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PhD defence Temmy Sunyoto

Access to leishmaniasis care in Africa

25 Jun 201910:00

Image 1/1 : Temmy Sunyoto


  • Prof. Dr. Marleen Boelaert, Institute of Tropical Medicine
  • Dr. Albert Picado de Puig, ISGlobal, Universitat de Barcelona, Spain


Leishmaniasis is a group of diseases caused by an obligate protozoan Leishmania and transmitted by sand flies. As a neglected tropical disease (NTD), leishmaniasis disproportionately affects the poorest populations and those living in rural, remote areas or conflict zones with limited or no access to health care. Without vaccine or effective vector control, the pillar of control strategy in Africa remains diagnosis and treatment. However, ensuring that all individuals suffering from leishmaniasis have prompt access to effective treatment remains a challenge for resource-constrained health systems. The rk39 rapid test is less accurate and treatment options are limited. A 17-day combination of antimonial and paromomycin is the first line treatment for VL in the region, requiring prolonged hospitalisation and increased economic burden for the patients and their households.

Despite the progress in tackling NTDs, access to care for leishmaniasis is often taken for granted. Especially in Africa, access remains problematic and the current body of literature shows critical evidence gaps. Low coverage of the health services, accessibility and availability of quality care, limited diagnostic and therapeutic options along with inefficient procurement and supply remain significant challenges in the region. Delay in seeking treatment not only increase morbidity and mortality but also sustain transmission.

This thesis aims to improve our understanding on access to care in Africa, by documenting availability, affordability and accessibility of care, explore novel ways of enhancing such care, and provide insights into specific elements of access to formulate coherent policy recommendations for leishmaniasis in eastern Africa. Three specific objectives were formulated: the first is to update the disease burden, second to examine access issues ‘upstream' i.e. the R&D process and third, assess access issues ‘downstream’. Methodologies include context analysis, systematic reviews, case study and qualitative research.

The works in this thesis (6 publication in peer-reviewed journals) provide insights into the complexity of access to care for leishmaniasis in Africa. The We synthesized evidence on leishmaniasis care in a fragile setting (Somalia), burden of cutaneous leishmaniasis in sub-Saharan Africa and the economic burden faced by households affected by leishmaniasis. We examined the role of Public Private Partnership in the R&D for NTDs and critically analysed the access failure for Miltefosine, the only oral drug approved to treat leishmaniasis. The biography of this breakthrough drug provided many lessons learned resonant to access to medicines today. We explored perspectives of stakeholders of the barriers in leishmaniasis supply chain in 6 countries in eastern Africa, while we also voiced the perspectives of the community living in Gadarif state of eastern Sudan on the barriers they faced when seeking care. Inadequate access is rarely a single-failure problem. Affordability, availability and quality remain as barriers at various levels and there should be more collective efforts to address these.

The current efforts to control leishmaniasis in eastern Africa need to deal first and foremost with access to care, which sadly remains inadequate. Conflict-affected areas require innovative strategies. Developing improved diagnostic and treatment control tools is crucial, and so is ensuring that these tools reach the patients who need them the most.