Injections, cocktails and diviners: therapeutic flexibility in the context of malaria elimination and drug resistance in Northeast Cambodia

PLoS One. 2013 Nov 11;8(11):e80343. doi: 10.1371/journal.pone.0080343. eCollection 2013.


Background: Adherence to effective malaria medication is extremely important in the context of Cambodia's elimination targets and drug resistance containment. Although the public sector health facilities are accessible to the local ethnic minorities of Ratanakiri province (Northeast Cambodia), their illness itineraries often lead them to private pharmacies selling "cocktails" and artemether injections, or to local diviners prescribing animal sacrifices to appease the spirits.

Methods: The research design consisted of a mixed methods study, combining qualitative (in-depth interviews and participant observation) and quantitative methods (household and cross-sectional survey).

Results: Three broad options for malaria treatment were identified: i) the public sector; ii) the private sector; iii) traditional treatment based on divination and ceremonial sacrifice. Treatment choice was influenced by the availability of treatment and provider, perceived side effects and efficacy of treatments, perceived etiology of symptoms, and patient-health provider encounters. Moreover, treatment paths proved to be highly flexible, changing mostly in relation to the perceived efficacy of a chosen treatment.

Conclusions: Despite good availability of anti-malarial treatment in the public health sector, attendance remained low due to both structural and human behavioral factors. The common use and under-dosage of anti-malaria monotherapy in the private sector (single-dose injections, single-day drug cocktails) represents a threat not only for individual case management, but also for the regional plan of drug resistance containment and malaria elimination.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antimalarials / therapeutic use*
  • Cambodia / epidemiology
  • Cross-Sectional Studies
  • Humans
  • Malaria / drug therapy*
  • Malaria / epidemiology


  • Antimalarials

Grant support

The qualitative study and the household survey received financial support from the Belgian Cooperation within the Framework Agreement III consisting of a bilateral cooperation between the Institute of Tropical Medicine (ITM), Antwerp, Belgium and the National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia. The cross-sectional survey was financially supported by the Bill and Melinda Gates Foundation within the framework of the project ‘Repellents as an added control measure to LLINs in Southeast Asia’. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.