When ownership is not enough: Evaluating the co-development and uptake of the Options Assessment Toolkit (OAT) for Plasmodium vivax radical cure in malaria-endemic countries

This qualitative study of the Options Assessment Toolkit (OAT) for *Plasmodium vivax* radical cure reveals that while inclusive co-development fostered strong stakeholder ownership, the tool's influence remained limited to supporting structured deliberation rather than driving formal policy adoption, highlighting that ownership alone is insufficient for institutional uptake without alignment to system readiness and formal regulatory processes.

The Gist

The Big Picture: A Recipe Book That Nobody Cooks With

Imagine the World Health Organization (WHO) is like a famous, strict head chef who writes the official "Malaria Cookbook" for the whole world. Most countries just follow this cookbook exactly because they trust the chef and don't have their own kitchen staff to test new recipes.

However, malaria is tricky. A specific type called Plasmodium vivax is hard to cure completely (called "radical cure"). New medicines are coming out, but the official cookbook hasn't been updated yet. Countries are stuck waiting, unsure if they should try these new ingredients on their own.

To help, a team created a tool called the Options Assessment Toolkit (OAT). Think of this not as a new recipe, but as a kitchen planning checklist. It was designed to help countries figure out: "Do we have the right stove? Do we have enough water? Can we actually cook this new dish safely before the official cookbook says so?"

How They Made It: Building the Tool Together

The researchers didn't just hand this checklist to countries. They built it with them. They invited health officials from Afghanistan, the Solomon Islands, and Vietnam to sit at the table and help design the checklist.

• The Result: The countries felt a strong sense of ownership. It was like they helped build the house, so they felt proud of it. They said, "This tool feels like ours, not something forced on us from the outside."

The Twist: They Liked the Tool, But Didn't Use It to Change Rules

Here is the surprising part of the study. Even though the countries loved the tool and felt they owned it, none of them actually used it to officially change their malaria treatment rules.

Instead of using the checklist to say, "Okay, let's switch to the new medicine today," they used it as a thinking tool.

• The Analogy: Imagine you have a map for a new hiking trail. You don't necessarily hike the trail immediately because the path is muddy or you don't have boots. Instead, you use the map to talk about the trail, plan for the mud, and realize you need to buy boots first.
• What happened: The tool helped officials have better conversations. It helped them realize, "Oh, we don't have enough blood tests (G6PD kits) to use this new drug safely," or "We don't have enough trucks to deliver the medicine."

Why Didn't They Change the Rules? (The Three Big Hurdles)

The paper found three main reasons why the tool didn't lead to immediate action:

1. The "Ready or Not" Problem:
   The tool suggested new treatments, but the countries' health systems weren't ready. It's like having a Ferrari (the new medicine) but no gas station nearby (no diagnostic tests or trained doctors). The officials said, "The tool is great, but we can't drive the car yet because the roads aren't paved." They judged the tool's value based on whether they could actually do what it suggested, not just on the idea itself.

2. The "Wait for the Chef" Problem:
   Even though they built their own checklist, the countries still felt they had to wait for the WHO (the head chef) to officially say, "Yes, this new dish is safe." They felt that if they changed the rules without the WHO's stamp of approval, they were taking too much risk. The WHO's word was seen as a shield against blame if something went wrong.

3. The "Small Order" Problem:
   Some new medicines are hard to get in small amounts. Pharmaceutical companies didn't want to sell tiny batches to small countries. It's like a bakery refusing to sell a single loaf of bread to a small village because they only want to sell whole truckloads. This made the new options impossible to buy, no matter how good the planning tool was.

The Special Case of Nepal

The researchers also asked Nepal (who didn't help build the tool) to try it out.

• In Nepal, the tool worked a bit differently. Instead of just waiting for the WHO, the tool helped them start thinking for themselves. It was like a training wheel that helped them learn how to ride a bike before the official coach gave them the green light.

The Main Lesson: Ownership Isn't Enough

The biggest takeaway from this paper is a simple truth: Just because you build something together and feel proud of it, doesn't mean you will use it to change the rules.

• The Metaphor: Giving a country a beautiful, custom-built map (the OAT) doesn't mean they will start driving a new route. If the roads are blocked, if they don't have a car, or if they are afraid to drive without a police officer's permission, they will just look at the map and say, "Good map, but we can't go yet."

Conclusion

The tool was successful at helping countries think and plan, but it failed to make them act immediately. To make these tools work in the real world, they need to be more than just checklists. They need to be part of the official government planning, connected to money (financing), and linked to the actual rules of how to buy and use medicines. Until the "roads" (health systems) are fixed and the "police officer" (WHO) gives the signal, the map will remain a tool for discussion, not a tool for driving.

Technical Summary

Technical Summary: When ownership is not enough: Evaluating the co-development and uptake of the Options Assessment Toolkit (OAT) for Plasmodium vivax radical cure

Problem Statement
National Malaria Control Programs (NMCPs) face increasing complexity in policy decision-making regarding Plasmodium vivax radical cure due to the emergence of new treatment options (e.g., tafenoquine, high-dose primaquine) and a shifting global landscape toward "living guidance." Currently, malaria treatment policies are heavily dependent on centralized World Health Organization (WHO) guidance, which limits local adaptation and creates a reliance on external normative authority. This dependence is exacerbated by declining global financing and reduced technical support for interpreting evidence. While the Options Assessment Toolkit (OAT) was co-developed (2020–2022) to support NMCPs in contextualizing these decisions, there is limited empirical evidence regarding how such decision-support tools function within hierarchical global health governance systems, specifically concerning the translation of "ownership" into institutional uptake and policy change.

Methodology
This study employed a qualitative approach to evaluate the co-development, uptake, and influence of the OAT.

• Study Design: A qualitative study utilizing in-depth interviews and thematic analysis guided by the COREQ criteria.
• Population and Sampling: Purposive sampling was used to select senior technical and managerial representatives from National Malaria Programs (NMCPs).
  • Co-developers: Afghanistan, the Solomon Islands, and Vietnam (participants involved in the original OAT development).
  • New User Context: Nepal (participants who had not participated in co-development).
• Data Collection: Conducted between January and March 2025. Data collection included 10 virtual interviews (Microsoft Teams) and one in-person interview with two respondents. Interviews were conducted in English and Nepali, audio-recorded, transcribed, and validated by participants.
• Analysis: Data were coded line-byline using NVivo 12, employing a combination of deductive coding (aligned with research objectives) and inductive coding (to capture emergent themes). The analysis focused on institutional constraints, legitimacy, and feasibility rather than solely on reported tool usage.

Key Contributions and Results
The study identifies four primary themes regarding the OAT's impact:

1. Ownership vs. Instrumental Uptake:

   • Participants from co-developing countries reported strong "ownership" of the OAT due to the inclusive, consultative development process. They valued the tool as a "thinking tool" that facilitated structured dialogue, anticipatory planning, and the identification of programmatic gaps.
   • Critical Finding: Despite this strong ownership, none of the co-developing countries used the OAT for formal policy decision-making or to directly revise national malaria treatment guidelines. The tool was utilized for conceptual purposes (structuring conversations, planning) rather than instrumental adoption (changing policy).

2. Conflation of Decision-Support and Implementation Feasibility:

   • A significant barrier to uptake was the tendency of stakeholders to conflate the toolkit's analytical recommendations with the feasibility of implementation.
   • Participants evaluated the OAT's value based on whether the recommended strategies (e.g., high-dose primaquine, tafenoquine) could be operationalized within existing system constraints.
   • Key constraints cited included the absence of G6PD diagnostic testing, lack of trained personnel, supply chain limitations (specifically the inability to procure small quantities of tafenoquine), and weak pharmacovigilance systems. Where these foundational systems were weak, enthusiasm for the OAT diminished, regardless of the tool's design.

3. Reliance on WHO as a Legitimacy Mechanism:

   • In settings with limited internal capacity for independent evidence appraisal (e.g., Solomon Islands, Afghanistan), WHO endorsement was viewed as a prerequisite for policy change and a source of institutional protection against political and professional risk.
   • Stakeholders were reluctant to advance OAT-recommended options independently without WHO validation.
   • Nuance: In Nepal, where the OAT was introduced post-development, it was perceived as a tool for contextual interpretation that encouraged independent thinking, though WHO guidance remained central.

4. Contextual Variability:

   • In Vietnam, where established technical structures and guideline processes already existed, the perceived added value of the OAT was lower, with participants noting it was not significantly different from existing national processes.

Significance and Claims
The paper claims that ownership alone is insufficient for the institutional uptake of decision-support tools. The study challenges the assumption that participatory design automatically leads to policy revision. Instead, the findings suggest:

• Mechanism of Influence: Decision-support tools like the OAT exert influence primarily by reshaping deliberation, framing problems, and strengthening capacity for anticipatory planning, rather than by directly altering guidelines.
• Structural Barriers: Instrumental uptake is constrained by institutional structures, regulatory pathways, financing cycles, and the "conflation" between analytic appraisal and implementation readiness.
• Future Implications: For decision-support tools to have sustained impact, they must be explicitly designed to integrate readiness mapping and financing pathways, and they must be embedded within formal policy cycles (e.g., National Strategic Plan revisions).
• Global Governance Context: As global health financing and technical support potentially decline, reliance on WHO endorsement as the primary pathway for policy validation may become unsustainable. The study posits that nationally anchored deliberation mechanisms could enhance the resilience of malaria governance systems.

The authors conclude that while the OAT successfully facilitated structured reflection and identified gaps, its inability to drive immediate policy change highlights the need for tools that bridge the gap between evidence appraisal and the operational realities of health system implementation.