Policy for anti-malarial chemotherapy

I was under the impression that the WHO and other international health organizations laid down (non-mandatory) policy guidelines for the treatment of malaria and that endemic countries did not really care about those guidelines. After all, doctors prescribe the medication and are trained to tailor it to the needs of their patient, right ? As I read on the subject though, I quickly found that the Medical Association and Health Department of every malaria-endemic country has it's own mandatory policy based on the WHO's guidelines.

An overview of the chemotherapy policies for different regions are listed on the WHO's website here. (WHO, 2013)

Even as early as 1990, the WHO had some "General considerations for the development of  a malaria treatment policy". I have briefly discussed some of them here, but the considerations are not restricted to the ones listed below.

 The seasonality of the disease and the level of acquired immunity in the population are epidemiological factors that must be accounted for in Rx policies. Severity of illness is severely influenced by the species of Plasmodium that has infected the person. Drug resistance too depends on the species, with P.falciparum being the most prone to develop drug resistance. So, prevalance and drug sensitivity studies are essential before polices are drafted.

Availability of malaria services in a region heavily influences the success of chemotherapeutic intervention policies. Malaria services are best implemented in association with general health services, than as stand alone programs. Such an integration, if necessary, must be spelled out clearly.

It is also essential to identify and define high risk groups/individuals, who would need prophylaxis. This would help in triage in outbreak settings and also in delivering radical curative treatment in unstable malaria areas.
Treatment regimens are also usually available in the policies , for different age groups and physiological conditions (pregnancy etc). However, these must be tailored to suit each individual patient's needs as many of the regimens are based on clinical trials and are not validated for field conditions. Regimens must take into account the medical supervision available for the treatment, that is, different forms of the drugs can/must be used for outpatients and some other forms are better suited for in-hospital administration.

Sociological aspects such as self medication must be taken into account too.

Unit cost of the drug and number of doses needed form the basis of the economy of chemotherapy Subsidies play a huge role in adherence to therapy regimens, by giving a pseudo-increase in buying power. But, even with subsidies and free medication, adherence is not 100%, which on a side note is one of the driving forces for resistance development.

Here is an example , from India, of the national drug policy against malaria :

The chemotherapy recommendations are given by the National Vector Borne Disease Control Programme, operating under the Ministry of Health & Family Welfare, Govt of India. The policy statement, in the 2013 edition, declares that one of the aims is "to minimize the risk of spread of drug resistant parasites by use of effective drugs in appropriate doses for everyone". With that goal in mind, the drug policy is intended to be "Appropriate for today and safe for tomorrow".

The ultimate goals of these policies are to provide complete clinical and parasitological cure of all malaria cases, prevent the progression of uncomplicated malaria into severe malaria and thereby reduce mortality, prevent relapse by administration of chemotherapeutic agents, interrupt transmission by the use of gametocytocidal drugs and prevent the development of drug resistant malaria .

References:
 Neave PE, Taylor S, Behrens RH. Does public subsidy of the cost of malaria chemoprophylaxis reduce imported malaria? A comparative policy analysis. Malar J 2013;12:238.

Country antimalarial drug policies: by region. (n.d.). WHO. Retrieved October 22, 2013, from http://www.who.int/malaria/am_drug_policies_by_region_afro/en/index.html

National Vector Borne Disease Control Programme (NVBDCP). (n.d.). National Vector Borne Disease Control Programme (NVBDCP). Retrieved October 22, 2013, from http://nvbdcp.gov.in/