Despite changes in policy in many African countries, most cases of malaria are still treated with old drugs that often fail, say researchers in this week's BMJ.

The steady increase of drug-resistant malaria across Africa has prompted many countries to adopt artemisinin combination therapies (ACTs) as policy. These drug combinations are highly effective, and appear to be safe and well tolerated.

Yet a study from Zambia, one of the first adopters of ACTs, shows that only 22% of children eligible for ACTs actually received them. Although the use of chloroquine was successfully discontinued, the change in drug policy does not necessarily translate into adequate use of this drug at the point of care, the authors conclude.

These challenges are discussed in an accompanying editorial. Dr Christopher Whitty and colleagues believe that the primary problem with deployment of ACTs in Africa is cost, but equally challenging is how to deploy ACTs to maximise their effectiveness and cost effectiveness.

The clear tension between the need to restrict drug use to slow the development of drug resistance, and the need to expand access so that malaria is treated before it becomes severe, is also a formidable barrier, they add.

All of these problems can only be solved through partnership between African ministries and regional and local international researchers, they write. “ACT deployment has the potential to be one of the major public health interventions for Africa in this decade. We must get it right.”