The Amazon Malaria Initiative (AMI) is an association of technical assistance organizations and Latin American and Caribbean countries financed by the US Agency for International Development (USAID) that supports the control and eventual elimination of malaria in the region. Since 2002, several projects implemented by Management Sciences for Health have been part of the initiative and have played an important role in introducing medicines combined with artemisinin after the documentation of P. falciparum resistance to chloroquine. SIAPS became an AMI partner in 2012.
SIAPS’ methodological approach considered the following factors:
Although the incidence of malaria has decreased significantly in the region, there are countries and areas within countries where the incidence remains high.
Any technical assistance needs to simultaneously consider both low- and high-incidence areas.
Given the disparity in the epidemiological situation and the operative conditions of malaria control programs, SIAPS simultaneously supported interventions that were regional, national, and local in scope.
The strategies and tools used to ensure a continuous supply of medicines in countries and areas of low malaria incidence differ from those in areas of high incidence, but the results of different approaches have not been documented. SIAPS has supported the design, implementation, and evaluation of both approaches.
Project Highlights
Introduced artemisinin fixed-dose combinations (FDCs): Before 2012, Bolivia and Peru were using artemisinin as monotherapy in combination with other antimalarials. In 2012, FDCs were introduced in Bolivia and Peru through pilot programs. SIAPS supported the collection of evidence, prepared policy briefs, advocated to change treatment policies, and developed a plan to introduce FDCs in Peru.
Central Medical Store, Iquitos, Peru [Click to enlarge]Supplied antimalarials to low- and null-incidence areas: Prior to 2012, the supply of antimalarials to low- and null-incidence areas that were still at high risk of reintroduction was not considered. Estimations and operative plans were developed to supply antimalarials to these areas. SIAPS supported the production of national guidelines to estimate needs and distribute antimalarials to low-incidence areas and supported the development and implementation of a regional antimalarial stock monitoring system and quarterly information bulletins.
Introduced a regional procurement scheme for antimalarials: Before 2012, the procurement of antimalarials relied on national providers. Many countries, including Honduras, Peru, and Ecuador, had local bids with few competitors. SIAPS organized regional workshops and coordination meetings with the PAHO Strategic Fund, which led to implementation of a pooled procurement mechanism for antimalarials and a regional scheme for donating medicines for severe cases.
Improved storage conditions: Previous projects documented poor storage conditions for antimalarials in low-incidence areas. To address this, SIAPS developed guidelines to improve storage conditions of antimalarials in low-incidence areas.[1]
Trained primary health workers: Before 2012, local providers had limited information on diagnosis and treatment in low-incidence areas. SIAPS developed educational materials and trainings on diagnosis and treatment in low-incidence areas.
Results
Despite the complexities of supplying medicines in low-incidence situations, the SIAPS approach allows for a continuous supply of antimalarials. Availability in central stores has been above 80% since 2012.[2] Quarterly data recorded by the regional stock monitoring system show that in 2016, the availability of antimalarials in central and regional warehouses was 85%,[3] a significant improvement from the 79% reported in 2012.[4] In addition, the regional information system and special studies that have been carried out have identified persistent problems, and potential solutions have been proposed.
Immediate and direct consequences include organization of a regional pooled procurement scheme, led by the PAHO Strategic Fund, and the donation of medicines among AMI countries. On the basis of information provided by the regional stock monitoring system, as of December 2014, AMI countries with overstocks donated 2.4 million antimalarial units, valued at USD 95,000, to countries facing potential stock-outs.[5]
The introduction of these new therapeutic and epidemic control strategies has contributed to a reduction of nearly 70% in the incidence of the disease since 2000. At the beginning of 2016, 18 countries in the region had declared their intention to implement strategies to eliminate malaria.[6]
Project Legacy
The transition from malaria control to elimination demands a regional approach to prevent outbreaks that originate in neighboring countries and to organize a coordinated operative response. The systemic approach applied by SIAPS allows the simultaneous implementation of different interventions that address the weaknesses of a particular country or the region as a whole.
The pharmaceutical management of antimalarials in low-incidence areas requires a different approach. SIAPS has developed methodologies and tools that have been successfully used in Latin America and could be adopted in other countries moving toward elimination.
Although occasional stock-outs have been recorded in the central stores, SIAPS interventions have prevented the effects from extending to health facilities and patients. The challenge for the coming years is to institutionalize the use of these tools so that timely treatment becomes the cornerstone of eliminating malaria in the region.
[2] Regional Bulletin for the Availability of Antimalarial Medicines (Boletín Regional de Monitoreo de la Disponibilidad de Medicamentos Antimaláricos), Issue 1.
[3] Pan American Health Organization/Systems for Improved Access to Pharmaceuticals and Services (2015). Regional bulletin for the availability of antimalarial medicines: Third Quarter 2016.
