principles for action, and actions to be taken on health, drawing on the expertise of international institutions. We also agreed to establish a follow-up mechanism to monitor our progress on meeting our commitments.

46. In view of sustainability we aim at ensuring that disease-specific and health systems approaches are mutually reinforcing and contribute to achieving all of the health MDGs, and will focus on the following:

(a)We emphasize the importance of comprehensive approaches to address the strengthening of health systems including social health protection, the improvement of maternal, newborn and child health, the scaling-up of programs to counter infectious diseases and access to essential medicines, vaccines and appropriate health-related products. We reiterate our support to our African partners’ commitment to ensure that by 2015 all children have access to basic health care (free wherever countries choose to provide this). We underline the need for partner countries to work toward sustainable and equitable financing of health systems. We also welcome the efforts of the Providing for Health Initiative as well as the International Health Partnership and the Catalytic Initiative. We reiterate our commitment to continue efforts, to work towards the goals of providing at least a projected US$ 60billion over 5 years, to fight infectious diseases and strengthen health. Some countries will provide additional resources for health systems including water.

(b)Reliable health systems require a reliable health workforce. To achieve quantitative and qualitative improvement of the health workforce, we must work to help train a sufficient number of health workers, including community health workers and to assure an enabling environment for their effective retention in developing countries. In this regard, we encourage the World Health Organization (WHO) work on a voluntary code of practice regarding ethical recruitment of health workers. The G8 members will work towards increasing health workforce coverage towards the WHO threshold of 2.3 health workers per 1000 people, initially in partnership with the African countries where we are currently engaged and that are experiencing a critical shortage of health workers. We will also support efforts by partner countries and relevant stakeholders, such as Global Health Workforce Alliance, in developing robust health workforce plans and establishing specific, country-led milestones as well as for enhanced monitoring and evaluation, especially for formulating effective health policies. In this context, we take note of the Kampala Declaration and Agenda for Global Action adopted in March 2008 at the First Global Forum on Human Resources for Health.

(c)We note that in some developing countries, achieving the MDGs on child mortality and maternal health is seriously off-track, and therefore, in country-led plans, the continuum of prevention and care, including nutrition should include a greater focus on maternal, new born and child health. Reproductive health should be made widely accessible. The G8 will take concrete steps to work toward improving the link between HIV/AIDS activities and sexual and reproductive health and voluntary family planning programs, to improve access to health care, including preventing mother-to-child transmission, and to achieve the MDGs by adopting a multisectoral approach and by fostering community involvement and participation.

(d)As part of fulfilling our past commitments on malaria, we will continue to expand access to long-lasting insecticide treated nets, with a view to providing 100 million nets through bilateral and multilateral assistance, in partnership with other stakeholders by the end of 2010.

(e)To maintain momentum towards the historical achievement of eradicating polio, we will meet our previous commitments to maintain or increase financial contributions to support the Global Polio Eradication Initiative, and encourage other public and private donors to do the same.

(f)To build on our commitments made on neglected tropical diseases at St Petersburg, we will work to support the control or elimination of diseases listed by the WHO through such measures as research, diagnostics and treatment, prevention, awareness-raising and enhancing access to safe water and sanitation. In this regard, by expanding health system coverage, alleviating poverty and social exclusion as well as promoting adequate integrated public health approaches, including through the mass administration of drugs, we will be able to reach at least 75% of the people affected by certain major neglected tropical diseases in the most affected countries in Africa, Asia, and Latin America, bearing in mind the WHO Plan. With sustained action for 3-5 years, this would enable a very significant reduction of the current burden with the elimination of some of these diseases.

(g)We support ongoing work to review travel restrictions for HIV positive people with a view to facilitating travel and we are committed to follow this issue.

Can African Union Muster Political Commitment against Malaria?

The recent African Union Summit in Egypt came to a close with Civil Society and Non-Governmental Organizations questioning whether the organization had the strength and will to tackle the really serious issues facing the continent. The Inter Press Service of Johannesburg reported that, “some civil society groups felt that the AU Summit lacked the critical analysis and genuine commitment to action needed to bring forth positive interventions in conflicts such as that in Zimbabwe or on other critical issues in Africa.” In addition, “Members of the NGO community criticised the summit for not devoting enough time to pressing issues such as the ongoing food and health crisis in Africa.”

News coverage of the Summit, especially in the North, was dominated by Zimbabwe’s plight, and doubts that the African Leaders could do much of substance to this thorn in their side. The New York Times, for example, editorialized that, “The signals from Monday’s opening session of the African Union summit, with Mr. Mugabe smugly in attendance, were not encouraging.”

The theme of this Summit was “Meeting the Millennium Development Goals (MDGs) on Water and Sanitation.” A report on the Status of Malaria in Africa was also scheduled. The report issued two years ago at AU’s AIDS, TB and Malaria special Summit noted progress in policy and planning, but deficiencies in monitoring and evaluation. Concern was expressed for greater coordination on treatment/drug policies among countries. Slow implementation of IPTp was noted. The report also highlighted difficulties in achieving ITN/LLIN coverage and its proper measurement.

au-malaria-elim.jpgThen last year the AU launched the Africa Malaria Elimination Campaign. The AU communique stated that, “Stakeholders at all levels were called upon to scale up efforts and supplement each other’s role. The AU Commission should ensure that Malaria Elimination for eventual Eradication is kept high on the agenda of the AU, RECs and international organisations.” With this developing history, we are more than curious to know the next steps against malaria outlined at the 11th AU Summit.

There are many reasons for concern about the effectiveness of international and regional bodies like the African Union. One would hope that such a body could foster healthy competition among members to work toward eliminating malaria. Also as the theme of this year’s World Malaria Day makes clear, malaria is a disease without borders, and regional cooperation is needed. If all leaders at such assemblies can do is find ways to avoid embarrassing each other, there is not much hope that they can successfully tackle a disease like malaria.

Malaria on the Campaign Trail

Many candidates for the 2008 US Presidential Election have mentioned an interest in continuing disease control commitments made by the US government to date. Last week more specific numbers were given to these proposals by Hillary Clinton. On 29 October the Roll Back Malaria Partnership reported that “U.S. Presidential candidate Hillary Clinton today pledged to expand the U.S. government commitment to malaria to US$1 billion a year if elected, setting the goal of ending malaria-related deaths in Africa by the end of her second term. The campaign said this funding would be in addition to U.S. government support of malaria control through the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which finances the majority of malaria control efforts around the world.”

This pledge can also be considered in light of recent discussions to eradicate malaria, which certainly will be an extremely costly endeavor. An RBM meeting participant did just this -“It’s encouraging to see a leading U.S. presidential candidate step out with such a bold commitment on malaria,” said Rajat Gupta, Chairman of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. “We have the opportunity to eliminate malaria as a global health concern but we’ll need continued American leadership to do it.”

The candidate is said to have pledged for$50 billion for HIV/AIDS. The proposed $1 billion dollars over five years for malaria is not much different that the current requests/projections for the President’s Malaria Initiative, which covers only 15 countries. So $1 billion for malaria seems paltry, especially in light of the candidate’s own words that, “To end AIDS, we need to end malaria in Africa. Malaria is overwhelming the health infrastructures in the developing world, accounting for 40 percent of health spending in many countries – money we need to fight AIDS.”

At any rate, the candidate’s commitment to tackle malaria is sincere as evidenced by her comments that, “Malaria is a challenge to our conscience in its own right. It is appalling that more than a million people die every year from a bug bite. And nearly all of them are children. A child in Africa dies from malaria every 30 seconds. We made a decision to eradicate malaria in North America and in Europe. And we can do the same in Africa and Asia. So I’ll set a goal of ending all deaths from malaria in Africa by the end of my second term. We can do this if we are committed together.”

There seems to be little doubt that the next President of the United States will be under moral obligation to continue funding the international partnership against malaria. The US public has certainly joined in with many NGOs raising money to buy ITNs. In this regard the public may be out in front of most candidates who should all catch up before the primaries and caucuses start.

Kenya’s Comprehensive ACT Approach

kisumu-district-clinics.JPGFront line clinics in Kenya, such as the one pictured here, carry four different dosage packs of Coartem to cover all age groups. In addition, coartem is given for free to all patients, and people over five years of age are generally tested before this artesunate-based combination therapy (ACT) drug is prescribed. This comprehensive approach means that there is no discrimination in providing care.

In other countries free ACTs that have been provided through donor support are intended only for children less than five years of age. ACTs for the remainder of the population have not been bought by health authorities based on concerns for cost. Sometimes then, the free ACTs from donor programs have been used inappropriately for older patients. Kenya appears to be avoiding this problem.

kmoh-act-sm.jpgThe lesson is even larger than that of the need for drug forecasting and adequate procurement. The Kenyan Ministry of Health recognizes that ACT has a preventive effect as reported by Sutherland and colleagues whose “results suggest that co-artemether has specific activity against immature sequestered gametocytes, and has the capacity to minimize transmission of drug-resistant parasites,” though this can be modest in some settings. If only a portion of the population is treated, this benefit of reducing transmission is missed.

Another benefit is economic. The Kenyan Ministry of Health also recognizes that if a parent is sick with malaria and misses work, the whole family will be affected. Just as WHO is calling for free nets for all, there also needs to be free ACTs for all who are infected with malaria. To do this we need continued donor and country support as well as a wider range of WHO pre-qualified ACTs to create competition and bring ACT prices down.

Kenya Addresses Equity in Net Distribution

Thursday the 16th of August 2007 marked a dual launching of two related malaria documents in Nairobi. WHO released its new guidance on insecticide-treated bed nets, and the Ministry of Health (MOH) in Kenya shared its impact report on malaria control interventions. Both stressed the importance of mass distribution of free Long Lasting Insecticidal Nets to achieve coverage of vulnerable populations. WHO explained that Kenyan evidence on net distribution modalities and improvements in malaria morbidity and mortality reinforced the need eventually to cover the entire population in endemic areas to achieve maximum health and economic benefits.

The Washington Post reported that the WHO guidance may put to rest the argument between proponents of free nets and those who believe that, “people who spend their own money on them are more likely to value them and use them properly.” Both documents indicated that equity in reaching the poorest portion of the population was best achieved by providing free nets, but that highly subsidized nets through clinic voucher programs and social marketing may play some role in improving access to LLINs in the poorer segment of society.

improving-equity-in-net-use-coverage-in-kenya.jpgData from the Kenya document seen in the attached picture show that over the past three years the gap between the higher and lower income quintiles of the population has been narrowing. This is an indication of how malaria control can contribute the goal of reducing health inequalities enshrined in Kenya’s National Health Sector Strategic Plan for 2005-10.

WHO also commended Kenya for implementing its national malaria strategy through a broad based international partnerships including DfID, UNICEF, USAID, GFATM, WHO and the Wellcome Trust among others. As the Times reported, donor funding helped make it possible for Kenya to give free nets.

The Kenyan MOH reported that the donor partnership has made one-quarter of a million US dollars available for malaria control since 2002. This amount should be viewed in the light of estimated budgetary needs of US $105 million for the current year alone. The fight against malaria in Kenya requires not only continued donor support, but also greater Kenyan government contributions and wise management of donor support to achieve the greatest health and equity impacts.

Politicizing Global Health

The Washington Post reported today that a key official in the US President’s Administration has been blocking the publication of the Surgeon General’s 2006 “Call to Action on Global Health,” a draft of which is available on the link provided. Specifically the Post noted that, “A surgeon general’s report in 2006 that called on Americans to help tackle global health problems has been kept from the public by a Bush political appointee without any background or expertise in medicine or public health, chiefly because the report did not promote the administration’s policy accomplishments, according to current and former public health officials.”

Reading through the report one does not find specific mention of the President’s Malaria Initiative (PMI) but does cite the President’s Emergency Plan for AIDS Relief. The report does highlight various global efforts such as the Global Fund to Fight AIDS, TB and Malaria, of which the U.S. is a major supporter/donor, the Roll Back Malaria Partnership, and the United Nations Millennium Development Goals. Concerning the MDGs, the draft report states, “Beyond reducing the disease burden, a successful fight against malaria will have far-reaching impact on child morbidity and mortality, maternal health, and poverty, which in turn could increase global stability.”

The draft report emphasizes that, “Malaria treatment, control and prevention should be an integral function of an effective health system, supported by strong community involvement. Sustained success in malaria reduction calls for development of the health sector; improved case management, the use of intermittent presumptive treatment programs for pregnant women, insecticide-treated bed nets, and spraying of households with insecticide.” This recognition of a comprehensive approach to malaria control programming by the United States certainly needs to be shared widely with other donors and endemic country policy makers.

The draft report also touches on an issue that has been politically sensitive to the Administration, global warming. The report explains the link between malaria and global warming as follows: “The distribution of insects and other organisms that serve as hosts to the microorganisms that cause infectious diseases is likely to be affected. This could lead to changes in disease patterns. For example, malaria might appear in areas where it is currently unknown because of the spread of the mosquito that carries the disease.” In another politically sensitive move the report acknowledges malaria research and technical efforts by the French, the Japanese and the Multilateral Initiative for Malaria.

Although the current Bush Administration may have brought attention to malaria to a new level through PMI, the U.S. has been a leader and a champion of malaria control and prevention for decades through the US Centers for Disease Control and Prevention, the National Institutes of Health, and USAID, to name a few. Some sense of balance is needed. One certainly does not want to see a document that is only a self-congratulatory piece, but one would also expect to see adequate recognition of all contributors and stakeholders who promote global health. The report does deserve to have wide circulation to stimulate greater discussion of and commitment to solving global health challenges by US Citizens and their elected representatives.

IPTp Still Valuable

Intermittent preventive treatment (or therapy) in pregnancy (IPTp) with the drug sulfadoxine-pryimethamine (SP) is a key strategy for controlling morbidity and mortality associated with malaria in both pregnant women and newborns. IPTp when given at least twice, one month apart after quickening, reduces maternal anemia, placental malaria, and low birth weight. IPTp with SP has many characteristics of a good public health intervention in that is is relatively low cost, is easy to deliver, and is generally acceptable and available. The longer half-life of SP gives it comparative advantage over alternatives.

basics_mip_ipt_sm.jpgRecently questions have arisen about the value of SP as IPT when there are increasing reports of drug resistance when tested and used in children under five years of age. Of note is a lack of study of resistance in pregnant women themselves, which always poses an ethics problem for researchers. WHO African Region issued a statement in 2005 on the efficacy of SP even under conditions of drug resistance in children under 5 and recommended continued use of SP even where resistance levels in children were up to 50%.

To support this position ter Kuile et al. concluded in the June 20th 2007 issue of JAMA that, “In areas in which 1 of 4 treatments with sulfadoxine-pyrimethamine fail in children by day 14, the 2-dose IPT with sulfadoxine-pyrimethamine regimen continues to provide substantial benefit to HIV-negative semi-immune pregnant women. However, more frequent dosing is required in HIV-positive women not using cotrimoxazole prophylaxis for opportunistic infections.” O’Meara et al. further contend that IPTp is unlikely to significantly impact the spread of SP resistant parasites.

While alternative drugs are being considered, none so far are as cheap as SP. These also require more than one dose and thus make directly observed treatment within the context of antenatal care quite difficult. More research is needed to find appropriate substitutes. Basically it is important for countries to continue using SP for IPTp for the meantime, and of course ensure that all pregnant women obtain and sleep under ITNs.