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

IntroductionRadical cure of Plasmodium vivax malaria remains a major challenge in endemic countries. New treatment options add opportunities but also increase complexity of policy decisions. Malaria treatment policies are often shaped by World Health Organisation (WHO) guidance, limiting scope for local adaptation. The Options Assessment Toolkit (OAT) was developed to support national policy making for the radical cure of vivax malaria. This study evaluates its co-development, uptake and practical influence. MethodsWe conducted a qualitative study with stakeholders in Afghanistan, the Solomon Islands, and Vietnam (co-developers) and Nepal (new user context). In-depth interviews were conducted with representatives from the National Malaria Programs between January and March 2025. Thematic analysis was conducted using NVivo 12, guided by pre-defined research questions, and reported according to COREQ criteria. ResultsParticipants described a strong ownership resulting from the inclusive co-development process. However, none of the co-developing countries used the OAT for formal policy decision-making. Instead, it primarily supported structured deliberation, planning, and contextual appraisal of emerging treatment options. A key finding was the conflation between decision-support and implementation feasibility: the toolkits perceived value was often judged according to whether recommended strategies could be operationalised within existing system constraints. Instrumental uptake was shaped by institutional structures, system readiness, variation in national analytic capacity, and reliance on WHO endorsement. ConclusionsThe findings suggest that ownership alone is insufficient for institutional uptake. Decision-support tools exert influence primarily by reshaping deliberation, but require embedding within formal policy, regulatory, and financing processes for sustained impact.