1. After Policy Change: MSF perspective
Practising what we preach

2. 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

3. 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

4. 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)

5. 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%)

6. 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

7. 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.

8. Outreach

9. 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.

10. 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

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