The implementation of a new Malaria Treatment Protocol in Timor-Leste: challenges and constraints

Abstract

Background Timor-Leste changed its malaria treatment protocol in 2007, replacing the first-line for falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. This study explored the factors affecting the implementation of the revised treatment protocol, with an emphasis on identifying key constraints.Methods A mixed method approach drew on both qualitative and quantitative data. The study included data from District Health Services in seven districts, community health centres in 14 sub-districts, four hospitals, five private clinics, one private pharmacy and the country's autonomous medical store. In-depth interviews with 36 key informants, five group interviews and 15 focus group discussions were conducted. A survey was also undertaken at community health centres and hospitals to assess the availability of a physical copy of the Malaria Treatment Protocol, as well as the availability and utilization of artemether-lumefantrine and sulphadoxine-pyrimethamine.Results Many factors impeded the implementation of the new malaria protocol. These included: inadequate introduction and training around the revised treatment protocol; unclear phasing out of sulphadoxine-pyrimethamine and phasing in of the revised treatment, artemether-lumefantrine, and the rapid diagnostic test (RDT); lack of supervision; lack of adherence to the revised guidelines by foreign health workers; lack of access to the new drug by the private sector; obstacles in the procurement process; and the use of trade names rather than generic drug description. Insufficient understanding of the rapid diagnostic test and the untimely supply of drugs further hampered implementation.Conclusion To effectively implement a revised malaria treatment protocol, barriers should be identified during the policy formulation process and those emerging during implementation should be recognized promptly and addressed.

Malaria case management in Papua New Guinea following the introduction of a revised treatment protocol

“…For example, three years after the implementation of a protocol stipulating routine microscopy or RDT testing of all adult fever cases and the prescription of AL to test positive cases in Kenya, testing rates in health facilities with RDT or microscopy available did not exceed 54% and nearly a third of test negative cases were prescribed AL [7]. Similar accounts of poor health worker adherence and other institutional barriers to the implementation of an RDT/artemisinin combination therapy-based malaria treatment policy have been documented elsewhere [8,9], including neighbouring Timor-Leste [10]. …”

Changing the malaria treatment protocol policy in Timor-Leste: an examination of context, process, and actors’ involvement

“…While this may have slowed aspects of the process, it bore fruit during policy implementation given the sense of ownership by many of those involved. Some weaknesses remained and have been described elsewhere [7]. This study also demonstrates that while political crises bring violence, destruction and disruption of people’s lives and livelihoods, quality leadership and development partner support can, even in these situations, open and see through “windows of opportunity” to introduce longer term policy and systems change.…”

“…Translation into Tetum (to ensure availability to local Timorese health care staff) and Spanish (to inform treatment by personnel associated with the Cuban Medical Brigade) took place between July and September 2007. The socialisation of the new MTP took place between October and December 2007 [7]. …”

“…A similar letter was issued again in March 2008 to the country’s District Health Offices to implement this MTP by the newly appointed Director General who replaced the Permanent Secretary. A study aiming at evaluating the implementation of this new MTP has been published [7]. …”

“…The revised MTP also included the use of a rapid diagnostic test (RDT) [2]. The revised MTP has been used since 2008 to date [7]. At the launch of the third edition of the MTP in June 2007, the then Minister for Health, Dr Rui Maria de Araujo, stated that the replacement of the existing treatment protocol for malaria was based on the increased reported cases of P. falciparum resistance to chloroquine and SP and the increasing use of ACT for treating falciparum malaria in South East Asia region [8] .…”