The implementation of a new Malaria Treatment Protocol in Timor-Leste: Challenges and constraints

Background: Timor-Lestechanged its malaria treatment protocol in 2007, replacing the first-line forfalciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine.This study explored the factors affecting the implementation of the revisedtreatment protocol, with an emphasis on identifying key constraints.

Methods: A mixedmethod approach drew on both qualitative and quantitative data. The studyincluded data from District Health Services in seven districts, communityhealth centres in 14 sub-districts, four hospitals, five private clinics, oneprivate pharmacy and the country's autonomous medical store. In-depthinterviews with 36 key informants, five group interviews and 15 focus groupdiscussions were conducted. A survey was also undertaken at community healthcentres and hospitals to assess the availability of a physical copy of theMalaria Treatment Protocol, as well as the availability and utilization ofartemether-lumefantrine and sulphadoxine-pyrimethamine.

Results: Many factorsimpeded the implementation of the new malaria protocol. These included:inadequate introduction and training around the revised treatment protocol;unclear phasing out of sulphadoxine-pyrimethamine and phasing in of the revisedtreatment, artemether-lumefantrine, and the rapid diagnostic test (RDT); lackof supervision; lack of adherence to the revised guidelines by foreign healthworkers; lack of access to the new drug by the private sector; obstacles in theprocurement process; and the use of trade names rather than generic drugdescription. Insufficient understanding of the rapid diagnostic test and theuntimely supply of drugs further hampered implementation.

Conclusion: Toeffectively implement a revised malaria treatment protocol, barriers should beidentified during the policy formulation process and those emerging duringimplementation should be recognized promptly and addressed.