A quiet revolution in malaria care is unfolding across Ghana, starting with the most accessible healthcare providers in local communities.
In the bustling streets and remote villages of Ghana, a profound shift in malaria treatment has been taking place. For millions of Ghanaians, the first stop for fever and malaria symptoms isn't the hospital or clinic, but the local licensed chemical seller (LCS)—small retail shops that serve as the frontline of healthcare in many communities4 . These establishments have long provided convenient access to medicines, but historically faced challenges in delivering appropriate malaria treatment1 7 .
When Ghana implemented its new national anti-malaria drug policy, replacing older, less effective drugs with artemisinin-based combination therapies (ACTs) as the recommended first-line treatment for uncomplicated malaria, it marked a critical turning point7 . This article explores what happened when this new policy reached the grassroots level—through the licensed chemical sellers who dispense hope and healing in their communities.
Walk through almost any neighborhood in Ghana, and you'll find them—small shops stocked with various medicines, often identified by their distinctive green cross signs. These licensed chemical sellers (LCS) are auxiliary pharmaceutical outlets permitted to retail specified over-the-counter medicines, including some antimalarials4 . They fill a critical gap in the healthcare system, particularly in rural or underserved areas where access to formal health facilities is limited1 4 .
In some regions, chemical sellers account for up to 83% of initial treatment seeking1 .
However, this accessibility historically came with concerns. Before the policy change, research revealed troubling patterns in malaria treatment at these outlets. A 2007 study published in Malaria Journal found that 76% of patients who had taken antimalarial drugs prior to attending health facilities had used chloroquine—then being phased out due to resistance issues7 . Even more concerning, 77% of these patients had used the medicines inappropriately, with incorrect dosages or treatment durations7 .
Ghana's revised national anti-malaria drug policy represented a strategic response to the growing challenge of drug-resistant malaria parasites. The policy established artemisinin-based combination therapies (ACTs) as the first-line treatment for uncomplicated malaria, specifically recommending combinations such as artesunate-amodiaquine and artemether-lumefantrine4 . These combinations work by attacking the malaria parasite in different ways, making it harder for resistance to develop.
ACTs combine an artemisinin derivative with a partner drug to:
WHO recommends testing all suspected malaria cases before treatment to:
Implementing this new policy at chemical shops presented unique challenges. Most licensed chemical sellers lack formal medical training, and their business model traditionally focused on selling medications rather than providing comprehensive care1 . The transition required them to adopt new practices, including:
How did this policy transition actually work on the ground? A revealing study conducted in the Kintampo North and South districts of Ghana provides valuable insights4 . Researchers trained LCS attendants in malaria symptom recognition, finger-prick blood sampling for rapid diagnostic tests, and appropriate treatment based on results, following national guidelines4 .
The study design was straightforward yet powerful. Attendants from 42 licensed chemical shops received specialized training and were supplied with malaria rapid diagnostic test (mRDT) kits, safe disposal bins, and logbooks for recording patient information4 . These trained attendants then managed clients presenting with fever or other malaria symptoms through a standardized process:
Assessing symptoms and checking for danger signs requiring referral.
Performing mRDT tests using finger-prick blood samples when appropriate.
Interpreting results and providing appropriate treatment based on findings.
Recording data on client presentations, test results, and treatments given.
Referring complicated cases or negative-test clients with persistent symptoms4 .
The findings demonstrated significant improvements in appropriate malaria treatment. The table below shows key outcomes from the study:
| Metric | Result | Significance |
|---|---|---|
| Clients with positive mRDT | 66% of febrile clients | Confirmed high malaria burden in the study area |
| Appropriate ACT treatment | 86% of clients with positive mRDT | Majority received correct medication for confirmed malaria |
| Client recovery rate | 97.8% by day 7 | Demonstrated effectiveness of the prescribed treatment |
| Referral rate for negative mRDT | Only 4.1% | Highlighted ongoing challenge of managing non-malaria fevers4 |
Table 1: Outcomes of Test-Based Malaria Management at Licensed Chemical Shops4
Client Recovery Rate
ACT Treatment
These results revealed both the promise and the challenges of the new approach. The high rate of appropriate ACT prescribing and excellent recovery outcomes demonstrated that chemical sellers could effectively implement the new policy when properly trained and equipped4 . However, the very low referral rate for clients with negative malaria tests highlighted an area needing improvement—specifically, the need for better guidance on managing non-malaria fevers4 .
The transformation of Ghana's chemical shops reflects broader trends in malaria treatment across Africa. The global malaria treatment market is evolving rapidly, with ACTs now established as the gold standard for uncomplicated malaria2 . Market analyses project continued growth in this sector, with the malaria treatment market expected to rise from an estimated $1,894.5 million in 2025 to $3,113.8 million by 20352 .
Malaria treatment market projected to grow from $1.9B (2025) to $3.1B (2035)2
WHO reported over 247 million malaria cases in 20222
Crucial for improving access to affordable antimalarial drugs2
Despite the progress, challenges remain in ensuring optimal prescription patterns at chemical shops. The pre-policy research revealed several concerning practices:
| Practice Issue | Finding | Implication |
|---|---|---|
| High inappropriate use | 77% of clients used antimalarials incorrectly | Wasted resources, potential treatment failure |
| Chloroquine dominance | 76% of pre-facility antimalarials were chloroquine | Continued use of less effective treatment |
| Home medication use | 20% used leftover drugs from home | Unsupervised treatment, improper dosing |
| Knowledge gaps | Only 24% knew malaria danger signs | Limited ability to recognize severe cases7 |
Table 2: Pre-Policy Antimalarial Use Patterns at Chemical Shops in Ghana7
These findings highlight why the policy change and training initiatives were so critical. The transition from chloroquine to ACTs represented not just a drug substitution, but a comprehensive transformation of malaria management at the community level.
Implementing effective malaria treatment at chemical shops requires specific tools and resources. The table below outlines key components of the "malaria management toolkit" for licensed chemical sellers:
| Tool/Resource | Function | Importance |
|---|---|---|
| Malaria rapid diagnostic tests (mRDTs) | Confirm presence of malaria parasites | Enables targeted treatment; avoids ACT overuse |
| Artemisinin-based combination therapies (ACTs) | First-line treatment for confirmed uncomplicated malaria | Highly effective against resistant parasites |
| Training manuals & protocols | Guide proper symptom assessment and treatment | Ensures standardized, correct practices |
| Record-keeping logbooks | Document patient presentations and outcomes | Facilitates monitoring and quality improvement |
| Safe disposal systems | Proper disposal of sharps and medical waste | Prevents disease transmission and environmental contamination4 |
Table 3: Essential Tools for Malaria Management at Chemical Shops4
While Ghana's experience demonstrates significant progress in transforming prescription patterns at chemical shops, the journey is far from over. The emergence of drug resistance remains a persistent threat to current ACTs, requiring ongoing monitoring and potential future treatment adjustments2 . Additionally, funding limitations continue to challenge malaria control efforts globally; in 2023, the global investment of $4 billion was less than half of the $8.3 billion needed to meet targets.
Source: World Malaria Report 2024
"To reduce the world's malaria burden, we need to invest in primary health care as the foundation for strong, equitable health systems."
Ghana's experience in transforming malaria treatment at licensed chemical shops offers valuable lessons for other malaria-endemic countries. By training and equipping these frontline medicine sellers to implement the national anti-malaria drug policy, Ghana has taken crucial steps toward more rational drug use and improved patient outcomes.
The transition hasn't been perfect—challenges remain in ensuring consistent adherence to guidelines and managing non-malaria fevers. However, the demonstrated success of test-based management in these informal retail settings provides a promising model for expanding access to appropriate malaria care in communities where formal health services are scarce.
As the global community continues its fight against malaria—which still claims hundreds of thousands of lives annually—the critical role of licensed chemical sellers becomes increasingly clear. They're not just shopkeepers; they're essential healthcare providers in the battle against one of humanity's oldest diseases. Their evolving prescription patterns reflect both the challenges and progress in this ongoing fight, offering hope for more effective malaria management at the grassroots level where it's needed most.