Priority setting in selection and distribution of new antimalarials in Tanzania, analysis and evaluation against accountability for reasonableness

Abstract

Background: Tanzania like many other malaria endemic countries changed its National Malaria Treatment Policy in 2006 due to parasite resistance to Sulphadoxine/Pyrimethamine (SP). Selection of Artemether-Lumefantrine (ALu) as the first line antimalarial drug and its selective distribution to Public and Faith based health facilities were two priority-setting decisions underlying the policy change. However, today, there are people who are still using Sulphadoxine/Pyrimethamine because they have no access to Artemether-Lumefantrine. Objective: To analyze and evaluate whether the priority decisions for selection and distribution of subsidized Artemether-Lumefantrine satisfies the conditions of fair process as suggested in the ethical framework of accountability for reasonableness. Method: A Qualitative study involving review of the guidelines and in-depth interviews with key informants from the task force was conducted. The analysis followed an editing organizing style. The audio data was transcribed into text and loaded into QDA program whereby coding, connections and analysis was performed. The results are presented under the four thematic areas of the accountability for reasonableness (AfR) framework which are publicity, relevance, appeals & revision and the enforcement conditions. Results: Publicity: The decision and the rationales for selection of Artemether-Lumefantrine were made public, contrary to the selective distribution decision and its rationales. Public and the patients were indirectly but inadequately represented. There was no explicit mechanism to involve the stakeholders and as a result the task force lacked professional, institutional and countrywide representation. Relevance: Selection of Artemether-Lumefantrine was based on relevant evidence; however its selective distribution was partly based on donor requirement. Appeals & Revision: there was no well defined and reliable appeal mechanism, apart from the use of newspapers. Enforcement: There was not any enforcement mechanism to ensure the other three conditions are fulfilled.

VI Conclusions and Policy implications: The change of National Malaria Treatment Policy was necessary, however the priority decisions of selection and distribution of Artemether- Lumefantrine which underlined this change does not fully satisfy the four conditions of fair process prescribed in the ethical framework of accountability for reasonableness. Decision making in priority setting is considered to be a technical area for experts and their views are assumed to represent those of other people in the society. This study suggests involvement of 'lay' people and other stakeholders directly through personal representation complemented by inputs obtained from large scale survey studies, focus group discussions and by rapid appraisal method. Task forces or committees are formed to oversee priority setting decisions; however, the whole process is conducted in ad hoc and under limited freedom to discuss issues of significant implications. Reliable appeal and revision mechanisms need to be put in place to accommodate new findings, arguments and deliberations once priority decisions have been made. This will make the whole process of policy making to be continuous rather than an event.