Department of Global Health & Development, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
Malar J. 2011 Aug 18;10:243. doi: 10.1186/1475-2875-10-243.
Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme. The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance.
尽管一些人群最近经历了疟疾的急剧下降，但大多数最容易感染恶性疟原虫疟疾的人仍然无法获得有效的青蒿素联合疗法（ACT）治疗，而其他人已经面临对青蒿素类药物产生抗药性的寄生虫。在这种情况下，迫切需要通过增加高质量的 ACT 和寄生虫学诊断，来改善 ACT 的可及性和针对性。在许多国家，私营商业部门在疟疾治疗中发挥着重要作用，因此这一问题在私营商业部门中变得越来越紧迫。负担得起的疟疾药品基金（AMFm）是一项新的倡议，旨在通过对制造商进行补贴，增加公共、私营和非政府组织部门提供负担得起的 ACT。然而，迄今为止，在私营部门实施补贴 ACT 的方案执行方面，几乎没有记录在案的经验。柬埔寨的独特之处在于，不仅在实施补贴 ACT 方面拥有 10 多年的经验，而且还在全国范围内实施快速诊断测试（RDT）作为社会营销计划的一部分。该方案包括行为改变沟通以及对私营供应商的培训，以及销售和分发推荐的 ACT 药物 Malarine 和 RDT Malacheck。本文通过利用该方案启动以来进行的家庭和供应商调查的结果，描述和评估了这一经验。现有证据表明，供应商和消费者对 Malarine 的认识迅速提高，但对 Malacheck 的认识则相对较少。此外，ACT 和 RDT 的供应和采用的改善相对缓慢，特别是在更偏远的地区。调查方法缺乏标准化以及数据存在空白，突显了为类似举措建立明确监测和评估系统的重要性。尽管存在这些限制，但仍然可以吸取一些重要的经验教训。这些经验教训包括全面的沟通策略的重要性，以及产品的持续可靠供应，同时关注两者的地理覆盖范围。其他重要的挑战涉及到激励供应商和消费者不仅选择推荐的药物，而且在选择药物之前进行确认性血液检测并确保供应商遵守检测结果和患者遵守治疗方案的困难。在柬埔寨，由于药物本身以及青蒿素耐药性的出现所固有的问题，这一点尤其复杂。
