Introducing new policies of radical cure for P. vivax malaria in Asia Pacific countries: Global recommendations, evidence uptake, policy processes, stakeholders and contextual factors influencing policymaking

My thesis suggests ways to accelerate evidence-informed policy change for improved radical cure of P. vivax malaria. The overall objective was to support Asia Pacific countries reach regional malaria elimination goals via enhanced policymaking strategies for P. vivax malaria. It investigated how global malaria recommendations, evidence uptake, stakeholder networks, policy processes, and contextual issues inform global and national policy change. First, I considered further evidence needed by Asia Pacific countries to change policy for safe and effective radical cure of P. vivax malaria. Second, policy processes for changing antimalarial policy in seven countries were investigated to understand stakeholder types, relationships, and specific processes driving these national processes. Third, I studied the World Health Organization’s malaria policymaking processes to understand how these processes could be optimised to better align with countries’ needs. Finally, I compared antimalarial policy change processes in three Asia Pacific countries, Laos, Pakistan, and the Solomon Islands, to gain in-depth insights on these national level processes, the stakeholders and contextual factors influencing policy change in these countries. The first study, conducted in 2019, highlighted that evidence required by national and external stakeholders to change antimalarial treatment policy varied considerably. The priority for national stakeholders was data on effectiveness of different treatments and patient adherence to these treatments. At least some of those evidence gaps have been addressed since then and ultimately led to policy changes. Key recommendations from this work are that researchers need to closely consult country partners to address relevant evidence gaps and ensure effective national policy change. The second study showed that national policymaking context depends upon available funding for malaria control programs, population size, socio-economic status and governance systems, and there was limited documentation of policy processes or terms of reference for actors involved. Better alignment of antimalarial policymaking processes with in-country health policymaking processes would strengthen health governance and facilitate better timelines for policy change that will be critical to achieving ambitious 2030 regional malaria elimination targets. The third study identified potential ‘triggers’ for updating the World Health Organization’s global malaria recommendations and initiating its Prequalification processes. However, I demonstrated that these triggers did not immediately initiate these processes for P. vivax malaria. Despite a rigorous global evidence review system, policy update prioritisation within the Global Malaria Programme influenced new policy recommendation development timelines. Ideally, the identified triggers should initiate global policy change processes and be communicated clearly to stakeholders external to the World Health Organization. The fourth study compared country ownership of antimalarial policymaking processes in three countries: Laos, Pakistan and the Solomon Islands. It highlighted that country ownership is moderated by dependence levels on external donor support to initiate national policy change. Availability of donor support for countries to access new tools to tackle P. vivax malaria is often moderated by availability of updated World Health Organization recommendations on new tools. Overall, nuanced factors moderate country ownership of national antimalarial policymaking. My five-year study highlights the above complex factors influencing the introduction of new policies of radical cure for P. vivax malaria globally and nationally. This is partly because of the complexity of the disease and partly because of the complexity of aligning macro level global malaria policy priorities with meso level national ones. Overall, better aligning antimalarial research activities with countries’ needs, enhanced global and regional evidence collation and presentation, and optimised global and national policy decision-making processes will facilitate timely introduction of enhanced P. vivax malaria treatment policy in Asia Pacific countries and are likely applicable to other areas of malaria policymaking too. Such measures will be critical to control and ultimately eliminate malaria regionally.