Home management of malaria, that is giving households drugs and allowing them to self-treat presumptive cases of malaria, has been advocated for the treatment of malaria. Malaria outcomes improve markedly when treatment is given early but only a fraction of all people with malaria symptoms seek formal care or they wait too long to seek care. There has been a big push to get drugs into households so that they can treat at the first sign of fever. Seems like a good idea.

A recent article in the Lancet suggests that this might not be the best strategy everywhere, in particular when we are talking about home management with ACTs. In a relatively small randomized trial in an urban setting in Kampala, children were randomized to receive the home management with ACTs or standard care. Over the course of a year, the treatment children received treatments many times more often but clinical outcomes between the two groups did not differ markedly. The authors conclude that home management may not be the most cost-effective treatment strategy in an urban context where physical access to facilities is good and where transmission of malaria is relatively low.

This is just one more example of how global health policies tend to be too blunt. All poor children in all poor countries tend to be treated equally and the reality is that there is a of variation. Setting targets like 80% of children should sleep under a bet net gives an incentive to cover children in urban areas first, as they are easier to reach, but means that the interventions do always go to those who would benefit the most. We know more and we should use more of what we know into our guidelines.

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