After Policy Change: MSF perspective Practising what we preach

Rationale To ascertain if the MSF malaria policy has been fully implemented To see if barriers still exist to good quality implementation (within MSF programmes) To learn lessons about how to bring about change in medical practice

Study Method Mainly qualitative information Countries in Africa selected according to region, endemicity and national framework Observations in MSF supported facilities and others, and on national policy and supply issues Additional information from other reports and countries

ACT Implementation: National   < 2001 2001 2002 2003 2004 2005 2006 Angola Burundi Chad Ethiopia S Leone Uganda Zambia Studies Policy to ACT National implementation of ACT Time between policy change and national implementation averaged 13 months (range 9-33)

ACT implementation: MSF Implementation in MSF projects in Africa Projects reaching general population in 19 countries After 12 months full implementation in 10 (53%) After 18 months full implementation in 11 (58%) After 24 months full implementation in 14 (74%)

Implementation in vertical programmes In 5 additional countries MSF had vertical (HIV) programmes only 2 years after the MSF malaria policy, only 1 of these projects was using ACT for malaria

Awareness raising Discussions with villagers in Burundi and Zambia showed lack of knowledge of ACT, although new treatments had been available for at least three years. In neither country had MSF undertaken awareness-raising. In one project in Angola where intensive IEC was done, there was evidence of fewer cases of severe malaria.

Outreach

Financial barriers Study in Sierra Leone by MSF B Cost to the patient reduced by: flat-rate fee covering all care; still excluded many people and over half had problems meeting the cost free care; consultations for <5 increased by 60% and less hospitalisation due to earlier treatment-seeking.

Case Management RDT technique Interpretation of RDT or microscopy Treatment on clinical suspicion Severe malaria: under use of artemisinin (Burundi, Zambia, Ethiopia); monitoring BG; pre-transfer treatment

Conclusion: Barriers to quality ACT implementation in MSF Awareness-raising Outreach Cost to the patient Case management Response to mortality data