In traditional medicine whole plants or mixtures of plants are used rather than isolated compounds. There is evidence that crude plant extracts often have greater in vitro or/and in vivo antiplasmodial activity than isolated constituents at an equivalent dose. The aim of this paper is to review positive interactions between components of whole plant extracts, which may explain this.

Traditional medicines have been used to treat malaria for thousands of years and are the source of the two main groups (artemisinin and quinine derivatives) of modern antimalarial drugs. With the problems of increasing levels of drug resistance and difficulties in poor areas of being able to afford and access effective antimalarial drugs, traditional medicines could be an important and sustainable source of treatment. The Research Initiative on Traditional Antimalarial Methods (RITAM) was founded in 1999 with the aim of furthering research on traditional medicines for malaria.1 The initiative now has in excess of 200 members from over 30 countries. It has conducted systematic literature reviews and prepared guidelines aiming to standardise and improve the quality of ethnobotanical, pharmacological, and clinical studies on herbal antimalarials and on plant based methods of insect repellence and vector control. We review some of this work and outline what can be learnt from the developing countries on the management and control of malaria. We carried out searches of relevant articles published up to 2004 through Medline, Embase, CAB, Sociofile, and the central clinical trials database of the Cochrane Library, using the terms “traditional medicine” and “malaria”, “malaria-therapy”, “knowledge,-attitudes,-practice”, “self-medication”, and “drug-utilisation”. We also searched the references of identified articles and handsearched journals on ethnobotany, herbal medicines, and tropical medicine, such as the Journal of Ethnopharmacology, Fitoterapia, Transactions of the Royal Society of Tropical Medicine and Hygiene, Tropical Medicine , and International Health . Authors were contacted for unpublished papers. #### Summary points Over 1200 plant species from 160 families are used to treat malaria and fever On average, a fifth of patients use traditional herbal remedies for malaria in endemic countries Larger, more rigorous randomised controlled trials are needed with long term follow up So far only a few studies have reported on side effects from …

The World Health Organization defines a “critical shortage” of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. This study is a review of published and unpublished “grey” literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. There is an “inverse primary health care law” in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

A “reverse pharmacology” approach to developing an anti-malarial phytomedicine was designed and implemented in Mali, resulting in a new standardized herbal anti-malarial after six years of research. The first step was to select a remedy for development, through a retrospective treatment-outcome study. The second step was a dose-escalating clinical trial that showed a dose-response phenomenon and helped select the safest and most efficacious dose. The third step was a randomized controlled trial to compare the phytomedicine to the standard first-line treatment. The last step was to identify active compounds which can be used as markers for standardization and quality control. This example of “reverse pharmacology” shows that a standardized phytomedicine can be developed faster and more cheaply than conventional drugs. Even if both approaches are not fully comparable, their efficiency in terms of public health and their complementarity should be thoroughly considered.