The impact of anti-malarial markets on artemisinin resistance: perspectives from Burkina Faso.

BACKGROUND: Widespread artemisinin resistance in Africa could be catastrophic when drawing parallels with the failure of chloroquine in the 1970s and 1980s. This article explores the role of anti-malarial market characteristics in the emergence and spread of arteminisin resistance in African countries, drawing on perspectives from Burkina Faso. METHODS: Data were collected through in-depth interviews and focus group discussions. A representative sample of national policy makers, regulators, public and private sector wholesalers, retailers, clinicians, nurses, and community members were purposively sampled. Additional information was also sought via review of policy publications and grey literature on anti-malarial policies and deployment practices in Burkina Faso. RESULTS: Thirty seven in-depth interviews and 6 focus group discussions were conducted. The study reveals that the current operational mode of anti-malarial drug markets in Burkina Faso promotes arteminisin resistance emergence and spread. The factors are mainly related to the artemisinin-based combination therapy (ACT) supply chain, to ACT quality, ACT prescription monitoring and to ACT access and misuse by patients. CONCLUSION: Study findings highlight the urgent requirement to reform current characteristics of the anti-malarial drug market in order to delay the emergence and spread of artemisinin resistance in Burkina Faso. Four recommendations for public policy emerged during data analysis: (1) Address the suboptimal prescription of anti-malarial drugs, (2) Apply laws that prohibit the sale of anti-malarials without prescription, (3) Restrict the availability of street drugs, (4) Sensitize the population on the value of compliance regarding correct acquisition and intake of anti-malarials. Funding systems for anti-malarial drugs in terms of availability and accessibility must also be stabilized.

Ethical considerations in deploying triple artemisinin-based combination therapies for malaria: An analysis of stakeholders' perspectives in Burkina Faso and Nigeria.

BACKGROUND: Artemisinin-based combination therapies (ACTs) are the recommended treatment for uncomplicated Plasmodium falciparum malaria in all malaria endemic countries. Artemisinin resistance, partner drug resistance, and subsequent ACT failure are widespread in Southeast Asia. The more recent independent emergence of artemisinin resistance in Africa is alarming. In response, triple artemisinin-based combination therapies (TACTs) are being developed to mitigate the risks associated with increasing drug resistance. Since ACTs are still effective in Africa, where malaria is mainly a paediatric disease, the potential deployment of TACTs raises important ethical questions. This paper presents an analysis of stakeholders' perspectives regarding key ethical considerations to be considered in the deployment of TACTs in Africa provided they are found to be safe, well-tolerated and effective for the treatment of uncomplicated malaria. METHODS: We conducted a qualitative study in Burkina Faso and Nigeria assessing stakeholders' (policy makers, suppliers and end-users) perspectives on ethical issues regarding the potential future deployment of TACTs through 68 in-depth interviews and 11 focus group discussions. FINDINGS: Some respondents suggested that there should be evidence of local artemisinin resistance before they consider deploying TACTs, while others suggested that TACTs should be deployed to protect the efficacy of current ACTs. Respondents suggested that additional side effects of TACTs compared to ACTs should be minimal and the cost of TACTs to end-users should not be higher than the cost of current ACTs. There was some disagreement among respondents regarding whether patients should have a choice of treatment options between ACTs and TACTs or only have TACTs available, while ACTs are still effective. The study also suggests that community, public and stakeholder engagement activities are essential to support the introduction and effective uptake of TACTs. CONCLUSION: Addressing ethical issues regarding TACTs and engaging early with stakeholders will be important for their potential deployment in Africa.

Ethical, Regulatory and Market related aspects of Deploying Triple Artemisinin-Based Combination Therapies for Malaria treatment in Africa: A study protocol.

Introduction: According to the World Malaria Report 2019, Africa accounts for 94% of the global malaria deaths. While malaria prevalence and mortality have declined over the years, recent reports suggest that these gains may stand the risk of being reversed if resistance to Artemisinin Combination Therapies (ACTs) spreads from Southeast Asia to Africa. Efforts are being made to develop new treatments that will address the looming threat of ACT resistance, including the development of triple artemisinin combination therapies (TACTs). The proposed study seeks to explore the views of stakeholders on the key ethical, regulatory and market-related issues that should be considered in the potential introduction of triple artemisinin combination therapies (TACTs) in Africa. Methods: The study employed qualitative research methods involving in-depth interviews and focus group discussions (FGDs) with stakeholders, who will be directly affected by the potential deployment of triple artemisinin combination treatments, as regulators, suppliers and end-users. Participants will be purposively selected and will include national regulatory authorities, national malaria control programs, clinicians, distributors and retailers as well as community members in selected districts in Burkina Faso and Nigeria. Discussion: The proposed study is unique in being one of the first studies that seeks to understand the ethical, social, regulatory and market position issues prior to the development of a prospective antimalarial medicine.

To what extent are the antimalarial markets in African countries ready for a transition to triple artemisinin-based combination therapies?

INTRODUCTION: Triple artemisinin-based combination therapies (TACTs) are being developed as a response to artemisinin and partner drug resistance in the treatment of falciparum malaria in Southeast Asia. In African countries, where current artemisinin-based combination therapies (ACTs) are still effective, TACTs have the potential to benefit the larger community and future patients by mitigating the risk of drug resistance. This study explores the extent to which the antimalarial drug markets in African countries are ready for a transition to TACTs. METHODS: A qualitative study was conducted in Nigeria and Burkina Faso and comprised in-depth interviews (n = 68) and focus group discussions (n = 11) with key actor groups in the innovation system of antimalarial therapies. RESULTS: Evidence of ACT failure in African countries and explicit support for TACTs by the World Health Organization (WHO) and international funders were perceived important determinants for the market prospects of TACTs in Nigeria and Burkina Faso. At the country level, slow regulatory and implementation procedures were identified as potential barriers towards rapid TACTs deployment. Integrating TACTs in public sector distribution channels was considered relatively straightforward. More challenges were expected for integrating TACTs in private sector distribution channels, which are characterized by patient demand and profit motives. Finally, several affordability and acceptability issues were raised for which ACTs were suggested as a benchmark. CONCLUSION: The market prospects of TACTs in Nigeria and Burkina Faso will depend on the demonstration of the added value of TACTs over ACTs, their advocacy by the WHO, the inclusion of TACTs in financial and regulatory arrangements, and their alignment with current distribution and deployment practices. Further clinical, health-economic and feasibility studies are required to inform decision makers about the broader implications of a transition to TACTs in African counties. The recent reporting of artemisinin resistance and ACT failure in Africa might change important determinants of the market readiness for TACTs.

[Functional disability in activities of daily living and instrumental or domestic activities of daily living in the elderly living at home in Bobo-Dioulasso (Burkina Faso)]. / L'incapacité fonctionnelle dans les domaines des activités de la vie quotidienne et domestique chez les personnes âgées vivant à domicile à Bobo-Dioulasso (Burkina Faso).

In sub-Saharan Africa, various studies have been conducted on severe disability in activities of daily living, instrumental or domestic activities. These studies have reported different rates without describing the social context for understanding their results. This study was conducted in Burkina Faso to fill the gaps in scientific information on disability in these areas. We conducted a cross-sectional descriptive study in Bobo-Dioulasso among the older population, aged 60 and above. Their functional status was evaluated using the Functional Autonomy Measurement System (SMAF). Data analysis was done with the help of Stata. A systematic random sample of 351 aging adults was interviewed. Moderate to severe functional disability or the need for supervision or assistance was present in 7% in activities of daily living and 86% in instrumental or domestic activities of daily living. This need for assistance varied according to the different activities or items in each domain. The proportions of disability found in this study are higher than those of previous studies that measured the often severe disabilities. All persons with disability claimed to have stable human resources which help them to manage their disabilities. The social context instrumental or domestic activities of daily living are divided by generation and/or by sex. That explains some results. With this division, it's inacceptable in some family that elders and/or old men do instrumental or domestic activities of daily living as prepare meals, do laundry, carry water to wash. The variation of this division from one family to another complicates the assessment of functional disability. To best manage elders disabilities, strategies must develop to: 1) retard the resignation of the family in care of its elderly in functional disability, 2) anticipate the preparation of formal social networks, public structures to support the elderly.

[Quality of chronic patient care according to the Chronic Care Model in Burkina Faso]. / Qualité de la prise en charge des malades chroniques au Burkina Faso selon le Chronic Care Model.

INTRODUCTION: There is a lack of organizational knowledge concerning optimal management by the health care system for patients with chronic health conditions in sub-Saharan Africa. The objective of this study was to describe the quality of chronic patient care at first-line heath facilities in Bobo-Dioulasso, Burkina Faso. METHODS: We conducted a cross-sectional study in six health facilities in Bobo-Dioulasso from October to November 2013. The chronic care model was used as a reference to describe the care of hypertensive patients. A score was calculated for each item in the model, and the strengths and weaknesses of health care organization were identified RESULTS: The overall level of support for the management of hypertensive patients was "basic" for all surveyed structures: median score and IQR 3.7 (3.4, 4.4). The level of support was basic for primary health facilities (median score 4.4), district hospitals (median score 4.1) and the University health center (median score 5.4). The relationship with the community and support to decision-making were identified as weak components of the model. CONCLUSIONS: To improve the quality of chronic patient care in first-line health facilities in Burkina Faso, efforts must be made to strengthen clinical governance and partnership with the community.

Prevalence and patterns of multimorbidity among the elderly in Burkina Faso: cross-sectional study.

OBJECTIVES: To assess the prevalence and distribution patterns of multimorbidity among urban older adults in Burkina Faso. METHODS: Cross-sectional study among community-dwelling elderly people aged ≥60 in Bobo-Dioulasso. We performed interviews, clinical examination and medical record review. Multimorbidity was defined as co-occurrence of at least two chronic diseases in one person whether as a coincidence or not. RESULTS: The overall prevalence of multimorbidity among older adults was 65%. Age ≥70 was associated with multimorbidity in multivariate analysis: adjusted OR = 1.65, 95% CI (1.01-2.68, P = 0.04). The most common chronic diseases were hypertension (82%) 95% CI (78; 86), malnutrition (39%) 95% CI (34; 44), visual impairments (28%) 95% CI (24; 33) and diabetes mellitus (27%) 95% CI (22; 31). Those aged ≥70 had significantly more malnutrition (50% vs. 31%, P = 0.0003) and osteoarthritis (8% vs. 3%, P = 0.01) than those aged 60-69. CONCLUSIONS: The high prevalence of multimorbidity requires a reorganization of healthcare systems in sub-Saharan Africa, especially in Burkina Faso. Interventions and care guidelines usually focused on individual diseases should be improved to better reflect this reality.

The key actors maintaining elders in functional autonomy in Bobo-Dioulasso (Burkina Faso).

BACKGROUND: Globally, a significant increase in functional disability among the elderly is expected in the near future. It is therefore vital to begin considering how Sub-Saharan Africa countries can best start building or strengthening the care and support system for that target population. Study objectives are: 1) identify the key actors of the social system who maintain elders in functional autonomy at home in Bobo-Dioulasso (Burkina Faso) and 2) to describe the functional status of older people living at home. METHODS: We conducted a longitudinal descriptive study among the elderly aged 60 and above (351). Their functional status was evaluated using the Functional Autonomy Measurement System (SMAF). Data analysis was done using the statistical software package STATA (SE11). RESULTS: In Bobo-Dioulasso, 68% of seniors have good functional capacity or a slight incapacity and 32% have moderate to severe incapacities. Older people die before (3%) or during (14%) moderate to severe disabilities. This would mean that the quality of medical and/or social care is not good for maintaining functional autonomy of older people with moderate to severe disabilities. Two main groups of people contribute to maintain elders in functional autonomy: the elderly themselves and their family. Community, private or public structures for maintaining elders in functional autonomy are non-existent. The social system for maintaining elders in functional autonomy is incomplete and failing. In case of functional handicap at home, the elders die. But stakeholders are not conscious of this situation; they believe that this system is good for maintaining elders in functional autonomy. CONCLUSION: It is likely that the absence of formal care and support structure likely shortens the lifespan of severely disabled older people. Stakeholders have not yet looked at this possibility. The stakeholders should seriously think about: 1) how to establish the third level of actors who can fulfill the needs to maintain elders in functional autonomy that are not satisfied by others (family members or the older individuals themselves), and 2) how to reinforce the role of each actor and the collaboration between the different groups of people of this system.

[The elderly in sub-Saharan Africa: a vulnerable population often ignored in public policy]. / Les personnes âgées en Afrique subsaharienne : une population vulnérable, trop souvent négligée dans les politiques publiques.

Many people and financial institutions believe that the elderly are not a priority in sub-Saharan Africa, a region marked by serious economic, socio-political and health crises. The purpose of this paper is to describe and analyze the assumptions and arguments underlying this view and to demonstrate that the elderly are a vulnerable priority population ignored by all stakeholders and primarily by technical and financial partners. The premise is that development must be viewed as a whole. In addition to improving the living conditions of children, youth and women, efforts to promote development in Africa must also take into account the needs of the elderly. The paper argues that there are four main reasons for focusing on the elderly in sub-Saharan Africa: systemic reasons, ethical/humanitarian reasons, developmental reasons and/or the interests and future of youth and adults.

[Functional disabilities in elderly people living at home in Bobo-Dioulasso, Burkina Faso]. / Les incapacités fonctionnelles des personnes âgées vivant à domicile à Bobo-Dioulasso, Burkina Faso.

In sub-Saharan Africa, very little research has been conducted on moderate to severe disabilities affecting mobility, communication and mental function in elderly people living at home. The studies that have been conducted have not always described the broader social context, a key factor for understanding and interpreting results. This study was conducted in Burkina Faso and was designed to fill the gaps in our understanding of disability in these areas. A cross-sectional descriptive study was conducted in Bobo-Dioulasso among the elderly population (aged 60 and above). Functional status was assessed using the Functional Autonomy Measurement System (SMAF). Data analysis was performed using Stata software. Interviews were conducted with a systematic random sample of 351 elderly adults. Moderate to severe functional disability or the need for supervision or assistance were related to mobility in 10 % of cases, to mental function in 28 % of cases and to communication in 37 % of cases. The need for assistance varied according to the different activities or items in each domain. The rates of disability in this study were higher than those found in previous studies, which have often assessed severe disabilities. All individuals affected by disability stated that they had a stable support network to manage their disability. Families were found to be the primary source of support. The results can be explained by the social context. A good visibility of moderate to severe disabilities should contribute to the development of effective policies to provide care and support to the elderly.