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    Mosquitoes around the home can be reduced significantly by minimizing the amount of standing water available for mosquito breeding. Residents are urged to reduce standing water around the home in a variety of ways.


    The best way is to avoid being bitten by mosquitoes.This can be accomplished using personal protecting  while outdoors when mosquitoes are present. Treated bed nets should be used sleeping. Mosquito repellent should be used when outdoor.


    Nearly half of the world’s population is at risk of getting malaria. Pregnant women are particularly at risk of malaria. Children under 5 years are at high risk of malaria.


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Public Health Realities

Frantic moments greeted recent research findings that anti-malarials like chloroquine and sulfodoxine-pyrimethamine (SP) were still being used for the treatment of uncomplicated malaria and not by un-trained health professionals.

Within minutes of the release of the findings at a meeting in Accra, the boss of the Ghana Health Service, (GHS) the implementing arm of Ghana's Health Ministry, asked that a directive be sent out to stop the practice especially in public health facilities.

The swift response came from Dr Frank Nyonator, Acting Director-General of the GHS, at the second stakeholders meeting on the INDEPTH Effectiveness and Safety Studies (INESS) to disseminate preliminary findings from the on-going survey on the project.

The survey, conducted in private and public health settings and within the communities, was not just to collect statistics but to unmask the real-life i s s u e s b e h i n d p u b l i c h e a l t h interventions in the deployment of anti-malarials and artemisinin-based combination therapies (ACTs) in particular in order to assess not only its efficacy, but to monitor its travels from clinical trials in the laboratories to its usage in real-life settings among end users.

There were even more disturbing news from the findings of the quantitative and qualitative survey as both acts of omission and commission by health workers and patients were brought to light. Health facilities, both public and private and trained health professionals were engaged in some of these acts.

Dr Frank Atuguba, INESS Site Coordinator at the Navrongo Health Research Centre, said the study found out that of the many people who present with fever at health facilities, only a
few get properly diagnosed, are given effective malaria treatment and also comply with treatment regimen.

Many reasons ranging from cost of drugs, access to health facilities, attitude of health workers and patients, among others, account for some of the poor malaria diagnosis and treatment, which INESS seeks to expose.

Researchers are becoming worried and argue that it is no longer sufficient to talk about figures in malaria treatment but the time has come to make public health intervention effective by extending its clinical trials to real-life settings to test its ability to solve real health problems.

This is what the survey sought to do in bringing out the real feelings and behavior of respondents (health providers and ordinary folks) who took part in the study. The data from the study came in many forms including, interviews, focus group discussions and questionnaires and this helped in exposing the real attitudes and behaviours of health practitioners and patients in relation to malaria treatment.

For instance, reports showed that while some people were turning to herbal remedies and sea water to treat malaria within the study areas of the survey, some clinicians were also found to be indulging in presumptive diagnosis and treating patients with ACTs even after laboratory diagnosis and the use of
rapid diagnostic test kits (RDTs) confirm the absence of malaria parasites.

This was being done despite that fact that Ghana has pushed for the adoption of WHO policy of evidence-based treatment using laboratory diagnosis or the deployment of RDTs.

The attitude of some health workers towards patients who access health facilities were also brought out by the survey. Findings from a Focus Group Discussion captured the thoughts of community members.

“Some of the problems are with the attitude of health workers. They always complain that some of the patients visit the hospital too often because they have health insurance and this sometime makes one feel reluctant and afraid to go to the health facility” said a respondent.

“I also experienced a similar situation with a friend of mine when we went to  the health facility. A woman had  brought her child and wanted the health worker to attend to her. At the time the in-charge was not there and the health worker started shouting at the woman: “You were here yesterday and today too. Are you the only one with health insurance? I sat somewhere quietly and watched what was happening. If the person wasn't sick would she have even bothered coming to the health facility?”

These are interesting responses from the study participants in the Focus Group Discussions. No wonder some patients turn to self medication rather than going to the health facility for medical interventions.

The survey, which is part of the larger INESS project, was carried out between 2009 and June this year in the three Demographic and Health Surveillance Sites in Dodowa, Kintampo and Navrongo, sites taking part in the INESS project.

Researchers from the three sites, regulators, policy makers, political heads, malaria experts and the media among others, who had gathered at the dissemination forum in Accra, could not wait to get into action and following in the footsteps of the Boss of the GHS, groups within the gathering were t a s k e d t o a s s i g n r o l e s a n d responsibilities to all stakeholders to deal with some of the negative findings immediately, an indication that INESS will not allow research findings to gather dust on the shelves.

The robust response given to the findings is all about using real-life evidence to effect policy change in the deployment of anti-malarials.

The INESS project therefore seeks to provide real-life evidence on ACTs to find out if they are efficacious, safe, affordable, accessible and how prescribers and clients are complying with the treatment regimen, especially within health systems.

The purpose of the four-year project being supported by the Bill & Melinda Gates Foundation, is the first-ever Phase Four malaria clinical studies in Africa and is being carried out in Ghana, Tanzania, Burkina Faso and Mozambique, with the aim of also examining the social, cultural and behavioural factors affecting the uptake of and adherence toACTs in real life settings.

Anti-malarials such as artesunate amodiaquine and artemether-lume fantrine known as ACTs have officially replaced mono-thrapies in treating malaria, because the parasites have
become resistant to old anti-malarials like chloroquine and the INESS study is aimed therefore at providing decision makers across Africa with independent and objective real-life evidence on the safety and effectiveness of ACTs when deployed in health systems.

Public health specialists are saying efficacy under trial conditions is almost always greater than effectiveness in real-life situations and it is important to evaluate the performance of public health tools within the health system to see how effectively they work. In Ghana the research has been looking at Artesunate-Amodiaquine (ASAQ) and Artemether-Lumefantrine (ALU) in Tanzania.

According to Prof Fred Binka, Principal Investigator of the INESS Project, public health tools such as drugs, bed nets and vaccines are developed under stringent clinical conditions but the bigger question is to find out how they work in real-life among end users and when deployed in health systems after regulatory approval and registration for use.

He said INESS is the platform that takes a product from registration and beyond and fills in on the post-market surveillance and pharmacovigilance aspects of public health interventions with safety and efficacy becoming critical watch words.

INESS, it is expected, will address how determinants of effectiveness of anti-malarial drugs, like cost, health-worker attitude and patients' behaviour work
under real-life situations.

Prof. Binka said results from the INESS project will feed independent data into the framework of malaria treatment policy in African health systems and minimize the time between licensure and the adoption ofACTs.

He has, meanwhile, thrown a challenge to journalists present at the Accra meeting to visit Ghana's largest teaching hospital, Korle Bu, to find out why lots of people are reporting there with kidney problems, which may be linked to widespread use of herbal remedies without active ingredients to cure ailments.

Ms Livesy Abokyi, a Researcher at the Kintampo Health Research Centre, who spoke on community compliance and acceptability of ACTs, touched on these herbal remedies and said the survey found out that there were widespread use of herbal remedies to treat malaria, both home brewed and pre packed at shops.

She said leaves of trees like neem, pawpaw, mango and acacia are boiled together and measured out with a 'small' cup and drunk three times a day as cure to malaria while some are boiled and steam-inhaled. Others are bathed and some people use the herbal enemas to wash “dirty” stomach linked to malaria.

On private health providers, MsAbokyi said they stock many mono and combination therapies and treat based on what patients ask for or what drug store operator prefers with little regard for guidelines on malaria treatment.

On how communities perceive malaria treatment when they are able to access health facilities, she explained that there were widespread complaints about not being examined or tested for malaria.

All these sum up to what is termed as system effectiveness study and it is expected to bring up options on how to improve access, and consequently the effectiveness of ACTs in Ghana and across Africa.

Eunice Menka - Ghana

Eighth Edition