Implementing ideal health policy in a fragile health system: the example of expanding the use of malaria rapid diagnostic tests in mainland Tanzania

In recent papers in Malaria Journal, Graz et al [1] and D'Acremont et al [2] provided a good insight on the policy of malaria confirmation prior to treatment in areas with different transmission intensities. Graz et al [1] questioned WHO recommendations of the 'test and treat' strategy, whereas D'Acremont et al demonstrated how programmatic implementation of malaria rapid diagnostic tests (RDTs) in moderately malaria endemic areas drastically reduced over-treatment with anti-malarials [2]. These articles give a clear viewpoint of the future of malaria diagnosis in endemic countries, particularly in sub-Saharan Africa. Given the growing evidence of advantages acquired by introduction of malaria RDTs, it is to be expected that most malaria endemic countries will opt for a confirmatory policy. Apart from the issue of different policies in malaria diagnosis cited by Graz and coworkers, other issues are to be considered in order to ensure successful adoption of such policy. In particular, the countries' health systems must have appropriate resources and skills in place.Increased coverage of malaria confirmation prior to treatment by use of RDTs represents renewed hope for quality management of malaria cases. In Tanzania, a country with high to low malaria transmission, RDTs are currently being rolled out. The advantages of confirming malaria before treatment has been extensively explored by both Graz and D'Acremont and colleagues [1,2]. The fact that RDTs will be made available to the dispensaries-the lowest level of the formal health care system in Tanzania, closer to the population-ensures that the strategy will be widely accessible. However, the strategy is faced with many organizational, logistical and technical challenges. The introduction of RDTs in Tanzania has uncovered many health system bottlenecks that necessitate the development of new approaches to deliver quality health care. The World Health Organization (WHO) health systems building blocks [3] provide a g