Implementation of safe and effective radical cure vivax malaria – a policy analysis approach

Project Details


This project investigates how evidence informs policy change processes, namely, how stakeholder networks, policy processes and contextual factors shape introduction of a radical cure for P. vivax malaria in three countries. It considers hierarchy and types of stakeholders involved in national policy making and how policy decisions are made in these countries. It also seeks to identify contextual factors influencing policy guidance changes, namely, evidence required to introduce radical cure, the political economy of change, rationale for change, relevant socio-cultural factors, and the broader impact of a policy change to countries. Impact of the World Health Organization’s (WHO) global malaria treatment recommendations on National Strategic Plans is also considered.

P. vivax malaria is one of the most challenging malaria species to control. This is because it forms dormant liver stages (hypnozoites) that can reactivate weeks or months following an acute infection. Recurrent infections are associated with a febrile illness, a cumulative risk of anaemia, direct and indirect mortality and onward transmission of the parasite. P. vivax has a wide geographic distribution with approximately 35% of the world’s population at risk and an estimated 14.3 million cases reported in 2017 [1, 2]. The only hypnozoitocidal drug currently widely available to treat the disease is Primaquine (PQ) typically administered over 14 days. There are several challenges involved in treating vivax with PQ including health worker compliance and patient adherence to treatment. Health worker compliance to PQ treatment is often poor because PQ can cause haemolysis in patients with G6PD ─ an enzyme deficiency. However, until recently, no point-of-care (PoC) tests were available to health workers at peripheral levels of the health system to guide them in treatment of vivax patients. Additionally, as patients receive PQ with a blood-stage treatment that resolves symptoms after three days, ensuring adherence to a full 14-day course is challenging. Studies done in Indonesia and Ethiopia indicate that the effectiveness of 14-day unsupervised PQ treatment is extremely poor, resulting in high risk of relapse [3, 4].

Availability of PoC G6PD tests and shorter treatment regimens could address these challenges. The former are becoming available and for the latter, recently published studies demonstrate potential effectiveness of higher dose 7-day PQ treatment and single-dose treatment of a new drug tafenoquine(TQ) [5-7]. However, introduction of new diagnostic and treatment regimens into endemic health systems will create an additional challenge for treatment policy change. A key determinant of whether and when countries adopt a shorter PQ regimen or TQ is endorsement by the WHO’s Global Malaria Programme (GMP) as well as national policy recommendations and antimalarial treatment guidelines. At global and national levels, processes by which evidence informs policy are unclear regarding what triggers or what evidence underpins policy change [8]. WHO’s GMP and prequalification programme went through extensive review in 2019 addressing this shortcoming. It is presently trialling a new prequalification and policy process aimed at decreasing time lag between availability of new tools and prequalification, and WHO policy recommendations required for countries that rely on external donors to procure new tools [9]. At national levels, degree of transparency regarding how policy and treatment guidance changes are made varies but is vital to understand if countries are to meet 2030 malaria elimination goals [10].
Effective start/end date27/04/21 → …

IWETO expertise domain

  • B680-public-health