topnaman | Malaria blog » Delivery

Low-tech coolers for storing malaria rapid diagnostic tests in remote areas

naman — Thu, 04 Mar 2010 18:56:51 +0000

Rapid diagnostic tests for malaria (and other diseases) can extend diagnosis to remote areas. This is sorely needed. Beyond benefits against the disease at hand, the introduction of diagnostics along with associated systems of quality assurance can strengthen the overall health system (previously discussed here). A major barrier for expanding the use of rapid tests is a short-shelf life under field conditions. Tropical temperature and humidity degrade such diagnostics, which use delicate reagents like antibodies, in a matter of months. The short shelf life can necessitate restocking at a frequency which may not be logistically feasible. Thus, routine operation in many countries leads to the use of compromised, or a complete wastage of, tests.

Cambodia has a solution. The National Malaria Program designed ‘cooler boxes’ using the simple technology of evaporative cooling.They tested the boxes and their ability to maintain temperature, humidity, and extend the usability of malaria tests. RDTs in ambient conditions tested negative on control blood at 210 days while RDTs kept in the cooler box provided positive results up to 360 days. I love this story. First, it tackles a small but immediate need in current operations. Second, the cooler boxes were developed by Cambodia for use in their own programs. Third, they rigorously tested it – with the help of some WHO support (David Bell has been relentlessly working to advance all things rapid diagnosis). It is a judicious use of aid reminiscent of a past WHO where more funds were spent on research, small victories, and demonstration projects.

Launch of the Affordable Medicines Facility for Malaria

naman — Sat, 18 Apr 2009 06:18:52 +0000

Today, the Affordable Medicines Facility for Malaria was unveiled in Norway (great NY Times piece) with an initial $225 million. The subsidy program aims to increase the availability of affordable artemisinin combination therapies (ACT) – the recommended first line treatments for malaria – through private drug shops. Many people in some countries self-treat with antimalarials bought from these private shops since they can be closer to their home, don’t have long queues, etc. ACTs are rarely bought because of their higher prices so the idea is to make them inexpensive and reduce the incentive to buy otherwise cheaper, but less efficacious, antimalarials.

The article suggests that “For a poor farmer in Cameroon or a poor market woman in Ghana, the difference between 20 cents and $8 is huge” which is true but fails to mention that in many countries ACTs are available free of charge through public and private health facilities. ACTs are already subsidized through national control programs though the extent of their reach could be expanded. I must admit I have my doubts about this plan. First, as Dr. Bernard Nahlen notes in the Times article, there’s scant evidence for a scale-up of this approach. The deputy director of the President’s Malaria Initiative (a solid CDC EIS alumnus – random aside I think CDC involvement is a key reason for PMI’s to date success) is justified in his skepticism. The bulk of data are basic case studies from a few Clinton Foundation pilot projects. Second, even if more rigorous evaluations demonstrate some impact, is it really a desirable way forward?

We need more delivery channels and increasing the availability of ACTs is critical, but it should be done as a component of improving overall case management. The idea of encouraging indiscriminate pill-popping (even if it is the current scenario) with better drugs probably does not align with most countries health priorities. Additionally, there are also the inherent risks of missing other etiologies of fever and increasing drug pressure. On the other hand, cheap ACTs in drug kiosks may be able to provide quick wins in areas which have seen little progress, but countries should think carefully before embarking on this road. It may be an OK stop gap to stave off some morbidity and mortality in places with non-existent health systems but could sabotage development in the long run.

A follow-up comment I posted on Science magazine’s blog which I think adds some more information:

Going the private route is not new. Global Fund drugs get distributed through private channels in many countries whether it is NGOs or partnerships with industries that have medical facilities. What is newer is the use of drug kiosks but even Cambodia for a few years has been marketing ACTs through private shops – with questionable impact. We’ll see how this effort progresses but it is not likely to help build health systems.

Dreams of silver bullets

naman — Sun, 01 Jun 2008 07:54:13 +0000

My friend Atanu Dey at Deeshaa.org often speaks of the fallacy of implementing technological solutions to overcome fundamentally non-technological problems. While Atanu usually invokes this paradigm in reference to India’s primary education challenge, I believe the same concept is relevant to public health efforts. Many public health problems today are non-technological, i.e. we have effective tools for the prevention and treatment of many diseases. This is not to say improved tools won’t help – the smart use of technology helps us solve problems, but rather the fundamental problem is not the lack of effective interventions. In fact, it is usually the deficit of financial/technical resources, delivery mechanisms, and good governance. Without these ingredients sustainable public health gains, including malaria control, will remain elusive.

Studying the science of health delivery

naman — Sun, 24 Feb 2008 03:26:20 +0000

Studying health delivery means figuring out which techniques work for getting the interventions to the people who need them the most. It means studying how to scale effective techniques, and studying how we can speed up policy making processes. Sounds simple doesn’t it? Unfortunately, its rarely done and certainly without the scientific rigor we apply to other types of research. Harvard professor Jim Kim refers to an “implementation bottleneck” between what we know and are able to apply. At the recent meeting of the American Association for the Advancement of Science Dr. Kim, formerly head of the WHO’s HIV/AIDs department (which was apparently a controversial tenure), urged the creation of “the science of healthcare delivery”. It’s a message which strongly resonates with me. We can control malaria if we deploy our current tools widely and effectively. First, we need to learn how.