https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60829-1.pdf

Human African trypanosomiasis

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

Quinine remains an important anti-malarial drug almost 400 years after its effectiveness was first documented However, its continued use is challenged by its poor tolerability, poor compliance with complex dosing regimens, and the availability of more efficacious anti-malarial drugs This article reviews the historical role of quinine, considers its current usage and provides insight into its appropriate future use in the treatment of malaria In light of recent research findings intravenous artesunate should be the first-line drug for severe malaria, with quinine as an alternative The role of rectal quinine as pre-referral treatment for severe malaria has not been fully explored, but it remains a promising intervention In pregnancy, quinine continues to play a critical role in the management of malaria, especially in the first trimester, and it will remain a mainstay of treatment until safer alternatives become available For uncomplicated malaria, artemisinin-based combination therapy (ACT) offers a better option than quinine though the difficulty of maintaining a steady supply of ACT in resource-limited settings renders the rapid withdrawal of quinine for uncomplicated malaria cases risky The best approach would be to identify solutions to ACT stock-outs, maintain quinine in case of ACT stock-outs, and evaluate strategies for improving quinine treatment outcomes by combining it with antibiotics In HIV and TB infected populations, concerns about potential interactions between quinine and antiretroviral and anti-tuberculosis drugs exist, and these will need further research and pharmacovigilance

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Quinine, an old anti-malarial drug in a modern world: role in the treatment of malaria

Ill-health contributes to impoverishment, a process brought into sharper focus by the impact of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic. This paper reviews studies that have measured the economic costs and consequences of illness for households, focusing on malaria, tuberculosis (TB), and HIV/AIDS. It finds that in resource-poor settings illness imposed high and regressive cost burdens on patients and their families. Direct and indirect costs of illness for malaria were less than 10% of the household income, but still significant when combined with the costs of other illnesses. The costs of TB and HIV/AIDS were catastrophic for households (more than 10% of the income). Health service weaknesses in many countries, including low coverage, user charges, and poor quality of care, contributed to high costs. Poor households in developing countries with a member with TB or HIV/AIDS struggled to cope, highlighting the urgent need for a substantial increase in health sector investment to expand access to preventive and curative health services. Government and non-governmental interventions should also be broadened to encompass measures that reduce the substantial indirect costs associated with diseases such as malaria, TB, and HIV/AIDS.

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The economic burden of illness for households in developing countries: a review of studies focusing on malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome.

Over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. Following their introduction in the 1970s, many large-scale CHW programs declined during the 1980s, but CHW programs throughout the world more recently have seen marked growth. Research and evaluations conducted predominantly during the past two decades offer compelling evidence that CHWs are critical for helping health systems achieve their potential, regardless of a country's level of development. In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family-planning services, and contributing to the control of HIV, malaria, and tuberculosis infections. In many middle-income countries, most notably Brazil, CHWs are key members of the health team and essential for the provision of primary health care and health promotion. In the United States, evidence indicates that CHWs can contribute to reducing the disease burden by participating in the management of hypertension, in the reduction of cardiovascular risk factors, in diabetes control, in the management of HIV infection, and in cancer screening, particularly with hard-to-reach subpopulations. This review highlights the history of CHW programs around the world and their growing importance in achieving health for all.

Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness.

Economic burden of malaria illness on households versus that of all other illness episodes: a study in five malaria holo-endemic Nigerian communities.

There is little existing knowledge about actual quality of drugs provided by different providers in Nigeria and in many sub-Saharan African countries. Such information is important for improving malaria treatment that will help in the development and implementation of actions designed to improve the quality of treatment. The objective of the study was to determine the quality of drugs used for the treatment of malaria in a broad spectrum of public and private healthcare providers. The study was undertaken in six towns (three urban and three rural) in Anambra state, south-east Nigeria. Anti-malarials (225 samples), which included artesunate, dihydroartemisinin, sulphadoxine-pyrimethamine (SP), quinine, and chloroquine, were either purchased or collected from randomly selected providers. The quality of these drugs was assessed by laboratory analysis of the dissolution profile using published pharmacopoeial monograms and measuring the amount of active ingredient using high performance liquid chromatography (HPLC). It was found that 60 (37%) of the anti-malarials tested did not meet the United States Pharmacopoeia (USP) specifications for the amount of active ingredients, with the suspect drugs either lacking the active ingredients or containing suboptimal quantities of the active ingredients. Quinine (46%) and SP formulations (39%) were among drugs that did not satisfy the tolerance limits published in USP monograms. A total of 78% of the suspect drugs were from private facilities, mostly low-level providers, such as patent medicine dealers (vendors). This study found that there was a high prevalence of poor quality drugs. The findings provide areas for public intervention to improve the quality of malaria treatment services. There should be enforced checks and regulation of drug supply management as well as stiffer penalties for people stocking substandard and counterfeit drugs.

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Quality of anti-malarial drugs provided by public and private healthcare providers in south-east Nigeria.

Non-compliance to correct dosing is thought to be one of the main causes of treatment failure of chloroquine in the home management of childhood malaria. There are few studies of compliance to drugs used for tropical diseases. In order to study compliance in the rural setting, chloroquine syrup was packaged with a novel pictorial insert for compliance to correct dosing. Compliance was assessed in a field trial in September 1996–December 1997, involving 632 children with uncomplicated malaria in Udi local government area in Nigeria. Written informed consent was obtained from mothers/guardians before children were enrolled in the study. There were 3 arms to the trial: control villages (group I) received chloroquine syrup without further intervention, group II received a pictorial insert with chloroquine syrup, and group III received chloroquine syrup, the pictorial insert and verbal instructions. Each group was made up of 3 health centres. Compliance was assessed by volumetric measurement of the chloroquine syrup left in 30-mL bottles and by questionnaires administered to mothers/helpers of the children. Control villages recorded full compliance for 36·5 ± 4·4% of the children, group II for 51·9 ± 7·9% and group III for 73·3 ± 4·2%. There was a significant correlation (P

Compliance to correct dose of chloroquine in uncomplicated malaria correlates with improvement in the condition of rural Nigerian children

OBJECTIVES To determine the hypothetical and actual willingness of households to pay (WTP) for insecticide-treated nets (ITNs), and compare these in areas with and without previous exposure to free ITNs. METHODOLOGY The contingent valuation method was used to determine the willingness of the heads of 1908 randomly selected households from five communities in south-east Nigeria to pay for two sizes of ITNs. Two communities previously had free access to ITNs. Validity was assessed using multiple regression analyses, and by offering ITNs for sale to 200 randomly selected people drawn from the original sample. The data was collected between March and September 1998. FINDINGS Most respondents were willing to pay for ITNs: Mbano (93.26%), Ugwogo (97.69%), Orba (83.24%), Alor-uno (95.37%), and Ibagwa-ani (87.34%). In multivariate analyses, WTP was significantly associated with the number of people living in a household, sex of the respondent, average yearly expenditure on gifts and the type of savings scheme (P < 0.05). Some of the residences were also statistically significant in the two models used, and those with prior exposure to free ITNs were negatively related to WTP. Seventy-six percent of those who were hypothetically willing to pay actually purchased them, and the WTP technique correctly predicted the choices of 80% of the respondents. CONCLUSION There was good evidence that stated WTP could be translated into actual WTP. However, peoples' perception of affordability of the nets and its link to their WTP needs further exploration. The WTP technique is a potentially valid tool for market research in healthcare, as it was able to predict the direction of actual WTP for the ITNs. The hypothetical WTP amounts could be used as guide to know either the optimal price to charge for the ITNs or the level of subsidy to introduce.

Hypothetical and actual willingness to pay for insecticide-treated nets in five Nigerian communities

Human pharmacokinetic data on the new anti-parasitic agent, ivermectin, are scanty. For the evaluation of its disposition a specific HPLC assay with sensitive fluorescence detection was developed. Applying equilibrium dialysis, plasma protein binding of ivermectin was measured in five healthy individuals and it averaged 93.2 +/- 4.4% (SD). Such strong binding should be taken into consideration, especially in patients with malnutrition or with diseases in which a decrease in plasma proteins and consequently a higher free fraction of ivermectin could be expected.

Paul O. Okonkwo

Papers

Economic burden of malaria illness on households versus that of all other illness episodes: a study in five malaria holo-endemic Nigerian communities.

Quality of anti-malarial drugs provided by public and private healthcare providers in south-east Nigeria.

Compliance to correct dose of chloroquine in uncomplicated malaria correlates with improvement in the condition of rural Nigerian children

Hypothetical and actual willingness to pay for insecticide-treated nets in five Nigerian communities

Ivermectin binds avidly to plasma proteins