Use of evidence to inform policy change: The case of Adequacy of antimalarial drug efficacy studies in Ethiopia

Abstract

Malaria in Ethiopia is seasonal and unstable. Prompt malaria treatment with effective antimalarial drugs is the mainstay but often challenged by drug resistance. The need to ensure availability of effective antimalarial drugs is a public health priority. This paper describes the characteristics, findings and actions taken based on in vivo antimalarial drug efficacy studies on P. falciparum infections conducted in the Ethiopia.
Published and unpublished in vivo antimalarial drug efficacy studies on P. falciparum infections conducted in Ethiopia were reviewed and scored based on nine indicators for study completeness, timeliness and representativeness compared to the WHO recommended standards. A combined score of at least 60% was set as a cut-off for study adequacy and study gaps identified in order to formulate recommendations for prospective studies.
Of the 24 in vivo therapeutic efficacy studies on P. falciparum conducted from 1972 to 2010, only 2(8.3%) of the studies had a combined adequacy score of 66.7%. Most of the studies (91.7%, n=22) had a score of less than 60%. Retrospective chronological mapping of the antimalarial drug efficacy study findings indicate that chloroquine was replaced by sulfadoxine-pyrimethamine (SP) when its efficacy failure increased from 22% in 1985 to 65% in 1998. SP was replaced by artemether-lumefantrine (AL) when it efficacy failure increased from 7.7% in 1998 to 36% in 2004. Nearly eight years after the introduction of AL as the first-line treatment for P. falciparum, isolated studies show a decrease in its efficacy from 99% in 2003 to 93.3% in 2008.
This study has shown that the adequacy of studies used for initiating policy change was not optimal; but is also emphasizes the fact that 20% of studies were useful in the implementation of change. This finding suggests that policy change process is beyond collecting the correct evidence at the right time, it should be based on an institutional mechanism managed by appropriate personnel who have the right skills.