Adoption of evidence-based global policies at the national level: intermittent preventive treatment for malaria in pregnancy and first trimester treatment in Kenya, Malawi, Mali and The Gambia.

Jayne Webster,Mwayi Madanista,Lucinda Manda-Taylor,Ludovica Ghilardi,Jane Achan,Simon Kariuki,Samba Diarra,George Okoth,Jenny Hill,Umberto D’Alessandro,Jenna Hoyt,Kassoum Kayentao

doi:10.1093/heapol/czaa132

Abstract

In 2012, the World Health Organization (WHO) updated its policy on intermittent preventive treatment in pregnancy with sulphadoxine–pyrimethamine (IPTp-SP). A global recommendation to revise the WHO policy on the treatment of malaria in the first trimester is under review. We conducted a retrospective study of the national policy adoption process for revised IPTp-SP dosing in four sub-Saharan African countries. Alongside this retrospective study, we conducted a prospective policy adoption study of treatment of first trimester malaria with artemisinin combination therapies (ACTs). A document review informed development and interpretation of stakeholder interviews. An analytical framework was used to analyse data exploring stakeholder perceptions of the policies from 47 in-depth interviews with a purposively selected range of national level stakeholders. National policy adoption processes were categorized into four stages: (1) identify policy need; (2) review the evidence; (3) consult stakeholders and (4) endorse and draft policy. Actors at each stage were identified with the roles of evidence generation; technical advice; consultative and statutory endorsement. Adoption of the revised IPTp-SP policy was perceived to be based on strong evidence, support from WHO, consensus from stakeholders; and followed these stages. Poor tolerability of quinine was highlighted as a strong reason for a potential change in treatment policy. However, the evidence on safety of ACTs in the first trimester was considered weak. For some, trust in WHO was such that the anticipated announcement on the change in policy would allay these fears. For others, local evidence would first need to be generated to support a change in treatment policy. A national policy change from quinine to ACTs for the treatment of first trimester malaria will be less straightforward than experienced with increasing the IPTp dosing regimen despite following the same policy processes. Strong leadership will be needed for consultation and consensus building at national level.

Highlights

Malaria in pregnancy (MiP) causes adverse effects for both the mother and baby including increased risk of maternal anaemia, low birthweight and prematurity (Desai et al, 2007)
Context included the presentation of stakeholder perceptions of policy legitimacy, stakeholder power, followed by presentation of perceptions of the revised IPTp-SP policy (World Health Organization, 2012) and the treatment of first trimester malaria
In this study, covering a timeline from 2012 to 2018, we investigated the perceptions of national level stakeholders on the adoption of two global malaria control policies into national level policies in four subSaharan Africa (SSA) countries; the 2012 revised IPTp-SP policy (World Health Organization, 2012) and a potential future policy change on the use of artemisinin combination therapies (ACTs) for first trimester treatment of MiP (WHO Malaria Policy Advisory Committee, 2016a)

Summary

Introduction

Malaria in pregnancy (MiP) causes adverse effects for both the mother and baby including increased risk of maternal anaemia, low birthweight and prematurity (Desai et al, 2007). Findings of a meta-analysis of two vs three or more doses of IPTp with SP (Kayentao et al, 2013) were presented at WHO’s Evidence Review Group (WHO-ERG) on MiP in July 2012 who, in turn, presented their recommendations to WHO’s Malaria Policy Advisory Committee (MPAC) in September 2012 (WHO Malaria Policy Advisory Committee, 2012). This led WHO to update its original two-dose IPTp policy to ‘a dose of SP at every ANC visit in the second and third trimester, at least one month apart’. The policy was subsequently communicated to WHO’s African Member States (WHO Global Malaria Programme, 2013) and several countries have ratified the updated policy and/or begun implementation (Henry et al, 2018)

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