Analysis of malaria policies in ghana health essay

Dr Francisco Torti was the first to use the term” Malaria”. It originated from Italian word Mala meaning ”bad ” and ”aria” meaning ”air” in 18th century when people thought the syndrome was caused by a foul air from a swampy area. This notion was still there until the scientist discovered in 1880 that malaria was a parasite transmitted by the anopheles mosquito which infects the host with a cell parasite called plasmodium. (World Health Organisation (WHO). It was also discovered that malaria is an infectious disease caused by a parasite called Plasmodium, which affect the red blood cell. In this essay the analysis of Malaria Policy in Republic of Ghana will be discussed . There are various policies developed in Ghana on malaria, as a means to reduce the mortality and morbidity rate caused by malaria. These policies include Malaria Control Policy, Malaria Treatment Policy and Anti Malaria drug Policy, although these policies will be briefly discussed, but this essay will be focusing mainly on the Anti-Malaria drug policy. Firstly, it will introduce the definition and background of Malaria in Ghana. Secondly, it will cover the analysis and the implementation of the Anti Malaria policy in Ghana. Thirdly, the contextual factors of the policy will be discussed and lastly, it will attempt to bring a proposal that enhance future change of the policy and make appropriate recommendations to stakeholders, Health Management Teams and Organizations involved in the fight against malaria to effect the needed changes for policy direction and eventually reducing the burden of malaria. Malaria can be described is a life-threatening parasitic disease transmitted from one person to another through the bite of a female Anopheles mosquito, which requires blood to fertilise her eggs. (Medical news today, May 2009). Malaria remains a serious health burden especially in African countries, with an annual incidence of 247 million cases and about one million deaths, most of which afflict children living in Africa . Malaria is a serious parasitic disease in the developing world, causing high morbidity and mortality. The cause, development and effect of malaria are complex, and the proven presentation of this disease ranges from severe to complication (WHO, 2009). 3. 5 million People contract malaria everyYear. According to UNICEF Ghana fact sheet published in July 2007, it was revealed that approximately 20, 000 children die from Malaria every year (25 per cent of the deaths of children under the age of five) and a child that survives is prone to severe malaria such as convulsions or brain dysfunction which can hamper long-term development and schooling. It was also revealed that the annual economic burden of malaria is estimated 1-2 per cent of the Gross Domestic Product (GDP) in Ghana. Malaria has become a major public Health concern in Ghana; it has become a hyper endemic in all part of the country with the entire population of 24million at risk. Malaria is the most important cause of mortality and morbidity especially among children under five years, pregnant women and the poor although transmission rates are lower in the urban areas, over 3million cases of Clinical malaria are reported in public health facilities every year and about nine hundred thousand cases are Children below five years of age. Ghana Health Services (GHS, 2007).

Analysis of Anti-Malaria Drug Policy.

The Anti-Malaria Drug Policy in Ghana was formulated in 2004 by the Ministry of Health(MoH), however the first revised version was done in 2007 and the second revised version was in 2009 which is the current version. The latest revised edition of the Anti-Malaria Drug Policy is based on current evidence on malaria treatment and lessons learnt in the implementation of the previous policy. The revision is borne out of consultative meetings of all relevant stakeholders involved in malaria case management in Ghana. The policy is built on evidence, as consultation process has been open to the reports from key stakeholders make up of expert people. According to Ghana Health Services (GHS) facility data malaria has been identified as number one cause of morbidity, accounting for about 38% of all outpatient illness, 36% of all hospital admission, and 33% of all death in children fewer than five years. In 2008 and estimation of 14, 000 deaths in children under five were attributed to malaria. Also verbal autopsy component of household survey of Ghana Demographic and Health Survey (GDHS 2008), confirmed that malaria accounted for 43% of all death in children aged 29 days old to 5 years old occurred at home. The policy document is a Top to bottom model approach and it is at macro level. It is built on evidence as it is written in a simple and precise language to make it easy for everyone to read and understand. The document aim at ensuring effective treatment of malaria and reduce the malaria burden in Ghana. It is a regulatory policy, therefore all stake holders and health professionals both in public and private sectors are expected to comply with the guidelines contained in the policy document . The Honourable Minister for Health(Ghana), Dr. George Sipa-Adjah Yankey recognises the importance of creating wealth through a healthy living when he says ”It is my hope that, the New Malaria Treatment Policy will form the basis for the standardization of the management of all types of malaria throughout the country as it supports the new paradigm of creating wealth through health”. The operation of the model is programmatic. A well planned nationwide public education campaign and training for health professionals and health care providers on the policy was to be embarked on. The Ministry of Health (MoH) was also to go on board on appropriate continuing education programme to educate all health professionals in both public and private sector on the policy. The curriculum of pre-service training institutions of health professionals was to be reviewed to be in line with the policy. (MoH, 2005)In most African countries, it is known that Malaria is a leading public health problem. In Ghana, as well as other African countries, one of the essential elements of the approach for the control of malaria is based on prompt and effective treatment. Programmes that were put in place to control malaria are in danger of eliminating the increase of drug resistance to mono- therapies requiring revisions of treatment policies. It is therefore require that a quick and effective treatment, as an essential component of the strategy to control malaria is adopted. (Sirima and Gansané, 2007). Over the years, there has been a high level of resistance of the major class of P. falciparum which is responsible for malaria to mono therapies, (Chloroquine) the first line treatment for uncomplicated malaria. In this view, Ghana originated the process of using Artemisinin-Combination Therapy (ACT) in 2002 in line with world health organisation (WHO) recommendations for all countries experiencing resistance to mono-therapies in the treatment of falciparum malaria (WHO, 2001). Change of first-line treatment of uncomplicated malaria to Artemisinin-Combination Therapy (ACT) is widespread not only in Ghana but also in Africa as a whole. To expand knowledge of safety profiles of ACT, pharma covigilance activities are included in the implementation process of therapy changes. (Majori, 2004) In 2005, according to World Health Organisation (WHO) recommendation, a new anti-malaria drug policy was introduced, therefore there was the need for Ghana to implement Artesunate-Amodiaquine as the first line treatment for uncomplicated malaria. (Koram et al, 2003). Drug exploitation data is an important element of determining drug safety, it is also imperative to know how anti-malarial were prescribed within a prospective pharma covigilance study in Ghana following anti-malarial treatment policy change.(Dodoo et al 2009, 8: 2) evidence of efficiency, compliance , administration route, side effects, cost effectiveness, impact on local industry and key demographic variables such as the suitability for treating malaria in children under five years and in pregnancy.(MoH 2007) . The lifetime of most of the drugs used for the treatment and prevention of malaria could be long-lasting if better arranged, also if they are reasonably combined together on two distinctive features. (Majori, 2004). The combination therapy (CT) concept depend on the extra effectiveness of two or more drugs, to improve therapeutic efficiency and also hinder the development of resistance to the individual components of the combination (Majori, 2004). The main objective of combining artesunate with an existing antimalarial medicine is to improve cure rates; delay emergence of resistance to component drugs and reduce parasite clearance time, (Barenness et al, 2004). By this, the combination could also reduce treatment failure and transmission potential (Adjuik et al, 2004). Although they are expensive, their advantages over monotherapy far outweigh the cost. Artemisinin-based combination chemotherapies have been documented to consistently produce faster relief of clinical symptoms and parasite clearance in uncomplicated malaria than any other currently used antimalarial drug (Owusu-Agyei et al, 2005). However, the short half-lives of artemisinins result in frequent recrudescent infections when used alone and therefore, much interest lies on the choice of the combination partner drug.

Implementation of Anti-Malaria drug Policy

This implementation of this policy was at different level according to different categories of all malaria cases in Ghana with same objective of providing prompt, safe, effective and appropriate anti- malaria treatment to the entire population. (MoH 2005). The implementation sought to improve the overage of malaria control activities by adopting an inter-sectoral approach involving and promoting partnership with the private sector and the community. The first stage was the Roll back system (RBM) initiated by the World Health Organisation (WHO). This was between (1998-2002) and was tagged ” Medium Term Strategic Pan for Malaria Control in Ghana”(MoH). In 2005 however, Ghana implemented a new antimalarial policy to treat all malaria cases in all categories of the population in order to reduce morbidity and mortality especially in children under five and pregnant women. A transition period was allowed to rid the market of all monotherapies for the treatment of uncomplicated malaria whilst ensuring the availability and accessibility of the combination therapies under this policy. During this period, the Food and Drugs Board disallow the importation of monotherapies for the treatment of uncomplicated malaria. Local manufacturers also was granted a reasonable period of time to exhaust their existing stocks of raw materials, following which the manufacture of monotherapies for the treatment of uncomplicated malaria were not allowed.(GHS, 2007)The revised edition of the policy was implemented through an immediate nationwide rollout which also targets at achieving specific targets on malaria prevention and control. The new policy chose Artesunate-Amodiaquine because it is an efficacious combination drug with low side effects, known worldwide for its high parasitic clearance and cure rate with adequate treatment duration. The combination is also safe for use in children and can also be used with caution in pregnancy. comparatively less expensive to all other alternatives and compliance can be improved with unit-dose co packaging. (Global Fund 2004). The implementation required that, both chloroquine (CHQ) and Artesunate-Amodiaquine (AT/AQ) should be allowed on the market for one year whilst efforts are made to de-emphasise production of the chloroquine and its use in the treatment for uncomplicated malaria. As part of monitoring, focus was to be on availability and quality of AT/AQ, quinine and S/P in health institutions, prescriber prescribing habits and dispensing habits of medicines selling outlets. The NMCP was to liaise with Pharmacovigilance Centre to develop procedure for adverse drug reporting (ADR). (Global Fund 2004). The Ministry of Health (MoH) was also to embark on appropriate continuing education programme to educate all health professionals in both public and private sector on the policy. The curriculum of pre-service training institutions of health professionals was tobe reviewed to be in line with the policy. (Global Fund 2004). As part of monitoring, focus was to be on availability and quality of AT/AQ, quinine and S/P in health institutions, prescriber prescribing habits and dispensing habits of medicines selling outlets. The NMCP was to liaise with Pharmacovigilance Centre to develop procedure for adverse drug reporting (ADR). (Global Fund 2004). Gaps on the implementationImplementation of the policy has not been that smooth right from the onset. However, the implementation process was faced with challenges such as adverse drug reactions, lack of other treatment options and safety concerns. It has therefore become necessary to review the drug policy and address all identified concerns. Three years after its inception, no assessment has been done on the challenges and successes of the treatment policy. (MoH 2009)At the launch of the new treatment policy, some clients experienced severe adverse reaction that were publicised. This created doubts in many providers and the general public about the combination. The policy may therefore not achieve the main objective for which it was adopted if the pattern remains as it is now (Yeboah , 2006). . After the policy change, a study conducted by National Centre for Pharmacovigilance in 2006 on prescribers and dispensers indicated that 45. 9% of respondents prescribed or dispensed AT/AQ combination, 40. 5% of respondents were still prescribing monotherapies of Artemisinin derivative, 21. 6% gave out only AQ and 45. 9% prescribed or dispensed SP (Fansidar) for uncomplicated malaria. (Centre for Pharmacovigilance, 2006, unpublished). A study conducted in December 2006 by the Quality Health Partners (QHP), a five-year USAID funded bi-lateral assistance project that aims to improve the quality of reproductive and child health in 30 target districts of Ghana, found that 100% of facilities were prescribing the new combination therapy, but only 16. 7% of them knew the correct dosage according to weight (Bruce, 2007). But more detail is needed to understand the level of adherence. It therefore calls for regular monitoring to assess its success or otherwise. Looking at the economic implication of the policy on Ghana’s economy, Malaria remains hyper endemic in Ghana and Apart from the health consequences; malaria puts a heavy burden on productivity and hence economic development. (Global fund 2004) In Ghana, Malaria is estimated to cause the loss of about 10. 6% Disability Adjusted Life Years (DALYs) costing an equivalent of up to 6% of GDP annually in economic burden. Therefore, malaria control is identified as one of the key health sector interventions. In this regard, in 2002 Ghana initiated the process of using ACTs following WHO recommendations for all countries experiencing resistance to mono-therapies in the treatment of falciparum malaria. Based on evidence of efficacy, compliance, side effects, cost effectiveness, impact on local industry and key demographic variables such as the appropriateness for treating malaria in children under five years and in pregnancy, Artesunate-Amodiaquine was selected as the first line drug for the treatment of uncomplicated malaria. (WHO, 2009)The local pharmaceutical manufacturing industry has been engaged throughout the policy development process to facilitate a smooth process with minimal cost to both industry and public health. A lot of public and private sector investments in equipment and infrastructure have already gone into the production and distribution of Artesunate-Amodiaquine combination therapy. The introduction of the more expensive Artemisinin-based Combination Therapies (ACTs) has further cost implications. To reduce the increased cost burden of ACTs on the most vulnerable populations and ensure their availability and affordability to the population, the recommended ACTs have been incorporated into the National Health Insurance Medicines List. (MoH 2007)Government also has the task of ensuring access to medicines and product safety to forestall the implementation challenges. It is critical that all antimalarials deployed are of good quality, safe and efficacious. To this end, the pharmaceutical inspection programmes of the national drug regulatory authority have been intensified and national drug quality control laboratories further equipped and resourced. Improved patient acceptance of Artemisinin-based Combination Therapies (ACTs) shall be promoted by appropriate agencies of the Ministry of Health to ensure compliance. This will entail extensive public education on the new management of malaria using multiple approaches, through print, mass media, and community based Information, Education and Communication strategies. The FDB shall ensure the quality and safety of ACTs to increase public confidence in the implementation of this policy. A team commissioned by the Minister of Health was tasked to review existing policy guidelines and select additional ACT drugs and dosage forms to cater for those who for one reason or another, cannot tolerate Artesunate- Amodiaquine. Two additional ACTs namely; Artemether- Lumefantrine and Dihydroartemisinin/Piperaquine were selected. Nevertheless, Artesunate-Amodiaquine still remains the preferred ACT for the treatment of uncomplicated malaria. This document is thus a revision of the 2004 anti-malarial policy and provides policy measures and an implementation framework for the treatment of malaria. RecommendationsIn the midst of shortage of staff, the District Health Management Teams should ensure that for each level of care, there is a minimum qualification required of a staff before he/she can deliver so that optimum care for patients is obtained even in remote areas. Certain duties like medicines prescribing is delicate and as such calls for certain minimum technical qualification otherwise medicines could be given out in contraindicated cases. The Ministry of Health should support the local pharmaceutical manufacturing industry to build capacity to meet internationally accepted requirements of Good Manufacturing Practices in the production of ACTs. This will facilitate sustainability of this policy especially the provision of facilities for conducting bioavailability and bioequivalence studies among others so as to enhance the manufacture and supply of the ACTs to both the public and the private sectors. The Ministry of Health and other relevant agencies should ensure the availability of all recommended anti-malarial for the treatment of uncomplicated and severe malaria. The FDB should monitor the quality as well as any reported Adverse Drug Reactions(ADRs) resulting from the use of all anti-malarial in accordance with the provisions of the Ghana National Drug Policy. Preventive treatment of malaria in pregnancy is produced locally and therefore should be readily available. The FDB should continue to monitor the quality of these products whether locally produced or imported as well as the Adverse Drug Reactions (ADRs) associated with their use. There should be access to drugs under this policy in order to ensure smooth implementation of this policy. The Mohr and its agencies should ensure access and availability of the recommended anti-malarial under this policy in all facilities. Procurement Mechanisms should be put in place to ensure minimal price disparities between products from the public and private sectors. The National Health Insurance Drug List (NHIDL), and other guidelines for health workers, curricula or documents recommending treatments for malaria shall be revised. The revision shall be harmonised with the development of the Behavioural Change Communication to ensure that the same messages are communicated to health care workers and members of the public, Health professional s , policy makers , manufacturers, and other service providers. Relevant training institutions (including medical schools, nurses’ training colleges, pharmacy schools etc), health managers in the public and private sector as well as the general public should be well informed about the new policy. A comprehensive training programme should be conducted for all relevant healthcare providers prior to the roll-out of public education programmes. Training programmes should be organized at all levels of the health care system to include licensed chemical sellers, medicine counter/pharmacy assistants, community leaders and workers to understand the policy. Training needs should be assessed and training manual should be developed and updated to ensure that every target group is catered for. The health industry shall be re-oriented to become responsive to local needs and not compromise on quality and value for money. Public education should be directed at all target groups including health professionals, community-based service providers and the general public using the appropriate tools and media. The MoH should ensure appropriate activities are conducted to facilitate the smooth implementation of this policy. A framework for monitoring this policy should include prescribing and dispensing, practices at all service delivery . Points shall be monitored to enhance rational use of the Anti-malarial. The Ministry of Health (Mohr) and its agencies should conduct regular surveys to assess patient compliance and acceptance of the drugs under this new policy. Post marketing surveillance and laboratory testing should be conducted by the FDB to ensure that both imported products and locally manufactured products meet the relevant pharmacopoeia and manufacturing standards of quality and efficacy. The health agencies and research institutions should develop and outline procedures for efficient safety monitoring nationwide. Relevant indicators should be developed to measure and monitor the availability and accessibility of the products under this policy to the general public. Only anti-malarial recommended by the policy and duly registered by the Food and Drugs Board should be authorised for supply and use by the general public. This will involve going through a drug registration process that includes information on efficacy and safety. The current policy should build on the earlier work of capacity building in the private sector and other providers of care, emphasising on ways to promote the adoption of standards and regulation of the industry in collaboration with the Ministry of Trade and Industry, the Ghana Standards Board, Association of Ghana Industries, and other relevant regulatory agencies. The MoH should encourage collaboration with all stakeholders in the industry to understand the components, structure, conduct, performance and contribution to the national economy, and the local industry should be motivated to develop and market products and services for the health care market, create and support intra-sect oral policy dialogue, coordination, planning and accountability. The Ministry should provide a framework of relevant incentives as well as sanctions that enhance performance, promote accountability and continuously refine the role of Government in the delivery of health. The Ministry should provide the platform for local pharmaceutical manufacturers to re-engineer their technologies and systems for the local production of Anti-Malaria drugsGovernment should actively facilitate the process to ensure a successful change particularly in view of the current additions. Innovative research within the local industry should be promoted by Government to aim at the development of co-formulated Anti-Malaria drugs for enhanced compliance. ConclusionMalaria as it is now in Ghana, present a significant and urgent challenge to health nationwide in terms of mobility and mortality rate and also the cost implication to the economy of Ghana. Significant progress in malaria control can be achieved through combine effort of the Global Fund, PMI and other partnerAs malaria has become hyper endemic in all part of the country and the entire population of 24 million at risk, political commitment is thereby needed to generate strategies, policies, programmes and services that improve the control and treatment of malaria in Ghana. Implementation can be at different level (macro and micro), coordinating and direction is also required nationally and internationally in view of the global nature of the coming epidemic and its profound fiscal and societal impacts.