Beyond evidence: a retrospective study of factors influencing a malaria treatment policy change in two South African Provinces

There is a growing appreciation that decisions on changing drug treatment policy should be based on robust evidence of drug effectiveness. No published information describing the process of decision making prior to malaria treatment policy changes or subsequent success in implementing treatment policy changes exists in South Africa. This retrospective study of the differential implementation of a policy change from chloroquine to sulphadoxine-pyrimethamine for first-line treatment of malaria in two South African provinces, Mpumalanga and Limpopo Province, sought to explore the change from the perspective of national and provincial policy makers and programme managers. Focus-groups discussions, in-depth interviews, participatory exercises and archival documentary analysis were conducted. Policy makers and programme managers mentioned the need for local efficacy data as a prerequisite for changing malaria treatment policy. However, drug efficacy data alone were not sufficient to ensure effective policy making or implementation in this study. An effective strategy identified for motivating a change in policy was emphasizing the potential negative consequences of failure to implement a treatment change. In both provinces it was recognized that, for a policy change to be successful and applied at peripheral levels, the proposed change had to have official sanctioning from credible sources. Physical removal of all previously recommended medication from public healthcare facilities appeared to be a key factor in ensuring successful implementation. Lessons learnt through this retrospective analysis may be of value to a number of countries in sub-Saharan Africa, considering policy change in response to rapidly increasing anti-malarial drug resistance. However, additional case studies of the process of malaria treatment policy change are urgently needed from other African settings to determine commonalities and optimize the efficiency of formulating and implementing malaria treatment policy changes